Preoperative bowel preparation--is it useful?

Mechanical cleansing of the colon prior to elective colorectal surgery is a dogmatically established belief in surgery. Polyethylene glycol was extensively used in the 1980's and 1990's but has been largely replaced by other laxative solutions such as sodium phosphate which are better tolerated by the patient. Evidence-based data in the surgical literature question the dogma of routine mechanical bowel cleansing (8 randomized controlled studies and 4 meta-analyses). These data show with a good level of evidence that mechanical bowel preparation is unnecessary and perhaps harmful.     

Is synchronous bowel anastomosis safe?

In this study, we investigated the effects of synchronous anastomosis on intestinal healing in experimental colonic resection. Sprague-Dawley rats were randomized into 3 groups; control (group I), single anastomosis (group II) and synchronous (double) anastomosis (group III). Single and proximal anastomoses were located 3 cm distal to caecum, and distal anastomoses were done 3 cm distal to them. On the 7th postoperative day, bursting pressure, hydroxyproline level and histology of the anastomotic site were assessed. Bursting pressures and hydroxyproline levels indicated that impaired healing of proximal anastomoses in group III was evident. Proximal anastomoses in group III had the lowest hydroxyproline value and bursting pressure level. Significant fibrosis was observed in the histological examination of distal anastomoses in group III. Double colonic anastomoses is not as safe as single anastomoses and involves additional risk. The healing of proximal anastomosis is significantly altered after experimental synchronous resection.     

Short bowel syndrome and crohn’s disease

Patients with Crohn’s disease are at high risk for recurrent disease and often undergo multiple operations. Our aims were to evaluate surgical management and outcome of patients with Crohn’s disease who develop short bowel syndrome (SBS) and to identify factors leading to this complication. We reviewed the records of 170 adult patients with SBS evaluated over a 20-year period. Thirty (18%) had Crohn’s disease. SBS was defined as an intestinal remnant less than 180 cm with associated malabsorption. There were 20 women and 10 men ranging in age from 18 to 62 years. Eighteen (60%) presented initially with ileocolonic disease, seven (23%) with colonic disease, and five (17%) with small intestinal disease. The interval from initial diagnosis to development of SBS ranged from 2 to 32 years, with 21 patients (71%) having an interval greater than 15 years. The number of resections leading to SBS varied from 2 to 12 with 24 patients (80%) having four or fewer resections. Nineteen patients (63%) had an ostomy. Small intestinal remnant length was less than 60 cm in 10 patients, 60 to 120 cm in six patients, and greater than 120 cm in 14 patients. Only one patient underwent stricturoplasty before developing SBS. Five patients were initially diagnosed as having ulcerative colitis and underwent a pouch procedure, which was subsequently resected. Twenty patients (67%) required parenteral nutrition. Three patients have undergone reversed intestinal segment to slow intestinal transit. Two patients underwent intestinal transplantation. Two patients have died: one from parenteral nutrition-related liver failure and the other after intestinal transplantation. Crohn’s disease remains a common cause of SBS. Aggressive resectional therapy, surgical complications, and errors in initial diagnosis contribute to development of SBS in these patients. Selected patients are candidates for surgical therapy for SBS. Presented at the Forty-Fourth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Florida, May 17–22, 2003 (poster presentation).     

Does means of access affect the incidence of small bowel obstruction and ventral hernia after bowel resection? Laparoscopy versus laparotomy

BACKGROUND: Laparotomy for bowel resection is causally related to the development of small bowel obstruction (SBO) and ventral hernia, with incidences approaching 12% to 15% each. This report attempts to define the incidence of these access-related complications in a large group of patients undergoing laparoscopic-assisted bowel resection (LABR) and open bowel operation (OPEN). STUDY DESIGN: A retrospective cohort of 716 consecutive patients undergoing either LABR (n = 211) or OPEN (n = 505) procedures between January 1995 and July 2000 was identified and selected from a prospective registry. RESULTS: Index LABR (n = 211) and OPEN (n = 505) cases included segmental colectomy in 146 LABR and 408 OPEN patients; subtotal colectomy with or without stoma in 18 LABR and 6 OPEN patients; ileocolectomy in 37 LABR and 85 OPEN patients; and small bowel resection in 10 LABR and 6 OPEN patients. The mean followup periods in the LABR and OPEN groups were 2.71 years and 2.42 years, respectively.The incidence of wound hernia was significantly higher in OPEN cases (n = 65) compared with LABR (n = 5) (p < 0.05). The incidence of surgical repair of ventral hernia was also significantly higher in the OPEN group (28) compared with LABR (4) (p < 0.05). Postoperative SBO requiring hospitalization with conservative management occurred significantly less frequently in LABR patients (n = 4) compared with OPEN patients (n = 31) (p = 0.016). The need for surgical release of SBO was similar between the OPEN and LABR groups (n = 4 versus n = 11). The overall reoperation rate for these two complications was two times higher in the OPEN group than in the LABR group (7.7% versus 3.8%). CONCLUSIONS: The data demonstrate that laparoscopic access for bowel operation significantly reduces the incidence of ventral hernia and SBO rates compared with laparotomy. This reduces the need for readmission to the hospital and additional surgical procedures, providing a potential source of decreased morbidity. It should be considered as a means of cost savings associated with laparoscopic bowel operations.     

Can LigaSure seal and divide the small bowel?

BACKGROUND: The LigaSure system (Valleylab, Boulder, CO) seals vessels by reforming collagen and elastin in vessel walls. We studied the feasibility and effectiveness of LigaSure in dividing porcine small bowel. METHODS: Twelve porcine small bowel portions were randomized to division with either endoscopic linear stapler or LigaSure system and the burst pressure of the sealed ends were measured. RESULTS: Segments sealed with staples (6), LigaSure Atlas (Valleylab) (7), LigaSure Xtd (Valleylab) (4), and double-sealed with LigaSure Atlas (Valleylab) (4) were compared. Burst pressure for stapled segments was 131 (standard deviation [SD] 19) mm Hg; failure occurred in the bowel wall. Burst pressures for the 3 groups of Ligasure segments were 27 (SD 5), 20 (SD 6), and 11 (SD 13) mm Hg, respectively, with no statistically significant difference among them; failure occurred at the sealed end. Burst pressure for stapled segments was significantly higher than that of Ligasure segments (P < .001). CONCLUSION: LigaSure does not safely seal small bowel.     

Small bowel perforation: is urgent surgery necessary?

BACKGROUND: Controversies regarding how urgent bowel perforation should be diagnosed and treated exist in recent reports. The approach for early diagnosis is also debatable. The purposes of this study were to evaluate the relationship between treatment delay and outcome of small bowel perforation after blunt abdominal trauma and to determine the best assessment plan for the diagnosis of this injury. METHODS: One hundred eleven consecutive patients with small bowel perforations caused by blunt abdominal trauma were retrospectively reviewed. The patients were divided into four groups according to the time interval between injury and surgery. Hospital stay, time to resume oral intake, and mortality and morbidity rates were compared between groups. Physical signs, laboratory and computed tomographic findings, and the results of diagnostic peritoneal lavage were analyzed to find the most sensitive and specific test for early diagnosis of small bowel perforation. RESULTS: Delay in surgery for more than 24 hours did not significantly increase the mortality with modern method of treatment; however, complications increased dramatically. Hospital stay and time to resume oral intake increased significantly when surgery was delayed for more than 24 hours. Abdominal tenderness was a common finding, but it was not specific for bowel perforation. Only 40% of the computed tomographic scans were diagnostic for bowel perforations: 50% of them showed suggestive signs, and 10% were considered as negative. Persistence of abdominal signs indicated peritoneal lavage. By using cell count ratio in diagnostic peritoneal lavage and/or increased lavage amylase activity, presence of particulate matter and/or bacteria in the lavage fluid, all patients with intraperitoneal bowel perforation were diagnosed accurately before operation. CONCLUSION: Small bowel perforation has low mortality and complication rates if it is treated earlier than 24 hours after injury. The principle of "rushing to the operation suite" for a stable blunt abdominal trauma patients without detailed systemic examination is not justified. The priority of treatment for the small bowel perforation should be lower than the limb-threatening injuries. Diagnostic peritoneal lavage provides high sensitivity and specificity rates for the diagnosis of small bowel perforation if a specially designed positive criterion is applied.     

Blunt traumatic small bowel rupture: are children different?

BACKGROUND: In order to identify differences between children and adults with small bowel rupture (SBR) and to determine if a single diagnostic approach could be taught to paediatric and adult surgeons, a review of the experience at a children's and an adults' hospital was performed. METHODS: Using the hospital patient database 17 children were identified with SBR over a 13.6-year period, and clinical records were available for review for 14. Using a trauma registry 16 adults were identified with SBR over a 4.7-year period and clinical records were reviewed in all 16. RESULTS: The population incidence was 0.48/100000 per annum in children and 0.58/100000 per annum in adults. Motor vehicle crash was a less common mechanism of injury in children (35.7%) than in adults (75%). The time from injury to presentation (presentation interval) was significantly longer in children than in adults, even after excluding child abuse cases (median 2.9 h vs 65 min, respectively). The injury severity score was lower in children (median: 10) than in adults (median: 16.5). Peritoneal signs on follow-up examination were documented in 54.6% of children and in 90.9% of adults in whom follow-up examination was performed. Clinical findings on admission, findings on computed tomography, indications for operation and outcome were similar in children and adults. CONCLUSION: Children differed from adults in aetiology, longer presentation interval and fewer associated injuries. Similarities in diagnostic parameters suggest that a single diagnostic approach could be taught for children and adults provided that the limitations of physical examination in small children are recognized.     

Anastomotic insufficiency in small bowel surgery —incidence and treatment

Summary In the period 1977–1981 234 small bowel anastomoses were constructed in 143 patients. Eight anastomoses showed leakage (3.4%) and from nine anastomoses a fistula developed (3.8%): a total rate of disturbed healing of small bowel anastomoses (7.3%). In the presence of intra-abdominal infection this rate was 14.8%, in the absence of infection 0.8%. The results of treatment with oversewing and with resection and immediate anastomosis were disappointing. Better results were obtained by dismantling of the anastomosis, establishment of a split-enterostomy and reestablishment of continuity in a second stage. Mortality was 3/17 (18%). The literature is reviewed.

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Insuffizienz von Dünndarmanastomosen — Ineidenz und Therapie

Zusammenfassung In dem Zeitraum 1977–1981 wurden bei 143 Patienten 234 Dünndarmanastomosen angelegt. Acht Anastomosen zeigten eine Nahtleckage (3,4%), bei neun entwickelte sich eine Fistel (3,8%): die Gesamthäufigkeit von Wundheilungsstörungen bei Dünndarmanastomosen war 7,3%. Bei gleichzeitigem Vorliegen intraabdominaler Infektionen betrug die Häufigkeit 14,8%, ohne diese 0,8%. Die Resultate einer Therapie durch Übernähung oder Resektion mit sofort anschließender Reanastomosierung waren enttäuschend. Befriedigendere Ergebnisse wurden durch Aufheben der Anastomosen, Anlage einer split enterostomy unter Wiederherstellung der Kontinuität in einer zweiten Sitzung erzielt. Die Mortalität betrug 3/17 (18%). Ein Literaturüberblick wird gegeben.

     

Does octreotide impair anastomotic healing after small bowel resection?

Seventy two rats underwent small bowel resection followed by end-to-end anastomosis. The octreotide group consisted of 36 rats treated with octreotide (subcutaneously, 7 microg/kg/day, in two equal doses), and the control group consisted of 36 rats treated with the same volume saline. Twelve animals from each group were re-explored on the 4th, 8th and 15th postoperative day. Leakages, adhesions, obstructions were the clinical postoperative findings identified and recorded. Anastomotic bursting pressures were measured. Histochemical studies included haematoxylin-eosin and Van Gieson staining techniques and focused on the microscopic characterization of the healing process. Adhesions, leakages and obstructions were not different between octreotide and control groups. Anastomoses of the octreotide group had increased bursting pressures on the 8th and the 15th day (p < .05 , p < .05, respectively). Regarding the histogical results, on the 8th day the octreotide group compared to the control group, showed healing in more layers (p < .05), increased bright red collagen fibers and quantity of fibroblasts (p < .05), and on the 15th day, the octreotide group showed fewer gaps (p < .05), increased bright red collagen fibers and quantity of fibroblasts (p < .05). In this experimental model, it appeared that octreotide does not impair healing of small bowel anastomoses, but in contrast, there is some evidence that it enhances healing on the 8th and the 15th postoperative day.     

Long-term bowel disorders following radial cystectomy: an underestimated issue?

Purpose

Patients after radical cystectomy (RC) frequently complain about bowel disorders (BDs). Reports addressing related long-term complications are sparse. This cross-sectional study assessed changes in bowel habits (BH) after RC.

Methods

A total of 89 patients with a minimum follow-up ≥1 year after surgery were evaluated with a questionnaire. Patients with BD prior to surgery were excluded. Symptoms such as diarrhea, constipation, bloating/flatulence, incomplete defecation, uncontrolled stool loss, and impact on quality of life (QoL) were assessed.

Results

A total of 46.1 % of patients reported changes in BH; however, only 25.8 % reported experiencing related dissatisfaction. Primary causes of dissatisfaction were diarrhea and uncontrolled stool loss. The most common complaints were bloating/flatulence and the feeling of incomplete defecation, but these symptoms did not necessarily lead to dissatisfaction or impairment in quality of life. No difference was identified between an orthotopic neobladder and ileal conduit, and even patients without bowel surgery were affected. QoL, health status, and energy level were significantly decreased in unsatisfied patients.

Conclusions

About 25 % of patients complain about BDs after RC. More prospective studies assessing symptoms, comorbidities, and dietary habits are necessary to address this issue and to identify strategies for follow-up recommendations.

     

Acute endometrial bowel obstruction—A rare indication for colonic stenting

INTRODUCTIONPelvic endometriosis is an extremely rare cause of large bowel obstruction and the management can be challenging. Urgent surgery for acute colonic obstruction is known to carry high morbidity and mortality, and operation may be made more difficult in extensive pelvic endometriosis. Less invasive alternatives in the acute situation may need to be considered.PRESENTATION OF CASEPresented is the case of a 35-year-old lady with obstructive bowel symptoms caused by an endometriotic upper rectal stricture. She was initially treated using radiologically guided stent insertion, as an acute intervention, prior to an elective bowel resection and hysterectomy with bilateral salpingo-oophorectomy.DISCUSSIONColonic stenting is currently widely used in malignant obstruction. The use of self expanding metallic stents (SEMS) to treat benign conditions is controversial, however, due to associated long term complications. This case demonstrates that stenting can provide a bridge to major surgery in the rare event of acute endometriotic colonic obstruction. The initial acute treatment with stenting provides the advantage of time to involve the multi-disciplinary team, to medically optimise the patient and to better plan the definitive surgery.CONCLUSIONThe use of radiologically guided stents has a place in the treatment of benign recto-sigmoid obstruction due to endometriosis and therefore should be considered as a bridge to further surgical treatment.     

Small bowel intussusception: what is the role of laparoscopy?

Small bowel intussusception in adults is a rare surgical disease which almost always occurs as a complication of either benign or malignant lesion of the bowel that is working as a leading point. In adults, the surgical approach consists of the resection of the bowel involved to ensure the excision of the lesion below. The authors report a case of ileocecal intussusception occurred in a young woman, 35 years old, observed for abdominal pain and signs of small bowel occlusion. She underwent surgical resection of the ileocecal segment with laparoscopic approach. The authors discuss the feasibility of the laparoscopic approach in this rare surgical disease and its benefits in terms of patient's postoperative comfort and outcome.     

Laparoscopic surgery for inflammatory bowel disease: does weight matter?

Background  

Recent studies have shown improved outcomes after laparoscopic colorectal surgery compared with laparotomy for surgery for both benign and malignant colorectal diseases, including inflammatory bowel disease (IBD). This study was designed to evaluate the results of laparoscopic colorectal resections in normal weight patients compared with overweight and obese patients with IBD.     

What is the rate of small bowel obstruction after colectomy?

The rate of small bowel obstruction (SBO) after colectomy is unknown. Given the large number of colectomies performed in the United States, elucidating SBO rates, outcomes, and identifying predictors of readmission is important. Using the California Inpatient File, we identified all patients readmitted with a principle diagnosis of SBO at least once in the 3 years after colectomy (n = 4555). Patients admitted with a diagnosis of SBO in the 3 years before surgery were excluded. Overall, 10 per cent of patients were readmitted for SBO at least once after colectomy. Approximately 58 per cent were readmitted in the first year and 22 per cent of these patients required surgery. The most common operation performed was lysis of adhesions. Median length of stay was twice as long in the surgery group versus the no surgery group (12 vs 6 days). Overall mortality was higher in the nonsurgery group compared with the surgery group (33% vs 21%, P < 0.001) and highest in the elderly (44% vs 30%, P < 0.001). One in 10 patients without a history of SBO who undergoes a colectomy will be readmitted at least once in the subsequent 3 years for SBO, and there is a high mortality rate in this group, especially in the elderly.     

Small bowel obstruction: Is routine colonoscopy necessary after resolution?

Background: Small bowel obstruction is common in clinical practice and is most often due to adhesions. The aim of this study was to determine the significance of colon cancer presenting as a small bowel obstruction at a single institution and to find out whether routine colonoscopy was necessary in patients who had spontaneous resolution of their small bowel obstruction. Methods: A retrospective review of the medical records of patients presenting with small bowel obstruction from 1995 to 2000 at the Prince of Wales Hospital was performed. The clinical outcomes were obtained from the medical records and the clinical notes of each surgical consultant. Results: Over the study period, 251 patients presented with small bowel obstruction. The mean age at presentation was 63.8 years (range 21?95 years). A total of 149 patients (59.4%) were treated conservatively with an average hospital stay of 4.6 days (range 1?20 days). Another 100 patients (39.8%) were treated operatively with a mean time from presentation to operation of 2.2 days (range <24 h?14 days). The remaining two patients (0.8%) were managed palliatively because of known metastatic disease. At laparotomy, 13 patients (13%) had a colon cancer identified. A further three patients were identified to have a colon cancer on follow up colonoscopy. However, only one of the three patients had had a previous laparotomy, that is, only 0.7% (1/149) of patients with a spontaneously resolved small bowel obstruction (presumably secondary to adhesions) had actually had colon cancer. Conclusions: The overall incidence of small bowel obstruction secondary to colon cancer is significant at 6.4%. However, as the incidence of colon cancer in patients who had had a previous laparotomy and spontaneous resolution of their obstruction was very low at 0.7%, routine colonoscopy does not seem warranted.