This study relates our experience with local surgical management of perianal Crohn's disease.Of 1,735 patients with Crohn's disease seen between 1980 and 1990, records of 66 patients (3.8 percent) with symptomatic perianal Crohn's disease treated by local operations were retrospectively reviewed to study outcome of local surgical intervention.All patients had intestinal disease that was limited to the colon in 32 patients (48 percent), ileocolonic region in 22 patients (33 percent), and ileum in 12 patients (18 percent). Types of perianal disease encountered included perianal suppuration (57), anal fistula (47), anal fissure (21), anal stenosis (5), gluteal abscess (3), scrotal abscess (2), and anovaginal fistula (2). A total of 321 episodes of anal complications necessitated 256 local surgical interventions. Local anorectal operations performed included simple incision and drainage of abscess (57), fistulotomy (35), incision and drainage of complex anorectal abscesses and fistulas and insertion of seton (24), internal sphincterotomy (6), fissurectomy (1), and anal dilation (3). Of 24 patients with horseshoe abscesses and fistulas managed with insertion of a seton and 35 patients who underwent fistulotomy as a primary procedure or in conjunction with drainage of an abscess, none experienced fecal incontinence as a direct result of the operation. Thirteen patients required proctectomy to control perianal disease, and a similar number underwent total proctocolectomy for extensive intestinal disease. Forty patients (61 percent) continue to retain a functional anus.Patients with symptomatic low anal fistula involving minimum sphincter musculature can be treated safely with fistulotomy. In treatment of patients with horseshoe abscesses and high fistulas, aggressive local surgical intervention using a seton permits preservation of the sphincter and good postoperative function.

Obstetric trauma and excessive defecatory straining with perineal descent may lead to pudendal neuropathy with bilateral increase in pudendal nerve terminal motor latencies (PNTML). We have frequently observed unilateral prolongation of PNTML. Diagnostic and therapeutic implications of unilateral pudendal neuropathy are discussed.Records of 174 patients referred to pelvic floor laboratory for anorectal manometry and PNTML testing were reviewed. Computerized and manometry was performed using dynamic pressure analysis, and PNTML was determined using a pudendal (St. Mark's) electrode.No response was elicited from pudendal nerves to electric stimulation from both sides in 14 patients (8 percent) and from one side in 24 patients (13.8 percent). Bilateral PNTML determination was possible in only 136 patients (78 percent), of whom 83 patients (61 percent) had no evidence of neuropathy, revealing normal PNTML on both sides. Of 53 patients (39 percent) with delayed conduction in pudendal nerves, in 15 patients (28 percent), PNTML was abnormally prolonged on both sides, with an abnormal mean value for PNTML. In the remaining 38 patients (72 percent), PNTML was abnormal on one side; in 27 patients with an abnormal mean PNTML and in 11 patients with a normal mean PNTML.A significant number of patients with pelvic floor disorders have only unilateral pudendal neuropathy. Patients with unilaterally prolonged PNTML should be considered to have pudendal neuropathy, despite normal value for mean PNTML. This fact may be relevant in planning surgical treatment and in predicting prognosis of patients with sphincter injuries.

BACKGROUND: Recent pressures to decrease the cost of medical care have mandated preoperative outpatient bowel preparation (OBP) for elective colorectal surgery without any data documenting equivalent quality of care. This study examined the safety and efficacy of OBP compared with inpatient bowel preparation (IBP). METHODS: Records of all patients who underwent OBP for elective colorectal resection since the inception of the OBP program from July 1993 to June 1994 were compared with records of all patients who received IBP for elective procedures from January to June 1993. RESULTS: The two groups, 90 patients who underwent OBP and 98 patient who had IBP, were well matched for age, sex, diagnosis, and operations performed. The OBP group had a shorter length of hospital stay (median, 7vs.9 days;P< 0.0001; chi-squared analysis), whereas the complication rate was similar (19 percent in the OBP groupvs.18 percent in the IBP group), including infectious complications (10 percent in the OBP groupvs.7 percent in the IBP group). Although operating time was similar (mean, 199vs.213 minutes) and estimated blood loss (mean, 528vs.536 ml), the OBP group had significantly higher perioperative fluid requirements: intraoperative fluids (median, 4300vs.3700 ml;P< 0.05; Student'st-test), intraoperative colloid administration (48vs.29 percent;P< 0.0002; chi-squared), 24-hour postoperative fluids (3224vs.2700 ml;P< 0.0001; Student'st-test), and postoperative fluid challenges (50vs.20 percent;P<0.0001; chi-squared analysis). CONCLUSION: Outpatient bowel preparation for elective colorectal surgery is safe and effective. It offers shorter hospital stay, and, therefore, potentially reduces medical care cost. Patients with multiple medical problems may not tolerate extensive fluid shifts; therefore, other preoperative arrangements, such as inpatient or outpatient intravenous fluid therapy, need to be considered to minimize complications that may outweigh potential cost savings.

PURPOSE: Our purpose was to study the effect of unilateral pudendal neuropathy on the results of anal sphincter repair. METHOD: Fifteen female patients who underwent external sphincter repair for fecal incontinence were studied. In all instances, incontinence was the result of obstetric delivery injury. Anal manometry and neurophysiologic investigations to document sphincter defects and pudendal neuropathy were performed in all patients. Sphincter repair was performed using an overlapping suture technique. RESULTS: All patients had anterior sphincter defects. Seven patients (47 percent) had pudendal neuropathy: six (85 percent) had unilateral neuropathy, and one (15 percent) had bilateral neuropathy. Six patients (40 percent) had excellent results: three (20 percent) had good results; four (27 percent) were improved; two (13 percent) experienced no improvement after sphincter repair. All patients with excellent results had normal pudendal nerve terminal motor latency on both sides. Of the three patients with good results, on patient had unilateral pudendal neuropathy. The patients in the remaining two groups (improved and failed) had unilateral (six patients) or bilateral (one patient) pudendal neuropathy. CONCLUSION: We conclude that both pudendal nerves must be intact to achieve normal continence after sphincter repair. Patients with unilateral pudendal neuropathy are more likely to have poor than to have good postoperative function.

European Journal of Gastroenterology & Hepatology: February 1996 - Volume 8 - Issue 2 - p 189

Log in or Register Subscribe to journalSubscribe Get new issue alertsGet alerts Enter your Email address: Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent. For more information, please refer to our Privacy Policy. Subscribe to eTOC Secondary Logo Journal Logo All Articles Images Videos Podcasts Blogs Advanced Search Toggle navigation Subscribe Register Login Articles & Issues Current IssuePrevious Issues Published Ahead-of-Print Collections Anorectal DiseaseBenign Colorectal DiseaseClassic ArticlesClinical Practice GuidelinesColorectal Anal/NeoplasiaCurrent Status ReviewsDidactic Video CollectionEditorialsEndoscopyInflammatory Bowel DiseaseLegislative Updates and Healthcare EconomicsNew TechnologyPelvic FloorOutcomesReflectionsResident's Corner and Expert CommentarySocioeconomicTechnical NotesVideo Tips for Submitting ContentVideo VignetteViewpointView All Journal ClubVideos 2017 Best Videos of the ASCRS Annual Meeting2018 Best Videos of the ASCRS Annual Meeting2019 Best Videos of the ASCRS Annual Meeting2020 COVID (No Video)2021 Best Videos of the ASCRS Annual Meeting2022 Best Videos of the ASCRS Annual MeetingAll Videos Authors & Reviewers How to Submit a Manuscript投稿注意事项Language Editing Services投稿規定How to become a ReviewerAccountability in Peer ReviewResources for Authors and Reviewers Journal Info About the JournalAbout the SocietyHistoryAwardsEditorial BoardAdvertising InformationSubscription ServicesReprintsRights and PermissionsOpen Access Site Map All Articles Images Videos Podcasts Blogs Advanced Search

We reviewed the treatment outcome in 40 patients undergoing full-thickness local excision (seven patients) or electrocoagulation (33 patients) for adenocarcinoma of the rectum. Patients were followed up for a minimum of 5 years or until death (mean follow-up, 7.6 years). Twenty-two patients (55%) survived 5 years free of disease or were free of disease at the time of death due to other causes following local treatment. Eight (62%) of 13 patients with persistent or locally recurrent disease were successfully treated with additional local therapy, rectal resection, or combined radiation therapy and chemotherapy. Overall, 30 (75%) of 40 patients embarking on a program of local treatment for carcinoma of the rectum survived 5 years free of disease or were free of disease at the time of death due to other causes.

Many surgeons consider the ileoanal pouch procedure to be the procedure of choice for patients who require surgery for ulcerative colitis and familial adenomatous polyposis. To determine long-term results, 460 patients (mean +/- SD age, 31 +/- 9 years) who underwent the ileoanal pouch procedure from 1980 through 1991 were prospectively observed by computerized registry. The leading indication for operation was ulcerative colitis (n = 382; 83%). A J-shaped reservoir was created in 434 patients (94%). More than 5 years after ileostomy closure, the mean number of bowel movements was 5.8 +/- 2.2, and 13% of patients had leakage. Most patients (94%) were satisfied with their results. Sixteen patients (3.5%) required recreation of a permanent stoma for pouch failure. Complications (major and minor) occurred in 266 patients (58%) and included obstruction (n = 94; 20%), pouch fistula (n = 26; 6%), anastomotic stricture (n = 40; 9%), anastomosis separation (n = 14; 3%), and pouchitis (n = 83; 18%). Modifications in technique and increased operative experience have significantly decreased the incidence of obstruction (P = .05) and pouch-related complications (P = .004). Despite complications, long-term results are acceptable, and patient satisfaction remains high.

Mitra, A.; Walker, S. A.; Bayer, I.; Pickovsky, B.; Cohen, S. M.; Schmitt, S. L.; Lucas, F. L.; Wexner, S. D.; Szilagy, E. J.; Ryan, J. B.; Williams, J. G.; Deen, K. I.; Grant, E.; Kumar, D.; Wiltz, O. H.; Garcia, J. E.; Feliciano, R.; Martino, J.; Solomon, M.; McLeod, R. S.; O'Connor, B.; Steinhart, H.; Greenberg, G.; Cohen, Z.; Meagher, A. P.; Adams, W. J.; Lubowski, D. Z.; Ellis, C. N.; Boggs, H. W.; Coyle, D. J.; Blakemore, W. S.; Nahas, S. C.; Ibrahim, R. El; Pinotti, H. W.; Palakanis, K.; DeNobile, J.; Sweeney, B.; Blankenship, C.; Sun, J. H.; Stiegmann, G. V.; Kim, J. G.; Pearlman, N. W.; Landes, R. V.; Hankin, R. C.; Barkel, D. C.; Beauregard, W. L.; Poulik, M. D.; Chen, J. C.; Dmuchowski, C.; Cho, E.; Lee, P. Y.; Fletcher, W. S.; Sullivan, E. S.; Vetto, J. T.; Hull, T. L.; Lavery, I. C.; Saxton, J. P.; McCue, J.; Sheffield, J.; Phillips, R.; DiPierro, J.; Milsom, J. W.; Fazio, V. W.; Strong, S. A.; Vernava, A. M. III; Longo, W. E.; Wade, T. P.; Virgo, K. S.; Coplin, M. A.; Johnson, F. E.; Cavina, E.; Menconi, C.; Ghiselli, G.; Seccia, M.; Tjandra, J. J.; Lowndes, R.; McKirdy, H.; Schroeder, T.; Hughes, L. E.; Sentovich, S. M.; Rivela, L. J.; Thorson, A. G.; Blatchford, G. J.; Christensen, M. A.; Jensen, L. L.; Lowry, A. C.; Miller, R.; Mills, A.; Durdey, P.; Hock-Saive, D.; Lombard, R.; Jehaes, C.; Markiewicz, S.; Penders, L.; Fontaine, F.; Cusumano, P.; Nelissen, G.; MacDonald, A.; Baxter, J. N.; Bessent, R. G.; Gray, H. W.; Finlay, I. G.; Duthie, G. S.; Farouk, R.; Bartolo, D. C. C.; Ramanujam, P. S.; Venkatesh, K. S.; Oliver, G. C.; Vachon, D.; Eisenstat, T. E.; Rubin, R. J.; Salvati, E. P.; Dorsey-Tyler, K. R.; Harmon, G.; Medwell, S. J.; Binderow, S. R.; Noguerás, J. J.; Jagelman, D. G.; Decanini, C.; Bohm, B.; Stolfi, V. W.; Cataldo, P. A.; Hadick, C.; Resnikov, P.; Mellinger, J. D.; Cunningham, B.; Vayer, A. J. Jr.; Larach, S. W.; Williamson, P. R.; Ferrara, A.; Salomon, M.; Nogueras, J. J.; Sullivan, J.; Staniunas, R. J.; Keck, J. O.; Counihan, T.; Marcello, P.; Barrett, R. C.; Oster, M.; Roberts, P. L.; Schoetz, D. J.; Murray, J. J.; Veidenheimer, M. C.; Coller, J. A.; Sagar, P. M.; Lewis, W.; Williamson, M.; Holdsworth, P. J.; Johnston, D.; Jorge, J. M. N.; Morgado, P. J. Jr.; James, K.; Morgado, P. Jr.; Penna, C.; Kartheuser, A.; Tiret, E.; Parc, R.; McIntyre, P. B.; Pemberton, J. H.; Wolff, B. G.; Dozois, R. R.; Beart, R. W.; Kelley, K. A.; Harrison, J. B.; Hockenberry, S. E.; Williamson, M. E. R.; Lewis, W. G.; Sagar, P.; Armstrong, D. N.; Collopy, B. C.; Ryan, P. J.; Fink, R.; Mackay, J. R.; Woods, R. J.; Nazarian, H. K.; Kong, L. B.; Fleshner, P. R.; Keighley, M. R. B.; Farmakis, N.; Tudor, R.; Wiltz, O.; Wong, W. D.; Goldberg, S. M.; Rothenberger, D. A.; Arnold, M. W.; Schneebaum, S.; Martin, E. W. Jr.; Young, D. C.; Schechter, S.; Snyder, M. L.; Orkin, B. A.; Smith, L. E.; Dean, P. A.; Ramsey, P. S.; Nelson, H.; Barker, G.; Neoptolomos, J. P.; Patel, R. T.; Pall, A.; Adu, D. Author Information

American Society of Colon and Rectal Surgeons 91st Annual Convention Podium and Poster abstracts: PDF Only

Compared with the prolonged cumulative hospitalization and morbidity that accompany staged resection for the treatment of obstructing or inflammatory disorders of the left colon, our results confirm that resection with intraoperative lavage and primary anastomosis is a safe alternative. In the absence of intraoperative lavage, all patients in our series would have required a multistage procedure. Intraoperative lavage with primary anastomosis does not challenge the accepted criteria for safe bowel anastomosis. Rather, it offers another means for meeting those criteria. This alternative should be considered in the management of any patient whose primary indication for colostomy is the lack of adequate mechanical preparation of the colon. Although our experience indicates that intraoperative lavage and primary anastomosis can be employed safely in the treatment of inflammatory disorders of the colon, it is not recommended in the presence of fecal peritonitis, a large contiguous pelvic abscess, or systemic sepsis. In these individuals, the additional operating time required for intraoperative lavage and the potential consequences of anastomotic dehiscence pose too great a risk.

Fibrotic strictures of the small bowel are known to cause chronic bowel obstruction in patients with Crohn's disease. Strictureplasty without resection permits relief of bowel obstruction and preservation of bowel length. The records of 13 patients who underwent 52 strictureplasties for Crohn's disease at the Lahey Clinic Medical Center, Burlington, Mass, from 1982 through 1989 were reviewed to determine the results of this surgical intervention. Nine patients were treated with strictureplasty only, while the remaining 4 patients underwent concomitant small-bowel resection for stenosed areas not amendable to strictureplasty. One early complication occurred in a patient in whom a pelvic abscess developed. In a median follow-up period of 2 years (range, 0.5 to 7 years), 9 patients were rehospitalized because of obstruction from Crohn's enteritis. Four patients required further surgery, 3 patients underwent strictureplasty at a newly stenosed area of small bowel, and 1 patient required resection of the initial strictureplasty. Strictureplasty is an effective surgical option for patients with Crohn's disease who have symptomatic small-bowel strictures.