INTRODUCTION:To analyze the short-term results of laparoscopic colorectal surgery (LCRS) in the Canary Islands.MATERIAL AND METHODS:A questionnaire was sent to hospitals performing laparoscopy and retrospective data on demographic, perioperative and pathological variables in 144 patients who underwent LCRS between May 1993 and May 2003 were obtained.RESULTS:Sixty-five men and 79 women underwent colon (n=126) and rectal (n=18) surgery in the last 16 months of the study period. The most frequently performed procedure was sigmoidectomy in 85 patients (59%). The most frequent diagnosis was colon adenocarcinoma in 73 patients (50%), followed by diverticular disease in 36 patients (25%). The mean values of the variables studied were: body mass index, 27.3 (range, 22-35); operating time, 175 min (range, 60-255); blood loss, 183.6 ml (range, 50-500). Peristalsis reinitiated at 45 h; oral diet was introduced at 67 h and the overall mean length of hospital stay was 7.8 days (range, 3-30). The length of hospital stay was significantly longer in patients with complications (14.5 vs 6.4; p <.01). There were 7 conversions (4.86%). There were no perioperative deaths. The overall morbidity rate was 28%. The most frequent early complication was surgical wound infection in 9 patients (6.2%). Anastomotic leak was detected in 5 patients (3.4%).CONCLUSIONS:LCRS has been shown to be a safe and effective technique that has recently increased in the centers surveyed. The factor with the greatest influence on length of hospital stay was the development of postoperative complications.

PURPOSE:This study was designed to evaluate possible social and geographic factors that could have an impact on quality of life in patients after abdominoperineal excision of the rectum. Although the number of patients with rectal cancer who need to be treated with abdominoperineal excision of the rectum and construction of permanent colostomy has greatly decreased in the past, there is still controversy about the influence on quality of life caused by this procedure.METHODS:In a prospective trial, patients operated on for low rectal cancer by abdominoperineal excision of the rectum were evaluated by a quality of life questionnaire, modified from The American Society of Colon and Rectal Surgeons questionnaire, to assess fecal incontinence. The results for the four domains of quality of life (lifestyle, coping behavior, embarrassment, depression), as well as for subjective general health, were evaluated with regard to age, gender, education, and geographic origin in univariate and multivariate analyses.RESULTS:Thirteen institutions in 11 countries included data from 257 patients. Although the analysis of general health did not reveal any significant differences, the analysis of the four quality of life domains showed the significant influence of geographic origin. The presence of a permanent colostomy showed a consistently negative impact on patients in southern Europe as well as for patients of Arabic (Islamic) origin. On the other hand, age, gender, and educational status did not reveal a statistically significant influence.CONCLUSIONS:This is the first study to show the influence of geographic origin on quality of life of patients with a permanent colostomy. Possible factors that may influence the outcome of patients after surgical treatment of rectal cancer, such as weather, religion, or culture, should be taken into account when quality of life evaluations are considered.

Conclusions LCRS has been shown to be a safe and effective technique that has recently increased in the centers surveyed. The factor with the greatest influence on length of hospital stay was the development of postoperative complications.

Los defectos funcionales de la musculatura esfinteriana del canal anal, sin defectos estructurales aparentes, conllevan en muchas ocasiones incontinencia en forma de urgencia e incluso incontinencia insensible. En consecuencia, los pacientes presentan déficit importantes en su calidad de vida. El presente estudio muestra los resultados obtenidos en 9 pacientes con incontinencia fecal que han recibido estimulación de las raíces sacras (ERS) de forma permanente. Se incluyó a pacientes con incontinencia de más de un episodio a la semana y esfínter anal externo normal por ecografía (intacto o reparado). En todos ellos, el tratamiento médico previo había fallado, así como la terapia de biofeedback. En una primera fase los pacientes recibieron estimulación percutánea. En caso de presentar una reducción mínima del 50% en los episodios de incontinencia, el paciente fue candidato a implante del electrodo definitivo, así como de un generador de impulsos que se colocó en el espacio subcutáneo y que mantuvo la estimulación de forma continua. El seguimiento se realizó al mes y a los 3, 6 y 12 meses. En él se incluyó un diario de incontinencia (21 días), una manometría anal y un estudio de la calidad de vida (CV) mediante cuestionarios (SF-36 y el de la American Society of Colorectal Surgeons [ASCRS]), realizados en cada seguimiento. Entre junio de 1999 y septiembre de 2002 se testó a 18 pacientes y se incluyó en el estudio a los nueve que fueron candidatos a implante definitivo, es decir, que completaron la terapia. Las pacientes (todas ellas mujeres) tenían una edad media de 53,1 años (rango, 37-65 años). El diario basal de incontinencia mostró en una media de 10,2 ± 6,2 episodios de incontinencia a la semana. Se evidenció una reducción de la incontinencia media del 81% a los 6 meses (p < 0,0001), y se mantuvo la mejoría al año de seguimiento. Asimismo, se observó una mejoría significativa en la CV de las pacientes. La ERS resulta una terapia eficaz para la reducción del número de episodios de incontinencia en las pacientes con incontinencia fecal funcional. La mejoría en la continencia tiene un efecto directamente relacionado con el incremento de calidad de vida de las pacientes. Functional defects of the sphincter musculature of the anal canal, without apparent structural defects, frequently produces urge incontinence and even incontinence due to loss of sensation. Consequently, quality of life may be significantly impaired. The aim of this study was to present the results obtained in nine patients with fecal incontinence who received definitive stimulator implants. Patients with more than one episode of incontinence per week and normal anal sphincter findings (intact or repaired) on ultrasonography were included. All patients were unresponsive to prior medical treatment and biofeedback therapy. In the first phase, the patients received percutaneous stimulation. If a minimum reduction of 50% in incontinence episodes was achieved, the patient was considered a candidate for implantation of a definitive electrode as well as an impulse generator placed in the subcutaneous space, maintaining continuous stimulation. Follow-up was performed at months 1, 3, 6 and 12 and included an incontinence diary (21 days), anal manometry and quality of life evaluation using two questionnaires (SF-36 and ASCRS), administered at each follow-up visit. From June 1999 to September 2002, 18 patients were evaluated, including nine patients who had completed therapy and were candidates for a definitive implant. All the patients were women with a mean age of 53.1 years (37-65). The baseline incontinence diary showed a mean of 10.2 ±6.2 incontinence episodes per week. A mean reduction in incontinence of 81% was observed at 6 months (p < 0.0001) and this improvement was maintained at 1 year of followup. In addition, the patients’ quality of life significantly improved. Sacral nerve stimulation is effective in reducing the number of incontinence episodes in patients with functional fecal incontinence. Improved continence is directly related to increased quality of life.

BACKGROUND:In patients with faecal incontinence in whom conservative treatment fails, options are limited for those with a functionally deficient but morphologically intact sphincter. We investigated the effect of sacral nerve stimulation on continence and quality of life.METHODS:In this multicentre prospective trial, 37 patients underwent a test stimulation period, followed by implantation of a neurostimulator for chronic stimulation in 34. Effect on continence was assessed by daily bowel-habit diaries over a 3-week period and on quality of life by the disease-specific American Society of Colon and Rectal Surgeons (ASCRS) questionnaire and the standard short form health survey questionnaire (SF-36). Every patient served as his or her own control.FINDINGS:Frequency of incontinent episodes per week fell (mean 16.4 vs 3.1 and 2.0 at 12 and 24 months; p<0.0001) for both urge and passive incontinence during median follow-up of 23.9 months. Mean number of days per week with incontinent episodes also declined (4.5 vs 1.4 and 1.2 at 12 and 24 months, p<0.0001), as did staining (5.6 vs 2.4 at 12 months; p<0.0001) and pad use (5.9 vs 3.7 at 12 months; p<0.0001). Ability to postpone defecation was enhanced (at 12 months, p<0.0001), and ability to completely empty the bowel was slightly raised during follow-up (at 12 months, p=0.4122). Quality of life improved in all four ASCRS scales (p<0.0001) and in seven of eight SF-36 scales, though only social functioning was significantly improved (p=0.0002).INTERPRETATION:Sacral nerve stimulation greatly improves continence and quality of life in selected patients with morphologically intact or repaired sphincter complex offering a treatment for patients in whom treatment options are limited.

Valorar la seguridad, la efectividad y la tolerancia del fosfato sódico (NaP) y el polietilenglicol (PEG) en la preparación para la cirugía colorrectal. Cincuenta pacientes fueron prospectivamente aleatorizados, ingiriendo 90 ml de NaP o 4 l de PEG el día anterior a la cirugía. La seguridad del preparado se valoró con un análisis previo y tras la administración. En un detallado cuestionario los pacientes valoraron la facilidad de cumplimiento, la cantidad de fármaco ingerida, las molestias asociadas y el sabor; si habían recibido un preparado previo, valoraron la dificultad en completar la pauta, el grado de malestar y el sabor. La eficacia fue valorada por el cirujano abriendo la pieza quirúrgica. El estudio estadístico se realizó mediante la prueba de la U de Mann Whitney y el test de Shapiro-Wilk. Se apreció una mayor facilidad de cumplimiento en el grupo NaP con una significación estadística de p = 0,0001. El grado de cumplimiento de la preparación fue mayor en el grupo NaP (97,20 ± 10,6) respecto al PEG (90,21 ±16,4) (p = 0,034). No hubo diferencias en el grado de malestar ni en las molestias asociadas al preparado evacuante (p = 0,45). De los pacientes que habían recibido preparación para colonoscopia, los del grupo NaP tuvieron una menor dificultad en completar el tratamiento y en el grado de malestar (p < 0,001). No hubo diferencias en el sabor del producto (p = 0,4) ni en el grado de limpieza conseguido. El grupo NaP presentó un incremento en los valores de fósforo previo (3,4 ± 0,7) respecto a la determinación posterior a la ingesta de evacuante (4,2 ± 0,9) y un descenso en los valores de calcio tras la ingesta de NaP (9,4 ± 0,4 frente a 8,9 ± 0,2), ambos con significación estadística (p = 0,01 y p = 0,02, respectivamente), sin repercusión clínica. Se observó un descenso en los valores de potasio en ambos grupos (NaP, 4,3 ± 0,4; PEG, 3,8 ± 0,4), con significación estadística (p = 0,01), aunque sin repercusión clínica. En ningún caso se describieron reacciones adversas. Ambas soluciones son efectivas y seguras. La solución de NaP tiene una facilidad, un grado de cumplimiento y un grado de aceptación mayores que el PEG. Se ha observado una hiperfosfatemia e hipocalcemia estadísticamente significativa en el grupo NaP sin repercusiones clínicas. To assess the safety, efficacy and tolerability of sodium phosphate (NaP) and polyethylene glycol (PEG) in the preparation for colorectal surgery. 50 patients were prospectively randomized taking 90 ml of NaP or 4 liters of PEG the day before surgery. The safety of the solution was assessed with a previous and posterior blood analysis. In a questioner the patient evaluated the easiness of compliance, the amount of drug taken, the discomfort associated and taste. Patients who had previously talen a cleansing treatment assessed the difficulty to complete the regimen, the degree of discomfort and the taste. Cleansing efficacy was assessed by a surgeon opening the surgical piece. The statistical analysis was performed using the Mann-Whitney’s test and the Shapiro-Wilk test. An easier compliance was seen in the NaP group with a statistically significant difference p = 0.0001. Compliance with the preparation was higher in the NaP group (97.20 ± 10.6) than the PEG group (90.21 ± 16.4; p = 0.034). No differences were seen in the discomfort associated with the preparation (p = 0.45). The NaP group of patients who had previously received preparation for colonoscopy had less difficulty to complete the cleansing treatment and less discomfort (p < 0.001). There were no differences in taste (p = 0.4) nor in the degree of cleansing achieve. In the NaP group a statistically significant increase was seen (p = 0.01) from previous phosphorus levels (3.4 ± 0.7) in the measurement made after receiving the solution (4.2 ± 0.9) and also a significant decrease was seen in calcium levels (9.4 ± 0.4 vs 8.9 ± 0.2; p = 0.02). There was no clinical significance. In both groups a reduction in potassium levels was observed (NaP, 4.3 ± 0.4; PEG, 3.8 ± 0.4; p = 0.01) but not clinically significant. No adverse reactions were reported. Both solutions are effective and safe. The NaP solution is easier to administrate, has a better patient compliance, and is better accepted by the patient than the PEG. A statistically significant hyperphosphatemia and hypocalcemia were found in the NaP group. But casused no clinical signs.

OBJECTIVE:To assess the efficacy of transposition of gracilis muscle in the treatment of chronic recurrent fistulas and unhealed perineal wounds after proctectomy in patients with Crohn's disease.DESIGN:Retrospective study.SETTING:Academic clinic, United States.SUBJECTS:7 patients with Crohn's disease: 3 had unhealed perineal wounds and persistent sinuses; 2 had had several attempts to repair rectovaginal fistulas; 1 had a rectourethral fistula; and 1 a pouch vaginal fistula.INTERVENTION:Transposition of the gracilis muscle.MAIN OUTCOME MEASURE:Healing.RESULTS:Mean follow up was 18 months (range 3-30). All patients operated on for unhealed perineal wounds had healed completely within 3-6 months. The patients with a rectovaginal fistula and a rectourethral fistula had both healed by 1 month postoperatively. Two fistulas recurred, and the small pouch-vaginal fistula remained but was asymptomatic.CONCLUSIONS:Transposition of the gracilis is a viable option for the treatment of persistent sinus and unhealed perineal wound after proctectomy for Crohn's disease. It could also be an option before proctectomy for patients with other types of Crohn's-related or complicated fistulas for whom other treatments have failed. A larger series will be required before a definite conclusion can be drawn.

PURPOSE: The stimulated gracilis neosphincter is accepted as a viable option in select patients with fecal incontinence. The aim of this study was to review the initial problems and complications. METHODS: A prospective analysis of all patients who underwent this procedure was undertaken. Stage I consisted of the distal vascular delay of the muscle and creation of a temporary stoma. Stage II was the transposition of the muscle and implantation of the stimulator and electrodes. Low frequency electrical stimulation was applied to the muscle for 12 weeks, after which Stage III (stoma closure) was undertaken. RESULTS: From March 1993 to December 1995, 17 patients (9 females and 8 males) with a mean age of 42.2 (range, 19-72) years underwent the procedure. One patient died from pancreatitis and another from small-bowel adenocarcinoma, three and six months after the procedure, respectively. Two patients (one with Crohn's disease) required permanent stomas. One additional patient required a permanent stoma because of lead fibrosis. Other complications noted during ascent of the learning curve included seroma of the thigh incision, excoriation of the skin above the stimulator, fecal impaction, anal fissure, parastomal hernia, rotation of the stimulator, premature battery discharge, fracture of the lead, perineal skin irritation, perineal sepsis, rupture of the tendon, tendon erosion, muscle fatigue during programming sessions, and electrode displacement-from the nerve or fibrosis around the nerve. However, ultimately after rectification of these problems, 13 of the 15 eligible patients had stoma reversal. Manometric results showed an average basal pressure of 43 mmHg and an average maximum squeeze pressure that increased from 36 mmHg before surgery to 145 mmHg by stimulation (P < 0.01). Based on objective functional questionnaires, 9 of 15 (60 percent) evaluable patients reported improvement in continence, social interactions, and quality of life. Three of these nine patients require daily use of enemas. CONCLUSION: Although the stimulated gracilis operation is a feasible procedure for selected patients with severe incontinence, the learning curve is steep. Although the ultimate outcome in a selected group of patients can be very gratifying, major technical modifications are required before use beyond a research protocol setting. Furthermore, patients must have the psychological strength, emotional commitment, and financial resources that may be necessary for multiple revisional surgeries or ultimate device failure.