Need For Proctectomy Research Articles

Transanal Minimally Invasive Surgery.

Transanal endoscopic surgery (TES) techniques encompass a variety of approaches, including transanal endoscopic microsurgery and transanal minimally invasive surgery. These allow a surgeon to perform local excision of rectal lesions with minimal morbidity and the potential to spare the need for proctectomy. As understanding of the long-term outcomes from these procedures has evolved, so have the indications for TES. In this study, we review the development of TES, its early results, and the evolution of new surgical techniques. In addition, we evaluate the most recent research on indications and outcomes in rectal cancer.

A new instrumental platform for Trans-Anal Submucosal Endoscopic Resection (TASER)

### Message Existing trans-anal approaches for complete excision of large and complex rectal polyps (CRPs) remain suboptimal due to technical complexity and inflexibility leading to the risk of inadequate excision...

Is haemorrhoidectomy in inflammatory bowel disease harmful? An old dogma re‐examined

Haemorrhoidectomy and removal of anal skin tags in inflammatory bowel disease (IBD) have been considered to be potentially harmful, but the evidence for this is poor. A review of the literature was undertaken to determine the complications rate after haemorrhoidectomy in patients with IBD. A Medline, PubMed and Cochrane Library search was performed to retrieve studies reporting the surgical treatment of haemorrhoids in patients with IBD. All studies that investigated the complications of haemorrhoidectomy and skin tag removal in patients with IBD were included. Complications included local sepsis, fissure, ulcer, stenosis, faecal incontinence and the direct need for proctectomy or a stoma. Eleven retrospective studies including 135 patients were identified. Most series were small and lacked information on the interval between surgery and the onset of complications. The range of complications ranged from 0% to 100%. Taking the studies together, complications occurred more frequently in Crohn's disease (CD) (17.1%) than in ulcerative colitis (UC) (5.5%). The risk of complication was much higher in patients with unknown than in those with known diagnosis of IBD (50% vs 9.8% in CD; 9.1% vs 4% in UC). There is great variation in the incidence of complications reported after haemorrhoidectomy or removal of skin tags in patients with IBD and it is not possible to draw a firm conclusion. Nevertheless the incidence of complications is high in patients with CD.

Risk and Location of Cancer in Patients With Preoperative Colitis-Associated Dysplasia Undergoing Proctocolectomy

To evaluate the influence of preoperative dysplasia grade, appearance, and site on risk and location of cancer in patients with colitis. The ability to predict the presence and location of cancer in colitis patients with dysplasia is essential to facilitate recommendations regarding the necessity and type of surgery. Ulcerative and indeterminate colitis patients who underwent proctocolectomy for dysplasia were retrospectively selected. Patient characteristics and findings at colonoscopic surveillance were associated with findings on the surgical specimen by regression analysis. From 1984 to 2007, 348 proctocolectomy specimens with preoperative dysplasia showed cancer in 51 (15%) and dysplasia in 172 (49%) cases. Patients with preoperative high-grade dysplasia (HGD) had cancer in 29% compared with 3% in low-grade dysplasia (LGD) (P < 0.001). Patients with preoperative dysplasia-associated lesion/mass (DALM) had cancer in 25% compared with 8% in flat dysplasia (P < 0.001). In LGD with DALM, the risk of cancer was not significantly higher than in flat LGD (7% vs 2%, P = 0.3), but risk of cancer or HGD was higher with a threefold increase (29% vs 9%, P = 0.015). On multivariate analysis, HGD, DALM, and disease duration were independent risk factors for postoperative cancer. In patients with isolated colonic dysplasia above the sigmoid level, postoperative rectal involvement was limited. Risk of cancer for patients with HGD or DALM is substantial. Despite low risk of cancer in patients with flat LGD, threshold for surgery should be low given the high prevalence of postoperative pathologic findings. Only in selected cases, colonoscopic surveillance after discussion of associated risks may be acceptable, provided high patient compliance can be assured. Surgery should be considered in all other cases, because it is the only modality that can eliminate the risk of cancer. The location of preoperative dysplasia may allow for the clarification of the need for proctectomy especially in the poor risk surgical patient.

Surgical treatment of perianal fistulizing Crohn's disease: from lay-open to cell-based therapy--an overview.

Background. Perianal Crohn's disease (CD) can be challenging. Despite the high incidence of fistulizing CD, literature lacks clear guidelines. Several medical, surgical, and combined treatment modalities have been proposed, but evidences are scarce. Methods. We searched the literature to assess the facets of perianal CD, with particular focus on complex fistulae. Disease epidemiology, classification, diagnosis, activity scoring systems, and medical-surgical treatments were assessed. Results. Perianal fistulizing CD is common, frequently associated with upper gastrointestinal and colorectal CD. Complex fistulas often require repeated treatments. Continence is a major concern when dealing with repeated procedures. A prudent pathway is to resolve active sepsis and to limit damages, delaying a definitive treatment to the time when acute phase has been controlled. The improved diagnostic techniques allow better preoperative planning and are useful in monitoring the response to treatment. Besides newer devices, cell-based treatments are promising tools which have recently enriched the treatment portfolio. However, the need for proctectomy is still disturbingly high in CD patients with complex perianal fistulae. Conclusions. Perianal CD can impair quality of life and lead to need for proctectomy. A staged approach is reasonable. Treatment success can be improved by multimodal treatment and collaborative management by experienced gastroenterologists and surgeons.

Colonic Surgery in Patients With Juvenile Polyposis Syndrome: A Case Series

Juvenile polyposis syndrome is characterized by multiple hamartomatous polyps in the large intestine. When indicated, the surgical choices in symptomatic juvenile polyposis syndrome patients are colectomy with ileorectal anastomosis or proctocolectomy with pouch. The aim of this study was to evaluate the long-term outcomes of the surgical options in juvenile polyposis syndrome patients who present with symptomatic colonic polyps. The charts of all juvenile polyposis syndrome patients who had had at least one colonic operation since 1953 in our institution were reviewed. The following data were abstracted: demographics, the number and site of the polyps, symptoms, the intervals and types of the colonic operation, follow-up, and the patients' current status. There were 13 patients (6 males) with a median age of 10 years (range, 1-50 years) at the time of diagnosis. Patients had colonic (n = 13), rectal (n = 12), and gastric (n = 6) polyps. Rectal bleeding (n = 11) was the most common presenting symptom. Three patients underwent proctectomy as the initial operation. Although a rectum-preserving operation was initially performed in ten patients, a subsequent proctectomy was required in five of them within a median of 9 years (range, 6-34 years). Therefore, eight patients had their rectum removed during the study period; five had an ileal pouch-anal anastomosis, one had a Koch pouch as a restorative surgery, and two had an end ileostomy. No relation was observed between the number of colonic and rectal polyps and the type of surgery or the need for proctectomy. Patients were followed up a median of 3 years (range, 2-24 years) after their ultimate operations. During this period, one patient (20 percent) who underwent restorative proctectomy and 4 patients (80 percent) whose rectums were preserved required multiple endoscopic polypectomies for recurrent polyps in the pouch (first patient) or their rectums (the other four patients). The patient who underwent the Koch procedure required surgery for recurrent polyps in her pouch. One-half of the patients who initially underwent rectal preservation required subsequent proctectomy. The number of colonic or rectal polyps does not influence the choice of the surgical procedure. Both restorative proctocolectomy and subtotal colectomy with ileorectal anastomosis need endoscopic follow-up because of the high recurrence rates of juvenile polyps in the remnant rectum or pouch.

Success and failure after repair of rectovaginal fistula in Crohn's disease: analysis of prognostic factors.

To compare the healing rate after several types of surgical repair of rectovaginal fistula (RVF) in Crohn's disease, and to identify factors predicting a successful outcome. A Medline review of the literature since 1980 and analysis of our results in 32 consecutive patients was done. All types of repair (rectal, vaginal, anocutaneous advancement flap, or perineoproctotomy with fistula closure) seem to be equally effective. Healing after a first repair is observed in 58 (46-71)%. Healing can still be obtained at subsequent attempts in 62 (40-71)% of the patients. The reported overall healing rate is 75 (56-93)%. The need for proctectomy after an attempt to repair was 6 (0-27)% in these series. Using a tailored surgical approach, we observed primary healing in 57%, healing after one or more supplementary procedures in 71%, for a total 'definitive' closure rate of 75%. Anal continence was never compromised and all temporary stomas (12 patients) could be closed. Univariate analysis identified number of Crohn's sites, presence of extra-intestinal disease and previous Crohn's proctitis to be related with problematic healing after a surgical repair. A positive relation was found between extra-intestinal disease and the number of repairs needed to ultimately obtain healing, whereas the relation with previous right hemicolectomy was negative. Multivariate analysis revealed the number of Crohn's sites as the only factor predicting problematic healing. A defunctioning stoma was not related to the healing rate and had its intrinsic morbidity with supplementary hospitalization (9.6 days). After a median follow-up of 40.4 (range 8-87) months, we observed 4 late recurrences in 25 patients with healed RVF (16%). Closure of a RVF in Crohn's disease should not be considered an easy undertaking, especially in patients with several Crohn's sites. In this very heterogeneous group of patients the technique is adapted to the nature and the extent of accompanying anorectal disease. Construction of a temporary stoma is not mandatory and can be limited to complex cases. Healing can be obtained in 75% of all patients, although a late recurrence might occur.

Surgical treatment of anorectal complications in Crohn's disease

Background. The purpose of our study was to elucidate features, surgical procedures, and long-term results in patients with anorectal complications of Crohn's disease. Methods. Physical findings, surgical treatment, and long-term outcome were recorded prospectively for 224 patients who had anorectal complications of Crohn's disease between October 1984 and May 1999. Results. Presenting complications included abscess (n = 36), fistula-in-ano (n = 51), rectovaginal fistula (n = 20), anal stenosis (n = 40), anal incontinence (n = 11), or a combination of features (n = 66). Twenty-four patients did not undergo surgical treatment; the remaining 200 patients underwent 284 procedures. Ultimately, 139 patients (62%) retained anorectal function; reasons for proctectomy in the remaining 85 patients included disease (n = 66), extensive fistular disease (n = 15), fecal incontinence (n = 2), and tight anal stenosis (n = 1). Patients with rectal disease had a significantly higher rate of proctectomy than patients with rectal sparing (77.6% vs 13.6%, respectively, P <.0001). In the absence of rectal involvement, patients with multiple complications had a significantly higher rate of proctectomy than patients with single complications (23% vs 10%, P <.05). Conclusions. A wide spectrum of surgical techniques is required for the management of the diverse anorectal complications of Crohn's disease. Complete healing and control of sepsis can be achieved in the majority of patients. Active rectal disease and multiple complications significantly increase the need for proctectomy. (Surgery 2000;128:597-603.)

Rectovaginal fistulae in Crohn’s disease: a management paradox

Much has been written about the management of rectovaginal fistulae in Crohn's disease (CD), but there remains little or no consensus on the optimal therapeutic approach. This retrospective case review examined treatment and clinical outcome of women presenting with rectovaginal fistula between 1985 and 1995 in an attempt to clarify treatment guidelines. A total of 48 case notes was reviewed. Significant symptoms and signs were noted at presentation in 73% and 65% of women, respectively, and fistula classification revealed; three (6%) superficial, 36 (76%) transphincteric, six (12%) suprasphincteric and three (6%) unclassified. Fifteen patients were initially treated conservatively, of whom 73% were eventually rendered asymptomatic and none required proctectomy. Of the remaining 33 fistulae, 12 were treated by laying open or seton insertion, 13 by local repair using transperineal proctotomy or advancement flaps, two by defunctioning alone, and six by proctectomy. Eighty-three percent of patients undergoing laying open or seton insertion, 77% following local repair and 50% following stoma were eventually rendered asymptomatic. The proctectomy rates were 42%, 15%, and 50% in these three groups, respectively. The results of this study suggest that in the absence of significant symptoms, conservative management provides a good chance of fistula healing without need for proctectomy. However, if symptoms dictate the need for intervention, local repair provides a similar chance of success with a lower ultimate need for proctectomy than laying open or seton. Despite these broad generalities, this study highlights the difficulties we have in advising patients with proctovaginal fistulae in CD.

Management of anal fistulas in Crohn's disease: A surgical perspective

: Anal conditions caused by gastrointestinal Crohn's disease may be difficult management problems. Recent application of more aggressive surgical treatment of fistulas has challenged the traditional surgical dictum of avoiding anal surgery in patients with underlying Crohn's disease. Judicious patient selection combined with conservative and creative operative techniques may be expected to result in healing in the majority of patients, preventing the need for proctectomy while preserving satisfactory sphincter function.