Laparoscopic Ultralow Anterior Resection with Colonic J-pouch-Anal Anastomosis

Purpose  Optimal treatment of mid to distal rectal cancers includes total mesorectal excision for oncologic clearance and, where reanastomosis is feasible, a colonic J-pouch-anal anastomosis improves bowel function. There is recent interest in performing an ultralow anterior resection laparoscopically.1–3 A technique is described that includes specimen extraction through the eventual routine defunctioning colostomy or ileostomy site. Methods  Consecutive unselected patients who underwent laparoscopic ultralow anterior resection were recruited. Patients with adenocarcinoma underwent preoperative endorectal ultrasound to individualize for neoadjuvant chemoradiotherapy, based on local extent and lymph nodes seen. The operative procedures were as shown in the video. Posterior dissection along the “total mesorectal excision plane” included incision of Waldeyer’s fascia. Bowel continuity was restored by an intracoporeal double-cross stapled colonic J-pouch-anal anastomosis, but where not possible a coloplasty with pull-through handsewn coloanal anastomosis was performed. Results  Laparoscopic ultralow anterior resection was performed on 55 patients (35 men; median age, 63 (range, 33–90) years) from March 2004 to October 2006. The median body mass index was 26.3 (19–38); 14 patients (25 percent) had a body mass index >30. Ten patients (18 percent) had an American Society of Anesthesiologists’ classification of III. The indications were adenocarcinoma (n = 51), squamous-cell carcinoma of rectum (n = 1), dermoid tumor of mesorectum (n = 1), large villous adenoma (n = 1), and carcinoid with local lymph node metastases (n = 1). The adenocarcinomas were a median distance of 6 (3–12) cm from the anal verge. Neoadjuvant radiotherapy was given in 12 patients (24 percent) who had preoperative endoanal ultrasound findings of tumor extension beyond the muscularis propria and chemoradiotherapy in 7 (14 percent) of these patients where the tumor was more bulky and fixed. Laparoscopic ultralow anterior resection was completed at a median 180 (90–405) minutes, with 53.5 (2–2250) ml of blood loss, and the specimen was extracted through a 4.5 (3.5–11) cm wound. The latter included three cases (5 percent) that were converted. Significant adhesiolysis was required in 29 patients (52.7 percent) because of previous operations. The histologic grading or the adenocarcinoma patients were: Stage I, n = 14; Stage II, n = 23; Stage III, n = 11; Stage IV, n = 3. Of those who underwent curative resection (Stages I–III), the distal resection margin was 2.9 ± 0.7 cm (mean ± standard error) and the radial resection margins were at least 2 mm in all patients. The level of the coloanal anastomosis was a median 3.5 (0–4.5) cm from the anal verge; a coloanal pull-through anastomosis was required in one patient who had a distal cancer. The ileostomies functioned and patients tolerated free fluids at a median of two (1–9) days, and the median postoperative hospital stay was seven (3–22) days. At a median follow-up of 14 (2–33) months, none of the adenocarcinoma patients who had undergone curative resection had recurrences. Four patients (8 percent) had postoperative complications that required operative/invasive intervention (anatomotic leak n = 1, proximal bowel ischemia n = 1, port site hernia n = 1, pelvic collection n = 1). Four other patients had smaller pelvic collections that resolved with antibiotics; pelvic collections were associated with advanced stage of cancer (P = 0.047). Discharge was delayed by acute gastric distension in 11 patients; the latter was associated with poorer American Society of Anesthesiologists’ risk classification (P = 0.035). Erectile dysfunction occurred in ten men, and this was associated with adjuvant chemoradiotherapy (P = 0.042). One patient (2 percent) had persistent urinary retention that required catheterization at latest follow-up. The ileostomy had been closed in 50 patients, and at last follow-up, the median stool frequency was two (1–8) bowel movements per day. Conclusions  Laparoscopic ultralow anterior resection could be offered routinely and completed safely in Western populations, where obesity and adhesions from previous abdominal surgery is common. A laparoscopic technique readily allowed visual identification of the autonomic nerves in the abdomen over the aorta, which could then be followed down into the pelvis. If the pelvis was deep, inversion of the 30° laparoscope in the “upside down” position fascilited incision of Waldeyer’s fascia. This brought the rectum proximally and anteriorly, aiding with the laparoscopic stapler transection of the distal rectum, especially if the cancer was distal, the patient was obese, and the pelvis was narrow. Extraction of the specimen at the eventual defunctioning stoma site reduced the incisions required. Preoperative chemoradiotherapy may have a role in postoperative male sexual dysfunction. Further randomized, controlled studies that include assessing five-year cancer survival/recurrence, pelvic nerve dysfunction, and bowel function are needed before laparoscopic ultralow anterior resection becomes widely accepted. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Leakage After Resection and Intraperitoneal Anastomosis for Colorectal Malignancy: Analysis of Risk Factors

Purpose The study was designed to identify the risk factors associated with anastomotic leakage after an intraperitoneal large-bowel anastomosis in patients with colorectal malignancy. Methods The prospectively collected data of patients who underwent colorectal resection for malignancy with primary anastomosis above the pelvic peritoneal reflection for malignancy between 1996 and 2004 were reviewed. Thirty-five variables were evaluated using univariate and multivariate analysis. Results A total of 1,417 patients were studied and anastomotic leakage occurred in 25 patients (1.8 percent). Twenty-two patients (88 percent) required reoperation for anastomotic leakage. The hospital stay (28 vs. 10 days, P < 0.001) and mortality rate (32 vs. 4 percent, P < 0.001) of patients with anastomotic leakage were significantly increased compared with those without leakage. Multivariate analysis showed that American Society of Anesthesiologists Grade 3 to 5 (P = 0.04; odds ratio, 5.6; 95 percent confidence interval, 1.6–15.3) and emergency operation (P = 0.03; odds ratio, 4.6; 95 percent confidence interval, 1.9–9.8) were independent factors associated with anastomotic leakage. The risk of anastomotic leakage was 8.1 percent (odds ratio, 10.5; 95 percent confidence interval, 2.7–26.8) if both factors were present. Conclusions Intraperitoneal anastomosis after large-bowel resection is associated with a low leakage rate. Emergency surgery and a high American Society of Anesthesiologists grade are independent factors associated with an increased incidence of leakage. A temporary diverting stoma to protect the primary anastomosis or even avoidance of anastomosis could be considered for patients with the two risk factors present.     

Is C-Reactive Protein a Prognostic Factor of Colorectal Cancer?

Purpose C-reactive protein, a commonly used inflammation marker, has been reported to be a prognostic factor of colorectal cancer. This prospective study was designed to confirm the prognostic value of its preoperative levels and to observe their perioperative change. Methods Between January 2001 and September 2005, preoperative C-reactive protein levels were obtained for 212 consecutive patients (140 males) receiving elective open resection of colorectal cancer. A level higher than 0.5 mg/dl was defined as positive. They were analyzed against clinicopathologic factors. The survival of 158 curative resections was analyzed. Postoperative levels (at months 1, 3, and 6) were collected for analysis of changing trend, from the patients receiving curative surgeries. Results Median value of preoperative C-reactive protein was 0.54 mg/dl (48.6 percent positive). Positive rate was significantly correlated with ulcerative type, larger size, higher stage, and positive carcinoembryonic antigen (>5 ng/ml). In both univariate log-rank test and multiple Cox proportional hazards regression, stage (univariate P = 0.011, and multivariate P = 0.016; hazard ratio, 6.23; 95 percent confidence interval, 1.41–27.54), C-reactive protein (0.5 mg/dl; P = 0.005, and P = 0.016; hazard ratio: 6.51; 95 percent confidence interval: 1.41–30.05), and differentiation (P = 0.006, and P = 0.043; hazard ratio, 3.53; 95 percent confidence interval, 1.04–11.98) were significant factors. Analysis of disease-free interval showed C-reactive protein was significant (P = 0.03): as level rose, prognosis worsened. The quiescent inflammation-response group (≤0.1 mg/dl) had excellent outcomes. Postoperatively, the C-reactive protein levels declined at the third postoperative month. Conclusions Preoperative C-reactive protein is an independent prognostic factor. The levels declined postoperatively, although with a lag. These findings seem to support the response hypothesis regarding C-reactive protein. Supported by Taipei Veterans General Hospital Grant 97.     

The Effect of Restorative Proctocolectomy on Sexual Function,Urinary Function,Fertility, Pregnancy and Delivery: A Systematic Review

Purpose This study was designed to evaluate the effect of restorative proctocolectomy on sexual function, urinary function, fertility, pregnancy, and delivery in patients with ulcerative colitis. Methods A systematic literature search was performed of articles published between 1980 and 2005 on patients undergoing restorative proctocolectomy for ulcerative colitis reporting data on the outcomes of interest. A random-effect, meta-analytical model was used for pooled estimates and 95 percent confidence intervals. Results A total of 22 studies, with 1,852 females, were included. Infertility rate was 12 percent before restorative proctocolectomy and 26 percent after, among 945 patients in seven studies. The incidence of sexual dysfunction was 8 percent preoperatively and 25 percent postoperatively (7 studies, n = 419). Two studies (n = 62) reported no urinary dysfunction in patients undergoing restorative proctocolectomy. There was an increased incidence of cesarean section after restorative proctocolectomy. During the third trimester of pregnancy, there was an increase in stool frequency by 1.15 stools per day compared with before pregnancy frequency (n = 49 95 percent confidence interval, 0.28–2.03 P = 0.01 chi-squared statistic, 0.04 P = 0.84). No significant differences were seen in pouch function after vaginal delivery (n = 456; weighted mean difference, 0.23; 95 percent confidence interval, 0.43–0.88; P = 0.49; chi-squared statistic, 1.29; P = 0.26). Conclusions The incidence of dyspareunia increases after restorative proctocolectomy. There was a decrease in fertility after restorative proctocolectomy. Pregnancy after restorative proctocolectomy was not associated with an increase in complications. There was an increase in stool frequency and pad usage during the third trimester. Vaginal delivery is safe after restorative proctocolectomy. Pouch function after delivery returns to pregestational function within six months.     

The Impact of Preoperative Immunomodulation on Pouch-Related Septic Complications After Ileal Pouch-Anal Anastomosis

Purpose We studied preoperative and perioperative factors with particular attention to the role of immunomodulatory medication, which may impact the incidence of pouch-related septic complications. Methods A retrospective review of data from patients who underwent ileal pouch surgery during a 20-year period from 1985 to 2005 was performed. Preoperative use of immunomodulatory medication along with perioperative clinical, surgical, and disease variables were recorded. Patients were monitored for pouch-related sepsis in the early (within 30 days of surgery) and late (after 30 days of surgery) postoperative periods. Univariate and multivariate logistic regression analysis was performed. Results There were 445 patients (206 females; 46.4 percent). Median age was 36 (interquartile range, 27–46) years. Median follow-up period was 52 (interquartile range, 26–86) months. Complete data were available for 335 patients. Early sepsis was seen in 58 patients (17.3 percent). Another 22 patients (6.5 percent) developed late sepsis. On multivariate analysis, only steroid use remained predictive of higher rates of early sepsis (odds ratio, 1.81; 95 percent confidence interval, 1.02–3.45; P = 0.002). Likewise on multivariate analysis, both male gender (odds ratio, 0.24; 95 percent confidence interval, 0.09–0.71; P = 0.007) and 5-aminosalicylic-acid use (odds ratio, 0.22; 95 percent confidence interval, 0.08–0.76; P = 0.023) remained predictive of lower rates of sepsis. Conclusions Preoperative steroid use is associated with higher rates of early but not late pouch-related septic complications. We recommend that patients be weaned of steroids before ileal pouch surgery or be warned of the higher risk of postoperative sepsis. Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 4 to 7, 2006. Reprints are not available.     

Family History and Serology Predict Crohn’s Disease after Ileal Pouch-Anal Anastomosis for Ulcerative Colitis

Purpose Approximately 5 to 10 percent of patients undergoing ileal pouch-anal anastomosis with a diagnosis of ulcerative colitis are subsequently diagnosed with Crohn’s disease. Preoperative predictors for Crohn’s disease post-ileal pouch-anal anastomosis have not been prospectively defined. Methods A total of 238 consecutive patients with ulcerative colitis or indeterminate colitis undergoing ileal pouch-anal anastomosis were prospectively enrolled into a longitudinal database. Clinical factors were assessed perioperatively. Serum drawn preoperatively was assayed for anti-Saccharomyces cerevisiae, antiouter membrane porin-C, anti-CBir1, and perinuclear antineutrophil cytoplasmic antibody using enzyme-linked immunosorbent assay. Crohn’s disease was defined by small bowel inflammation proximal to the ileal pouch or a perianal fistula identified at least three months after ileostomy closure. Predictors were assessed in a multivariate Cox proportional hazards model to predict the rate of Crohn’s disease after ileostomy closure. Results Sixteen patients (7 percent) were diagnosed with Crohn’s disease; median time to Crohn’s disease was 19 (range, 1–41) months. Significant factors for postoperative Crohn’s disease after ileal pouch-anal anastomosis included family history of Crohn’s disease (hazard ratio, 8.4; 95 percent confidence interval, 2.96–24.1; P < 0.0001) and anti-Saccharomyces cerevisiae immunoglobulin-A seropositivity (hazard ratio, 3.14; 95 percent confidence interval, 1.1–9.81; P = 0.04). Crohn’s disease developed in only 8 of 198 patients (4 percent) without these predictors vs. 8 of 40 patients (20 percent) in those with at least one of these factors (P = 0.002). The cumulative risk of Crohn’s disease among patients with two risk factors (67 percent) was higher than in patients with either risk factor (18 percent) or neither risk factor (4 percent, P < 0.001). Conclusions Patients with ulcerative colitis and indeterminate colitis with a family history of Crohn’s disease or preoperative anti-Saccharomyces cerevisiae immunoglobulin-A seropositivity are more likely to be diagnosed with Crohn’s disease after ileal pouch-anal anastomosis. Poster presentation of distinction at Digestive Disease Week, Washington, D.C., May 19 to 24, 2007, and Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 7, 2007. Financial disclosures: Prometheus Laboratories Speakers’ Bureau (Eric A. Vasiliauskas, Konstantinos A. Papadakis, Marla Dubinsky, Andrew Ippoliti), shareholder (Carol Landers, Stephan R. Targan), and cofounder (Stephan R. Targan).     

Safety and morbidity after ultra-low coloanal anastomoses: J-pouch vs end-to-end reconstruction

Background and aims Anastomotic failure after ultra-low anterior rectum resection is the most important complication, and it is influenced by the type of reconstruction. The aim of this study was to compare retrospectively the straight coloanal anastomosis with the J-pouch reconstruction concerning the development of anastomotic leakage. Materials and methods Fifty-six of 381 consecutive patients underwent low anterior rectum resection with total mesorectal excision and ultra-low coloanal anastomosis at 3–4 cm from the anocutan line. A 5-cm J-pouch (side-to-end) was performed in 25, a straight coloanal anastomosis in 25, and a coloplasty in 6 patients, respectively. Results/findings No influence by age, body mass index, and operating time on anastomotic leakage rate was found. Leakage was found in eight patients with straight coloanal anastomosis, resulting in a leakage rate of 32% compared to one patient in the J-pouch group (P = 0.023). Interpretation/conclusion Patient’s safety is higher after J-pouch reconstruction because of the lower anastomotic failure rate, and functional results had been reported as similar after J-pouch reconstruction and straight coloanal anastomosis. Therefore, we clearly argue for a J-pouch reconstruction as the standard method after ultra-low coloanal anastomosis.     

Coloanal anastomosis: is a defunctioning stoma necessary?

The role of a temporary defunctioning stoma in patients undergoing coloanal anastomosis remains controversial. Previous experimental studies have shown that the defunctioned colon is more resistant to neoplasia. The aim of this study was to investigate whether a defunctioning stoma was able to decrease complication rates and, also, to evaluate whether it had any impact on recurrence and survival rates in patients who underwent coloanal anastomosis. The records of 173 patients, 54 with benign rectal disease and 119 patients with cancer, operated on between 1980 and 1996, were retrospectively reviewed. Eighty-nine patients had a defunctioning stoma, 34 in the benign rectal disease and 55 in the cancer group. Mean age was 57.2 years (range 17–88). There were 126 men and 47 women. Follow-up was 57.2 month (range 17–88). There were 126 men and 47 women. Follow-up was done by clinical examination, telephone or mailed questionnaire. Mean time of follow-up was 3.8 years (range 0–13 years). There was no operative mortality. Non-stoma patients tended to have more early complications (pelvic sepsis and obstruction) and more probability of having a permanent stoma than the stoma group, but no significant differences could be found between the two groups (P > 0.05). The probability of being free of stricture was greater in the non-stoma group (stoma 62.6%; non-stoma 78.5%; P < 0.05). Probability of disease-free survival, at 5 years, for rectal cancer patients, was 73.7% for the stoma group and 53.6% for non-stoma group (P = 0.02). After coloanal anastomosis, defunctioning stomas may decrease postoperative complications, increase the likelihood of anastomosis structure and allow a greater disease-free survival. Received: 29 December 1998 / Accepted: 15 April 1999     

Infliximab in Ulcerative Colitis is Associated with an Increased Risk of Postoperative Complications After Restorative Proctocolectomy

Purpose  Little data exist regarding infliximab use in surgical decision making and postoperative complications in ulcerative colitis. Our goals were to determine the rate of postoperative complications in infliximab-treated ulcerative colitis patients undergoing restorative proctocolectomy and to determine whether three-stage procedures are more often necessary. Methods  We studied a group of infliximab-treated patients and matched control subjects who underwent two-stage restorative proctocolectomy between 2000 and 2006. Postoperative complications were compared. In addition, the rate of three-stage procedures was compared between all infliximab- and noninfliximab-treated patients. Results  A total of 523 restorative proctocolectomies were performed. In the infliximab group, there were 46 two-stage and 39 three-stage procedures. Covariate-adjusted odds of early complication for the inflixmab group was 3.54 times that of controls (P = 0.004; 95 percent confidence interval (CI), 1.51–8.31). The odds of sepsis were 13.8 times greater (P = 0.011; 95 percent CI, 1.82–105) and the odds of late complication were 2.19 times greater (P = 0.08; 95 percent CI, 0.91–5.28) for infliximab. The odds of requirement for three-stage procedures was 2.07 times greater in the infliximab group (P = 0.011; 95 percent CI, 1.18–3.63). Conclusions  Infliximab increases the risk of postoperative complications after restorative proctocolectomy and has altered the surgical approach to ulcerative colitis. Potential benefits of infliximab should be balanced against these risks. Dr. Sandborn is a consultant (fees paid to Mayo Clinic) to Centocor, Abbott Laboratories, and UCB Pharma; research support for Centocor, Abbott Laboratories, and UCB Pharma. Dr. Pardi is a consultant to Abbott, Salix, Lonza, Elan, and Biobalance; research support for Salix, Proctor & Gamble, Astra Zeneca, Genzyme, Ocera, Optimer Pharmaceuticals, and Massachusetts Biologic Laboratories. Supported by the Edward and Josephine Story Cleveland Clinic Ileal Pouch Database Fund. Read at the meeting of The American Society Colon and Rectal Surgery, St. Louis, Missouri, June 2 to 7, 2007.     

Identification of Patients with High-Risk Stage II Colon Cancer for Adjuvant Therapy

Purpose Adjuvant therapy for Stage II colon cancer remains controversial but may be considered for patients with high-risk features. The purpose of this study was to assess the prognostic significance of commonly reported clinicopathologic features of Stage II colon cancer to identify high-risk patients. Methods We analyzed a prospectively maintained database of patients with colon cancer who underwent surgical treatment from 1990 to 2001 at a single specialty center. We identified 448 patients with Stage II colon cancer who had been treated by curative resection alone, without postoperative chemotherapy. Results With median follow-up of 53 months, 5-year disease-specific survival for this cohort was 91 percent. Univariate and multivariate analyses identified three independent features that significantly affected disease-specific survival: tumor Stage T4 (hazard ratio (HR), 2.7; 95 percent confidence interval (CI), 1.1–6.2; P = 0.02), preoperative carcinoembryonic antigen >5 ng/ml (HR, 2.1; 95 percent CI, 1.1–4.1; P = 0.02), and presence of lymphovascular or perineural invasion (HR, 2.1; 95 percent CI, 1–4.4; P = 0.04). Five-year disease-specific survival for patients without any of the above poor prognostic features was 95 percent; five-year disease-specific survival for patients with one of these poor prognostic features was 85 percent; and five-year disease-specific survival for patients with ≥2 poor prognostic features was 57 percent. Conclusions Patients with Stage II colon cancer generally have an excellent prognosis. However, the presence of multiple adverse prognostic factors identifies a high-risk subgroup. Use of commonly reported clinicopathologic features accurately stratifies Stage II colon cancer by disease-specific survival. Those identified as high-risk patients can be considered for adjuvant chemotherapy and/or enrollment in investigational trials. Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007. Reprints are not avaliable.     

A Diverting Stoma Is Not Necessary when Performing a Handsewn Coloanal Anastomosis for Lower Rectal Cancer

Purpose Although a temporary diverting stoma is a frequent surgical procedure for the protection of anastomosis in a sphincter-preserving operation for lower rectal cancer, its impact on anastomotic leakage is not conclusive. This study was designed to evaluate anastomotic complications after ultralow anterior resection and handsewn coloanal anastomosis without a diverting stoma for lower rectal cancer patients. Methods Between January 1995 and December 2005, 96 patients were treated by ultralow anterior resection and handsewn coloanal anastomosis for lower rectal cancer. Fifty-one patients received preoperative concurrent chemoradiation, whereas 45 had no preoperative treatment. No diverting stoma was created in any of these cases. The anastomotic complications were evaluated between the groups. Results Six of 96 patients (6.1 percent) developed anastomotic complications: three anastomotic stenoses, one partial anastomotic dehiscence, one retrorectal abscess, and one rectovaginal fistula. All of the complications occurred in the preoperative radiation group, whereas none from the nonradiation group had an anastomotic complication (P = 0.017). The patients with stenosis and partial dehiscence were managed conservatively. The patient with retrorectal abscess was treated with debridement, irrigation and drainage, and seton procedure with a transanal approach. The patient with rectovaginal fistula underwent a second coloanal anastomosis. Conclusions The anastomotic complication rate was low even without a diverting stoma. This study suggests that a diverting stoma is not necessary when performing a handsewn coloanal anastomosis for lower rectal cancer however, an effort should be made for healthy anastomotic healing in patients with rectal cancer who are preoperatively radiated. Presented at the Congress of the International Society of University Colon and Rectal Surgeons, Istanbul, Turkey, June 25 to 28, 2006. Reprints are not available.     

DNA Ploidy Status and Prognosis in Colorectal Cancer: A Meta-Analysis of Published Data

Purpose In colorectal cancer, the negative effect of aneuploidy has been a controversy for more than 20 years. Studies to determine a survival-deoxyribonucleic acid content relationship have conflicting results. A systematic literature search followed by a meta-analysis of published studies addressing prognostic effect of aneuploidy for patients who underwent surgical treatment of colon and rectal cancer was conducted. Methods The main outcome measure was the five-year overall mortality rate after surgical resection. For the selected studies, we estimated this outcome for three subsets of patients through separate meta-analyses: 1) for all patients with colorectal cancer; 2) only between patients with Stage II colon cancer; and 3) only for studies in which follow-up losses were declared. The presence of publication bias was assessed with a funnel plot for asymmetry. Results A total of 5,478 patients with colorectal cancer were represented in 32 studies (Group 1), we estimated a reduction in the five-year overall mortality from 43.2 percent for aneuploid tumors to 29.2 percent for diploid tumors (combined relative risk = 1.44; 95 percent confidence interval = 1.34–1.55; P < 0.001). In addition, 357 patients with Stage II colon cancer (Group 2) extracted from three studies had an absolute reduction of 14.3 percent in five-year overall mortality favoring diploid tumors (combined relative risk = 1.93; 95 percent confidence interval = 1.29–2.89; P = 0.001). Lastly, of 14 studies in which follow-up losses were declared (Group 3), 2,221 patients were represented and a 15.7 percent mortality reduction was measured favoring patients with diploid tumors (combined relative risk = 1.44; 95 percent confidence interval = 1.3–1.61; P < 0.001). Conclusions Patients who undergo an aneuploid colorectal cancer surgical resection have a higher risk of death after five years. This finding may ultimately impact survival of patients with node-negative colon cancer through adjuvant therapy. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 7, 2006.     

Assessment of the Risk Factors for Colonic Diverticular Hemorrhage

Purpose Colonic diverticulosis, although usually asymptomatic, sometimes causes diverticular hemorrhage. Studies about risk factors, other than nonsteroidal anti-inflammatory drugs, for colonic diverticular hemorrhage are limited. We conducted the present study to elucidate their significance as a risk factor. Methods Colonic diverticulosis was found in 1,753 patients and diverticular hemorrhage in 44 patients among 9,499 total colonoscopy examinees at the authors’ institutions between September 1995 and December 2005. After reviewing their clinical features, we chose two controls for each case with diverticular hemorrhage matched for age, gender, and the location of diverticulosis. We evaluated the effects of comorbidities (hypertension, hyperlipidemia, diabetes mellitus, cerebrovascular disease, ischemic heart disease), habits (alcohol, smoking), and medications, including nonsteroidal anti-inflammatory drugs, by using conditional logistic regression analysis. Results There were no significant differences between patients with diverticular hemorrhage and those with nonbleeding diverticulosis regarding age (67 ± 13 vs. 64 ± 11 years) or gender ratio (male/female ratio: 36/8 vs. 1,237/472). As for location, the proportion of bilateral diverticulosis was larger among patients with hemorrhage (43 vs. 22 percent). In the case-control study, nonsteroidal anti-inflammatory drugs (odds ratio, 15.6; 95 percent confidence interval, 1.1–214; P = 0.04), hypertension (odds ratio, 6.6; 95 percent confidence interval, 2.1–20.5; P = 0.0011), and aspirin and/or other anticoagulant (odds ratio, 3; 95 percent confidence interval, 1.04–8.6; P = 0.042) were shown to be significant risk factors by multivariate analysis. Conclusions Hypertension, nonsteroidal anti-inflammatory drugs, and anticoagulants, including aspirin, are independent risk factors for colonic diverticular hemorrhage. Presented at the meeting of the American Gastroenterological Association, Los Angeles, California, May 20 to 25, 2006. Reprints are not available.     

Risk Factors and Indications for Colectomy in Ulcerative Colitis Patients are Different According to Patient’s Clinical Background

Purpose Despite progress in medical treatment for ulcerative colitis, a considerable fraction of ulcerative colitis patients undergo colectomy. We analyzed the clinical variables of ulcerative colitis patients and determined the risk factors and indications for colectomy. Methods The clinical records of 981 consecutive Japanese patients with ulcerative colitis were reviewed both retrospectively and prospectively. Results Of 981 patients with ulcerative colitis, 85 patients underwent colectomy. Multivariate analysis indicated that male gender (risk ratio, 2.16; 95 percent confidence interval, 1.37–3.42), onset year during and after 2000 (risk ratio, 2.85; 95 percent confidence interval, 1.31–6.22), severe disease activity (risk ratio, 2; 95 percent confidence interval, 1.15–3.48), corticosteroid resistance (risk ratio, 7.05; 95 percent confidence interval, 4.29–11.59), and complications because of corticosteroid administration (risk ratio, 3.55; 95 percent confidence interval, 2.08–6.06) were significant risk factors for colectomy. In patients with disease duration of more than five years, only corticosteroid resistance and complications because of corticosteroid were significant risk factors for colectomy. When we stratified indications for colectomy for the 85 cases via patient disease duration, massive hemorrhage was a relatively frequent cause of colectomy in patients with a disease duration of less than five years (P = 0.091). On the other hand, colon dysplasia or cancer was a major cause for colectomy in patients with a disease duration of more than ten years (P = 0.0001). Conclusions In ulcerative colitis patients, the risk factors and indications for colectomy were different according to the patient's clinical background. Our findings may help to predict patients with ulcerative colitis who have a high risk for colectomy.     

Survival analysis of patients with dermatomyositis and polymyositis

To estimate the mortality rate and identify factors predicting survival in patients with polymyositis (PM) and dermatomyositis (DM). The medical records of 192 PM/DM patients who were treated at Chang Gung Memorial Hospital from 1999 through 2008 were retrospectively reviewed. The Taiwan National Death Registry (1999–2008) was used to obtain their survival status. Thirty-one (16.1%) of the 192 patients with PM/DM had an associated malignancy; 41 (21.4%) had interstitial lung disease (ILD). During the follow-up period, 55 (28.6%) patients died and the overall cumulative survival rate was 79.3% at 1 year, 75.7% at 2 years, 69.9% at 5 years, and 66.2% at 10 years. In univariate analysis, older age at PM/DM onset, anemia, thrombocytopenia, leukopenia, diabetes mellitus, ILD, cancer, and non-use of azathioprine were associated with higher mortality (p = 0.0172, 0.0484, <0.0001, 0.0008, 0.0001, 0.0036, 0.0010, and 0.0019, respectively). In multivariate Cox regression analysis, thrombocytopenia (hazard ratio [HR] 4.94, 95% confidence interval [CI] 2.60–9.37, p < 0.0001), diabetes mellitus (HR 2.57, 95% CI 1.38–4.80, p < 0.0001), cancer (HR 2.30, 95% CI 1.26–4.22, p = 0.0030), and ILD (HR 1.98, 95% CI 1.11–3.51, p = 0.0182) were positively associated with mortality. Use of azathioprine (HR 0.35, 95% CI 0.16–0.74, p = 0.0064) was negatively associated with mortality. This study confirmed the high mortality rate (28.6%) in PM/DM patients. Survival time was significantly reduced in patients with thrombocytopenia, diabetes mellitus, ILD, and cancer patients than in those without these conditions.     

The Comparison of the Risk Factors and Clinical Manifestations of Proximal and Distal Colorectal Cancer

Purpose Colorectal cancers in the proximal or distal site have distinct clinical characteristics. In this study, the authors compared the risk factors of proximal and distal colorectal cancer. Methods A 16-page questionnaire was administered to 529 patients with colorectal cancer before operation. Cancers were classified as proximal or distal relative to the splenic flexure. Of these 529 patients, 6 patients were excluded because of the presence of synchronous colorectal cancers. Data of the 523 patients were analyzed. Results Total numbers of proximal and distal cancers were 123 and 400. The proportion of patients with Type 2 diabetes was significantly higher for distal cancer (P = 0.034), whereas a greater proportion of patients with proximal cancer had a gallstone history (P = 0.005). Multivariate analysis revealed Type 2 diabetes to be a risk factor for distal colorectal cancer (P = 0.027) and cholelithiasis to be a risk factor for proximal cancer (P = 0.049). The odds ratio for distal colorectal cancer among males with Type 2 diabetes was 4.1 (95 percent confidence interval, 1.4–12.1). On the other hand, a gallstone history was more associated with proximal colon cancer, especially in females (odds ratio = 5.5; 95 percent confidence interval, 1.4–20.9). Conclusions A comparison of the risk factors of proximal and distal colorectal cancer showed that Type 2 diabetes is associated with distal colorectal cancer in males and that cholelithiasis is associated with proximal colon cancer in females. Poster presentation at the United European Gastroenterology Week (UEGW), Berlin, German, October 21 to 25, 2006.     

A systematic review of the function and complications of colonic pouches

Purpose This is a meta-analysis of randomized, controlled trials to compare the function and complications of a straight coloanal anastomosis to a colonic J-pouch after rectal excision at 1 year postoperatively. Materials and methods A search for articles from 1980 to 2005 was conducted on Medline, PubMed, and the Cochrane Controlled Trials Register using the keywords “colonic pouches, J-pouch, straight and coloanal anastomosis, rectal cancer, function and complications,” either singularly or in combination. Reference lists from short-listed articles were also manually searched for relevant articles, journals, and conference proceedings. Randomized controlled trials (RCTs) in English publications comparing colonic J-pouches to straight coloanal anastomosis were selected. Trials with similar patient characteristics, duration of follow-up, and outcome measures were pooled for analysis. Stool frequency and fecal continence at 1 year postoperatively were used as measures of functional outcome. Complication rates in terms of anastomotic leak and stricture formation were analysed. Results Ten RCTs with satisfactory methodology were identified. One trial reported the results at 2 years, while another reported results at 5 years only and were excluded from the meta-analysis, leaving only eight studies for further analysis. Overall, a colonic J-pouch appeared more favorable in terms of stool frequency (weighted mean difference of −1.21, 95% CI: −1.92 to −0.49) and continence (Odds ratio 0.23, 95% CI: 0.08–0.69), with a slightly lower risk of anastomotic dehiscence compared to a straight coloanal anastomosis (relative risk, RR 0.36; 95% CI: 0.12–1.08). Anastomotic stricture was reported in only two trials. They seemed more likely to occur after a pouch-anal anastomosis (RR 2.45, 95% CI: 0.79–7.57). However, the small numbers available for pooled analysis cannot allow these conclusions to be drawn with confidence. Conclusions A straight coloanal anastomosis resulted in poorer function due to loss of a rectal reservoir, while colonic J-pouches have improved frequency and continence up to a year. Although retrospective reports seem to favor the use of a pouch, there are limited longer term randomized trial data to suggest that the function and complications of a coloanal J-pouch is better than a straight coloanal anastomosis. Larger randomized studies are required to further verify the longer-term benefits of a coloanal pouch.     

Routine Mobilization of the Splenic Flexure is not Necessary During Anterior Resection for Rectal Cancer

Purpose Splenic flexure mobilization is widely considered to be an essential component of anterior resection for rectal cancer. It was our hypothesis that selective splenic flexure mobilization would reduce operative times without increasing morbidity or affecting cure. Methods A total of 100 consecutive patients with rectal cancer (mean 8 (range, 4–15) cm from anal verge) who underwent anterior resection for cure between 1996 and 2002 had splenic flexure mobilization only as required to achieve a tension-free anastomosis. Operative time, postoperative morbidity, pathologic findings, and recurrence rates were recorded. Results There were no clinicopathologic differences between those who had splenic flexure mobilization (n = 26) and those who did not (n = 74). Mean operative time in the splenic flexure mobilization group was longer, 167 (range, 130–200) minutes vs. 120 (range, 95–180) minutes in the nonmobilized group (P = 0.023). Mean length of specimen resected was longer in the splenic flexure mobilization group: 36 vs. 18 cm (P = 0.008). Anastomotic complications (4 percent), local recurrence (7 percent, median follow-up, 38 months), perioperative morbidity (32 percent) and mortality (2 percent), and survival did not differ between the two groups. Conclusions Routine splenic flexure mobilization is not required for safe anterior resection in patients with rectal cancer. Avoiding splenic flexure mobilization results in shorter operative times and does not increase postoperative morbidity, anastomotic leakage, or local recurrence. Presented at the Freyer Surgical Meeting, Galway, Ireland, September 2 to 3, 2005.     

Coloanal anastomosis for rectal cancer

PURPOSE: This study was designed to determine functional outcomes and rates of survival and recurrence of coloanal anastomosis in rectal cancer patients. METHODS: Between 1981 and 1991, 117 patients underwent coloanal anastomosis. Fifteen percent of the patients had a J-pouch; the rest had a straight coloanal anastomosis. Thirty-eight percent had no diverting stoma. Median distance of the tumor from the anal verge was 6.7 cm. RESULTS: Local recurrence rate was 7 percent. Five-year survival was fully 69 percent. Satisfactory fecal continence was achieved by 78 percent of patients; no J-pouch patient had frequent incontinence. Sixty-two percent of the patients had major (anastomotic leak = 18 percent) or minor complications; complications were not mitigated by a diverting stoma or worsened by adjuvant therapy. CONCLUSION: Although coloanal anastomosis is associated with a high chance of complications, the long-term outcome, in terms of disease-free survival and satisfactory function, is excellent.