Surgery

Surgical strategies to reduce recurrence in Crohn's disease Charlotte Austin, Randolph M Steinhagen World Journal of Colorectal Surgery 2019 8(1):1-3 Almost from the time of initial description of Crohn's disease 85 years ago, it has been known that surgical resection is not curative. The disease invariably recurs. Over this period of time, numerous strategies have been proposed in an attempt to reduce the recurrence rate, or delay the development of recurrent disease. The purpose of this review is to examine a number of strategies and to evaluate their effectiveness. It also aims to look at what might lie ahead in the future. This review consists of an English language literature search to identify previous studies that have proposed various surgical strategies to reduce the recurrence rate following surgery for Crohn's disease. A number of surgical strategies have been proposed including widening the resection margins, changing the type of anastomosis, use of laparoscopy, and most recently, resecting wide mesenteric margins. To date, none of these strategies has proven to be effective in reducing recurrence rates. Although a surgical strategy to reduce recurrence in Crohn's disease has not been identified, there are currently investigators looking at other possibilities that may be shown to be effective in the future.

Evaluating the efficacy of biofeedback for chronic constipation using the constipation severity instrument and constipation-related quality of life measure Yuan-Tzu Lan, Lillian G Jahan, Madhulika G Varma World Journal of Colorectal Surgery 2019 8(1):4-9 Background: Many studies have described using biofeedback to treat chronic constipation, but few reports have addressed its impact on quality of life (QOL). Objective: The aim was to evaluate the effect of biofeedback with a validated Constipation Severity Instrument (CSI) and Constipation-Related QOL (CRQOL) measure. Design: Prospectively collected data with retrospective analysis. Setting: Tertiary care academic center. Patients and Methods: Patients referred to the Center for Pelvic Physiology with chronic constipation and objective signs of pelvic floor dyssynergia, who received a complete course of biofeedback therapy and returned all of their questionnaires, were enrolled in the study. Questionnaires were given upon initial evaluation, immediately after the complete course of biofeedback, and 6 months later. Main Outcome Measures: Improvement of dyssynergia symptom and QOL by CSI and CRQOL. Sample Size: A total of 25 patients (20 females and 5 males) were included. Results: Overall, 75% of patients reported satisfactory symptom and QOL improvement. CSI total scores decreased after treatment (35.0 vs. 31.0, P = 0.06) and at 6-month follow-up (35.0 vs. 30.0, P = 0.05). Only the obstructive defecation (OD) subscale of CSI improved significantly after treatment (median 21.0 vs. 16.5, P < 0.01) and sustained to 6 months after therapy (median 21.0 vs. 18.5, P = 0.03). Statistically significant improvement was seen in the distress subscale of the CRQOL immediately after biofeedback (24.0 vs. 18.0, P = 0.02). Conclusions: This study demonstrated that the active effects of biofeedback in constipated patients were specific to OD symptoms and the distress subscale for QOL. CSI and CRQOL are both useful tools to evaluate the specific response of constipated patients after biofeedback therapy. Limitations: The study limitation was the small sample size due to difficulty in obtaining complete information in the enrolled patients.

Outcomes in cecal volvulus: Does age affect outcomes in patients who undergo surgery? Ashley M Tameron, Amy E Murphy, Lala R Hussain, David Lee, Hamza Guend World Journal of Colorectal Surgery 2019 8(1):10-13 Background: Colonic volvulus is a rare cause of bowel obstruction with an incidence of 2%–10%. Cecal volvulus accounts for 10%–40% of cases, with a mean age of 53 years. There is a paucity of literature reporting how older patients with cecal volvulus fair relative to their younger counterparts. Objective: The goal of our study is to evaluate the outcomes after surgical resection in patients ≥50 years old with cecal volvulus. Design: The design of the study was to collect the National Surgical Quality Improvement Program (NSQIP) data and analyze primary outcomes. Settings: These data were collected from NSQIP database focusing on patients with cecal volvulus. Materials and Methods: We utilized the NSQIP database. We identified volvulus by ICD-9 code 560.2. We selected patients with cecal volvulus who underwent surgical resection by specifying the CPT codes for open and laparoscopic right hemicolectomy. Main Outcome Measures: The primary outcomes were mortality and major and minor postoperative complications. Student's t-test was used to compare continuous variables. Chi-square and Fisher's exact tests were used to compare categorical variables. Sample Size: Analyzing the NSQIP database from 2010 to 2015, 1220 patients were identified. Results: 21.8% of patients were <50 years old and 78.2% were ≥50 years old. Patients aged ≥50 years had higher rates of comorbid conditions. There was no significant difference in mortality between the two groups or major and minor complications. Patients aged ≥50 years had a longer length of total hospital stay, i.e., days from operation to discharge. Conclusion: Cecal volvulus is an uncommon reason for bowel obstruction with unclear outcomes in elderly patients in the literature. Our study demonstrates no differences in outcomes after surgical intervention for cecal volvulus. Limitations: Limitations of this study include large database collection and selection bias. As we specifically included right hemicolectomy, this excludes patients who underwent nonresection intervention.

Right versus left Colon cancer: Is there a difference in outcomes? Aris Plastiras, Evangelia Iosif, Georgia Georgiou, Amyn Haji, Asif Haq, Savvas Papagrigoriadis, Joseph W Nunoo-Mensah World Journal of Colorectal Surgery 2019 8(1):14-21 Background: Colorectal cancer is a major healthcare problem due to its high prevalence and mortality rates. Objective: The objective of the study is to delineate the relationship between the location of the colon cancer and the outcomes. Design: This is a retrospective, single-center study including patients diagnosed with right and left colon cancer from January 2010 to December 2015. Setting: Patients with no rectal or synchronous metastatic disease were included in the study. Diagnosis was confirmed following a computed tomography and colonoscopy. Patients and Methods: Four hundred and seventy-five patients with colon cancer were included; 226 right-sided tumors (RCC) and 249 with left-sided colon cancer (LCC) underwent surgery. Main Outcome Measures: We compared right- and left-sided tumors in terms of epidemiological, histological, clinical, and perioperative characteristics, and we also attempted to determine whether there is a difference in the overall and per stage survival. Sample Size: Four hundred and seventy-five patients with colon cancer. Results: Patients with colon cancer were analyzed, 226 (47.5%) with RCC and 249 (52.4%) with LCC underwent surgery. Patients with RCC were more likely to be women, older, and with more comorbidities. Furthermore, RCC were more likely to be poorly differentiated (29.65%, P < 0.001) and more locally advanced at the time of diagnosis (P < 0.001). Controlling the differentiation for each stage, there was no statistical significant difference between left and right survival and recurrence (P > 0.05). When stratified according to tumor stage, Stage II LCC had better overall survival (odds ratio [OR], 1.694, 95% confidence interval [CI], 1.015, 2.827) and Stage III LCC had a better overall survival (OR, 1.403, 95% CI, 1.007, 2.143), disease-free survival (OR, 1.293, 95% CI, 1.011, 1.714), and less cancer-related deaths (OR, 0.282, 95% CI, 0.080, 1.000). Conclusions: Comparing similar stages, patients with LCC appear to have better oncological outcomes irrespective of tumor differentiation. Limitations: Single-center, retrospective study without excluding patients with hereditary cancers. Oncological biomarkers were not available in all patients, and further analysis was not performed.

The hanging pouch Daniel J Wong, Michael Q Tran, Vitaliy Y Poylin World Journal of Colorectal Surgery 2019 8(1):22-23 Ileoanal pouch reconstruction can be complicated intraoperatively by the inability for the pouch to reach the anus in a tension-free manner. Here, a case is presented where standard “mesentery lengthening” procedures did not allow the pouch to reach the anus and thus the pouch was left hanging in situ resulting in pouch lengthening over several months and a successful anastomosis at a later date.

Leiomyoma of the sigmoid mesocolon associated to hemorrhagic infarct and high count of mast cells Carlo Lozano-Burgos, Claudio Etcheverry-Pizarro, Wilfredo Alejandro González-Arriagada, Paola Ochova-Gallardo World Journal of Colorectal Surgery 2019 8(1):24-26 Leiomyoma is a soft-tissue benign tumor and its occurrence in the mesocolon is extremely rare. We present a particular case of a leiomyoma of the sigmoid mesocolon of a 58-year-old man, associated to a hemorrhagic infarction treated surgically and without recurrences after 1 year of follow-up. The macroscopic, histopathologic, and immunohistochemical features are presented and discussed. The high mast cell count associated with a low rate of cell proliferation is a sign of the benign biological behavior in this entity and may be helpful hallmarks for the differential diagnosis with other gastroenterological neoplasia.

Rare complication of a common disease: Coccygeal osteomyelitis following Pilonidal sinus Mugdha Kowli, Pranav Mandovra, Gautam Zaveri, Roy Patankar World Journal of Colorectal Surgery 2019 8(1):27-29 Pilonidal sinuses commonly arise in the sacrococcygeal region. The common complications are local cellulitis, abscess formation which is related to the infectious process, and recurrence after surgery. They rarely evolve with osteomyelitis, meningitis, or malignant transformation. Coccygeal osteomyelitis as a direct complication of sacrococcygeal pilonidal sinus disease (PSD) is extremely rare with limited data. We report a case of complicated sacrococcygeal PSD with coccygeal osteomyelitis. It was managed with: wide local excision of the pilonidal sinus, coccygectomy, perineal musculature reconstruction, and defect closure by Limberg rhomboid flap.

Right hemicolectomy in a patient with heterotaxy syndrome Maxime Dewulf, Roel Beckers, Pieter Pletinckx World Journal of Colorectal Surgery 2019 8(1):30-33 In this communication, we present a first description of right hemicolectomy in a patient with heterotaxy syndrome (HS). A 78-year-old male was admitted to the outpatient clinic with complaints of dysphagia. Diagnostic workup revealed the presence of an esophageal web. On subsequent colonoscopy, a tumoral lesion was found in the ascending colon. Computed tomography scan illustrated abdominal situs ambiguous with right-sided polysplenia, right-sided stomach, and intestinal nonrotation. Furthermore, a preduodenal portal vein, azygos continuation of the inferior vena cava, and hemiazygos continuation of the left renal vein were observed. After careful assessment of the anatomy, a right hemicolectomy with radical lymphadenectomy was performed. HS consists of a rare and complex situs anomaly, with an abnormal arrangement of the thoracic and/or abdominal organs along the left–right axis. To our knowledge, right hemicolectomy has not been described in patients with HS.