Do I need a colonoscopy?

 
Yes
 
No
   
 
 
  Family/personal history of colorectal cancer
 
 
  Family/personal history of colorectal polyps
 
 
  Age 50 or older without symptoms
 
 
  Rectal bleeding (bleeding is never "normal")
 
 
  Abdominal pain

Contact Us

General Information

Call us:  317.841.8090 or 800.872.5123 in Indiana

Our Hours:  Monday - Friday: 8:30am - 4:30pm

We know that with less cutting comes a higher quality of life, reduction of patient costs, and a quicker return to full activity. We wrote the book on minimally invasive colon surgical techniques and our center is Indiana's champion of laparoscopic colon cancer treatment. We offer cutting edge scarless surgeries (single incision laparoscopic surgery or SILS), and robotic surgery (Da Vinci) with the benefit of 3D imaging technologies and greater preservation of sexual function which can be damaged in conventional pelvic procedures.

We embrace new surgical techniques that are proven to result in higher quality of life and less postoperative discomfort. Some exciting up and coming techniques we offer in anorectal surgery include:

artificial sphincter implantation

  • an alternative to colostomy for some patients
  • success rate 70-85%
  • first performed in Indiana by our surgeons

procedure for prolapse and hemorrhoids (PPH)

  • less pain
  • less blood loss
  • less time loss from work

stapled transanal rectal resection (STARR)

  • relieves constipation
  • improves rectal emptying
  • satisfaction rate of 85%
  • first performed in Indiana by our surgeons

transanal endoscopic microsurgery procedure (TEM)

  • avoids need for colostomy
  • shorter recovery time
  • shorter hospitalizations

In colonoscopy, experience makes results and our center has over 50,000 complication-free colonoscopies since 1979. During video inspection of the colon our surgeons can sweep the bowel of polyps (polypectomy), spray vital dyes to reveal cancers (chromoendoscopy), bolster intestinal walls against swelling, constrictions, and blockage (stent placement), clot bleeding vessels, mark tumors for removal and remove contained cancer.

Noninvasive in-house tests and treatments often won't take longer than a lunch break. A patient with hemorrhoids and 20 minutes can shrink their hemorrhoids with the simple application of a band (band ligation) or treatment with a laser (infrared photocoagulation). A 10 minute Botox injection to relax the sphincter stimulates healing of anal fissures. And diagnostic exams can measure anal sensation and muscle pressure (manometry) and image the rectal muscles to pinpoint rectal masses or fistulas (endoanal ultrasound) within half an hour.

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Physician Newsletter

Colon and Rectal Watch; Vol. 12, Issue 1; March 2014

Colorectal Cancer Screening

Colorectal Cancer Screening

Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the second leading cause of cancer deaths in the U.S. The 5-year survival for early stage cancers is 90%, while only 10% of patients with advanced cancers survive 5 years. As most cancers arise in polyps, and it takes an average of 10 years for a small polyp to progress to a cancer, screening should lead to a decrease in CRC related deaths.

Screening Patients at Average Risk:

Screening for patients at average risk for CRC should begin at age 50. The simplest option is fecal occult blood testing (FOBT). Patients should collect three separate stool samples at home on a yearly basis. Since samples from digital rectal exam have a high false positive rate, they should not be used. All positive tests mandate total colonoscopy (TC). FOBT testing should occur on a yearly basis in conjunction with other screening tests. In prospective randomized trials, this approach has decreased CRC mortality by 15-33%.

Another option, flexible sigmoidoscopy, should be performed every 5 years. Sigmoidoscopy is most effective when combined with yearly FOBT and with intermittent barium enemas to evaluate the right colon. As with FOBT, all positive tests mandate TC. Double contrast barium enema (DCBE) every 5-10 years is another option. DCBE does offer evaluation of the entire colon, but has only 83% sensitivity. Furthermore, no studies demonstrate that DCBE lowers CRC related mortality.

TC every 10 years may be the best method for CRC screening. TC offers the advantages of complete colonic visualization with therapeutic potential. Although no direct studies evaluate whether screening TC reduced CRC related mortality, the National Polyp Study estimated that 76-90% of colon cancers could be prevented through routine colonoscopic screening.

Furthermore, TC is an improvement upon sigmoidoscopy, and there is direct evidence thatsigmoidoscopy reduces CRC mortality. TC has a sensitivity of 93% for detecting CRC.

Several reports have generated interest in CT colography (virtual colonoscopy) as a non-invasive method to evaluate the colon. At this time there is no solid evidence demonstrating equivalent effectiveness at finding early cancers compared with currently recommended screening tests. More studies are needed before recommending it as a screening test for the general public. At this time, CT colonoscopy represents a promising, but experimental, approach.

Screening High Risk Patients:

Individuals with a family history of CRC or adenomas in first-degree relatives should undergo TC every 3-5 years beginning at an age 10 years younger than the youngest effected relative. Hereditary non-polyposis colorectal cancers should be suspected in any patient with several relatives with CRC, especially if any of the relatives was diagnosed before age 50. Colonoscopic evaluations should be performed in these patients every 2 years starting at age 25, or 5 years younger than the earliest diagnosis of CRC, whichever is younger. After age 40, TC should be done annually.

Personal history of CRC requires TC before surgery or within 12 months of resection. If negative, subsequent procedures can be deferred for 3 years. Frequency of endoscopy in patients with a personal history of adenomatous polyps depends on the number and type of polyps initially treated. Although therapy for these patients should be individualized, TC is the preferred method of follow-up.

We believe colonoscopic screening most effectively reduces mortality from colon cancer; it is the most sensitive test and allows concurrent therapy. Unfortunately, only 1/3 of patients actually undergo adequate screening. In order to improve this community’s screening rate, we have a program in place to allow easy, prompt scheduling of this vital exam.(Gastrointest Endosc. 2000 Jun;51(6):777-82. Other sources available on request) Summarized by Arun Gowdamarajan, MD.

Option for Fecal Incontinence has Excellent Success Rate

Fecal incontinence is defined as the involuntary loss of rectal contents with an inability to delay evacuation until it is socially convenient. It is a very common problem. Estimates of incidence range between 2-18% of the population, but its taboo nature makes accurate assessment difficult.

Consequences of fecal incontinence are significant in many ways. Patients can develop co-morbid conditions (skin breakdown, decubitus ulcers, urinary tract infections), direct and indirect financial costs, and impact on the quality of life (shame, social isolation).

After a thorough workup including colonoscopy and anorectal physiology testing, the patient is usually started on a conservative treatment plan. Surgical intervention is typically explored in patients with significant symptoms refractory to conservative measures.

If an anatomic defect is present, initial surgical treatment centered around restoration/repair of the sphincter complex is initiated. While short-term results of this approach were good, the long-term function tended to deteriorate over time.

Another option was sphincter replacement with an artificial sphincter. While associated with excellent results, there are multiple situations where the device is contraindicated, and it has limitations based on infection and erosion into the sphincter.

If other therapies have failed, or co-morbidities preclude a more aggressive approach, creation of a colostomy remains an option. While this does not restore continence, it does allow the patient to regain control of waste management and resumption of a more normal life style.

Recently, the sacral nerve stimulator has gained FDA approval for the management of fecal incontinence. The mechanism of action regarding nerve stimulation is uncertain. However, over 70% of patients markedly improve their continence with this therapeutic modality. Patients who demonstrate initial improvement maintain their results. In 10 year follow up, 92% of these patients continued to have markedly improved continence after implantation of the sacral nerve stimulator.

At Colon & Rectal Care, Inc., we are extremely excited about this option for fecal incontinence. We underwent the necessary training to bring this exciting technique to our patients. We have performed many successful procedures that have lead to a dramatic increase in quality of life for these patients.(Wexner S. Ann of Surg. 2010 Mar, 251(3); 441-9. Lim. Dis Colon Rectum. 2011 Aug; 54(8)869-74.) Summarized by Arun Gowdamarajan, MD.

This newsletter is produced by Doctors Shekar Narayanan, Arun Gowdamarajan, Ateet H. Shah and Sanjay Thekkeurumbil, specialists in Colon and Rectal Surgery. Our practice includes an onsite anorectal floor lab and ambulatory surgery center. Comments or requests to subscribe can be e-mailed to info@colonandrectalcare.com.

Colon and Rectal Watch; Vol. 6, Issue 8; August 2011

Exciting New Option for Fecal Incontinence

Exciting New Option for Fecal Incontinence

Fecal incontinence is defined as the involuntary loss of rectal contents with an inability to delay evacuation until it is socially convenient. It is a very common problem. Estimates of incidence range between 2-18% of the population, but its taboo nature makes accurate assessment difficult. 

Consequences of fecal incontinence are significant in many ways. Patients can develop co-morbid conditions (skin breakdown, decubitus ulcers, urinary tract infections), direct and indirect financial costs, and impact on the quality of life (shame, social isolation). 

After a thorough workup including colonoscopy and anorectal physiology testing, the patient is usually started on a conservative treatment plan. Surgical intervention is typically explored in patients with significant symptoms refractory to conservative measures. 

If an anatomic defect is present, initial surgical treatment centered around restoration/repair of the sphincter complex is initiated. While short-term results of this approach were good, the long-term function tended to deteriorate over time.

Another option was sphincter replacement with an artificial sphincter. While associated with excellent results, there are multiple situations where the device is contraindicated, and it has limitations based on infection and erosion into the sphincter.

If other therapies have failed, or co-morbidities preclude a more aggressive approach, creation of a colostomy remains an option. While this does not restore continence, it does allow the patient to regain control of waste management and resumption of a more normal life style.

Recently, the sacral nerve stimulator has gained FDA approval for the management of fecal incontinence. The mechanism of action regarding nerve stimulation is uncertain. However, over 70% of patients markedly improve their continence with this therapeutic modality. Patients who demonstrate initial improvement maintain their results. In 10 year follow up, 92% of these patients continued to have markedly improved continence after implantation of the sacral nerve stimulator.

At Colon & Rectal Care, Inc., we are extremely excited about this new option for fecal incontinence. We have undergone the necessary training to bring this exciting technique to our patients. Patients are currently enrolling in this program, and we will start performing the procedure this month. (Wexner S. Ann of Surg. 2010 Mar, 251(3); 441-9. Lim. Dis Colon Rectum. 2011 Aug; 54(8)869-74.) Summarized by Arun Gowdamarajan, MD.

Is There a Benefit to Routine Antibiotics for Anorectal Abscesses?

The usual treatment for anorectal abscesses consists of incision and drainage. The main concern is the risk of subsequent fistula formation. It has been hypothesized that insufficient drainage of an abscess may contribute to an indolent infection, which can lead to a fistula. 

A recent study evaluated the routine use of antibiotics and surprisingly found a significantly higher rate of fistula formation in patients who underwent routine antimicrobial therapy.

At Colon and Rectal Care, we have found that prompt surgical drainage is the mainstay of treating abscesses. We reserve antibiotic use postoperatively in selective patients based mainly on comorbidities. (Sozener. Dis Colon Rectum 2011 Aug; 54(8) 923-29) Summarized by Arun Gowdamarajan, MD.

Highlights from the 2011 ASCRS Meeting

The recent American Society of Colorectal Surgeons meeting in Vancouver had the largest number of attendees outside of a combined meeting in the history of the society. There were several excellent sessions ranging from Robotics to new innovations in fecal incontinence to management of fistulas. This is a brief summary in regards to Robotics and anal fistulas.

As the first group in the state to perform a robotic colectomy, we have been watching the trends and outcomes as it related to traditional laparoscopic surgery with the DaVinci Robotic System. The company has improved the ergonomics and ease of the system over the past few years. During the meeting, there was a large symposium discussing the merits of the Robotic System. Presently, Robotics in colorectal surgery is most widely used in pelvic dissections (Rectal Cancer and Pelvic Prolapse). The basic tenant of the discussion was whether the improved ergonomic, 3D view and accessibility were improved compared to traditional laparoscopy. The panel showed that in THEIR hands they had comparable to even improved results in regards to length of stay, leak rates and complications. The trend towards longer operative time remains. However, several audience members highlighted the fact that NO study has shown an overall benefit in robotics as compared to traditional laparoscopy…… YET. We, at Colon & Rectal Care, Inc., continue to offer Robotic Colon Surgery to select patients. We are measuring our personal outcomes and times to be sure we are offering our patients the best modalities and treatment in a cost effective way.

Anal fistulas continue to be a difficult problem for both patients and colorectal surgeons. Several techniques have been tried recently including fibrin glue therapy and the “Anal Fistula Plug”. These results,

though initially promising, are now ranging between a 9-50% success rates. The Ligation of Intersphincteric Tract (LIFT) was first described and presented at our annual meeting 3 years ago. This technique has been gaining popularity over the past few years. Data has shown success rates ranging from 50-80%. Mushaya et al, performed a randomized trial comparing the LIFT to the traditional gold standard for complex fistulas…. Rectal Advancement Flap (ARAF). They performed a randomized prospective trial between 2007-2010. Forty-two patients were randomized during the study. They measured operative times, complications and success rates. The major difference noted was in operative times. The ARAF took an average of THREE TIMES longer to perform. There was no difference in morbidities and there was only a single recurrence in both groups. Thus, the authors concluded the LIFT was a viable option and further investigations and trials are needed. Tan et al, studies their failure of the LIFT over a 4-year period. Ninety-three patients had the procedure and they had only 6 failures for an 87% success rate. What was fascinating is the failures were then studied by endoanal ultrasound. They found the fistulas tracts were converted to intersphincteric rather than transphincteric fistulas. Thus, five of the six failures underwent traditional fistulotomy with success. The authors concluded that the LIFT is an excellent option for complicated fistulas with a very high success rate. We, at Colon & Rectal Care, Inc., have used the LIFT technique in a small subset of patients thus far. We have been very happy with initial data, and much of it parallels the work done by both Mushaya and Tan. We continue to offer our patients the full gambit of fistula operations and tailor our therapy based on anatomy, continence status and patient wishes. (Prasad et al. Robotics Symposium. ASCRS Meeting 2011. Mushaya et al.”Randomized Controlled Trial Comparing LIFT to Advancment flap…” Podium Presentation. ASCRS Meeting 2011. Tan et al. “The anatomy of failures following LIFT Technique…”Podium Presentation. ASCRS Meeting 2011) Summarized by Shekar Narayanan, MD.

Colon and Rectal Watch; Vol. 6, Issue 6; May 2010

Colorectal surgeons are proficient at performing screening colonoscopy
What is a Colorectal Surgeon?

Colorectal surgeons are proficient at performing screening colonoscopy

Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the second leading cause of cancerrelated deaths in North America. Screening for CRC and its precursor lesions has become an increasingly prevalent practice. Colonoscopy is considered to be the gold standard for detecting and removing adenomas, and colonoscopic polypectomy is associated with a reduced incidence of CRC1. Two large population-based studies have demonstrated that the risk of developing CRC after a negative colonoscopy is reduced for at least 10 years as compared with the general population2,3.

However, a small number of patients will develop CRC after a negative colonoscopy. There are several reasons why this may occur. Incomplete bowel preparation precluding adequate mucosal visualization, incomplete polypectomy, missed polyp or cancer due to poor endoscopic technique, or a rapidly progressing cancer that was not present at the time of initial colonoscopy have all been proposed as potential explanations for this phenomenon.

A recent study published in Clinical Gastroenterology and Hepatology4 evaluates the importance of endoscopist specialty in the effectiveness of screening colonoscopy in preventing development of subsequent CRC. The authors analyzed a cohort of 110,402 residents of Ontario who underwent negative initial colonoscopy, 1596 (14.5%) of whom developed CRC over the 15-year follow-up. The authors offer the bold conclusion that “after a negative colonoscopy, those who have had their procedures performed by a gastroenterologist are less likely to develop CRC”. This article has led some in the medical community to falsely advertise gastroenterologists as the only specialty adequately trained to perform screening colonoscopy.

We have carefully analyzed this study and found several major flaws that make its conclusions especially irrelevant when considering the performance of screening colonoscopy by colon and rectal surgeons.

Colon and rectal surgeons are different than general surgeons

No studies compare gastroenterologists with colon and rectal surgeons

Secondly, the authors offer, as support for their conclusions, three other past studies that demonstrate that gastroenterologists are more proficient than nongastroenterologists at performing colonoscopy 2,5,6. Rex DK et al. (Gastroenterology, 1997) did demonstrate that the chance of a missed cancer when a colonoscopy is performed by a nongastroenterologist is significantly greater than when performed by a gastroenterologist (odds ratio 5.36). However, their nongastroenterology group includes only general surgeons, internists, and family practitioners, but no colon and rectal surgeons. Even Rex DK et al. admit in their paper that there were no colorectal surgeons included in their study, which highlights the importance of considering this specialty as a group unique from other “nongastroenterologists” who perform colonoscopy. Singh et al.(JAMA, 2006) demonstrates no significant difference in the subsequent development of CRC following negative colonoscopy between different endoscopic specialties, though there was a nonsignificant trend towards an increased risk of CRC after colonoscopy performed by general practitioners. Similarly, Bressler et al.(Gastroenterology, 1997) demonstrates that colonoscopy performed by an internist or family practitioner was independently associated with a new or missed cancer.Neither of these studies included colorectal surgeons.

The bottom line is that no study has demonstrated that colorectal surgeons are inferior to gastroenterologists in the performance of screening colonoscopy. Based on training and volume of practice, colorectal surgeons are at the very least, as proficient in the performance of screening colonoscopy as gastroenterologists.

We perform a highvolume of colonoscopies

Rabeneck et al (Clin Gastroenterol Hepatol, 2010) stratified endoscopists in terms of annual endoscopic volume, with the highest volume endoscopists performing between 5081102 colonoscopies per year. Though there was not a statistically significant difference in development of CRC based on endoscopic volume, there certainly was a trend towards the highestvolume endoscopists having the lowest rates of development of CRC. We at Colon and Rectal Care are proud to state that based on our endoscopic productivity, our surgeons fall into the highest volume endoscopic group. Again, this highlights the importance we place on the performance of colonoscopy in our practice.

Conclusion

We would like to emphasize that we take pride in our performance of colonoscopy. It was a significant part of our specialty training and is a significant part of our practice. Our goal is clinical excellence, and we perform very thorough and accurate screening colonoscopies. Our patients also benefit from the fact that, if they are unfortunate enough to have an abnormality discovered on their screening colonoscopy that requires surgical intervention, we have the expertise to provide it.

What is a Colorectal Surgeon?

Colorectal surgeons are individuals who have completed a residency in general surgery as well as an additional residency in colorectal surgery. This additional year allows for intensive education in diseases of the small intestine, colon, rectum and anus.

To obtain board eligibility for the colorectal surgical board examination, an individual must complete an accredited residency program that in one short year provides an adequate volume of colonoscopy, abdominal surgical procedures, and anorectal surgical procedures. An average graduate will have completed over 300 colonoscopies, 200 anorectal surgeries, and 150 colon resections. This intense oneyear experience provides a greater training experience with these procedures than in any other subspecialty. Trainees also spend extensive amounts of time in outpatient care learning the most up to date ways to manage diverticulitis, inflammatory bowel disease, and a wide variety of anorectal disorders. The emphasis is on appropriate diagnostic testing as well as on determining whether surgical or medical management would provide the best results for the patient.

With such a deep experience, it is not surprising that no data exists in the literature to demonstrate that colorectal surgeons provide substandard surgical or endoscopic care. On the contrary, many studies do demonstrate better results with colorectal surgeons and have demonstrated a significant decrease in local recurrence when a colorectal surgical specialist performs the operation. Nonspecialty surgeons have recurrence rates 300% higher than colorectal specialists. Colon and Rectal Care physicians have over 46 years of experience in the diagnosis and treatment of colorectal diseases.

1) Winawer SJ et al. Prevention of colorectal cancer by colonoscopic polypectomy. N Engl J Med 1993; 329:19771981 2) Singh H et al. Risk of developing colorectal ca following a neg colonoscopy exam: evidence for a 10year interval between colonoscopies. 3) AMA 2006; 295: 23662373 4) Lakoff J et al. Risk of developing proximal versus distal colorectal cancer after a neg colonoscopy: a populationbased study. Clin Gastroenterol Hepatol 2008; 6:11171121. 5) Rabeneck L et al. Endoscopic specialty is assocd with incident colorectal ca after a neg colonoscopy. Clin Gastroenterol Hepatol 2010; 8: 275279. 6) Bressler et al. Rates of new or missed colorectal cancer after colonoscopy and risk factors: a populationbased analysis. Gastroenterology 2007; 132:96102. 7) Rex DK et al. Relative sensitivity of colonoscopy and barium enema for detection of colorectal ca in clinical practice. Gastroenterology 1997; 112:1723. Summarized by Arun Gowdamarajan, MD and Ateet Shah MD

Colon and Rectal Watch; Vol. 6, Issue 5; April 2010

Ileus after abdominal surgery: What is being done to decrease it?
What is diverticular-associated colitis?

Ileus after abdominal surgery: What is being done to decrease it?

Ileus (antonym) of the intestine after surgery can occur in up to 50% of patients undergoing a colon/small bowel operation. This leads to increased length of stay, delay in oral intake, delay in return to the activities of daily living (working) and overall cost.

Over the years, many changes in post-operative care have decreased ileus rates and length of stay. These include early feeding, lack of nasogastric tubes (NG), early ambulation and the use of post-operative epidural/spinals for pain management. Roig et al surveyed the Spanish Coloprocotological Association members. They concluded that the use of fast tract (FT) clinical pathway, epidural analgesia, warm fluids and absence of NG tube allowed for minimizing ileus rates. The routine use of NG tubes, among colorectal surgeons in the United States, is now obsolete. However, what is the data to support the other factors and what medications are being used to improve bowel function? Minig et al studied 143 patients over an 11- month period of time. The patients were included in a randomized control trial between traditional feeding (TF) and early feeding (EF). The data found the EF group had an early return of GI function, higher patient satisfaction, lower complication rate and an earlier discharge. Gum chewing has been studied extensively over the years, but 2 recent studies appear to show promise. Fitzgerald et al did a meta-analysis of randomized controlled studies using gum chewing and ileus rates. They found the first flatus after surgery was 12.6 hours earlier and first bowel movement was 23.1 hours earlier. They concluded that it appeared beneficial in open abdominal surgery. Vasquez, et al also did a meta-analysis using the Cochrane database. Six trials including 244 patients were studied. They found statistically significant difference between the gum chewing and non gum-chewing group as it relates to time to first flatus and bowel movement. However, there was no change in length of stay.

Over the past few years, the medication Entereg (Amlovipan) mu antagonist has been introduced to decrease ileus rates. Two trials have analyzed this drug extensively. Senagore et al studied 5 randomized, double blind phase III trials to determine its efficacy. They excluded epidural patients to allow for a more equal group. They found, for open laparotomy cases, a statistically significant factor related to first bowel movement and toleration of a regular diet in all subsets of patient population.

Finally, the major study comes from Ludwig et al who conducted a multi-center, phase III double blind study using Entereg BID on colorectal anastomotic patients. End points were first bowel movement/flatus, toleration of solid diet and time to discharge. The study showed a significant impact. There was a statistical difference in all three factors with a p-value of less than .001. Most notable was a length of stay difference of 5.2 vs. 6.2 days.

At Colon & Rectal Care, Inc., we have been using gum chewing, early ambulation and feeding for over 8 years. We also employ routine epidural/spinals for our patients. Over the past 1.5 years, we have added Entereg to our regimen. Our preliminary data shows a reduction of about one day in total length of stay. We have been able to discharge a handful of our colectomy patients on postoperative day 2 and a large portion on post-operative day #3 or #4. We have had no ill effects to date. We continue to strive to better our patient care and allow them the highest quality of care with the least time in the hospital so they may return to their families and activities of daily living. Roig. Colorectal Dis. 2009 Nov; 11(9); 976-83, Fitzgerald. World J Surg. 2009 Sep.; Vasqueaz. J. Gastrointest Surg. 2009 Apr;13(4); 649-56, Senagore. Surgery; 2007 Oct; 142(4); 478-86; Ludwig Arch Surg. 2008 Nov; 143(11):1098-105. Summarized by Shekar Narayanan, MD.

What is diverticular-associated colitis?

Diverticular associated colitis (DAC) refers to inflammation, resembling inflammatory bowel disease (IBD), in a segment of colon affected by diverticular disease. DAC is under recognized and under diagnosed as a distinct clinical entity. It can be difficult to distinguish between DAC and IBD clinically and histologically.

Clinical manifestations, such as hematochezia, urgency, diarrhea, and cramping are similar to that seen with IBD. Etiology may be related to a genetically predisposition as well as an abnormal immune response. There may also be a subserosal peridiverticulitis and suppuration.

Patients with DAC have also been known to suffer from extraintestinal disorders like pyodermal gangrenosum, ankylosing spondylitis, and erythema nodosum. As these processes are usually associated with IBD, their appearance in DAC serves to further confuse this disease with IBD and lead to subsequent mismanagement.

Histologic features of affected colonic biopsies are not pathognomonic and can be associated with IBD, mucosal trauma, or diverticulitis. A clinical scenario can occur when patients have what appears to be IBD in the presence of diverticula.

There is a lack of uniformity regarding the precise diagnostic criteria for DAC. Most commonly, DAC is described as “IBD-like” inflammation in an area of diverticula with sparing of the remaining colon.

DAC may respond well to medical therapy utilized for IBD. Treatment of segmental colitis with 5- aminosalicylic acid medications, like Mesalamine, is usually successful. When surgery is required, postoperative recurrences have been reported to be rare with follow-up times ranging from 1 to 7 years.

A few cases in the literature hypothesize that DAC may also progress to classical IBD with a mean progression time of 18 months. Most of these cases occur in patients who have already undergone segmental resection for DAC. It has been speculated that there may be a pathogenetic relationship between DAC and ulcerative colitis (UC). Others have speculated that DAC could be an atypical manifestation of UC.

Surgery is indicated in patients with persistent symptoms despite medical management. Therapy usually consists of resecting the diseased portion of the colon.

At Colon & Rectal Care we have been utilizing Mesalamine products for several years as part of a successful treatment plan for acute diverticulitis, as well as with DAC. We have also provided surgical care for patients with refractory symptoms with excellent results. Peppercorn MA. The overlap of inflammatory bowel disease and diverticular disease. J Clin Gastroenterol 2004; 38 s8-10 Harpaz n, Sachar DB.Segmental colitis associated with diverticular disease and other IBD look-alikes. J Clin Gastroenterol 2006; 40: S132-5. Summarized by Arun Gowdamarajan, MD.

Patients with diverticular disease are frequently advised to avoid eating seeds, nuts, corn and popcorn. This suggestion persisted despite a paucity of evidence suggesting the efficacy of this change. Recent data, however, demonstrates that consumption of these foods does not increase the risk of diverticulitis or diverticular bleeding. In fact, increased consumption of these foods was found to decrease the incidence of diverticular complications.

We have long espoused the lack of efficacy of these dietary modifications in the long-term management of diverticular disease. Strate LL et al. Nut, corn, and popcorn consumption and the incidence of diverticular disease. JAMA 2008; 300: 907-14. Summarized by Arun Gowdamarajan, MD.

Colon and Rectal Watch; Vol. 6, Issue 4; January 2010

What is laparoscopic surgery?

What is laparoscopic surgery?

Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the second leading cause of cancer deaths in the U.S. The 5-year survival for early stage cancers is 90%, while only 10% of patients with advanced cancers survive 5 years. As most cancers arise in polyps, and it takes an average of 10 years for a small polyp to progress to a cancer, screening should lead to a decrease in CRC related deaths.

Screening Patients at Average Risk:

Screening for patients at average risk for CRC should begin at age 50. The simplest option is fecal occult blood testing (FOBT). Patients should collect three separate stool samples at home on a yearly basis. Since samples from digital rectal exam have a high false positive rate, they should not be used. All positive tests mandate total colonoscopy (TC). FOBT testing should occur on a yearly basis in conjunction with other screening tests. In prospective randomized trials, this approach has decreased CRC mortality by 15-33%.

Another option, flexible sigmoidoscopy, should be performed every 5 years. Sigmoidoscopy is most effective when combined with yearly FOBT and with intermittent barium enemas to evaluate the right colon. As with FOBT, all positive tests mandate TC. Double contrast barium enema (DCBE) every 5-10 years is another option. DCBE does offer evaluation of the entire colon, but has only 83% sensitivity. Furthermore, no studies demonstrate that DCBE lowers CRC related mortality.

TC every 10 years may be the best method for CRC screening. TC offers the advantages of complete colonic visualization with therapeutic potential. Although no direct studies evaluate whether screening TC reduced CRC related mortality, the National Polyp Study estimated that 76-90% of colon cancers could be prevented through routine colonoscopic screening.

Furthermore, TC is an improvement upon sigmoidoscopy, and there is direct evidence that sigmoidoscopy reduces CRC mortality. TC has a sensitivity of 93% for detecting CRC.

Several recent reports have generated interest in CT colography (virtual colonoscopy) as a non-invasive method to evaluate the colon. At this time there is no solid evidence demonstrating equivalent effectiveness at finding early cancers compared with currently recommended screening tests. More studies are needed before recommending it as a screening test for the general public. At this time, CT colonoscopy represents a promising, but experimental, approach.

Screening High Risk Patients:

Individuals with a family history of CRC or adenomas in first-degree relatives should undergo TC every 3-5 years beginning at an age 10 years younger than the youngest effected relative. Hereditary non-polyposis colorectal cancers should be suspected in any patient with several relatives with CRC, especially if any of the relatives was diagnosed before age 50. Colonoscopic evaluations should be performed in these patients every 2 years starting at age 25, or 5 years younger than the earliest diagnosis of CRC, whichever is younger. After age 40, TC should be done annually.

Personal history of CRC requires TC before surgery or within 12 months of resection. If negative, subsequent procedures can be deferred for 3 years. Frequency of endoscopy in patients with a personal history of adenomatous polyps depends on the number and type of polyps initially treated. Although therapy for these patients should be individualized, TC is the preferred method of follow-up.

We believe colonoscopic screening most effectively reduces mortality from colon cancer; it is the most sensitive test and allows concurrent therapy. Unfortunately, only 1/3 of patients actually undergo adequate screening. In order to improve this community’s screening rate, we have a program in place to allow easy, prompt scheduling of this vital exam. (Gastrointest Endosc. 2000 Jun;51(6):777-82. Other sources available on request) Summarized by Arun Gowdamarajan, MD.

What is Laparoscopic Surgery?

Laparoscopic or “minimally invasive” techniques have revolutionized the practice of surgery. Initially, laparoscopic surgery was used primarily for gynecologic surgery and cholecystectomy. Over the past 10 years, its role has been expanded to include colon and rectal surgery. In traditional “open” surgery, the surgeon uses a single incision to enter into the abdomen and complete an operation. Laparoscopic surgery uses several 0.5-1 cm incisions, called “ports”. Specialized instruments and a camera known as a laparoscope are passed through these ports. The laparoscope transmits images from the abdominal cavity to high-resolution video monitors in the operating room, and the surgeon performs the operation by watching detailed images of the abdomen on the monitor. This system allows the surgeon to perform the same operations as traditional surgery but with smaller incisions.

We perform most of our abdominal surgery laparoscopically. This includes surgery for Crohn’s disease, ulcerative colitis, diverticulitis, cancer, rectal prolapse, and severe constipation.

What are the Advantages of Laparoscopic Surgery?

In comparison to conventional colectomy, the benefits of laparoscopic colectomy include reduction of postoperative ileus, less postoperative pain and concomitant reduction in need for analgesics, an earlier tolerance of diet, a shortened hospital stay, and improved cosmetic results.

Perhaps more important than a decreased hospital stay is the fact that patients undergoing laparoscopic colectomy return to normal activities and employment 3-4 weeks earlier than patients undergoing open colectomy. This benefit seems especially important in the current difficult economic environment.

Is Laparoscopic Surgery Safe?

Laparoscopic surgery is as safe as traditional open surgery with regard to morbidity and mortality. One of the factors that initially prevented the adaptation of laparoscopic colectomy for colon cancer was early data that suggested an inferior oncologic outcome with the laparoscopic approach. Since 2002, however, there have been four large randomized controlled trials comparing laparoscopic versus open colectomy for colon cancer. These trials have demonstrated that laparoscopic colectomy is equivalent to open colectomy in oncologic outcomes such as adequacy of resection, recurrence, and survival. This has led to the widespread adaptation of the laparoscopic approach in the treatment of colon cancer.

There are fewer randomized controlled trials evaluating the effectiveness of laparoscopy in the treatment of rectal cancer. However, the published series that are currently available suggest that there is no difference in oncologic outcomes between laparoscopic and open resection for rectal cancer.

What About Robotic Colectomy?

Unlike other surgical subspecialties, such as urology, robotic surgery has been slow to enter the realm of colon and rectal surgery. This is due to the fact that most minimally invasive intestinal surgery can be performed with the same ease laparoscopically as with a robot, with much lower associated costs. Rectal surgery, however, may be well-suited for robotics because of the difficulty of performing a laparoscopic resection and anastomosis within the pelvis. Early reports do confirm that robotic rectal cancer surgery is safe and feasible. We are currently investigating the benefit of robotic colectomy for our patients and have successfully employed this technique in several recent cases involving deep pelvic dissection.

In conclusion, we perform approximately 90% of our intestinal surgery laparoscopically. Our patients have left the hospital as early as 2-3 days after surgery, and many are back to work within 3-4 weeks after surgery. We are dedicated to the use of minimally invasive techniques for our patients and are constantly exploring ways to reduce pain, length of hospital stay, and the time they must remain off work.

Marcello PW, Young-Gadok T. Laparoscopy. In: The ASCRS Textbook of Colon and Rectal Surgery. Springer Science and Business Medica, LLC, 2007: 693-712. Koopman MC, Heise CO. Laparoscopic and minimally invasive resection of malignant colorectal disease. Surg Clin N Am 2008; 88: 1047-72. http://www.fascrs.org/patients/treatments_and_screenings/laparosco pic_surgery/. Summarized by Ateet H. Shah, MD.

Colon and Rectal Watch; Vol. 6, Issue 3; October 2009

Hemorrhoids
Single incision laparoscopic colectomy; Fad or wave of the future

Hemorrhoids

Despite popular misconceptions, hemorrhoids are normal anatomic structures. They are vascular cushions in the distal rectum and anal canal, with unknown functional significance. There are three main fibrovascular cushions located in the left lateral, right anterior and right posterior positions of the anus, with intervening secondary complexes in some individuals.

What symptoms do hemorrhoids cause?

Symptomatic internal hemorrhoids usually cause painless bleeding or prolapsing tissue. The bleeding is usually bright red, and can be seen with wiping or in the toilet. Anemia can rarely occur (0.5 per 100,000 population per year). Prolapse of tissue can require manual reduction. Internal hemorrhoids can also cause chronic drainage and soiling of underclothes. Pain associated with internal hemorrhoids usually presents as a dull ache. Sharp, acute pain is most commonly associated with thrombosed external hemorrhoids.

What conservative measures best treat hemorrhoids?

Only minimal peer reviewed literature exists regarding conservative management of hemorrhoids. The best evidence regards the use of fiber. Six weeks after increasing fiber intake, 84% of patients noted improvement or resolution of symptoms vs. 54% of placebo. Over the counter topical agents and suppositories containing local anesthetics, corticosteroids, astringent, antiseptics and protectants are available and may alleviate symptoms of pruritus and discomfort. However, long-term use of these agents should be discouraged, particularly corticosteroid preparations, which can permanently damage or cause ulceration of the perianal skin. No randomized controlled trials are available to support their widespread use.

What is the role of minimally invasive treatments of hemorrhoids

The goal of these procedures, is to ablate the vessels involved and fix the sliding hemorrhoidal tissue back onto the muscle wall of the anal canal in order to improve symptoms of bleeding and prolapse. These procedures are recommended for most patients with refractory Grades I, II or III hemorrhoids. Only 5-10% of patients require surgery. Options include: Infrared coagulation - Infrared photocoagulation for internal hemorrhoids uses infrared light directed at the hemorrhoidal tissue, which then dries and shrivels. A simple light-conducting handle is attached to a lamp and timer. The quartz barrel is then inserted via an anoscope. One to two second bursts of light are used over each base. The procedure takes approximately five minutes to perform. Many patients require multiple sessions. Patients on Coumadin or Plavix should attempt to have the medication held prior to treatment to diminish the risk of severe hemorrhage. Multiple studies have demonstrated the efficacy of this technique in patients suffering from grade I - grade II hemorrhoids. Rubber band ligation - Through an anoscope, an atraumatic clamp is used to retract the tissue at the apex of the hemorrhoidal complex into a ligator, and an elastic band is fired from the drum. In our practice we prefer single ligations with several week intervals to minimize discomfort. Band ligation is very effective in treatment of Grade II or III hemorrhoids. Some authors suggest it for Grade IV hemorrhoids as well. We use both techniques for effective treatment of hemorrhoidal symptoms with minimal morbidity and discomfort. Nivatvongs S. Hemorrhoids. In: Gordon PH, Nivatvongs S, eds. Principles and Practice of Surgery for the Colon, Rectum, and Anus. 3rd ed. New York: Informa Healthcare USA, 2007: 143-166. McRae HM, McLeod RS. Comparison of hemorrhoidal treatments: a meta-analysis. Dis Colon Rectum 1995; 38: 687-694. Keighley MR, Buchamann P, Minervium S et al. Propesctive trials of minor surgical procedures and high fiber diet for hemorrhoids. BMJ 1997; 2:967-969. Summarized by Arun Gowdamarajan, MD.

Single incision laparoscopic colectomy; Fad or wave of the future

Single Incision Laparoscopic Surgery (SILS) first was introduced in the late 1990’s. Due to issues of instrumentation, learning curves and physician awareness, it did not gain acceptance. However, there has been a marked increase in usage in the past three years (22%). In the following article, we will explain what the procedure is, how it may benefit your patients, and our single institution experience.

SILS involves making a 2-3 cm incision around the navel. A “port” is then placed that contains several small holes for both a camera and 2-3 instruments to work. All work of dissecting and/or removing the specimen is accomplished through this incision. Several applications are now available in the US; most notably for cholecystectomy, appendectomy, bariatrics and hernia surgery. However, in the realm of colorectal surgery, very little has been written. Below are some articles regarding SILS surgery and colorectal problems.

Single incision surgery is not new. Hsu et al studied 316 patients operated on between 2000-2003 using only a 7 cm incision. They found no difference in leak rate, wound complications, technical difficulties and operative time. The authors proposed this method due to significantly diminished cost.

Remzi et al (1) performed the first SILS colectomy at the Cleveland clinic in July of 2008. A 3.5 cm incision was made and a right colectomy performed. The patient was discharged on post-operative day #4 without complication. The authors concluded it was safe and allowed for “essentially” scarless surgery, as the incision is hidden in the navel.

Bucher et al (2), in early 2009, performed the first SILS colectomy in Geneva, Switzerland. They chose a 34- year-old female with colonic endometriosis and a BMI of 34. The operative time was 125 minutes and the patient had no post-operative complications. The authors bring up a valid point stating “It has to be determined if SILS offers benefit to the patient, except in cosmesis, compared to standard laparoscopic sigmoidectomy”. Certainly, this is something that future randomized trials will try and answer.

Rieger et al (3), in August of 2009, performed seven colonic resections for cancer with traditional laparoscopic equipment via a single umbilical incision. The average incision length was 3.1 cm, the length of stay was 5.4 days and the average lymph node harvest was 15. This data falls in line with traditional laparoscopic colectomies with the added benefit of a smaller scar and potentially fewer adhesions. Of most interesting development of late, is the combined usage of robotics and SILS. Ostrowitz, et al performed SILS right colon resections using a DaVinci S system and a 4 cm umbilical incision. 1/3 was converted to open due to technical issues, but the other two were completed without incident. The operative time was 152 minutes and there were no complications.

We, at Colon and Rectal Care, performed one of the first SILS colectomies in the state of Indiana in July of 2009. The patient finished with 3.4 cm umbilical incision. He was discharge on post-operative day #4 and resumed normal work/home activities in ten days. SILS colectomy continues to be in the early stages of development for colorectal diseases. We are comparing its value versus traditional laparoscopy, robotic colectomy and hand-assisted colectomy. We believe each avenue offers an advantage to each individual patient. The combination of robotics and SILS is interesting, but the added cost and time must be considered in the selection process. In conclusion, we believe it has a place for select patients and we continue to explore ways to reduce risk, pain, length of hospital stay and allow them to return to the lives in a faster way.Hsu. Am J Surg 2005 July; (1): 48-50, Remzi. Colorectal Dis. 2008 Oct; 10(8):823-6, Rieger. Surge Endosc. 2009 Sep 16, Bucher. Colorectal Dis. 2009 Mar. 6, Ostrowitz. Int J Med Robot. 2009 Oct 5) Summarized by Shekar Narayanan, MD.

Colon and Rectal Watch; Vol. 6, Issue 2; February 2008

Colorectal Cancer Screening
Would STARR help my patient with constipation?

Colorectal Cancer Screening

Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the second leading cause of cancer deaths in the U.S.  The 5-year survival for early stage cancers is 90%, while only 10% of patients with advanced cancers survive 5 years.  As most cancers arise in polyps, and it takes an average of 10 years for a small polyp to progress to a cancer, screening should lead to a decrease in CRC related deaths.

Screening Patients at Average Risk

Screening for patients at average risk for CRC should begin at age 50.  The simplest option is fecal occult blood testing (FOBT).  Patients should collect three separate stool samples at home on a yearly basis.  Since samples from digital rectal exam have a high false positive rate, they should not be used.  All positive tests mandate total colonoscopy (TC).  FOBT testing should occur on a yearly basis in conjunction with other screening tests. In prospective randomized trials, this approach has decreased CRC mortality by 15-33%.

Another option, flexible sigmoidoscopy, should be performed every 5 years.  Sigmoidoscopy is most effective when combined with yearly FOBT and with intermittent barium enemas to evaluate the right colon.  As with FOBT, all positive tests mandate TC. Double contrast barium enema (DCBE) every 5-10 years is another option.  DCBE does offer evaluation of the entire colon, but has only 83% sensitivity.  Furthermore, no studies demonstrate that DCBE lowers CRC related mortality.

TC every 10 years may be the best method for CRC screening. TC offers the advantages of complete colonic visualization with therapeutic potential.  Although no direct studies evaluate whether screening TC reduced CRC related mortality, the National Polyp Study estimated that 76-90% of colon cancers could be prevented through routine colonoscopic screening

Furthermore, TC is an improvement upon sigmoidoscopy, and there is direct evidence that sigmoidoscopy reduces CRC mortality.  TC has a sensitivity of 93% for detecting CRC.

Several recent reports have generated interest in CT colography (virtual colonoscopy) as a non-invasive method to evaluate the colon.   At this time there is no solid evidence demonstrating equivalent effectiveness at finding early cancers compared with currently recommended screening tests. More studies are needed before recommending it as a screening test for the general public.  At this time, CT colonoscopy represents a promising, but experimental, approach.

Screening High Risk Patients

Individuals with a family history of CRC or adenomas in first-degree relatives should undergo TC every 3-5 years beginning at an age 10 years younger than the youngest effected relative.  Hereditary non-polyposis colorectal cancers should be suspected in any patient with several relatives with CRC, especially if any of the relatives was diagnosed before age 50.  Colonoscopic evaluations should be performed in these patients every 2 years starting at age 25, or 5 years younger than the earliest diagnosis of CRC, whichever is younger.  After age 40, TC should be done annually. 

Personal history of CRC requires TC before surgery or within 12 months of resection. If negative, subsequent procedures can be deferred for 3 years.  Frequency of endoscopy in patients with a personal history of adenomatous polyps depends on the number and type of polyps initially treated.  Although therapy for these patients should be individualized, TC is the preferred method of follow-up.

We believe colonoscopic screening most effectively reduces mortality from colon cancer; it is the most sensitive test and allows concurrent therapy.  Unfortunately, only 1/3 of patients actually undergo adequate screening.  In order to improve this community's screening rate, we have a program in place to allow easy, prompt scheduling of this vital exam.(Gastrointest Endosc. 2000 Jun;51(6):777-82.  Other sources available on request)Summarized by Arun Gowdamarajan, MD.

Would STARR help my patient with constipation?

Approximately 80% of all individuals suffer from constipation at one point or another. 33% of patients suffer from these problems more than occasionally.  These symptoms may include excessive straining, hard stools, digitation, incomplete evacuation, a sense of anorectal blockage and less than three bowel movements per week. Fiber and numerous medications such as Miralax, Amitiza and, previously, Zelnorm have been used to promote bowel motility. However, some patients have pelvic floor dysfunction that prevents them from "emptying" their rectum. Most commonly in females, they complain of "incomplete evacuation", "it's down there and it won't come out", and then will often vaginally splint. These patients are often classified as having "Obstructive Defecation Syndrome" (ODS).

The work up for this problem often involves numerous tests. This includes anal manometry, surface electromyography, a defecating proctogram, colonic transit study and a colonoscopy.  The proctogram offers probably the most information. The test involves instillation of "barium paste" into the rectum and vagina (females). The design is to determine if the rectum is telescoping on itself (intussusception or internal rectal prolapse) or if there is development of a rectocele. Traditional surgical therapy (still applicable in many cases) for rectoceles has been either a transanal or transvaginal approach. The overall success rates have varied from 55-80%. However, with both approaches, concerns with fecal incontinence, dyspareunia, and stenosis have been described. Though mostly from urogynecologic data, mesh placement has also been used, but with varying success and with concerns about mesh erosions.

The STARR procedure (stapled transanal rectal resection) is a minimally invasive surgical approach to correct the anatomic disorder of ODS and allows patients to improve rectal emptying. The surgery involves using a circular stapling device to cut the "telescoping or prolapsing rectum" out via the anus in two half circles. Care must be taken to have the full thickness of the rectum, yet not incorporate the vagina. Most patients are kept in the hospital for 1-2 days. The original studies came from Boccasanta et al in 1994. They reported a 75% improvement in symptoms. Most notable were incomplete evacuation (98% to 19%), digitation (88% to 4%), laxative use (52% to 10%) and pain (63% to 10%). Their most frequent complications were fecal urgency (18%) and flatus incontinence (9%). The US pilot study began in 1995. For the initial 50 patients, the inclusion criteria were females (ages 21-80), and ODS symptoms for greater than 12 months. Excluded patients were those with anal incontinence, a resting enterocele, history of colorectal cancer or radiation, and those patients with previous colonic surgery of the sigmoid or rectum.  43 patients were able to be followed for up to 6 months after surgery.

The initial data was quite interesting. At 1 month, 71% of patients state they were greater than 50% better; at 3 months it was 62% and at 6 months it was 65%. The most notable improvements matched that of the European study, which were incomplete evacuation, digitations and laxative use. The most common adverse side effects were pain, bleeding and urinary retention. There were no rectovaginal fistulas or prolonged incontinence episodes. Overall, 59% of patients were completely satisfied with the procedure, and 88% were "above average" satisfied.

At Colon and Rectal Care, we are proud to be the first group in the state of Indiana to have been performing this procedure. We are near twenty patients over the past year (including four men). Our initial data suggests an overall satisfaction rate of 85%. Several patients have stated, "you have given me my life back". We have had no episodes of rectovaginal fistula, prolonged incontinence or persistent pain. We certainly feel this procedure has a place in the algorithm for the management of constipation. All patients should have a careful work up as described above, but if they meet clinical indications, they can often have their quality of life improved significantly. (Corman et al. Colorectal Disease 2005. Boccasanta et al. DCR. 2005. Boccasanta et al. Int J. Colorectal Dis. 2004). Summarized by Shekar Narayanan, MD.

Colon and Rectal Watch; Vol. 5, Issue 10; August 2007

Laparoscopic colon surgery: Who is benefiting?
For Patients Requiring Colorectal Evaluation to Assess for Possible Cancer, what is the Current Role for CT Colonography vs Standard Optical Colonoscopy?

Laparoscopic colon surgery: Who is benefiting?

Several years ago, the COST study showed laparoscopic surgery for colon cancer with equivalent results with no increase in morbidity, mortality or recurrence over traditional open surgery. We are now asking if ALL patients benefit from laparoscopic surgery for colon cancer. Plus, what are the financial ramifications of laparoscopic surgery? Four podium presentations helped to address this issue. Moolo, et al reviewed 387 consecutive laparoscopic colectomies done between 1991-2005. Theses included those cases that were “excluded” in the COST trial (metastatic disease, BMA > 30, transverse  colon lesions, and nonadenocarcinoma pathology).

Two groups were created (IG- originally included in the COST trial; EG- excluded). In analyzing data in regard to length of stay, intra-operative and postoperative complications and operative time, they found no difference. They did note that patients with transverse colon lesions and BMI’s >30 did have a high post-operative complication rate. However, most importantly they noted NO difference in 5-Year survival based on TNM staging. The authors concluded that ALL patients might benefit from laparoscopic surgery for colon cancer. Braga et al, decided to study the effects of laparoscopy (LPS) and age, in regards to the appropriateness of offering LPS to those patients over 70 years of age. Among the elderly patients 89 were assigned to the LPS and 112 to the open group. What was most interesting was in the OPEN group, where there was a significantly higher incidence of length of stay, wound infections, cardiac complications and infectious complications. This was NOT seen in the LPS.

The authors actually found a statistically significant difference in morbidity in elderly patients when comparing LSP to open surgery, but this was not realized in the non-elderly patients. Delaney, et al studied the outcomes of patients discharged within the first three days of surgery, as compared to those who stayed longer. 70% of patients met criteria for early discharge. There was no statistical difference in readmission rate, morbidity or mortality. By extrapolation, there is a significant economic advantage both within the hospital setting and for patients’ return to the activities of daily living.

Finally, Dobson et al studied the effects of laparoscopic surgery (LS) on surgical site infections (SSI) with the associated cost analysis. 603 patients, between 2003- 3006, were case matched to 2,246 consecutive open patients. Overall, SSI was noted in 5.8% of the LS group and 4.8% of the open group. However, only ONE of the LS patients required hospital readmission and NONE required surgery. But, in the open group, 52% required readmission and 12% underwent reoperation. In addition, there was a significantly higher incidence of needing home care ($162./dressing change) and placement of a wound vacuum device ($176.86/day). From a patient’s perspective, 92% of patients in LS with wound infections were able to manage their wound independently, compared to only 37% of the open patients. This study clearly shows the effects on wound, and with recently SSI cost analysis by CMS, this becomes a very warranted study. We, at Colon and Rectal Care, have been performing laparoscopic colon surgery for over 15 years. We concur with these studies that laparoscopic colon surgery patients suffer fewer wound complications, a shorter length of stay, and are to return to work/activities of daily living much faster, and no difference in oncologic recurrence for those patients operated on for a neoplasm. Our goal is to continue to reduce our incidence of SSI and sustain our high level of success with laparoscopic colon surgery. Moloo et al. Podium Presentation. ASCRS meeting. 2007. Braga et al. Podium Presentation. ASCRS meeting. 2007. Delaney et al. Podium Presentation. ASCRS meeting. 2007. Dobson t al. Podium Presentation. ASCRS meeting. 2007. St. Louis, MO. Summarized by Shekar Narayanan, MD.

For Patients Requiring Colorectal Evaluation to Assess for Possible Cancer, what is the Current Role for CT Colonography vs Standard Optical Colonoscopy?

The recommendation for colorectal cancer screening has been well established. Cost effectiveness and cancer related death prevention are just two recognized benefits to the colon cancer screening and endoscopic polypectomy in those who meet criteria. Currently, amongst other indications, the general consensus suggests that anyone 50 years of age or older be considered for this evaluation.

CT colonography is a relatively new modality and ongoing research is looking into the ideal imaging protocols and the appropriate clinical circumstances in which sensitivity and specificity for screening is optimized with this technique and able to approach the current gold standard of colonoscopy.

The prep used for the CT colonography is typically the sodium phosphate type, which limits the amount of remnant fluid within the bowel lumen after the bowel prep. This feature enables a wider contrast necessary to detect lesions with comparable accuracy to colonoscopy. However, more recent data has become available concerning the safety of this preparation in patients with renal insufficiency and even many patients with no lab detected or previously diagnosed renal insufficiency. Currently at Colon and Rectal Care, Inc., none of the surgeons use this sodium phosphate preparation for any patient undergoing colonoscopy as a result of the concern regarding its safety in the general population.

To achieve good results with CT colonography, both supine and prone patient positioning appears to be necessary which can be difficult for some patients. Radiation exposure and the theoretical risk of cancer induction as a result, seem to be of limited concern with this modality. The Health Physics Society suggests that epidemiologic studies do not support any adverse health effects when patients are exposed to less than 50 mSv per year or 100 mSv in their lifetime beyond baseline natural exposure. The dosage for a CT colonography is quite low and on the order of 8-12 mSv since a substantially lower radiation dose than that used in standard CT scan imaging still enables adequate visualization of the bowel lumen. The downside is that the overall sensitivity for detecting extracolonic abnormalities is substantially lower than regular CT. This means that a patient who recently had a CT colonography with no other abnormal findings does not mean that they recently had a “negative CT” in terms of evaluating for other indications such as abdominal pain, etcetera. In addition, statistically, 7-11% of these studies show some other abnormality necessitating a workup that leads to a relevant finding in only 2-3%.

Same day referrals for patients having an incomplete colonoscopy is possible and enables the patient to avoid another bowel prep, however barium is typically given as part of the prep for the planned CT colonography which would not be present in that situation and therefore the specificity may be a bit compromised.

Benefits to the CT study compared to colonoscopy include the evaluation of the rare submucosal lesion,which is probably better seen with this modality than optical colonoscopy. The precise anatomic localization inherent to the CT scan can be quite difficult to achieve with colonoscopy in the very tortuous colon.

However, with lesion tattooing at the time of endoscopy, predictably accurate localization in preparation for surgery is much less of an issue. Evaluation of the colon proximal to a nearly or completely obstructing colon lesion in preparation for surgery is a real advantage to the CT. CO2 is used instead of oxygen and easily passes by the lesion enabling the proximal evaluation. Also for the patient needing colonic evaluation for synchronous lesions in the immediate postoperative setting after surgery for an  obstructed or perforated colon cancer, this is an ideal modality.

At Colon and Rectal Care, we believe that colonoscopy is still the gold standard for colorectal cancer screening and the therapeutic interventions that have led to the reduced rates of death from this cancer since the advent of screening. Nonetheless, we recognize the growing role for CT colonography under certain clinical circumstances and await further data on this most interesting subject. 1) Curr Probl Diagn Radiol July/August 1991; 123- 51. 2) Gastroenterology 2003;125:311- 319. 3) Semin Colon Rectal Surg 2007; 18(2):88-95. 4) Radiology 2006; 231:417-425. Summarized by Joseph C. Muller, MD.

Colon and Rectal Watch; Vol. 5, Issue 9; May 2007

Colorectal Cancer Screening
Clostridium difficile is a problem, but what are the real facts?

Colorectal Cancer Screening

Colorectal Cancer Screening

Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the second leading cause of cancer deaths in the U.S.  The 5-year survival for early stage cancers is 90%, while only 10% of patients with advanced cancers survive 5 years.  As most cancers arise in polyps, and it takes an average of 10 years for a small polyp to progress to a cancer, screening should lead to a decrease in CRC related deaths.

Screening Patients at Average Risk

Screening for patients at average risk for CRC should begin at age 50.  The simplest option is fecal occult blood testing (FOBT).  Patients should collect three separate stool samples at home on a yearly basis.  Since samples from digital rectal exam have a high false positive rate, they should not be used.  All positive tests mandate total colonoscopy (TC).  FOBT testing should occur on a yearly basis in conjunction with other screening tests. In prospective randomized trials, this approach has decreased CRC mortality by 15-33%.

Another option, flexible sigmoidoscopy, should be performed every 5 years.  Sigmoidoscopy is most effective when combined with yearly FOBT and with intermittent barium enemas to evaluate the right colon.  As with FOBT, all positive tests mandate TC. Double contrast barium enema (DCBE) every 5-10 years is another option.  DCBE does offer evaluation of the entire colon, but has only 83% sensitivity.  Furthermore, no studies demonstrate that DCBE lowers CRC related mortality. 

TC every 10 years may be the best method for CRC screening.  TC offers the advantages of complete colonic visualization with therapeutic potential.  Although no direct studies evaluate whether screening TC reduced CRC related mortality, the National Polyp Study estimated that 76-90% of colon cancers could be prevented through routine colonoscopic screening.

Furthermore, TC is an improvement upon sigmoidoscopy, and there is direct evidence that sigmoidoscopy reduces CRC mortality. TC has a sensitivity of 93% for detecting CRC.

Several recent reports have generated interest in CT colography (virtual colonoscopy) as a non-invasive method to evaluate the colon.   At this time there is no solid evidence demonstrating equivalent effectiveness at finding early cancers compared with currently recommended screening tests. More studies are needed before recommending it as a screening test for the general public.  At this time, CT colonoscopy represents a promising, but experimental, approach.

Screening High Risk Patients

Individuals with a family history of CRC or adenomas in first-degree relatives should undergo TC every 3-5 years beginning at an age 10 years younger than the youngest effected relative.  Hereditary non-polyposis colorectal cancers should be suspected in any patient with several relatives with CRC, especially if any of the relatives was diagnosed before age 50.  Colonoscopic evaluations should be performed in these patients every 2 years starting at age 25, or 5 years younger than the earliest diagnosis of CRC, whichever is younger.  After age 40, TC should be done annually. 

Personal history of CRC requires TC before surgery or within 12 months of resection; if negative, subsequent procedures can be deferred for 3 years.  Frequency of endoscopy in patients with a personal history of adenomatous polyps depends on the number and type of polyps initially treated.  Although therapy for these patients should be individualized, TC is the preferred method of follow-up.

We believe colonoscopic screening most effectively reduces mortality from colon cancer; it is the most sensitive test and allows concurrent therapy.  Unfortunately, only 1/3 of patients actually undergo adequate screening.  In order to improve this community's screening rate, we have a program in place to allow easy, prompt scheduling of this vital exam. (Gastrointest Endosc. 2000 Jun;51(6):777-82.  Other sources available on request). Summarized by Arun Gowdamarajan, MD.

Clostridium difficile is a problem, but what are the real facts?

For any physician or healthcare worker involved in the care of hospital inpatients in 2007, clostridium difficile is a likely problem they will encounter.  Essentially, this is a spore forming anaerobic and contagious bacteria.  It is known to secrete toxins that lead to a potentially profound systemic inflammatory response syndrome (SIRS) and extensive cytotoxicity mediated by the toxins.  The phenomena results from selective elimination of bowel flora through the patient's treatment with an antibiotic that exposes a suitable environment for clostridial bacterial proliferation.  Ultimately, in those that do not respond to medical therapy for this microorganism and require surgery, a 25-70% mortality rate is reported.  This is particularly true in the immunocompromised patient who is also at greater risk of developing the disease in the first place.

"C. diff" as it is routinely called, produces a toxin A which is a cytotoxin in and of itself that creates a bowel wall inflammatory reaction that increases bowel mural permeability to the even more cytotoxic toxin B.  A collagenase is also secreted that increases bacterial translocation leading to the release of inflammatory mediators that result in the SIRS response.  Since 2001, new strains have been found as well that secrete yet another "binary toxin" which further potentiates the toxicity to the patient and increases morbidity and mortality.

Clostridium difficile is also known as pseudomembranous colitis (PMC) and is most often and effectively detected through an ELISA testing for the toxin B that yields a 70-95% sensitivity and a 99% specificity.  A stool culture can be done as well, but this takes longer and has some degree of inaccuracy associated with it, as there are about 3% of asymptomatic carriers in the population that are completely healthy.  Endoscopy can be done to identify the pseudomembranes, but only about 50% of the patients with an ELISA positive test for the toxin B (indicating presence of toxic C. diff.) will have pseudomembranes present and be seen endoscopically.

Also, a flexible sigmoidoscopy will miss up to 70% of patients with PMC unless performed beyond the rectum and will still miss 10% even if performed to the most proximal extent of the scope.  Therefore, colonoscopy is really the gold standard for endoscopic diagnosis.

Treatment includes discontinuing the original antibiotic that enabled the process to start.  This may be the only treatment necessary in some cases.  First line treatment after this would be Metronidazole that may be taken orally (500 mg PO tid for 10-14 days) or intravenously, but the oral route is most effective for the disease.  For patients who have not responded to the Metronidazole, Vancomycin may be used (125 mg PO qid for 7 days).  However, the IV version of this is not at all effective for C. diff. and it is much more expensive.  Further preventing Vancomycin's first line use is the very real concern with the proliferation of Vancomycin resistant enterococcus.  Bacitracin (20,000-25,000 units qid for 7-14 days) is another option.  Non-antibacterial options include anion exchange resins which can be used when antibiotics fail, but cannot be used with Vancomycin, as they will bind the drug as well as the toxin.  Data on the use of probiotics is conflicting at this time.  When all else fails, surgery is necessary and should be nothing less extensive than a total abdominal colectomy with an end ileostomy, which may be converted to an ileorectal anastomosis at a much later date, if the patient recovers satisfactorily.

Antidiarrheal medications are absolutely contraindicated in a patient with PMC, as this may exacerbate the disease and lead to fulminant colitis or toxic megacolon.  CT scan findings are non-specific.

Don't be fooled by a "normal CT" in a patient with diarrhea and abdominal pain.

The surgeons at Colon and Rectal Care remain cognizant of the seriousness of this disease and the importance of a timely intervention when necessary.  We continue to evaluate new data as it becomes available on this issue. Dis Colon Rectum 2000;43:551-554.   Am J Gastroenterol 2006;101:812-822.  Lancet 2005;366:1079-1084 + comment 1053-4.   Infect Control Hosp Epidemiol 1995;16:459-477.  Clinics in Colon and Rectal Surgery 2007;20:13-17. Summarized by Joseph C. Muller, MD.

Colon and Rectal Watch; Vol. 5, Issue 8; March 2007

Diverticulitis in younger patients: Surgery vs expectant management
When surgery is done for rectal cancer, What Factors Influence the Likelihood that it will Recur?

Diverticulitis in younger patients: Surgery vs expectant management

Diverticulitis continues to be a major medical issue that appears to be affecting younger and younger patients. The previous algorithm for such patients was to offer surgery after an initial attack to “prevent” future problems. Several papers have addressed this issue in hopes of understanding whether this is a different subtype and the appropriate therapy. Guzzo et al, in 2004, performed a retrospective review of 762 patients admitted between 1990 to 2001. 34% were less than age 50. They found no difference in the risk of requiring surgery between groups younger and older than age 50. They did find a statistical difference in overall surgical requirement due to an increase in colonic resections (40% vs. 26%), respectively. The authors concluded that after a single attack of uncomplicated diverticulitis, routine surgical intervention is not warranted in those patients less than 50 years of age. West et al, retrospectively, studied 64 patients during a six-year period of time. They again found no statistical difference in surgical intervention in those patients less than age 50.

As time has gone on, we have come to realize that it is possible that “young diverticulitis” may be a different type of pathologic problem. Controversy does exist as to the “aggressiveness” of the disease process. Two studies have attempted to address this issue. Lahat et al, studied 207 patients between January of 2000 to February of 2005. 12% were younger that age 45. In this subset they found these patients to have a  male predominance, a higher recurrence and complication rate (32% vs13%), and thus surgical intervention was performed in 38% vs. 13% of patients. Zaidi et al studied the CT scan and clinical features of diverticulitis in young patients. Of 104 patients they found that the 25% were younger than age 40. They also found that the subset of patient between the ages of 20-50 had greater abdominal obesity. However, they DID NOT find a difference in hospital admission,

surgery and/or percutaneous drainage of abscesses between the groups. Nelson et al, analyzed 5500 patients with diverticulitis over a 13-year period of time. 962 were younger than age 50. Comparing rates of emergency surgery, colostomies and recurrence rates, they found no statistical difference between the two groups. The authors concluded that “young patients with diverticulitis should be treated according to the same criteria used for older patients”.  With all this said, is 50 the correct age to set as “young”?Pautrat et al, have challenged that notion with some interesting data. They studied 284 patients between 2000 and 2004. They found 52 patients to be younger than age 50 and sub-categorized into two groups based on a cutoff of age 40.  94% had CT confirmation of diverticulitis. They found that the rate of complicated diverticulitis (abscess/perforation), immediate surgical intervention and major operations were all higher in the age group less than 40 years of age (p<.05). This is the first study in recent times that has changed the “age” criteria for young diverticulitis. A retrospective review from a multi-center trial would be valuable in ascertaining whether the age of 40 should be a criterion for surgical intervention.

We, at Colon and Rectal Care, continue to aggressively treat and manage simple and complicated diverticulitis. We, too, have found a trend in our data for surgical intervention in patients younger than age 40. However, we still maintain that each patient and their treatment algorithm should be done on a case-by-case basis.

Many patients younger than age 40 can still be treated conservatively with diet and/or prophylaxis with medications such as Xifaxan. However, certainly those patients with perforation, abscess or fistula should be referred for surgical intervention. Guzzo. DCR. 2004. Jul;4797):1187-90, West. Am J Surg. 2003 Dec;186(6):743-6, Lahat. World J Gastroenterol. 2006 May 14;12(18):2932-5, Zaidi. AJR. 2006 Sep;187(3):689-94, Neson. DCR. 2006 sep;4999):1341-5, Pautrat. DCR 2006. Dec. 13.  Summarized by Shekar Narayanan, MD.

When surgery is done for rectal cancer, What Factors Influence the Likelihood that it will Recur?

The principles guiding the current management of rectal cancer involve surgical resection, coupled with adjuvant therapy, usually consisting of chemotherapy and radiation.  Cancer staging is important for many reasons as it dictates appropriateness for adjuvant therapy, stratifies patients in terms of their potential for cure versus palliation, and provides a framework from which to estimate statistics such as likelihood of recurrence, disease free survival, and overall survival.  Therefore, the first step to answer this question involves staging.  Staging is currently done through biopsies, endorectal ultrasound versus MRI, and radiographic imaging to assess for metastases such as a chest x-ray and CT scan of the abdomen and pelvis.  With this information, an estimate of the prognosis may be obtained.  From this baseline, the individual’s actual prognosis does vary somewhat based upon the specific tumor biology and details of surgical and adjuvant treatment management.

From a surgical standpoint, a number of details exist that markedly affect the local recurrence rate and quite possibly overall survival.  In addition, the goal of optimizing survival and minimizing local recurrence always has to be weighed against the potential morbidity and mortality of a proposed intervention. 

Surgical resection that does not result in the resection of absolutely all of the viable tumor cells is likely to result in recurrence either locally or distant.  Thus, surgical therapy is aimed at removing all tissue likely to harbor these cells based on imaging and staging if a cure is felt to be possible.  Some limits are placed on the general morbidity.  For example, there is probably a very small subset of patients that undergo major abdominal surgery for rectal cancer who will recur not as a result of inadequate proximal, distal, or circumferential margins on the resected tumor, but due to a para-aortic lymph node that is positive and is not removed with the surgery.  However, the likelihood of tumor existing in one of these nodes alone with no subclinical involvement of the liver, is very low.  Plus, the increased intraoperative and postoperative complication rate and decrease in patient quality of life associated with a para-aortic lymph node dissection is not felt to be justified by most authorities.

Total mesorectal excision was proposed by Heald1 in 1979, based on the hypothesis that the 30-40% accepted local recurrence rate at the time after rectal cancer surgery was mostly due to inadequate excision of the mesorectum.  Although few surgeons have duplicated his extremely low reported local recurrence rate with this technique, total mesorectal excision has been shown in many studies to result in a statistically significant reduction in local recurrence and has now become the essential standard of care.  Reported local recurrence rates in many busy centers have now dropped into the 10-15% range since incorporating this practice. 

To optimize postoperative quality of life and function, great care is taken to offer autonomic nerve preservation (ANP).  Achieving a resection with adequate margins but without unnecessarily sacrificing nerves that may lead to impotence, urinary dysfunction, retrograde ejaculation and potential incontinence is where the skill and experience of the surgeon is most important.  Of all factors that affect a patient’s likelihood of developing a recurrence, the surgeon’s skill set is probably the most important consideration.

At Colon and Rectal Care, all four of the surgeons appreciate the very important role they play in providing the individual patient the greatest chance of a cure from this very troublesome disease.  They have undergone specialized training to enable strict adherence to the principles shown in the literature to result in the lowest possible recurrence rates and post-operative morbidity such as total mesorectal excision, autonomic nerve preservation, and restorative proctectomy whenever possible.  1Br J Hosp Med 1979;22:277-81.   2Dis Colon Rectum 2007;50: 29-36.  3Dis Colon Rectum 2007;50:168-175. Summarized by Joseph C. Muller, MD.

Colon and Rectal Watch; Vol. 5, Issue 7; January 2007

What is the role of HPV vaccination for perianal condyloma?
Do spicy foods affect hemorrhoidal symptoms?
Inflammatory bowel disease and osteoporosis
Medical management of anal fissures

What is the role of HPV vaccination for perianal condyloma?

Genital and perianal warts (condylomata acuminata) constitute a significant health problem in the United States.  This disease, which is caused by infection with the human papilloma virus (HPV), is the most common viral sexually transmitted disease with a rapidly growing incidence.  It has also been linked to the development of cervical and anal cancer.  High-risk serotypes (16,18,31,33,35,39,45,51, and 52) in particular seem to lead to dysplastic, pre-cancerous and malignant changes.

Until recently, therapy was limited to treating lesions after they were discovered with surgery or office based chemical treatments.  Recently, a vaccine has been released for prevention of the most common serotypes of HPV (6,11,16 and 18).  This vaccine is nearly 100% effective in preventing infection.        

Although studies have reported a prevalence of HPV infection in up to 75% of sexually active males, the currently released vaccine is only indicated for use in female patients aged 11-26 for prevention of HPV infection.   This is despite the fact that there is no difference in the immunologic response to the vaccine between males and females. 

There is currently no data to suggest that the current vaccine is effective in treating established HPV infection.  However, another vaccine currently in clinical trials shows great promise in treating patients already infected with HPV.  This vaccine has been shown to induce a profound immunologic response to the virus and has even been demonstrated to cause marked regression in high-grade cervical intraepithelial neoplasia (CIN). 

Almost all of the studies involving these vaccines have been in women and have dealt with prevention of cervical cancer.  This implies a benefit in the prevention of squamous cell carcinoma of the anus, as this disease paradigm is believed to be similar to

cervical cancer.  It has been suggested that anal cancer may arise from anal intraepithelial neoplasia (AIN) lesions in a fashion similar to the evolution of cervical cancer from CIN.  As HPV DNA is found in more than one-half of patients with squamous cell carcinoma of the anus, the current HPV vaccine will likely decrease the incidence of anal cancer markedly, and the investigational vaccine may have a role in treating high grade AIN.

At Colon and Rectal Care, we believe that the best approach to the problem of HPV related diseases would be widespread immunization.  As this is not currently feasible, vaccination in patients at high- risk of HPV infection may benefit from this exciting new therapy. Pediatrics.  2006 Nov; 118(5): 2135-45.  Cancer Gene Ther.  2006 Jun; 12(6):  592-7.  Lancet 2004 Nov; 364(9447): 1757-65).  Summarized by Arun Gowdamarajan, MD.

Do spicy foods affect hemorrhoidal symptoms?

A wide proportion of the world population enjoys spicy foods.  These foods, however, have long been blamed for causing hemorrhoids or exacerbating hemorrhoidal symptoms.  However, until recently, there was no scientific evidence to support this claim.  A recent study gave patients with symptomatic hemorrhoids a capsule containing red chili powder.  The patients were assessed using a scoring system.  The results of this study showed no change in hemorrhoidal symptoms before and after administration of the red chili powder when compared to placebo.  These results clearly demonstrate that use of chili peppers, as a seasoning during a meal has no effect at all on hemorrhoidal symptoms.  So, when patients are unhappy because they believe they need to eliminate spicy foods from their diets because of hemorrhoidal symptoms, let them know that there is no need for them to eliminate these foods.    Dis Colon Rectum.  2006.  49(7):  1018-23.  Summarized by Arun Gowdamarajan, MD.

Inflammatory bowel disease and osteoporosis

Inflammatory bowel disease (IBD) is known to be associated with an increased risk of osteoporosis and related problems such as fragility fractures and osteonecrosis.  Causal factors for this phenomenon include vitamin D and calcium malabsorption, treatment with glucocorticoids, high concentration of inflammatory cytokines associated with IBD, and hypogonadism induced by the bowel disease.  Measurement of bone mineral content by absorptiometry at the time of the initial diagnosis of IBD as well as laboratory evaluation of serum calcium and phosphate will help to plan the anti-osteoporosis regimen for these patients at high risk for osteoporosis.  Calcium and vitamin D supplementation and use of bisphosphonates and calcitonin may need careful consideration.  Bone density measurement is the well-accepted marker for osteoporosis.  Treatment options from management of postmenopausal and glucocorticoid-induced osteoporosis will be helpful in managing patients with IBD. 

When patients with IBD need steroid therapy on a continued and recurrent basis, osteoporosis prophylaxis is often prescribed.   Since there are no controlled trial data available re the efficient osteoporosis prophylaxis in patients with IBD, we are forced to extrapolate data from prevention and management of postmenopausal osteoporosis.  

We prescribe calcium supplementation of 1500 mg/day as well as 1000 units/day of vitamin D for our patients with IBD needing short-term glucocorticoidal therapy.  Patients needing high-dose steroid therapy may have to take bisphosphonates or activated form of vitamin D to achieve adequate prevention of osteoporosis.   Curr Opin Gastroenterol. 18:428, 2002. Inflamm Bowel Dis. 12:797, 2006. Summarized by Rama M. Jager, MD, Ph.D.

Medical management of anal fissures

Anal fissure is considered an ischemic ulcer of the anoderm.  Abnormally high internal anal sphincter tone decreases the anodermal blood flow by compressing the arterioles traversing through the sphincter. High internal anal sphincter tone can lead to anorectal pain, anal fissures and often associated with thrombosed external hemorrhoids.  The resting tone of the internal anal sphincter is mostly myogenic and may depend on

neurohormonal substances such as Angiotensin II.  The sphincter relaxation is neurogenic through activation of non-adrenergic and non-cholinergic pathway that functions through release of Nitric Oxide and Vasoactive Intestinal Polypeptide. 

Pharmacologic means of decreasing the anal sphincter including the use of anticholinergics, calcium channel blockers, arginine and Botulinum toxin as well as surgical means such as internal anal sphincterotomy and CO2 laser photodestruction of superficial fibers of internal anal sphincter all are intending to counter the pathologically high internal anal sphincter tone. There are many advantages of  "chemical sphincterotomy” using medications such as Bethanechol, Nifedipine, Arginine and Botulinum Toxin A in contrast to surgical internal anal sphincterotomy since the surgical sphincterotomy can lead to clinical anal incontinence that is irreversible and not easily correctable. 

Our treatment of anal fissures always includes an initial trial with "chemical sphincterotomy" with a topical spasmolytic agent containing Bethanechol, Arginine and Nifedipine followed by intrasphincteric injection of Botulinum toxin A. Some of us also use photothermal destruction superficial fibers of the internal anal sphincter with a CO2 laser, which also decreases internal anal sphincteric tone aiding healing of the fissure. Surgical internal sphincterotomy is only considered if medical options fail. 

We are currently considering the topical use of the macrolide antibiotic Azithromycin to treat anal fissures.  Macrolides have a direct relaxant effect on the internal anal sphincter and also have bacteriostatic and anti-inflammatory effects, which will be helpful in promoting healing the anal fissure.  Azithromycin has a "concentration-dependent, epithelium-independent, direct relaxant effect" on smooth muscle through a mechanism independent of calcium channels.  It also inhibits IL17-induced IL8 production reducing the inflammatory response. Topical Azithromycin has been used for dermatologic and ophthalmic lesions and thus its topical use has been evaluated previously.  Its topical use may also be helpful in promoting healing of anal fissures.   Eur J Pharmacol.  553:280, 2006     Gastroenterology.  ;129:1954, 2005  Neurogastroenterol Motil.  17 Suppl 1:50, 2005. Summarized by Rama M. Jager, MD, Ph.D.

Colon and Rectal Watch; Vol. 5, Issue 6; November 2006

Should we screen men who have sex with men for anal intraepithelial neoplasia (AIN) just as we screen women for cervical introepithelial neoplasia (CIN)? Should anything be done about AIN if it is identified?
Robotically assisted colonic surgery: Has the time come?

Should we screen men who have sex with men for anal intraepithelial neoplasia (AIN) just as we screen women for cervical introepithelial neoplasia (CIN)? Should anything be done about AIN if it is identified?

In women, an association between high-risk HPV has been linked to the development of cervical cancer.  These high-risk types of human papilloma virus (16, 18, 31, 33, 35, 39, 45, 51, and 52) seem to predispose the development of what is known as a high-grade squamous intraepithelial lesion (HSIL).  It has been shown that statistically, about 36% of cervical HSIL’s progress on to an invasive cervical cancer over a 20 year period.1    Since screening for cervical cancer with ablative therapy has been done for high-grade HSIL, there has been a 78% reduction in the incidence of cervical cancer.2  There is a striking similarity between anal intraepithelial neoplasia (AIN) as a precursor to squamous cell cancer of the anus and cervical intraepithelial neoplasia (CIN) as a precursor to invasive cervical cancer.  Unlike cervical cancer, AIN has not been proven to be a precursor lesion to squamous cell cancer of the anus.  However, HPV DNA has been identified in 35 to 61 percent of squamous neoplasms of the anus1, suggesting a similar association and there is evidence that perianal Bowen’s disease is similar to anal HSIL and it is well established that Bowen’s disease is premalignant1.

Should anything be done about AIN if it is identified?

One approach to this problem favoring surveillance over intervention would point out that we currently have no acceptable way to cure dysplasia, so secondary prevention is impossible with current tools.3 The current data would suggest an exceptionally high recurrence rate of dysplasia approaching 100% by 50 months in the HIV population (which have 10 times the incidence of anal canal cancer over the general

population), regardless of any currently described modality of surgical therapy.3 In addition, even in the HIV negative population, after undergoing complete excision for Bowen’s disease (carcinoma in-situ), suffering complications such as stricture, ectropion, fecal incontinence, and often requiring extensive reconstruction, the recurrence rate has still traditionally been 25 to 50 percent.4 One would have to believe that the other less aggressive surgical modalities would have at least that high of a recurrence rate. One group recommends an algorithm of q 6 month surveillance with biopsies taken for suspicious lesions positive for even high-grade AIN-III with excision or chemoradiation only when actual invasive squamous carcinoma is identified.4 This considers the statistics once a patient gets invasive cancer from several phase II and III trials involving chemoradiation protocols for invasive anal canal cancer yielding colostomy-free survival rates in the range of 66 to 87 percent and overall survival rates ranging from 61 to 84 percent.5

Other proposed algorithms favoring intervention over surveillance have favored infrared photocoagulation of anal squamous intraepithelial lesions6, Pap smears of the anus with high resolution anoscopy with biopsy and cauterization of aberrant lesions1, and application of topical agents such as 5 Fluorouracil or Imiquimod.7 These proposals have noted that Bowen’s disease may progress to an invasive cancer 2-5% of the time7 and so some intervention should be considered, but they share the concern over the morbidity and high recurrence rate of the complete excision option. One paper suggests a 16-week regimen of topical 5-FU therapy after initial anal mapping biopsies for near circumferential AIN-3 with breaks in between for poor tolerance and follow up biopsies with mapping within one year. Out of 11 patients treated, all but one were completely free of any dysplasia at one year and also later at a mean follow up of 39 months. The one patient was HIV positive, placing him at a much higher risk for recurrent dysplasia regardless of any intervention. Imiquimod was suggested for lower grade AIN-1 or 2 lesions.

Ongoing study will be needed to determine the appropriateness of these proposed interventions and the surgeons at Colon and Rectal Care maintain an interest in the data available to help our patients with these problems choose the right path for them. For now, there does not seem to be a right answer, per se. However, one thing is clear, patients with high-grade dysplasia will, at the very least, require close supervision and a low threshold for biopsy of any abnormal lesions. 1Dis Colon Rectum 2002;45:453-458. 2Dis Colon Rectum 2000;43:346-352. 3Dis Colon Rectum 2006;49:36-40. 4Br J Surg 1999;86:1063-6. 5Dis Colon Rectum 2005;48(9):1742-51. 6Dis Colon Rectum 2005;48(5):1042-1054. 7Dis Colon Rectum 2005;48(3):444-450. Summarized by Joseph C. Muller, MD

Robotically assisted colonic surgery: Has the time come?

Robotically assisted surgical procedures are becoming more commonplace. The technology has essentially become the standard for prostatectomies, and has increasing usage for gynecology, urogynecology, thoracic and cardiovascular surgery. Recent data does suggest that its usage incolorectal surgery is feasible, but with inherent advantages and disadvantages.

Delaney et al, performed six robotically assisted colorectal cases between 2001 and 2002. Overall, there were no morbidities. There was, however, an increase in both cost and overall surgical time. They did note increased 3-dimensional visualization and dexterity. Braumann et al, studied its applicability in five patients with colorectal pathology. There were no morbidities, but there was difficulty with a lack of a large operative field and the need to dissect the flexures. They did note a great benefit with rectal dissection and pelvic visualization. Woeste et al, studied DaVinci (Robotic System) assisted colonic surgery in six patients (4 for Diverticulitis and 2 for Rectal Prolapse). They found NO difference in outcomes, morbidity or length of stay. There was, however, a significantly longer operative time.

Finally, Rawling et al, studied 30 consecutive colectomies performed with Robotic assistance between 2002-2005. There were 13 right colectomies and 17 sigmoid colectomies. The pathologies varied from cancer to unresectable polyps to diverticulitis.

They noted six complications in the study. These varied from a hip paresthesia, an anastomotic leak and a patient slipping off the operating room table. Overall, the length of operative time was longer but the length of stay was similar to standard laparoscopic surgery. The authors concluded that the procedure can be safely done with the assistance of the robotic system and recommended a large-scale trial to determine both feasibility and efficacy.

We at Colon and Rectal Care have been able to use the DaVinci Robotic system in selective patients with colorectal pathology. A total of three patients have been operated on to this point (One for a cecal polyp and two for rectal prolapse). Two out of the three had their operation completed with the Davinci system. We agree with the authors that the length of the operative time is certainly longer. However, the 3-dimensional viewing and dexterity is of great value. We especially find the system useful in the pelvic dissection in male patients and more importantly, being able to identify and preserve the hypogastric nerves that relate to sexual function.

Overall, these studies show that Robotic assisted colon surgery can be done safely and with good results. Issues related to operative time and cost certainly will play a large role in the eventual implementation of this technique. By no means do we feel standard laparoscopic surgery should be or will be replaced with this technique.

Our own experience has been positive and we continue to counsel and educate our patients on the various options for colonic surgery. Delaney. Dis Colon Rectum. 2003 Dec:46(12):1633-9, Braumann. Dis Colon Rectum. 2005 Sep; 48(9):182-7, Rawlings. Surg Endosc. 2006 Aug 28, Woeste. Int J Colorectal Dis. 2005 May; 20(3): 253-7.  Summarized by Shekar Narayanan, MD.

Colon and Rectal Watch; Vol. 5, Issue 5; September 2006

TEM now available in Indy: Avoids abdominal surgery and colostomy
What new options are available to treat Crohn's disease
Antegrade continent enemas for adults

TEM now available in Indy: Avoids abdominal surgery and colostomy

Currently, the transanal endoscopic microsurgery procedure (TEM) is indicated for rectal polyps (even very large ones) and T1 invasive cancers that are well or moderately differentiated as a technique for cure. 

On Friday, June 2, 2006, the first TEM was performed in the state of Indiana by Dr. Muller of Colon and Rectal Care, Inc.  For the treatment of mid and upper rectal polyps and earlier rectal cancers and for the appropriately chosen patient, the technique often enables an outpatient procedure with minimal postoperative discomfort when the only alternative may often require major abdominal surgery that sometimes may even involve a permanent colostomy. 

Most importantly, the data from at least two series demonstrates that this improvement in outcome can be achieved without increasing the likelihood of a tumor recurrence and without decreasing the 5-year survival rate for the patient. 

The key lies in appropriate patient selection, familiarity with the technique, and meticulous attention to detail to verify clear margins of the specimen.  The procedure involves using specialized equipment that includes an operating tube proctoscope that is inserted into the rectum through which instruments similar to those used in laparoscopic surgery can be used.  In this manner, lesions up to 25 cm above the anus may be excised, enabling pathologic confirmation of clear margins, determination of risk for local and distant spread, and estimating cure rates.  For older or debilitated patients who are not good candidates for extensive surgery for cure, this technique also offers another alternative for good local control for palliation.

Candidates are chosen based on endorectal or endoscopic ultrasound staging and lesion biopsy results as well as other clinical factors.   Despite the necessity of a proctoscope throughout most of the case, postoperative fecal continence is rarely affected. 

Studies have repeatedly demonstrated shorter operating times, less blood loss, shorter hospitalizations, and lower analgesic requirements after this surgery. Perhaps the most difficult step in providing this improved method of treatment for patients lies in letting patients and physicians know that this is now available. In our opinion, a patient with any type of growth in the rectum or lower colon that has not yet been definitively diagnosed as an invasive cancer, and who is considering undergoing a major abdominal surgery for treatment, should be evaluated to see if they are a candidate for the TEM technique. Patients that have an early stage cancer with favorable pathology characteristics on biopsy should also be evaluated.

Another very important role for this technique is completion excision of invasive carcinoma that first underwent piecemeal polypectomy using a colonoscope where cancer was then identified after the procedure.  Clean peripheral and deep margins after that situation is paramount for adequate staging and treatment planning to optimize outcome for the patient.

At Colon and Rectal Care we are excited to now offer this new technique to our patients as well as residents of Indiana and the surrounding areas.  We look forward to staying on the cutting edge to give patients with colorectal cancers the highest chance for survival and the best chance of successful treatment without the need for a colostomy.  We view any new technology that aims to advance either of these goals as a priority in our practice.  In addition, we carefully evaluate the efficacy and safety prior to offering any of these techniques to our patients.

If you believe you may have a patient or know of a patient that may qualify for this technique, you are encouraged to contact Colon and Rectal Care, Inc to discuss the case with one of the physicians to help determine candidacy. Dis Colon Rectum 2006; 49(2): 164-168.  Surg Endosc 2003; 17:1461-1463.   World J Surg 2001; 25: 870-875.  Dis Colon Rectum 2002; 45(5): 601-604.  Cancer Supplement 1992; 70(5): 1355-1363.   Dis Colon Rectum 2001; 44(9): 1345-1361

What new options are available to treat Crohn's disease

Crohn’s disease is a chronic disorder that causes inflammation of the digestive tract.  It can involve any area of the GI tract from the mouth to the anus.  It most commonly affects the small intestine or colon.  The disease is characterized by persistent diarrhea, crampy abdominal pain, fever, and at times, rectal bleeding.  Patients will go through periods in which the disease flares up, and times in which the disease decreases. 

Complications of the disease include intra-abdominal complications and anorectal complications.  Abdominal complications include abscesses, enterocutaneous fistulas, entero-enteric fistulas, and strictures leading to obstructions.   Anorectal complications include abscesses, fistulas, and fissures. 

Because there is no cure for Crohn’s disease, the goal of treatment is to suppress the inflammatory response.  Several different groups of drugs are used.  Aminosalicylates are used mainly for mild disease.  They do not have a role in maintenance therapy.  

Corticosteroids are often used to treat moderate to severely active disease.  Unfortunately, they have significant long-term side effects, and should not be used as a maintenance medication.  Immune modifiers, such as Azathioprine, are used to help decrease steroid usage and can help maintain remission. 

Biological therapies, such as Infliximab, are a newer class of drugs.  They are often utilized in patients who are not responding to other therapies.  Infliximab is also effective in treating fistulous disease.  Unfortunately, as Infliximab is manufactured from mouse proteins, patients can develop antibodies against the medication.  Over time, the medication also can lose effectiveness.

A new biologic agent, Adalimumab, is now available. This medication has recently completed evaluation for treating Crohn’s disease.  This agent is manufactured from human antibodies, so only 1% of patients treated developed antibodies against this medication.  In the difficult to manage patients who have been refractory to standard therapy, Adalimumab effectively induced remission in 39% of patients.  This is comparable to the historical rates achieved by Infliximab. 

At Colon & Rectal Care, we are excited about this cutting edge therapy directed towards Crohn’s disease.  We expect that the role of this drug will be in patients who are no longer deriving benefit, or are unable to take Infliximab due to intolerance.    Gastroenterology.  2006; 130(2) 323-33.   

Antegrade continent enemas for adults

Slow transit constipation in adults can be difficult to treat and often causes great discomfort.  Total colectomy is often offered but is associated with persistent constipation up to 20% of the time.  Recent long-term data is now available regarding the minimally invasive antegrade continent enema (ACE) in adults.

The ACE procedure is performed laparoscopically.  Through these small incisions, the native appendix is brought through the abdominal wall and tunneled subcutaneously.  The tip is then opened.  This opening allows introduction of a small catheter, which is used to irrigate the colon on a regular basis. This lavage facilitates complete emptying of the colon, preventing the symptoms of severe slow transit constipation.  

At 5 year follow up, 60% of patients maintained function of the ACE.  These patients demonstrated satisfactory improvement in bowel function and showed significant improvement in quality of life scores. 

At Colon & Rectal Care, this technique has been utilized successfully for years in patients with severe constipation.  We also utilize the predictive nature of this technique to manage selected patients with fecal incontinence.  Poster presentation ASCRS Conference 2006.

Colon and Rectal Watch; Vol. 5, Issue 4; July 2006

Highlights from the 2006 American Society of Colon and Rectal Surgeons meeting -
Rectal cancer
Anastomic leaks
Striving to improve quality care
Colorectal lymphoma: Rare but increasing in incidence

Highlights from the 2006 American Society of Colon and Rectal Surgeons meeting -

The annual American Society of Colon and Rectal Surgeons meeting was recently held in Seattle. Below are highlights of some of the extremely important directions colon and rectal surgery is moving toward and how we at Colon and Rectal Care are spearheading these movements for the Indianapolis community.

Rectal cancer

Several studies focused on the recurrence rates for transanal excision of early rectal cancer. What was most disturbing was the increasing rate of reported local recurrence (18-24%). Schochet et al reviewed their 10-year follow up of Transanal Excision (TAE) for T1 and T2 cancers. In addition, they analyzed those patients who received adjuvant radiation and/or chemotherapy. Their data once again showed an unacceptably high recurrence rate. Their local recurrence rate was 18/33% respectively for T1/T2 lesions. It was also alarming that those patients treated with adjuvant therapy had a recurrence rate of 30%. This has prompted many to challenge current surgical technique.

Transanal Endoscopic Microsurgery (TEM) was the most talked about modality change at this years meeting. Dixon et al. reviewed the data regarding a comparison between traditional transanal excision (TAE) and TEM. Over a 6-year period of time they had 102 patients with either a T1 or T2 rectal cancer that underwent either a TAE or TEM. The follow up rate was around 4 years for both groups. They found a recurrence rate of 20% for the TAE group and a 0% recurrence rate for the TEM group. These two studies show that TEM is the most promising new development for early rectal cancer. We at Colon and Rectal Care are proud to be the first group to offer this surgery in Indianapolis. We now consider this to be standard of care for patients with early stage rectal cancer (T1 only) and who do not have negative tumor characteristics. Dixon et al. Podium Presentation. ASCRS annual meeting. 2006, Schocet. Et al. Poster Presentation. ASCRS annual meeting. 2006. Buess. Expert Pane. ASCRS annual meeting 2006 Summarized by S. Narayanan MD

Anastomic leaks

Anastomotic leaks are the most feared complication for colon and rectal surgeons. Incident rates range from 3-10%. Low rectal cancers treated with pre-operative chemotherapy and radiation often require a temporary ileostomy. Several studies used different augmentation materials to try and determine if these would decrease these leak rates and potentially eliminate the need for temporary diversion. Madbouly et al randomized 108 patients to receive oxidized cellulose anastamotic reinforcement in low rectal cancer and they found statistically different leak rates between the reinforced group vs. the non-reinforced group (7 vs. 12%). They hypothesized these were related to a decreased incidence of a local hematoma. Hagerman et al, used bovine pericardium in a canine model to buttress colorectal anastamosis and determine burst/tensile strength. They found the unbuttressed anastamosis was likely to burst at the anastamosis (63%), whereas the buttressed anastamosis was more likely to burst the adjacent tissue (75%). Hunt et al, used alloderm to reinforce 20 colorectal anastamosis in a porcine model. Compared to controls, they found statistically significant differences in burst pressures, and leak rates. They did note a statistically significant difference in luminal size secondary to the fibrosis of the alloderm but NO evidence of structuring.We at Colon and Rectal Care are pleased to have an anastamotic leak rate much lower than the reported average. However, we continue to monitor the data and clinical trials in hopes of eliminating this complication. Madboull. Podium Presentation. ASCRS annual meeting. 2006, Hagerman. Poster Presentation.. ASCRS annual meeting 2006, Hunt. Poster Presentation. ASCRS annual meeting 2006 Summarized by S. Narayanan, MD

Striving to improve quality care

Several other papers and posters showed the societies desire to improve the quality of care for those patients afflicted with colorectal disorders. New treatment strategies were presented in treating anal fistulas, diverticulitis, large colon polyps and improvement in our Laparoscopic colon operations. We at colon and rectal care share the societies vision and desire to improve quality of care for those patients with colorectal disorders. Summarized by S. Narayanan, MD

Colorectal lymphoma: Rare but increasing in incidence

p>Although uncommon, colorectal lymphoma is an important clinical entity to consider. Lymphoma is the sixth most common cause of cancer death in the United States with the gastrointestinal tract being the most common site outside of the lymph nodes. 15-20% of gastrointestinal lymphomas are found in the colon or rectum. Statistically, 1.4% of all non-Hodgkin’s lymphomas are colorectal lymphoma. Overall, they comprise less than 1% of all colorectal cancers.

Diagnostic criteria for this entity involves lymphoma in the absence of systemic disease occurring in the colon or rectum that meets the following criteria: 1) the absence of clinically enlarged lymph nodes on physical examination, 2) the absence of enlarged mediastinal lymph nodes on chest x-ray or CT scan, 3) normal hematologic laboratory values and bone marrow biopsy, 4) normal-appearing liver and spleen, 5) no CT evidence of retroperitoneal lymphadenopathy.

Since definitive therapy is usually chemotherapy, the faster growing and more aggressive tumors often have the better prognosis because they respond better to chemotherapy. The most common type is diffuse large B-cell lymphoma that is usually quite aggressive. Other varieties include MALT-associated low grade B-cell lymphoma, Mantle cell lymphoma, Burkitt’s lymphoma, and follicular lymphoma. T-cell, and Hodgkin’s type are very rare.

More than 70% of colorectal lymphomas are found proximal to the hepatic flexure. The most common presenting symptoms are abdominal pain and weight loss, although up to half may present with an abdominal mass, leading observers to believe the patients may remain asymptomatic for quite some time. Clinically or pharmacologically immunosuppressed patients are at particular risk for developing this entity. Radiographic, endoscopic, and pathologic findings can vary markedly and are usually non-specific, although lymphoma is most often large and polypoid. In addition, radiographic findings of colorectal lymphoma can mimic Crohn’s disease or ulcerative colitis. This emphasizes the importance of colonoscopic evaluation with biopsies that are often diagnostic or can rule out lymphoma.

As with most cancers, treatment involves surgery, chemotherapy, and or radiation. However, in this disease, combination chemotherapy plays a primary role with surgery being necessary to improve outcomes through local control to reduce recurrence rates. Similarly, external beam radiation is helpful for adjuvant local control, but is not preferred in lymphomas of the small or large bowel due to the potential for major complications in this area.
Prognosis varies depending on tumor type and whether or not disease has spread to any of the lymph nodes. One report indicated that 14-24% of patients in their series had no tumor involvement outside the primary organ and that this was associated with an 83% 10 year survival. They also noted a 74% local or disseminated relapse rate in the portion of this sub-group of patients receiving surgery alone, strongly emphasizing the importance of chemotherapy in the treatment protocol. Nonetheless, considering all patients with colorectal lymphoma, despite the option of salvage chemotherapy for recurrence, 33-75% of patients will have a relapse and most of them will die of this disease. Our experience at Colon and Rectal Care reflects what is seen in the literature in terms of the relative infrequency of this disease process and the typical presentation. The importance of early identification through colonoscopic surveillance as illustrated by the above statistics cannot be overemphasized (screening flexible sigmoidoscopy will miss over 70% of these). Also, the necessity of a careful multimodality approach established through close interaction with our medical oncology colleagues is instrumental to optimize outcomes with this disease. Dis Colon Rectum 2000;43:1277-82. Clinics in Colon & Rectal Surgery 2006;19:49-53. J Clin Gastroenterol 1994;18:291-297. J Surg Oncol 2002;80:111-115. Summarized by Joseph Muller, MD

Colon and Rectal Watch; Vol. 5, Issue 3; May 2006

What new options are available to treat ulcerative colitis
Polythylene Glycol and its carcinopreventive effect
Improved results with transanal resection of rectal cancer
New option for treating anal fistula

What new options are available to treat ulcerative colitis

Ulcerative colitis is characterized by remissions and exacerbations of colitis associated with abdominal cramps, rectal bleeding, and diarrhea.  The disease usually affects patients in their youth or early middle age and can have devastating short and long-term effects.  There is no specific medical cure, although medical therapy may control exacerbations. 

Traditionally, medical therapy starts with mesalamine products for maintenance therapy as well as for treating acute attacks.  Should this fail oral corticosteroids are often added.  Failure of oral steroids to control the acute attack often leads to inpatient admission with the administration of intravenous steroids and gut rest.  Often, failure of these medications to adequately control the disease flare leads to surgical resection. 

Infliximab, a monoclonal antibody directed against tumor necrosis factor alfa was released several years ago.  It became an established treatment for Crohn’s disease.  In fact, it often effectively induced and maintained remission for prolonged periods of time in many patients with refractory Crohn’s disease.  These successes led to limited trials of Infliximab to treat refractory ulcerative colitis.  These initial studies produced equivocal results.  However, all of these studies were limited by extremely small sample size. 

Recently, two large prospective, randomized, blind studies evaluated use of Infliximab in moderate or severe, active ulcerative colitis.  Both studies demonstrated a significant clinical response in patients with severe, refractory ulcerative colitis. At eight weeks, 65% of patients demonstrated clinical significant clinical improvement (versus 29% in the placebo group).  One-year follow up demonstrated that this improvement was maintained in 45% of patients (versus 20% in the placebo group).  Further study to evaluate the long-term maintenance of remission is still needed.  At Colon and Rectal Care we have been using Infliximab in patients with refractory ulcerative colitis for several years based on the preliminary, smaller studies with comparable results to the most recent studiesRugeerts P.  N Engl J Med.  2005.  353(23):  2462-76.  Summarized by A. Gowdamarajan, MD

Polythylene Glycol and its carcinopreventive effect

Polyethylene Glycol 3350 (Miralax, Glycolax) is commonly used as a laxative in preoperative bowel preparation for colonoscopy.  PEG 3350 in smaller doses is also used to treat constipation.

PEG 3350 is an iso-osmotic laxative and works by decreasing water absorption from stool thus retaining water in colon. On the other hand, laxatives such as Lactulose, Magnesium sulfate and Sodium Phosphate withdraw water into the bowel lumen secondary to hyperosmotic luminal contents.

High molecular weight polyethylene glycols such as PEG 3350 are physiologically inert and are not absorbed to any significant degree, metabolized or fermented in the colon.   They do not have any known systemic toxicity and generally considered safe.

Intestinal absorption of oral polyethylene glycol is minimal. Only 0.01 and 0.51 % of the ingested PEG3350 is absorbed.  Inflammatory bowel disease may alter the intestinal permeability and thus theoretically can increase the amount of absorption of this polymer.  Recent studies however fail to confirm this assumption.

Polyethylene glycol delays gastric emptying although it accelerates the orocecal transit. This effect on gastric emptying may explain the occasional problem with nasea and vomiting with its use. Tegaserod, a HT4 antagonist may counter the delayed gastric emptying effect of PEG 3350, thus preventing nausea.  At the same time, it potentiates the colokinetic effect. In patients with diabetic gastroparesis, PEG3350 may not be tolerated well.  There may be a potential side-benefit from the use of PEG3350 in constipation.

Polyethylene Glycol with molecular weight between 3350 and 12000   inhibited azoxymethane-induced aberrant crypt foci, a precursor for colorectal cancer.

The number of colon carcinomas decreased twenty fold, and the incidence 10-fold, in animals treated with oral polyethylene glycol.  Mode of carcinopreventive effect of PEG is not known but hypothesized to be secondary to its mechanical lubricating effect as well as direct effect on colocytes.  In animal experimentations, PEG leads to a significant concentration-dependent induction of apoptosis in almost 50% of cells exposed to PEG. This suggests that induction of apoptosis may be a significant mechanism active in the carcinopreventive effect of PEG.  Even a short course of PEG for three days seemed to be effective in reducing the cancer-precursor lesions such as colonic aberrant crypt foci.

Since PEG 3350 is tolerated well, has minimal systemic side effects, and is tasteless and odorless.  We use PEG 3350 for management of constipation in most with both slow transit and normal transit constipation. Cancer Res.   2000  60:3160, Cancer Res.  1999   59:5143, Z Gastroenterol.  2006  44:167,  FEBS Lett. 2001  496:143 Summarized by R.M. Jager, MD, PhD

Improved results with transanal resection of rectal cancer

Transanal (local) excision of superficial rectal cancers offers patients a sphincter preserving procedure with less morbidity than a more radical trans-abdominal approach.  Unfortunately, standard trans-anal techniques have been plagued by an unacceptably high recurrence rate of 15% for the earliest of rectal cancers.  This is significantly higher than the expected recurrence rate of 3-5% utilizing trans-abdominal techniques in similar patients.  Trans-anal endoscopic microsurgery is a technique, which may be superior to the standard approach

Until recently, there have been no randomized studies comparing TEM with traditional local excision or with radical resections since very few centers have access to the specialized equipment required to perform TEM.

Recently, some data with long-term follow up is showing the superiority of TEM versus standard local excision.  One study with pT1 lesions and a mean follow up of 2.84 years demonstrated a local recurrence rate of 11%.  These patients underwent surgical therapy only.  Another recent study with five-year follow up demonstrated a local recurrence rate of 8.6%.  The patients only had surgery as well.  One recent study compared TEM with radical surgery in a randomized fashion for patients with T2 lesions.  These patients, however, all underwent preoperative chemotherapy and radiation therapy.  This study demonstrated a local recurrence rate of 5% in both groups with a minimum of 3-year follow-up.

At Colon and Rectal Care, we have recently obtained the equipment to utilize this technique.  We believe in selected patients with rectal cancer, and most patients with rectal polyps, this technique will greatly improve outcomes in a less invasive way.   Surg Endosc.  2005. June. 19 (6). 751-6. Surg Endosc. Feb.  (epub).  Dis Col Rectal 2006.  Feb.  49 (2) 164-8. Summarized by A. Gowdamarajan, MD

New option for treating anal fistula

The treatment goals in anal fistula surgery are to eliminate the fistula, prevent recurrence, and preserve anorectal function.  With complex fistulas involving large amounts of the sphincteric complex, a fistulotomy may not be an appropriate choice as it can lead to fecal incontinence.  Other alternatives, such as mucosal advancement flaps, are extensive operations associated with a fair amount of discomfort.  Recently, a technique utilizing a bioprosthetic plug has been introduced.  This plug is sutured into the internal opening of the fistula.  A recent study demonstrated excellent results in 15 patients with a healing rate of 87%.  This study is hindered by a small sample size, and short (3 month) follow up.  At Colon and Rectal Care we have been using this technique for the last 12 months with good results.  We believe that this technique is important because it can often allow effective treatment of complex fistulas without impacting on continence.  JohnsonDis Colon Rectum.  2006, 49(3):  371-6. Summarized by A. Gowdamarajan, MD

Colon and Rectal Watch; Vol. 5, Issue 2; March 2006

Clostridium difficile colitis on the rise
What is the first line of surgical therapy for fecal incontinence and who can expect improvement in their symptoms?
New Surgical Technique for Pilonidal Fistulas

Clostridium difficile colitis on the rise

At the recent American college of surgeons meeting, data was presented that suggests that the incidence and severity of C. Difficile Colitis is on the rise. Dr. Ricciardi et al, studied data from 7 million hospital stays per year, in 1000 hospitals in more than 30 states. He found 300,000 cases of C. Diff Colitis from 1999-2003. Nearly 22% were the primary cause of admission. This was a statistically and clinically relevant rise in both primary admission as well as secondary diagnosis over previous studies. This data has been replicated by smaller studies done in Pennsylvania, Oregon and Quebec.

More concerning is the aggressiveness of the disease. There was a 7.8% case fatality rate noted in 1993, which rose to 9.3% in 2003. In addition, the mortality rate per 100,000 discharges increased from 20 to greater than 50. Finally, the colectomy rate rose 300% with the largest jump between 2000 and 2003. The surgical mortality rate remains at 50%. Dr. Ricciardi’s data shows that the disease has evolved over the past 10-15 years. In this, the CDC has finding to suggest that the epidemiology of the disease has changed. Now close-contact transmission, high recurrence rate, bloody diarrhea and LACK of antimicrobial exposure should all be part of the potential pattern of C. Diff colitis.

What is most concerning is the CDC’s report from March of 2005 regarding 33 patients. Eight of those patients had no exposure to antibiotics. Tragically, a 31-year-old female who was 14 weeks pregnant with twins died from the disease despite maximal medical management and surgery. Her ONLY exposure had been a dose of Bactrim 3 months prior to the onset of diarrhea. We at Colon and Rectal Care have seen this type of increase regionally as well. Data from Dr. Ricciardi as well as from a local hospital show that aggressive surgical management should not be used as a last ditch effort. Working with our gastroenterolgy and infectious disease colleagues, we continue to aggressively investigate all patients who complain of diarrhea even with a negative stool test. Bates. Surgery News. Vol. 2. No. Feb. 2006. MMWR 2205; 54:1201-5 Summarized by S. Narayanan, MD

What is the first line of surgical therapy for fecal incontinence and who can expect improvement in their symptoms?

Fecal incontinence is a major cause of reduced quality of life for patients, in particular, women who have previously given birth vaginally.  Only recently has it become more common and popular for patients to open up to their physicians and admit these symptoms in hopes there are some viable options for them.  Sphincteroplasty is a technique that involves surgical entry over the perineal body, dissection of the rectovaginal septal scar, surgical reapproximation of the functional muscle fibers, and drainage to minimize postoperative infection.  The success rate seems to vary from one study to the next, but some patterns for better outcomes do emerge after reviewing the available literature. 

First of all, proper diagnosis with appropriate physiology testing performed by experienced individuals appears to prevent patients from undergoing inappropriate therapy about twenty percent of the time.  In a patient with compromised anorectal function, the wrong intervention could easily and unnecessarily further deteriorate their quality of life.  Findings during the ultrasound portion can also be helpful, anatomically, at the time of surgery.

Since postoperative infection has been linked to chronic poor wound healing and reduced procedural success, some individuals have proposed the idea of performing temporary fecal diversion with either a colostomy or ileostomy.  In comparing two groups, with and without diversion, the morbidity was clearly higher in the diverted group.  Similarly, the medically constipated patients had a higher incidence of postoperative fecal impaction and discomfort with noreduction in infection or improvement in final outcome.  Therefore, we generally do not perform either and patients are allowed to eat soon after their procedure. The data on whether patients fare better with sphincteroplasty when they are younger or older suggests improved outcomes in the younger patients but not to such an extent to discourage the procedure in the elderly.  Age related changes occur in the anal canal musculature such as increased fibrosis, deposition of collagen, and reduction in sensation, which is of paramount importance in the overall continence mechanism.  This emphasizes the need for both preoperative and postoperative biofeedback to optimize outcomes, especially in the elderly since strengthening and improvements in sensation thresholds are often both achieved with this modality.

What to do with the patient who has undergone surgical sphincteroplasty and still has a problem relies heavily on their improvement soon after their surgery and their physiology testing results before their first surgery compared to the results at the time of the re-evaluation.  Counter intuitively, results of “Re-do sphincteroplasty” are actually better than one might expect in the patients who were appropriately stratified at their initial presentation and who had any improvement after their first surgery.  Even after a second or third surgery over many years, the results are often markedly successful even 60% of the time.

That brings us to a final point of consideration.  What is the success rate?  Statistics are hard to define by the literature since the definition of success varies so markedly from one study to the next. 

Overall, however, there does seem to be general agreement that up to half of the patients with initial improvement that persists out to the three year mark, have return to baseline after ten years from their surgery.  With the success rate of repeat procedures, however, this factor is not as grim as it might initially seem.

At Colon and Rectal Care, we believe strongly in thebenefits of biofeedback therapy and physiology testing for fecal incontinence, but sometimes that is not enough. Artificial bowel sphincter is an option for some, but the first line surgical therapy remains sphincteroplasty.  Our results seem to reflect what is seen in the literature and many of our patients report substantial improvements in their function and quality of life after this procedure. Clinics in Col Rec Surg 2005;18(1):22-31.  DCR 2004;47:(727-31.  DCR 1997; 40: 197-200.  Brit Jourl Surg 1996; 83: 502-505. Summarized by J Muller, MD

New Surgical Technique for Pilonidal Fistulas

Pilonidal fistulas are a common yet challenging surgical problem. Though healing times are much quicker, traditional horizontal-vertical excision with primary repair has yielded recurrence rates ranging from 10-35%. Those who chose to leave the wound open for secondary intention closure had recurrence rates closer to 4-10%, however, the closure times could take up to 3 months. Mentes et al, described their technique of oblique excision and closure. From 1999-2001, 493 patients underwent surgical excision. Using the oblique method, the sinus and tract were removed and permanent sutures were placed.

The surgeons allowed 20 days for “resting” and sutures were removed after two weeks time at which full activities were allowed. They encouraged the use of a depilatory cream once monthly. The authors found a recurrence rate of 5.6% at 18 months and re-operated on one patient. The authors were unable to find a correlation to obesity, age, and previous history of abscess or the use of antibiotics in preventing recurrence.

We at Colon and Rectal Care find this data quite interesting. We have had previous success with a technique of lateral excision but continue to strive for improvement in outcomes. Therefore, a limited trial may be forthcoming to determine the efficacy of this novel approach. Mentes. Et al, DCR. Jan. 2006. (1); 49; 104-108 Summarized by S. Narayanan, MD

Colon and Rectal Watch; Vol. 5, Issue 1; January 2006

Have Barium Enemas Become Obsolete?
Is there a role for sentinel lymph node mapping for colon cancer?
Is Neoadjuvant Therapy better than Adjuvant therapy for rectal cancer?

Have Barium Enemas Become Obsolete?

Colonoscopy remains the diagnostic and therapeutic gold standard for evaluation of the colon.  The reliability of endoscopic evaluation is limited by the 4% rate of incomplete colonoscopy.  In this setting barium enema is the most commonly ordered test. 

A recent study demonstrated that barium enemas have a successful completion rate of 77% when performed immediately after failed colonoscopy.  Another study demonstrates a sensitivity of only 48% for barium enema. 

Initially, CT colonoscopy was greeted with great enthusiasm.  Early studies claimed sensitivities approaching that of colonoscopy.  Unfortunately, more recent studies have demonstrated a sensitivity of 55-80%. At Colon & Rectal care we believe that colonoscopy remains the best test for screening.  On the occasion that colonoscopy is incomplete, or inadequate, we prefer to refer our patients for CT colonoscopy.  We feel that recent studies have demonstrated that barium enemas have a very limited role in colon cancer screening. Lancet 2005, 22-28;365(9456):305-11. N Engl J Med 2005 .4;349(23):2191  Summarized by A. Gowdamarajan, MD

Is there a role for sentinel lymph node mapping for colon cancer?

Sentinel lymph node mapping has become an integral part of the management for many patients with breast cancer and melanoma.  Cancer typically spreads once there is breach of the basement membrane or “lymphovascular invasion”.  The spread usually occurs by local spread, lymphatic spread, via the bloodstream, or some combination of these.  Lymphatic spread in certain areas of the body occurs via an established pattern first to a particular lymph node that serves that given drainage area.  Flow then continues on to other lymph nodes in the regional lymph node basin and then on to more proximal nodes.  It has been shown that, at least for cancer of the breast and melanoma, the predictability of first spread to a single nearby node is very high. 

In other words, for cancer to spread anywhere via the lymphatic system, it must first pass through the “sentinel lymph node”.  Therefore, if that node is identified and thoroughly examined for the presence of any metastatic disease, if it is negative, there is an extremely high likelihood that no lymphatic spread has occurred.   For example, in melanoma, current estimates are that the sentinel node will reflect the status of the entire nodal basin in 98-99% of cases.  This likelihood is so high, that any further lymph node resection in that clinical circumstance is not warranted.   As a result, the technique of sentinel lymph node mapping and dissection has spared many patients the morbidity and reduction in quality of life associated with full axillary or groin nodal dissections.

Applicability of sentinel lymph node mapping has been tested in many other forms of cancer management, including adenocarcinoma of the colon.  A recent study looked at 41 patients with intraperitoneal colon cancer and performed sentinel lymph node mapping with blue dye only on these patients.  They found that out of the 32 percent of patients who had any positive lymph nodes, one patient had a sentinel node only that was positive and 9 patients had negative sentinel nodes despite the presence of other nodes that were positive.  Therefore, in this study, sentinel node mapping would have benefited only 3 percent, and failed to accurately identify nodal disease in 24 percent of the patients.  Other studies have revealed similar findings to question the accuracy of sentinel lymph node mapping in colon cancer.

Another study from Japan looked at 56 patients with curatively resectable colon cancer and performed sentinel lymph node mapping, but instead of blue dye, they used endoscopic injection of technetium 99m-labelled tin colloid injected, preoperatively.  Conversely, they encountered a 100% detection rate and diagnostic accuracy with this technique for their 29% of patients with T1 or T2 primary tumors.  They also found that, in colon cancer, their average number of “sentinel” nodes was not one or two, but 3.5.  The node distribution was also a bit less predictable with 78% of the sentinel nodes being found in the paracolic nodes only, 22% of patients having at least one sentinel node in the intermediate nodes, and 6% only in the intermediate nodes.

The authors conclusion from the Japanese study above was that lymph node resection using radioactive tracer is an effective lymph node navigator for both staging and treatment.  Although this may be true, there is no general increase in morbidity by removing the associated mesentery with a colon specimen at surgery, like there is by removing axillary or groin lymph nodes in melanoma or breast cancer.  Plus, there is now evidence in the literature that overall survival improves with increasing number of lymph nodes retrieved in the colonic resected specimen, even in node negative patients!  And finally, there would not be any change in the surgical management at the time of surgery based on the results of sentinel lymph node mapping or biopsy.  Prior studies have shown that an occasional aberrant lymphatic channel such that some lymph drainage could occur outside of the normal oncologic resection borders does exist.  However, this would not justify accepting the higher morbidity of a total colectomy for the statistically minimal oncologic benefit.  Thus, based on the available data now, the surgeons at Colon and Rectal Care do not currently practice sentinel lymph node mapping for colon or rectal cancer at this time.  We continue to evaluate new data as it becomes available on this issue. Dis Colon Rectum 2005;48:74-85. Adv Surg 2003;37:71-94. Dis Colon Rectum 2002;45:1476-80. Semin Surg Oncol 1998;14:283-290. Summarized by J. Muller, MD

Is Neoadjuvant Therapy better than Adjuvant therapy for rectal cancer?

Multimodality treatment is the preferred approach to treating low rectal cancers.  Some controversy existsregarding the optimum timing of chemotherapy and

radiation therapy; the data does not demonstrate a clear advantage in survival between adjuvant (postoperative) or neoadjuvant (preoperative) therapy.  

Proponents of adjuvant therapy cite the advantage of avoiding over-treatment as the decision to treat is based upon the final pathologic stage.  This approach avoids exposing patients unnecessarily to the toxicities of the therapy.   Also, patients receiving postoperative chemoradiation have a decreased rate of operative complications when compared to patients undergoing neoadjuvant therapy.

The primary advantage of preoperative therapy is the decrease in long-term complications from the radiation therapy; in patients undergoing neoadjuvant therapy, the radiation-damaged rectum is removed at the time of surgery.  Several recent studies have demonstrated that use of preoperative therapy results in significant reduction of tumor size and downstaging.  This allows for a higher rate of sphincter sparing operations in these patients with good long-term oncologic results.

Several recent studies have demonstrated that use of neoadjuvant therapy nearly doubles the surgeon’s ability to perform a sphincter saving operation.    The primary reason for this was the marked reduction in tumor size post-therapy.  In fact, up to 15% of the patients did not have any residual tumor on their final pathology; this finding was associated with the best long term results. At Colon and Rectal Care, we believe that rectal cancer therapy requires a team approach.  Cooperation and excellent communication between colon and rectal surgeons, medical oncologists and radiation oncologists provides the best oncologic results.  In our practice, we tend to favor neoadjuvant therapy in patients who are staged preoperatively as Stage II or Stage III.  We also utilize neoadjuvant therapy in select Stage I patients to optimize sphincter preservation.  Hepatogastroenterology. 2004;51(60):1703-7.  Eur J Surg Oncol. 2005 Nov 10 (epub). Ann Surg. 2001;234(5):633-40. Summarized by A. Gowdamarajan, MD

Colon and Rectal Watch; Vol. 4, Issue 10; October 2005

Should endoanal ultrasound be mandatory prior to fistula surgery?
Cecal diverticulitis: Surgical or medical problem?
Anorectal foreign body insertion

Should endoanal ultrasound be mandatory prior to fistula surgery?

Anal fistulas represent a complex issue due to factors related to recurrence, number of operations and incontinence. Delineating the primary tract and internal opening are paramount to success. Two recent studies have suggested that the use of endoanal ultrasound increases accuracy and thus overall success.  Ratto et a. studied 102 patient with anal fistulas. All underwent pre-operative endoanal ultrasound with the use of hydrogen peroxide. The results showed a 94% accuracy rate with ultrasonic images and findings at surgery. 94% of the primary tracts were identified and 91% of the internal openings were identified. Overall there was a 98% success rate and no patients with fecal incontinence. The authors recommend routine ultrasonographic imaging of fistula with improved surgical outcomes, and decrease recurrence and incontinence rates. Pascual et al, use ultrasound to identify the fistulas tract in 83 patients. They found 33% to be intersphincteric, 46% transphincteric, 4% suprasphincteric and 16% extra-sphincteric. There was 100% accuracy with surgical finding, and the internal opening was found in 96% present. Navarro- Luna studied 94 patients using anal ultrasound and hydrogen peroxide. In 85% the finding coincided with surgery. The internal opening was found in 94% but the most important aspect was that in 95% the tract was able to identify curvilinear vs. linear tracts. These studies emphasize the critical value of ultrasonography in the management of anal fistula. At Colon and Rectal Care, we have adopted ultrasound with peroxide as the standard for assessing fistula pathways and have comparable results. Ratto. Endosopcy 2005. Pascual. Rev. Esp. Enferm. Dis. 2005. Navarro-Luna. DCR. 2005 Summarized by S. Narayanan, MD

Cecal diverticulitis: Surgical or medical problem?

Sigmoid Diverticulitis is a common problem affecting the western world. Although Cecal diverticulitis is rare patients continue to present to emergency rooms and primary physicians with complaints of right-sided abdominal pain. With CT scanning becoming more standard, an increase in cecal diverticulitis is becoming more apparent.

Several studies have analyzed the ideal treatment. Hildebrand et al, found over an 8-Year period 12 cases of cecal diverticulitis treated surgically among 481 diverticular patients. There were no post-operative complications. However, the authors concluded that cecal diverticulitis should be treated conservatively until complications arise, as in sigmoid diverticular disease. Papaziogas found 8 cases over a 25-year period of time. They performed a divertuculectomy in 5 patients. They found this simple and with no morbidity or recurrence. They recommend this approach as a standard treatment. The largest series comes form Fang et al. They had 85 patients over an 18-year period. They found <40% of patients treated conservatively successfully avoided surgery. The authors recommended an aggressive approach in treating patients with cecal diverticulitis. Chiu et al, found intra-operative cecoscopy a valuable technique. 5 patients with suspected appendicitis were found to have an inflammatory mass of the right colon. Rather than subjective the patient to an immediate colectomy for possible neoplasia, a bronchoscope was introduced into the appendix and diverticulitis found. They recommended conservative treatment with antibiotics in this setting and NO resection. In an extensive literature review of this subject the data is NOT standard.Due to low population base for this disease, we at Colon and Rectal Care believe an individualized approach is a must in dealing with this problem. Patient symptoms, endoscopy and radiologic studies all impact decision-making. Certainly, patients with large wide mouth divertculi and an episode of disease may be good candidates for laparoscopic resection. Fang et a. Am J  Surg. 2003. Hildebrand et al. Zentalk. Chir. 2005. Papaziogas et al. Int. J Colorectal Dis. 200. Chiu et al. DCR. 2002 . Summarized by S. Narayanan, MD

Anorectal foreign body insertion

Rectal foreign bodies are often a topic of amusement upon presentation in the emergency room.  There is usually a story given by the patient pertaining to the circumstances surrounding their presentation.  Often, the credibility of the story is limited at best.  Unlikely claims such as “I slipped and fell in the shower” are fairly frequent.

The likelihood of obtaining an exaggerated or completely false history is high.  Nonetheless, it is worthwhile and important to gain as much information as possible.  Expressing the unlikely but potential extensive morbidity associated with extraction is frequently enough to motivate the patient to be a bit more truthful.  Details of the size, shape, texture, and technique used for insertion as well as actual elapsed time since insertion may be very important in the decision making for extraction.

Most rectal foreign bodies are able to be extracted transanally without a laparotomy or the requirement for colostomy.  Although it is possible to extract many of these foreign bodies in the emergency room, profound and involuntary anorectal muscular spasms will often make this quite difficult and painful.  It may also risk unnecessary further trauma to the anorectal musculature and anoderm.  This ultimately could lead to temporary or even permanent diminished anal sphincter function, depending on the patient’s baseline functional status.  A frequent circumstance is the development of proximal negative air pressure behind the foreign body within the rectum, which creates a tremendous suction effect and works against the majority of extraction techniques.  Insertion of a foley catheter around the object, if possible, with insufflation of air proximal to the object can sometimes facilitate extraction by reversing this phenomenon.  In addition, the foley balloon can be filled and used to create antegrade pressure, further facilitating extraction in some cases.

Although most rectal foreign bodies are removed without incident, great respect must be given to those objects, such as glass bottles and light bulbs, which can break and cause severe injuries upon extraction, especially if handled aggressively.  For many reasons, it is also common for patients to have a delayed presentation.  These patients may be markedly dehydrated, have electrolyte imbalances, and may have developed appreciable pressure necrosis of the rectum or sigmoid colon.  It is also not all that uncommon for there to be more than one foreign body and for it to be quite a bit different than anticipated by the patient’s history.  As a result, all rectal foreign bodies must be assumed to be a possible “worst case scenario” and therefore treated appropriately.  This involves atraumatic extraction, usually in the operating room or in the ER, with the assistance of conscious sedation or anesthesia.  Following extraction, assuming success, rigid or flexible sigmoidoscopy is mandatory to fully assess the integrity of the rectum and distal colon.  Delayed recognition of injury is the rule and can lead to extremely high morbidity and mortality rates associated with pelvic sepsis or fecal peritonitis.  These outcomes are usually quite preventable by adhering to the proper prophylactic measures.  These measures include maintaining a low threshold to perform diverting colostomy, primary repair, and presacral drainage with optional distal rectal washout in cases where rectal or colon wall integrity cannot be verified with certainty.  Today, a colostomy can even be done laparoscopically, leaving the patient with an eventual scar no larger than a dime after the colostomy is taken down.  

Once a fairly uncommon presentation, rectal foreign body insertion is on the rise.  It is more common in the homosexual population, but occurs in all age groups and cultural and socioeconomic backgrounds.  Certainly, the possibility of abuse, particularly in the pediatric and geriatric population needs to be considered and referred for further evaluation if appropriate. Outcomes with respect to anorectal function and prevention of complications are largely based on experience. Follow up is important. At Colon and Rectal Care, we are experienced and always available to manage these types of problems. Dis Colon Rectum 2004;47(10):1694-1698.  Colorectal Disease 2005;7(1):98-103.  Dis Colon Rectum 1996;39(8):935-937.  Dis Colon Rectum 1985;28(12):941-944. Summarized by J. Muller, MD

Colon and Rectal Watch; Vol. 4, Issue 9; September 2005

The Shortest Distance Between a Patient and Recovery
Advances in Fecal Incontinence
Is Local Excision of Early Rectal Cancers Adequate Therapy?

The Shortest Distance Between a Patient and Recovery

Surgical Option Now Offers Colon Cancer Patients Quicker Recovery time, Less Pain

Following the release of a landmark study in the New England Journal of Medicine, the American Society of Colon and Rectal Surgeons (ASCRS) released a supportive statement saying laparoscopic colectomy for curable cancer results in equivalent cancer related survival to open colectomy when performed by experienced surgeons.

The study, sponsored by the National Institutes of Health (NIH) and led by the Clinical Outcomes of Surgical Therapy (COST) Study Group, demonstrated the rates of recurrence were similar after laparoscopically assisted colectomy and open colectomy. This suggests  that the laparoscopic operation is an acceptable alternative to open surgery for colon cancer.

This year in the United States, approximately 150,000 people will be diagnosed with colorectal cancer. Currently, colon cancer is the third most common cancer found in men and women in the United States. Fortunately, if detected and treated early, colon cancer is one of the most curable forms of cancer. If colon cancer is diagnosed, the next step is working with your surgeon to decide the best course of treatment.

Traditional open surgery has been the most common treatment option for many patients. But now, thanks to surgical techniques available at Community Hospitals, patients may benefit from a minimally invasive operation.

During minimally invasive colon surgery, the surgeon makes a series of small incisions in the patient’s abdomen. A slender video camera, or a “scope” is placed in one of the incisions, providing the surgeon with a magnified view of the patient’s internal organs on a television monitor. Surgical instruments are placedthrough the other small incisions, allowing the surgeon to work inside and remove portions of the colon.

Laparoscopic colon surgery offers patients several benefits over traditional surgery including:

  • Quicker recovery time
  • Less time in the hospital (five days in the hospital if the procedure laparoscopically versus seven days with traditional surgery)
  • Less pain and fewer days that intravenous pain medication is needed (three days laparoscopic versus four days open)
  • Less scarring

Despite these benefits, less than five percent of procedures performed annually in the world are performed laparoscopically.

“For those cancer patients whose cancer is operable, the availability of this alternative procedure for colon cancer surgery is a great step forward Said Rama Jager MD, PhD. “This is a real victory for patients who can have a smaller reminder of their battle with colon cancer, with a quicker recovery time, less scarring and less pain’.

As with any surgical procedure, there are some risks that accompany minimally invasive surgery. Patients should discuss surgical options with their surgeons. For more information about the procedure please log on to www.colonsurgeryinfo.com or www.colonrectalcare.com  Summarized by R.M. Jager MD, PhD

Advances in Fecal Incontinence

Fecal incontinence is a socially crippling disorder.  Few people tolerate soiling or the escape of stool well.  The exact incidence of fecal incontinence is unknown.  The prevalence of fecal incontinence in the community has been estimated as high as 10% in males and 15% in females.

The exact etiology is often unknown, but several known risk factors exist.  Previous anorectal procedures, aging, rectal prolapse, radiation and obstetric injuries represent well-recognized contributing factors.  Treatment of this challenging problem requires anorectal physiologic evaluation with anal ultrasound, anorectal manometry, and pudendal nerve testing.  After a thorough evaluation, in appropriate candidates surgical correction can be attempted.

Up until recently, some patients, who were not candidates for sphincter reconstruction, would either require a colostomy, or they would have been forced to live with their malady.  A new procedure, placement of an artificial anal sphincter, provides hope for these patients.

Several studies have clearly documented great improvement in quality of life scores for patients who undergo the procedure.  These patients also demonstrate a great improvement in their continence.  The success rate is between 70-85%.  The primary cause of failure is infection, requiring ex plantation of the prosthetic device.

At Colon and Rectal Care, we not only provide complete anorectal physiology services to properly evaluate the incontinent patient, but we are the only center in Central Indiana implanting artificial bowel sphincters.  To date,w e have implanted 7 artificial sphincters with excellent results.  We believe that in the properly selected patients, this procedure greatly improves quality of life.  This technique may also prove beneficial in the future to preserve continence in patients with low rectal cancers. O’Brien PE, et al.  Dis Col Rect 2004; 47 (11):1852-60.Marchel F et al.Gastroenterol Clin Biol 2005; 29 (4):  425-8.  Parker SC et al.  Dis Col Rect 2003 46(6):722-9. Summarized by A. Gowdamarajan, MD

Is Local Excision of Early Rectal Cancers Adequate Therapy?

Transanal excision is an appealing treatment for low rectal cancers because of its low morbidity, mortality, and better functional results than trans-abdominal procedures.  However, controversy exists whether this technique compromises cure.

The primary complications of this technique are bleeding (less than 1%) and urinary retention.  This contrasts the potential loss of continence – even if the sphincter muscles are preserved, sexual dysfunction, anastomotic leak, and death associated with major resections. 

Historically, local recurrence rates for the earliest rectal cancers (T1 lesions) have been reported to be as high as 18% following transanal excision.  Of these local recurrences, 90% are located in the rectal wall.  Patients with local recurrence usually require radical excision; these patients demonstrate poorer results than expected for the stage of the recurrence. 

These higher recurrence rates lead investigators to evaluate adjuvant radiation therapy.  This lead to a marked decrease in local recurrence; in patients with T1 lesions, only 3% suffered local recurrence.  The disadvantage of adjuvant therapy lies in the toxicities, like incontinence, acute proctitis, and small intestinal injury, associated with radiation therapy.

One recent trial comparing major resections to transanal excisions demonstrated a 77% vs. 64% benefit of major resection in 5-year cancer free survival.  Local recurrence rates were twice as high in the local resection group as well. At Colon and Rectal Care, we believe that in highly selected patients, transanal excision of rectal cancers can achieve reasonable results when combined with judicious use of adjuvant therapy.  We include our patients in the decision making process as quality of life is often as important as oncologic results.  This technique is particularly useful in early, smaller rectal cancers, without any unfavorable pathologic features where radical resection would require resection of the sphincter complex.  Local resection is also a good option in patients who represent a prohibitive surgical risk.   Endreseth BH et al.  Dis Col Rect 2005 Jul; 48(7):1380-8.  Madbouly KM et al.  Dis Col Rect 2005 Apr; 48($):  711-9.  Weiser MR, et a.  Dis Col Rect 2005 Jun; 48(6):  1169-75. Summarized by A. Gowdamarajan, MD

Colon and Rectal Watch; Vol. 4, Issue 8; August 2005

Laparoscopic management of colovaginal and colovesical fistulas
Should routine ileoscopy be done during colonoscopy?
Notification of need for earlier colon cancer screening in the African American population
How likely is a patient to become noticeably incontinent if they undergo a sphincterotomy surgery for their anal fissure?

Laparoscopic management of colovaginal and colovesical fistulas

Diverticulitis and Crohn’s Disease remain the two most common causes of colovaginal and colovesical fistulas. Symptoms of fecaluria and stool per vagina are quite distressing and traditionally have been managed by formal laparotomy with repair. However, several recent studies have supported the concept of laparoscopic management of these complex problems. Regan et al., studies 72 patients undergoing laparoscopic treatment for enteric fistulas from Diverticulitis or Crohns Disease over an 8-Year period of time. 40% had previous abdominal surgery and 30% had multiple fistulas. There was a 4% conversion rate with the average length of stay around 5 days. There were no deaths and a morbidity rate around 10%. Moorthy at al, studied 14 patients with fistulizing disease who were treated with Laparoscopic division of the fistula without resection. He had a 23% conversion rate (bleeding), with only a single post-operative complication. In 2005 two studies have varied this earlier trials. Laurent et al, studied 16 patients who were operated on for fistulizing diverticulitis. They showed a conversion rate of 18% (majority were early in the study), with a mean hospital stay of 5 days and no mortalities. They concluded that Laparoscopic resection for fistulizing disease was safe and effective. Bartus et al, studies 40 patients over a 5-year period with diverticulitis induced colovaginal or colovesical fistulas. In comparing the fistulizing group of patients to those with repeated bouts of diverticulitis requiring surgery, the following data was accumulated. There was a tendency towards a longer hospital stay, and that was a statistical difference in operative time, and conversion rates. However, there was no difference in morbidity.

This study concluded though challenging, longer and with higher conversion rates, patients should be offered a laparoscopic approach. These studies clearly support the evolving role of laparoscopic surgery in the management of complicated colorectal issues.We, at Colon and Rectal Care, have been using laparoscopic approaches to all patients with fistulizing colonic disease and have been extremely please with the outcomes, conversion rates and patient satisfaction. Regan. Surg Endosc. 2004Feb;18(2):252-4, Moorthy. JSLS. 2004 Oct-Dec;8(4):256-8, Laurent. DCR. 2005 Jan;48(1):148-52, Bartus DCR. 2005 Feb; 48(2):233-6 Summarized by  S. Narayanan, MD

Should routine ileoscopy be done during colonoscopy?

Ileoscopy has been historically performed during colonoscopy only in the face pre-existing problems requiring small bowel evaluation such as diarrhea, abnormal imaging studies or the concerning for inflammatory bowel disease. However, two recent studies indicate that routine ileoscopy is safe, feasible and has a significant diagnostic yield. Ansari et al, performed a prospective study to determine the technical feasibility of routine ileoscopy. They studied 120 patients undergoing diagnostic colonoscopy. They were successful in 117/120 patients (97%). The median time to intubate the ileocecal valve was 55 seconds. Overall, the terminal ileum was abnormal in 21% of patients. They concluded the time, and technical difficulties were minimal with a fair number of abnormal findings, making routine ileoscopy a recommendation. Cherian et al, studied 1,222 consecutive colonoscopic patients over a 4-year period of time. At around 750 procedures the ileoscopy rate was close to 90%. The average time to reach the cecum was 2.5-7.5 minutes and to intubate the valve was 1.5 minutes. Up to 19% patients did have pathologic changes in the ileum. The authors conclude ileoscopy is the gold standard for documentation of a complete colonoscopy. At colon and rectal care, we have been attempting to evaluate the ileum in all patients. We are able to succeed in over 90% patients and have found pathology in numerous patients thus changing treatment outcomes and improving quality of life. Ansari. Scand J Gastroenterol. 2003. Nov;38(11):1184-8, Cherian. Am J Gastroenterol. 2004, Dec;99(12):2324-9 Summarized by S. Narayanan, MD

Notification of need for earlier colon cancer screening in the African American population

According to the Gastroenterology and Endoscopy News, The American College of Gastroenterology has chosen to make the formal recommendation that colon cancer screening in the African American population should begin a full five years earlier than the rest of the population, at age 45.  Reasons given by the college for this new recommendation include the following: 1) African Americans have the highest incidence of colon and rectal cancer of any racial or ethnic group, in the United States. 2) Compared with Whites, African Americans  have a younger mean age at  diagnosis and a greater proportion have proximal cancers.  3) Survival in African Americans with colon and rectal cancer is lower than in Whites.

Indeed, a recent study found 10.6% of the black population with colorectal cancer were diagnosed before age 50, compared with only 5.5% of the white population.   At Colon and Rectal Care, we have evaluated this data and find it fairly convincing.  We will be further reviewing the upcoming literature for more information on this topic but in the meantime, have lowered our threshold to perform earlier screening colonoscopy in the African American population.References: G&E News, 2005, June: 60.   AJG 2005;100(3):515-23.  Cancer. 2004 Jul 1;101(1):66-76.  Clin Cancer Res.  2003 Mar;9(8):1112-7.  J Assoc Acad Minor Phys. 2002 Jul;13(3):66-8. 

How likely is a patient to become noticeably incontinent if they undergo a sphincterotomy surgery for their anal fissure?

The reported incidence of fecal incontinence after sphincterotomy in the past literature has ranged from

1.3% to 66%. In 1999, in an effort to better define the risk, physicians at the Mayo Clinic looked at a group of

585 patients undergoing sphincterotomy. They noted an 8% recurrence rate for a fissure. At some point in their postoperative course, a full 45 percent of the patients experienced some type of incontinence. Incontinence occurred in 53.4% of women and 33.3% of men. At the time of a postoperative survey (mean of >5 years after surgery), 6% had incontinence to flatus, 8% had minor fecal soiling, and only 1% had loss of solid stool. Only 3% of all patients noted in their survey that their quality of life was affected at all by their degree of incontinence.

At the Cleveland Clinic this was reviewed as well. They reviewed the cases of 298 patients over a 9 year period. Their findings were a bit different. First of all, their recurrence rate for fissures was 5.6%. Temporary incontinence was reported as 31%. Incontinence to solid stool was 2.8%. Long-term incontinence to flatus alone, however, was 30%. Quality of life was similarly unaffected overall. When they analyzed the data further, they came to the following conclusions: Females after 2 or more vaginal deliveries should be warned about possible flatal incontinence and long term incontinence to flatus may occur in up to 1/3 of patients and possibly be permanent.

At Colon and Rectal Care, all four of the doctors have discussed our experience and stance on this topic. Because of the potential permanence of outcome following surgery, we each share a desire to maximize medical therapy prior to surgical intervention. All of us also share a very low threshold for preoperative physiology testing to identify structural or anatomic deficits that might put a particular patient at increased risk for incontinence. We occasionally determine that, based on that testing and our experience, the patient should not ever be considered for surgical sphincterotomy. In our practice, sphincterotomy, is usually a measure taken for the appropriately selected patient, after available conservative treatments have failed. References: DCR 2005;48(6):1193-99. DCR 1999;42(10):1306-10. Am J Surg 2000;179:201-2. NEJM 1993;329:1905-11.

Colon and Rectal Watch; Vol. 4, Issue 7; July 2005

The role of specialization in improving surgical outcomes
Prevention of intra-abdominal adhesions in our practice
Constipation and associated co-morbidities

The role of specialization in improving surgical outcomes

Over the last several years, data consistently demonstrates surgical specialty training improves patient outcomes. As in other surgical specialties, this holds true in colon and rectal surgery.

Colon and Rectal surgeons undergo an additional year of focused training after completing a General Surgery residency to gain additional expertise in treating problems such as colorectal cancer, inflammatory bowel disease, diverticular disease, fecal incontinence, hemorrhoids, anal fistulas and anal fissures.

This expertise is particularly important in curative cancer surgery. Several papers have demonstrated asignificant decrease in local recurrence when a colorectal surgical specialist performs the operation.  Colorectal surgeons have a local recurrence rate of 6% whereas non-specialty surgeons have a recurrence rate of 16%.  Furthermore, with low rectal cancers, colorectal surgeons achieve preservation of continence 52% of the time compared to the 30% continence rate achieved by non-colorectal surgeons.

Experience improves results in treating colon cancer laparoscopically. Currently, surgeons are expected to have performed at least 25 laparoscopic colectomies for benign diseases prior to attempting this technique for cancer in order to achieve optimal results. Colon and rectal surgeons gain this experience during their additional year of training. At Colon and Rectal Care we provide a full range of specialty care for diseases of the colon, rectum, and anus. All of our surgeons have undergone an additional year of specialty training to provide improved care for these patients. Dis Col Rec 2002; 45: 904-14. Dis Col Rec 2003; 46:1461-7.  NEJM2004;350: 2050-9. Summarized byArun Gowdamarajan, MD

Prevention of intra-abdominal adhesions in our practice

Laparotomy often leads to intra-peritoneal adhesions, which can produce chronic abdominal pain, repeated episodes of small bowel obstruction and in females, infertility. Pathogenesis of adhesion formation depends on 1. inflammatory response to injury and 2. fibrinolysis.

The initial inflammatory response to peritoneal injury and leads to extravasation of serum and cellular elements. The site of peritoneal injury is initially populated by polymorphonuclear cells enmeshed in fibrin strands, and later replaced by macrophages. When normal fibrinolysis occurs, macrophages regress, and mesothelial islands develop to repair the injury site, covering the entire defect within five days.

Various factors can affect the body’s natural inflammatory and fibrinolytic response to peritoneal injury.  Intra-peritoneal bleeding, tissue injury, foreign materials including the sutures used and talcum on the surgeons’ gloves and intra-abdominal infection all affect the healing process and increase the risk of adhesion formation.   If fibrinolysis is inhibited by any of these events, macrophages persist and fibroblasts proliferate at this site. In less than five days, the fibrin network between adherent structures is replaced by dense fibrous adhesions from proliferation of fibroblasts.

During repair of peritoneum after laparotomy, pro-inflammatory cytokines such as Interleukin-6, TNF-alpha and Interleukin-1 alpha increase COX-2 expression and consequent prostaglandin (PGF 2 d and PGE 2), formation.  NSAID, which inhibit prostaglandin production, have been shown to decrease adhesion formation. Nonspecific COX inhibitors, however, may affect platelet function and increase the risk of postoperative bleeding.  Selective inhibition of COX-2 decreases production of adhesiogenic cytokines and pro-inflammatory prostaglandins, providing anti-inflammatory and anti-adhesiogenic benefits with less significant effect on platelet function and bleeding time.

COX-2 inhibitors may also work in other ways. Surgical peritoneal injury, especially if associated with tissue hypoxia may up-regulate vascular endothelial growth factor (VEGF) with resultant neovascularization. COX –2 inhibitors may reduce VEGF levels minimizing the angiogenesis and development of dense vascular adhesions.Systemic and intraperitoneal C0X-2 inhibitors prevent adhesion formation from laparotomy and thus the selective suppression of inflammatory cascade may be systemic.

Various agents such as glucocorticoids, heparin and fibrinolytic agents have been used intra-peritoneally at the time of laparotomy with variable degree of success. At the present time, with the exception of barriers, there are no agents that can consistently and effectively reduce adhesion formation with minimal systemic risk.

In our clinical practice, we currently use barriers such as Seprafilm (containing two anionic polysaccharides, sodium hyaluronate and carboxymethylcellulose), which can reduce adhesion formation between the intestinal loops and the abdominal wall. Inter-loop adhesions, however are difficult to prevent with the barriers. Systemic administration of COX 2 inhibitors gives us an option to reduce the morbidity from intraabdominal adhesions.

Concern regarding increased risk of ischemic cardiac events with COX-2 inhibitors may not be valid for short-term administration of these agents perioperatively. We would like point out, however, that there is at least one published report of inhibition of anastomotic healing by COX 2 inhibitors.  In patients who did not have colonic or intestinal anastomosis, use of COX 2 inhibitors such as Celebrex will help reduce the risk of postoperative intraabdominal adhesions and consequent intraabdominal complications.(Acta chir Belg 104:97, 2004; Hum Reprod. 16:1732, 2001; Fertil Steril. 83:405, 2005; Br J Surg. 91: 1613, 2004). Summarized by Rama Jager MD, PhD

Constipation and associated co-morbidities

Constipation is common and often considered a benign, easily treated problem with minimal morbidity, systemic morbidity with a control group of more than 1.2 million patients point out various associated problems stemming from chronic constipation. The problems include Irritable Bowel Syndrome with gas and bloating (4 fold increase), fecal impaction (7 fold increase), volvulus (4 fold increase), anal fissures (5 fold increase), hemorrhoids  (5 fold increase), intestinal obstruction (4 fold increase), and stercoralulcers (3 fold increase).

Constipation is more common in females and in older age group. Various causal factors including colonic inertia from enteric neuropathy, pelvic floor dysfunction, dietary deficiencies, sedentary life style, side effects of medications and obstructive colorectal problems.

Quality of life in patients with chronic constipation is lower in patients with constipation.  The health-related quality of life often improves noticeably after appropriate treatment and symptom resolution.

Medical management with various osmotic laxatives, bulk agents, gentle colonic stimulants and recently introduced HT4 agonist Tegaserod is the initial mode of treatment after exclusion of obstructive lower g.i. lesions by careful diagnostic workup. However, a small subset of patients with colonic inertia may require surgical intervention. Diagnostic evaluation of constipation includes colonic motility studies by abdominal imaging as well as anorectal manometry and at times,endoanal ultrasound examinations. Surgical options include abdominal subtotalcolectomy and appendicocecostomy.  Proper evaluation of chronic constipation to determine appropriate medical and surgical treatment after exclusion of mechanical obstruction is necessary to improve the quality of life for the patients who not uncommonly self-medicate and rarely seek medical attention. (Pharmacoeconomics.  23:461, 2005; Am J Gastroenterol. 100: 232, 2005;. Tech Coloproctol.8:147, 2004; Presentation at DDW 2005.) Summarized by Rama Jager MD, PhD

Colon and Rectal Watch; Vol. 4, Issue 6; June 2005

Diverticulitis and age less than 50: Is surgery really indicated?
Helminthic therapy for inflammatory bowel disease: Are worms the answer?
Are my young female patients with ulcerative colitis who are considering pregnancy candidates for the pouch surgery and how does surgery affect fertility rate?
If one of my patients with an ileal pouch anal anastamosis becomes pregnant, should I recommend she deliver vaginally or by cesarean section?

Diverticulitis and age less than 50: Is surgery really indicated?

Traditional teaching has shown that an episode of diverticulitis requiring in-patient hospitalization in a patient less than 50 years of age has typically resulted in elective surgical resection. This was done due to the belief that future attacks would occur, and that the disease process is more virulent. However, several recent reports challenge this dictum. Guzzo et al, studied 762 patients over an 11-year period of time. 238 (30%) went on to have surgery for diveriticulitis. 298 (34%) were less than age 50. The risk of requiring surgery was similar between patients older and younger than 50. Of interest, only 1% of the 196 patients less 50 years of age treated medically ended up requiring surgery. This study showsroutine surgical intervention after a singe attack may not be warranted. Biondo et al, studied the outcomes in 327 patients admitted with diverticulitis over a 5-year period.  72 patients were less than 50 years of age. They found the recurrence rate for patients less than 50 was equivalent to those older than 50 (25% vs. 22%). The types of surgery done and the grade of peritonitis were equal. The authors conclude that diverticulitis in younger patients is NOT a more aggressive subtype. Finally, Anaya et al reported on their population based study. They found that out of 20, 136 patients having an episode of diverticulitis only 19% had a second attack and 3.8% a third attack.

Another study shows that operating after the fourth rather than second attack of diverticulitis reduces cost, morbidity and mortality. Additionally, numerous patients after surgery have “temporary” colostomies. However, they found only 56% of patients have their colostomy reversed. These studies clearly show that surgeons should individualize patients risk based on both age and number of prior attacks.At Colon and Rectal Care, we have adopted a conservative management program for several years. We have been using a non-absorbable oral antibiotic and individualized treatment program to best serve our patients. Guzzo et al. DCR. 2004 Jul;47(7):1187-90, Bionda et al. Br J Surg. 2002 Sep;89(9):1137-41, Salem et al. J Am Coll Surg 2002;199:904-12, General Surgery News. Mar 2005;Volume 32: 5 Summarized by S Narayanan, MD

Helminthic therapy for inflammatory bowel disease: Are worms the answer?

Treatment options for inflammatory bowel disease continue to evolve. One novel idea is the use ofhelminthic therapy. The eggs of Trichuris Suis, an intestinal worm, appear to work by altering the immune response to antigens. Researchers treated 54 patients with active ulcerative colitis. Randomizations were done to include a placebo group and subjects receiving worm therapy every 2 weeks for 12 weeks. 30 patients (43%) of the ova group experienced a drop in the Disease activity index vs. only 17% in the placebo. No adverse effects or complications were reported. A group at the University of Iowa described the development of a helminth that cannot multiply in the human body, limited colonization and not pathogenic. They gave the suspension to six patients; temporary clinical remission was achieved in five patients. Dr. Robert Summers and colleagues studied the use of pig whipworm in 29 patients with Crohns Disease. The patients took whipworm every three weeks. At 24 weeks follow-up, the disease response rate was nearly 80%, and the remission rate was 72%. They noted high compliance and no side effects, even with patient on immunsuppresives. In fact, those patients responded better. The data suggests a response rate greater than with placebo, prompting a double-blinded placebo trial.

Caution should be taken due to some animal and clinical case reports showing co-infections with campylobacter jejuni and perhaps other pathogens. Overall, these studies are fascinating and promising for the use of Helminthic therapy in inflammatory bowel disease. We are excited about this therapy, and will continue to monitor the evidence-based date for it’s clinical use. Gastroenterology 2005;128:825-832, 1117-1119, Gut 2005;54:6-8, 54-60, Surgery News. April 2005;1: 4 Summarized by S Narayanan, MD

Are my young female patients with ulcerative colitis who are considering pregnancy candidates for the pouch surgery and how does surgery affect fertility rate?

Since ulcerative colitis is often diagnosed before or during the childbearing years, how the disease presents, how it is medically managed, and the timing for surgery are often pertinent points of discussion in the female population. The literature seems to offer conflicting information on at least some parts of this topic. For instance, Dr. Johnson et al, looked at fertility rates in females following the ileal pouch anal anastamosis (IPAA) surgery versus fertility rates in those same females before their surgery and other females undergoing nonoperative management of their colitis only. Information was collected via a questionnaire.  The overall infertility rate in the surgically managed group was 38.6% versus 13.3% in the nonoperative group (p=0.004). However, there is likely some bias as to how severe the disease had been, with the more severe patients more likely to have undergone surgery possibly having a baseline higher infertility rate from that. Particularly concerning was the fact that 13.6% of the surgical group had infertility before disease diagnosis, another 6.7% after diagnosis but before surgery, and an alarming 79.7% after their surgery.  Infertility was defined as inability to achieve pregnancy after 12 months of unprotected intercourse. They concluded a 98% reduction in the odds of becoming pregnant after surgery. Similar statistics are reported by others, such as a five fold reduction in success of becoming pregnant after IPAA. Theories abound as to the cause, but a common feeling is that adhesions are at least a major cause.  Proponents for oopheropexy, anti-adhesion barriers, and the laparoscopic approach all exist to theoretically reduce clinically significant adhesions and indirectly improve fertility rates. Surgical alternatives such as an ileostomy or a Koch pouch, unfortunately, are even less promising. Reports have suggested a rate of complications during pregnancy of 3-7% for IPAA patients, 29% for ileostomy patients, and 53% for Koch pouch patients.  All of this information must be considered, but one must not forget that several studies have confirmed a high quality of life and patient satisfaction after the IPAA surgery. Fertility in females with active severe disease has not been evaluated specifically, but is quite likely decreased as well.  At Colon and Rectal Care, the importance of family planning with regard to timing of surgery is a high priority with any of our young female patients.  Great emphasis is placed on addressing this topic early with these patients. Dis Colon Rectum 004;47:1119-35.   Int J Gynecol Obstet. 1997;58:229-37.   Br J Surg 1999;86:493-5.   Dis Colon Rectum 1994;37:1126-9. Summarized by J Muller, MD

If one of my patients with an ileal pouch anal anastamosis becomes pregnant, should I recommend she deliver vaginally or by cesarean section?

Hahnloser et al at the Mayo Clinic looked at pregnancy and delivery before and after ileal pouch anal anastamosis. They found no difference in pouch function or long-term complications after vaginal versus cesarean delivery. They recommend vaginal delivery unless there are obstetric contraindications or unless the perineum is severely scarred or rigid and therefore unsuitable. Nonetheless, other studies seem to show occult sphincter injuries in up to 35% of vaginal deliveries. Vaginal delivery also likely increases the rate of pudendal nerve traction injuries, leading to further potential reduction in fecal continence.  At Colon and Rectal Care, we are very cognizant of the tight coupling of fecal continence to the perceived quality of life after the ileal pouch procedure for both ulcerative colitis and familial adenomatous polyposis.  This is taken into careful consideration when discussing delivery options, which is done as an individual recommendation depending on that particular patient’s unique circumstances.  Int J Colorectal Dis. 2004;19(3):215-8. Obstet Gynecol 1998;92:955-61. Br J Obstet Gynaecol 1997;104:1004-8. Summarized by J Muller, MD

Colon and Rectal Watch; Vol. 4, Issue 5; May 2005

The optimal surgical approach to sigmoid diverticulitis
Sphincter preserving options in rectal cancer

The optimal surgical approach to sigmoid diverticulitis

Sigmoid diverticulitis is a common problem. The incidence increases with age. The disease spectrum includes patients who get chronically recurrent sigmoid diverticulitis requiring antibiotic therapy to ruptured diverticulitis associated with fecal peritonitis.

Treatment of this common disorder and choice of proper and optimal surgical management requires careful evaluation of published surgical experience as well as the individual surgeon’s past results.

Two questions commonly arise in managing a patient with symptomatic complicated diverticulitis. First, when should the patient consider surgical sigmoid resection?

There is never any reason why sigmoid colectomy should be done for sigmoid diverticulosis on a prophylactic basis. The first attack of diverticulitis should always be treated medically with antibiotic therapy along with 5 ASA products. Elective sigmoid colectomy should be considered after the second attack and certainly after the third attack, especially if the diverticulitis is severe enough to be identifiable on the CT scan.

In immunosuppressed patients or patients, elective sigmoid colectomy needs to be done even after the first CT documented attack of diverticulitis. Aggressive surgical therapy is often needed in patients under the age of 50 because of higher risk of complications in surgically untreated patients in this subset of our patients.

Percutaneously draining the peridiverticular abscess and treating the intraabdominal infection with antibiotics, thus converting an emergency procedure to an elective sigmoid colectomy after resolution of the immediate suppurative process, can often avoid emergency sigmoid colectomy.

The second question is choice of treatment in patients with ruptured diverticulitis associated with fecal peritonitis. Older strategy of three stage operations which include an initial colostomy, resection and closure of colostomy is certainly the least desirable option. Although we are not aware that any of the surgeons in Indianapolis use the older three stage procedure, most surgeons at our hospital systems still conduct resection of the diverticulitis with closure of the rectal stump (Hartmann pouch) in managing ruptured diverticulitis.

This may not be ideal for the following reasons: Anastomosis of the left colon to the rectum after resection of the diseased sigmoid colon can be done safely even in the face of fecal peritonitis. Also, closure of Hartmann pouch at a later time involves a major abdominal procedure with consequent high risk of postoperative morbidity. Not uncommonly, patients end up with a “permanent” colostomy even though the intent was to accomplish temporary fecal diversion.

Our group favors resection of the diseased sigmoid colon and conduction of primary anastomosis, at times using intraoperative colonic lavage to increase the chances of anastomotic healing. In appropriate patients who have severe fecal peritonitis, temporary fecal diversion is often necessary even after primary resection and anastomosis.

Common surgical practice at our hospital systems for fecal diversion happens to be a temporary colostomy. Our group, in contrast, favors loop ileostomy than a colostomy since closure of ileostomy is associated with less morbidity compared to loop colostomy. We, in general, also avoid conduction of Hartmann pouch because of significant perioperative morbidity and risk associated with final closure of Hartmann pouch and establishment of gastrointestinal continuity. 

The option of Hartmann pouch is often reserved for patients with advanced fecal peritonitis, systemic sepsis, hypotension, ascites or patients who are immunocompromised. In this group of patients, rapid conduction of the surgical procedure minimizing operating time is crucial and thus primary anastomosis and intraoperative colonic lavage are not desirable.

The decision regarding primary sigmoid colectomy with anastomosis and Hartmann pouch procedure should be made based on the patient’s general status, septic status, degree of fecal peritonitis and thus require surgical finesse and expertise.  Based on our center’s experience with diverticular disease over the past 25 years, we feel that our patients are offered rationally optimal and appropriate surgical procedure for management of complicated diverticulitis. Am Surg. 2004;70:928-31,  J Clin Gastroenterol. 2004;38 S2-7. ; Am J Surg. 2003:186:696-701,. Int J Colorectal Dis. 2003;18:503-7Summarized by Rama Jager, MD, PhD

Sphincter preserving options in rectal cancer

Approximately 50,000 new cases of rectal cancer are diagnosed yearly in the United States.  Surgical management remains the foundation of curative therapy.  Traditionally, the operation of choice was the abdomino-perineal resection. This often creates fear in patients that they will require a permanent colostomy.  Sometimes, this fear leads patients to forgo definitive therapy. 

At least five papers have demonstrated that cure rates are improved and that the risk of a patient requiring a permanent colostomy can be reduced by nearly 50% if a surgeon who has undergone further specialty training treats the patient.  However, the successful treatment of rectal cancer with a sphincter saving low anterior resection (LAR) can still be associated with altered continence. 

Two specialized reconstructive techniques, the colonic J-pouch and coloplasty,may improve the quality of life in patients undergoing LAR.  Despite the preservation of sphincter function, patients often experience lifestyle-altering changes in bowel habits.  With a standard LAR continence may be compromised outright.  Furthermore, loss of the rectum’s reservoir function may cause patients to have radically altered defeCcatory habits.  These outcomes negatively impact quality of life.  Until recently, studies demonstrated improved continence following coloplasty and colonic J-pouch; these studies, however, were limited by their short follow up period, which seldom went beyond twelve months.  

A recently published prospective study followed patients for five years following LAR.  Patients were placed into equally sized groups of standard LAR or colonic J-pouch reconstruction. Patients were evaluated with both questionnaires and physiologic studies. The patients had a significant improvement in reported function following J-pouch reconstruction.    Results of physiologic testing demonstrated improved rectal sensation and improved reservoir function in the patients with a colonic J-pouch.

Currently, there little long -term data regarding function following reconstruction using the coloplasty technique.  The literature has long suggested that coloplasty and colonic J-pouch reconstructions have similar functional results in short-term follow up, with nearly identical physiologic findings.   One recent study clearly demonstrated that at five-year follow up, coloplasty and colonic J-pouch reconstructions improve functional outcome comparably when compared to standard LAR.   

These techniques are utilized in different patients based on various anatomic factors.  They can become technically challenging procedures in some patients; thus the best functional outcomes are attained when surgeons experienced with the techniques perform the procedures. In our group of specialty trained Colon and Rectal surgeons, we have been utilizing both coloplasty, and the colonic J-pouch to construct a neorectum in patients undergoing LAR.Dis Colon Rectum 2002;45:904-14 Dis Colon Rectum 2005: March issue: Dis Colon Rectum. 2004; 47:1578-85. Summarized by Jospeh Muller, MD

Colon and Rectal Watch; Vol. 4, Issue 10; April 2005

Stem cell transplantation and Crohn's disease
Novel approach in the treatment of recto-vaginal fistulas
What can be surgically done for constipation, and how does it effect the patient’s quality of life?

Stem cell transplantation and Crohn's disease

For many, Crohns disease is a debilitating autoimmune disease with no known cure. Recent attention has been paid to the idea of autologous hematopoietic stem cell transplantation in treatment of this debilitating disease.

This idea is based on resetting the immune system and thus inducing remission. Oyama et al, performed a phase I trial involving 12 patients with refractory crohns disease. The CDAI (Crohn’s Disease Activity Index) was between 250-400 despite maximal medical therapy and the use of infliximab.  The regimen consisted of cyclophosphamide and equine anti-thymocitic globulin. Overall the procedure was very well tolerated with the most common side effects being cytopenia, diarrhea and nausea/vomiting. 11/12 patients attained remission as defined by a CDAI of less than 150. After 18.5 months only one patient had developed a recurrence of active crohns disease. Granted, this is a phase I trial and the authors strongly believe a randomized, controlled study is needed before this avenue can be used. However, several case reports over the years also give credence to this treatment. Soderholm, et al reported in 2002 of a 54-year-old female with Crohns who developed acute myeloid leukemia. She underwent autologous stem cell transplantation. At 1,2, 3 and 5 years out, she had no evidence ofEITHER crohns or a relapse of her leukemia. Kreisel et al, reported on a 36 y.o. male with long standing history of Crohn’s disease that had failed medical management. He underwent autologous transplantation with out incident. He did have a relapse at one year and underwent repeat transplantation. At two years out he was a symptomatic, though on low dose steroids and methotrexate. The study and case reports are preliminary and certainly more testing is needed. We find this information exciting and fascinating and we be closely monitoring future studies to determine the efficacy of this treatment and a collaboration with our hematology and oncology colleagues. Oyama et al. Gastroenterology. 2005 Mar;128(3):552-63, Soderholm et al. Scan J Gastroenterology. 2002 May;3(715):613-6, Kreisel et al. Bone Marrow Transplant. 2003 Aug:32(3):337-40 Summarized by S. Narayanan, MD

Novel approach in the treatment of recto-vaginal fistulas

Rectovaginal fistulas represent less than 5% of anal fistulae, however are extremely debilitating and difficult to treat. Rectal, vaginal and perineal techniques have been used with varying success. The “gold standard” is a rectal advancement flap with success rates varying from 50-85%. Recently, evidence has been mounting regarding the use of synthetic mesh (cadaver, porcine, dermal graft) to repair the defect. Moore et al, found two patients with rectovaginal fistulas, which were not amenable to traditional repair. Both were fixed a collagen porcine dermal graft. Both patients did well, with no recurrence. Pye et al, had a 63 y.o. female who had failed traditional rectal advancement for a rectovaginal fistula. She then underwent repair with “Surgisis” mesh, which induced collagen incorporation and fibrosis. At one year, she remains a symptomatic. Finally, Wafisch et al, performed a repair on four patient using an absorbable “Dexon” mesh, which promoted scarring and fibrosis. It was successful in all four cases. Granted, this data is anecdotal, with no randomization. However, the concept of “dermal or collagen” meshes continues to gain support in treatment of fistula and hernias. We find this information of great value, and have adopted this technique in treating of variety of disorder including different types of fistulas, occasional hernia and rectoceles. Moore et al. Obsete Gynecol. 2004 Nov;104(5):1165-7, Pye et al. Dis Colon Rectum 2004;47(9):1554-6, Wafisch et al. Tech Coloproctol 2004. Nov;8)2):192-4  Summarized by S. Narayanan

What can be surgically done for constipation, and how does it effect the patient’s quality of life?

Those patients with any evidence of rectal evacuatory dysfunction, with or without slow transit, need to first undergo treatment for this.  Causes for this problem might include a rectocele, rectal prolapse or intussusception, rectal dysmotility, megarectum, and/or anismus. 

Physiology testing at the level of the anus is very important, since surgery for slow transit constipation will increase bowel frequency and promote or worsen a condition of fecal incontinence in a susceptible patient.  Surgical treatment for constipation has the potential to unmask a subclinical state of fecal incontinence with obvious ramifications on quality of life for that patient.  It also warrants consideration for sphincter surgery if the patient is a good candidate. If prolapse or a rectocele is present, surgical management of that problem is usually indicated before addressing the slow transit component.

If after the above issues are addressed, colonic transit study testing (off all medications and laxatives) is positive, metabolic causes for the problem have been ruled out, medical management has been exhausted, and the patient is an acceptable operative candidate, surgery is then contemplated.  The standard of care is generally a total abdominal colectomy with ileorectal anastamosis.  At Colon and Rectal Care, we often perform this laparoscopically, leaving the patient with multiple very tiny port site incision scars and a small Phannenstiel or midline wound, necessary to extract the specimen.  Another alternative that we also perform laprascopically at colon and rectal care is the Malone procedure for the appropriately selected subset of patients. Total colectomy results in a marked decrease in total transit time which may tremendously increase the frequency of stools.  To offset this, many have tried to leave part of the distal colon, performing an “ileosigmoid” anastamosis.  Although there have been anecdotal reports of success with this technique, the majority of the literature seems to point toward an unacceptable rate of recurrence of the original problem with this option.  Certainly a permanent stoma is always an option for any patient, but usually one of last resort.  A recent paper from Ireland looked at quality of life in patients with intractable constipation who failed medical management and were unsuitable for ileorectostomy, in their opinion, due to rectal inertia.  These patients underwent total proctocolectomy with ileal pouch anal anastamosis.  This technique is usually reserved for those patients with ulcerative colitis or familial adenomatous polyposis.  They found the technique in their carefully selected patients to be an option with a progressive improvement in quality of life.  This is rarely done.

Quality of life after colectomy and ileorectal anastamosis, however, has been a debated topic.   A discrepancy has emerged on specifically how to objectively quantify “quality of life”.  A recent retrospective paper suggested that out of the 67 percent of 112 patients responding to a post operative questionairre, 41% complained of abdominal pain, 21% described some fecal incontinence, and 46% described some diarrhea.  The authors use this information to limit the physician and patient’s expectations in terms of improvement in quality of life due to a possible trade-off in symptoms.  Nonetheless, in that same study, 81% were at least somewhat pleased with their bowel movement frequency, and more importantly, 93 percent of the patients stated they would undergo subtotal colectomy again if given a second chance.  At Colon and Rectal Care, we have been pleased with the success rate of this technique.  The procedure does not guarantee that the patient will be completely free of any gastrointestinal symptoms, but it does quite effectively manage intractable constipation not amenable to medical treatment.  Most other symptoms contributing to a limitation on the improvement of quality of life that is sometimes seen after surgery were either concurrently present preoperatively and unrelated to the constipation or developed as a result of the increase in bowel transit and may be improved with other interventions. References:  Pemberton et al., Ann of Surgery 1991;214:403-11.  Fitzharris et al.,Dis Colon Rectum 2003;46:433-40.  Kalbassi et al., Dis Colon Rectum 2003;46:1508-12.  Tjandra et al., Dis Colon Rectum 1999;42:1544-50.  Drelichman et al., Dis Colon Rectum 2003;46:1720-21.Summarized by J Muller, MD

Colon and Rectal Watch; Vol. 4, Issue 2; February 2005

Infrared photocoagulation therapy for internal hemorrhoids
Rubber band ligation for internal hemorrhoids
Stapled anopexy (hemorrhoidopexy) vs standard closed Ferguson hemorrhoidectomy?

Infrared photocoagulation therapy for internal hemorrhoids

Infrared photocoagulation for internal hemorrhoids uses infrared light directed at the hemorrhoidal tissue, which then dries and shrivels. A simple light-conducting handle is attached to a lamp and timer. The quartz barrel is then inserted via an anoscope. One to two second bursts of light are used over each base. The procedure takes approximately 5 minutes to perform. Most people require multiple sessions. Patients on coumadin or plavix should attempt to have the medication held prior to treatment to diminish the risk of severe hemorrhage.

Several studies have looked at the efficacy and overall satisfaction of infrared treatment of hemorrhoids. Charua et al, studies 60 patients with grade I/II internal hemorrhoids. There were equal numbers of males and females and the average age was 40. Patients were treated two weeks apart, and for 1-4 sessions. At 24 months follow up there was 94% success with 6% patients requiring surgery.  Gupta et al, reviewed the effectiveness of infrared treatment in comparing this to rubber band ligation in 100 patients. 46 patients were treated (average age being 38), they found their patients to resume duties quite quickly, a high rate of controlling symptoms. They found there only failures to be for grade III internal hemorrhoids. Both studies show the extremely safe and effective nature of infrared photocoagulation in treating internal hemorrhoidal disease. We have found the therapy to be extremely effective for Grade I-III internal hemorrhoids for associated symptoms of itching, bleeding and pain. We have used this technique in over 20,000 patients with minimal morbidity. Charua et al. Rev Gastroenterol Mex. 1998. July-Sep; 63(3):131-4. Gupta et al. Braz J Med Biol Res. 2003 Oct;36(10): 1433-9. Jager et al. Hemorrhoids: A Book For Silent Sufferers. 2004 Summarized by Shekar Narayanan MD

Rubber Band Ligation for Internal Hemorrhoids

Rubber band ligation for internal hemorrhoids

Rubber band ligation of internal hemorrhoids involves the placement of two small bands over the hemorrhoidal base. A specialized hemorrhoid grasper and “band applicator” are used. The rubber band cuts off the blood supply to the tissue and after 4-7 days, the tissues falls off leaving a scar. Minimal bleeding is expected once the band falls off. Several studies have reviewed the effectiveness of rubber band ligation. Komborozos et al. performed a prospective study in 500 patients using rubber band ligation for 2nd, 3rd and 4th degree internal hemorrhoids. Symptoms were mostly bleeding and prolapse. 90% of patients required multiple banding over a two-week span. 91% of patients resolved their symptoms at 2 years, with 9% requiring surgery. Iyer et al, did a retrospective review of 805 patients that have undergone rubber band ligation. They found an 80% success rate. Patients requiring more than 4 bands, Grade IV were associated with a higher failure rate. This study also warned of the bleeding risk with coumadin. Linares et al, performed prospective study of 295 patients undergoing rubber band ligation for grade III and IV internal hemorrhoids. They had 98% success with this technique. They found mild bleeding and tenesmus as their only morbidities. Overall rubber band ligation is highly effective for Grade II/III and occasional grade IV internal hemorrhoids. We restarted our band ligation program in 2002 and have performed over 500 procedures with minimal morbidity. Linares et al. Rev Esp Enferm Dig. 2001 Apr;93(4):238-47, Iyer et al. Dis Colon Rectum. 2004. August;37(8):1364-70, Komborozos et al. Dig. Surg. 2000; 17(1): 71-6, Jager et al. Hemorrhoids: A Book for Silent Sufferers. 2004 Summarized by Shekar Narayanan, MD

Stapled anopexy (hemorrhoidopexy) vs standard closed Ferguson hemorrhoidectomy?

The “stapled anopexy” refers to the circumferential excision of a mucosa and partial submucosal ring about 4 cm above the dentate line via the use of a circular stapling device.  The simultaneous resection and anastamosis results in returning the hemorrhoidal plexuses to their original position while ligating a good portion of the blood supply. This further limits their potential for future hyper-engorgement. As a result, the symptomatic problem with the hemorrhoids is addressed while preserving the structure and its natural role in maintaining fecal continence, particularly in the aging and post-obstetric population. In addition, no incision is created adjacent to or below the dentate, line which accounts for the dramatic improvement in postoperative pain levels when compared to the traditional method.

The first prospective, randomized, multi-center trial comparing the stapled versus the Ferguson (traditional) technique in the United States was published.  117 patients were randomized and it was determined that postoperative pain in the first 14 days, pain after the first bowel movement, and need for postoperative analgesics were all markedly lower in the stapled group.  In November of 2002, a similar British randomized, controlled study was released with data from 99 patients. The stapled technique showed a significantly reduced operative time and blood loss as well as much shorter rehab times. Multiple similar studies have shown an earlier return to work as well.

In terms of complications, the main one seems to be bleeding.  Ethicon (maker of the only FDA approved stapler for use in the USA) has recognized this problem and created a new generation of staplers, reducing the staple size from 1mm to 0.7mm.  Anecdotally, this change has resulted in a lower hemorrhage rate immediately after firing the stapler, which corresponds to a faster operative time and requirement for fewer sutures for hemostasis. Long term results are still pending to see if there is any noticeable change in short or long term post-operative bleeding with the new generation of staplers. Nowhere is this more important than in those patients on long-term anticoagulation with medications such as warfarin (Coumadin) or clopidogrel (Plavix).  One study from Italy reported a 1.3% overall hemorrhage rate after the stapled technique and presented their data on using a thrombin agent over the staple line after surgery with a theoretical further reduction in this rate.

If the Stapled technique seems to have so many advantages, why is the traditional hemorrhoidectomy still done? The traditional approach to hemorrhoids in this country has been the Ferguson closed type procedure involving one to 3 radial elliptical incisions within the anal canal and outside the anal verge, resecting redundant mucosa and underlying hemorrhoidal vascular plexuses and preserving the internal and external sphincter muscles. Great care is taken to prevent the resection of excessive mucosa and anoderm to prevent postoperative anal stenosis.  The stapled technique does little, if anything, for the patient with external disease or the presence of hemorrhoidal originated perianal tissue redundancy. This limits the patient’s ability to achieve adequate hygiene and often leads to chronic pruritis ani.  In addition, although rare, hemorrhoidal skin tags can mimic perianal malignancy, and thus resection becomes mandatory. Unfortunately, because of the extremely rich sensory innervation of the distal anal canal, the traditional technique is much more painful. This rich innervation is necessary, however, as part of the complex sensory motor feedback system integral to overall fecal continence mechanism.  Nonetheless, for the reasons described above and others, the traditional technique is still the right procedure for a number of our patients. At Colon and Rectal Care, we are very motivated to provide the most painless, least invasive, safest, and most effective management plan for our patients with symptomatic hemorrhoids.  Like many circumstances in medicine, however, there are often trade-offs and this results in the need for a carefully tailored plan for each patient based on their specific circumstances. Dis of Colon Rectum 2004 Nov 47(11):1824-36.G Chir 2003 Oct 24(10):377-81. Dis of Colon Rectum  2002 Nov 45(11):1437-44. Dis of Colon Rectum 2003 Jan 46(1):131.  Summarized by Joseph Muller, MD

Colon and Rectal Watch; Vol. 4, Issue 1; January 2005

The emerging role of laparoscopy in colorectal cancer
Microscopic colitis

The emerging role of laparoscopy in colorectal cancer

During the year 2000, 130,000 new cases of colorectal cancer were reported in the United States.  Even with declining mortality, approximately 50,000 deaths are attributed to colorectal cancer yearly in this country.   Although surgery remains the mainstay of therapy, newer, minimally invasive techniques were slow to catch on due to several oncologic – specific concerns including:  

(1) Could minimally invasive surgery achieve a proper oncologic resection, with the same extent of exploration and information about lymph-node staging provided by a standard open resection? (2) Were patterns of tumor-cell dissemination altered or enhanced by the use of laparoscopic techniques? These concerns increased when high rates of tumor recurrence at wound and trocar sites were reported with the use of laparoscopy.  Many surgical societies recommended that laparoscopic colectomy be limited to benign disease until these questions were answered.

In 1994, the Clinical Outcomes of Surgical Therapy (COST) Trial was initiated.  This randomized, prospective, controlled study evaluated these questions.  Patients were followed for 5 years following resection.  The investigators found laparoscopic operations to have equivalent oncologic resection, equivalent incisional recurrences, and equivalent complication rates when compared to open surgery.   The authors concluded that laparoscopic colectomy for curable cancer results in equivalent cancer related survival to open colectomy when performed by experienced surgeons. Adherence to standard cancer resection techniques including but not limited to complete exploration of the abdomen, adequate proximal and distal margins, ligation of the major vessels at their respective origins, containment and careful tissue handling, and en bloc resection with negative tumor margins using the laparoscopic approach will result in acceptable outcomes. 

The benefits of a minimally invasive approach are consistent and reproducible.  They include decreased postoperative pain with reduction in narcotic usage, earlier ambulation, faster return of bowel function, earlier return to normal oral intake, and earlier hospital discharge.   Quality of life (QOL) studies also show consistently higher QOL scores in patients who undergo laparoscopic resectionscompared with open resections.  Potential additional advantages currently under scrutiny include reduction in overall costs, return to full activity following hospital discharge, and a possible improved survival with laparoscopic resection.  In fact, some early European data demonstrates improved survival for patients with Stage III colorectal cancers after laparoscopic resections.  We believe that laparoscopic resection techniques offer benefits to patients without compromising oncologic principles.  Since the publication of the COST trial, we now routinely offer laparoscopic colectomy for colorectal cancer as well as for benign colorectal diseases. New England Journal of Medicine. 350(20):2050-2059, 2004.  Dis Colon Rectum.43:326–332, 2002..  Lancet. 359: 2224–2229, 2002Summarized by Arun Gowdamarajan, MD

Microscopic colitis

Microscopic colitis is a very common cause of watery non-bloody diarrhea and can be debilitating when associated with abdominal pain and weight loss.

Microscopic Colitis was first described less than 30 years ago but is currently noted to be a common cause of chronic diarrhea in the adults.  Almost 10% of patients with chronic diarrhea evaluated colonoscopically have microscopic inflammation on histologic examination of endoscopic mucosal biopsies even when the colonic mucosa appears endoscopically normal.  Microscopic colitis is  a descriptive conflation  that includes both lymphocytic and collagenous colitis.

The cause of microscopic colitis is unknown, but  immunologic similarities to celiac disease implicate a pathogenic role of luminal antigens. Microscopic colitis is often associated with other autoimmune diseases such as thyroiditis and diabetes mellitus, pointing to possible autoimmune etiology. Medications such as NSAIDS and Lanzoprazole may also induce microscopic colitis. 

dSudden onset, short duration and a single attack of watery diarrhea in patients with microscopic colitis also suggest a possible connection to a microbial etiology.

Symptoms are often managed with antidiarrheal agents, 5-aminosalicylate drugs, systemic corticosteroids, selective steroids which are more active topically such as budesonide, bile acid-binding agents such as cholestyramine and Colesevelam.  These medications usually provide good control of  diarrhea in patients with microscopic colitis.

In our experience bile salt agents such as Colesevelam and oral Budesonide have been very effective in leading to symptomatic resolution of microscopic colitis.  Never did we have to institute surgical colectomy for Microsocpic colitis.

Some patients may require immunosuppressive therapy with agents such as azathioprine andmethotrexate and on rare occasions, subtotal colectomy  has been reported to to be necessary for recalcitrant, debilitating microscopic colitis.

Endoscopic biopsies on histologic examination show intraepithelial lymphocytosis and expansion of the lamina propria with acute and chronic inflammatory  cells.  Crypt architecture is well preserved. These microscopic inflammatory changes, when associated with a thickened subepithelial collagen band, is identified as collagenous colitis. When the thickened subepithelial collagen band is absent, the syndrome is classified as lymphocytic colitis.  Since microscopic inflammation may be present even when the endoscopic mucosal appearance is normal, our current practice is to obtain mucosal biopsies in all our patients undergoing colonoscopy for chronic diarrhea.

dThe prognosis is good. Microscopic colitis rarely leads to Crohn’s disease or Ulcerative colits and neoplasia does not develop. Often the disease is benign, short-lived and medical management almost always resolves the syndrome.  (Inflamm. Bowel Dis10:860, 2004; Lancet. 364:9450, 2004; Am J Gastroenterol. 99:2459, 2004. Photomicrographs courtesy of Dr. Z. Lu) Summarized by Rama M. Jager MD PhD

This newsletter is produced by Doctors Rama M. Jager, Shekar Narayanan, Joseph C. Muller and Arun Gowdamarajan, specialists in Colon and Rectal Surgery. Our practice includes an onsite anorectal floor lab and ambulatory surgery center. Comments or requests to subscribe can be e-mailed to info@colonandrectalcare.com.

Colon and Rectal Watch; Vol. 3, Issue 6; December 2004

Is my patient with hemorrhoids a candidate for the "stapled" technique, and what are the benefits?
Sexual function and fecal incontinence following 3rd and 4th degree perineal lacerations: The role of sphincter reconstruction on sexual function
The role of porcine small intestine mucosa in the treatment of enterocutaneous fistulas

Is my patient with hemorrhoids a candidate for the "stapled" technique, and what are the benefits?

In the United States, the “gold standard” for surgical treatment of advanced hemorrhoidal disease has been the Ferguson Closed Hemorrhoidectomy.  This entails surgical excision of the 3 quadrants of internal and or external hemorrhoids with primary closure of the wounds.  In Europe, the Milligan-Morgan technique has been more widely practiced which is essentially the same procedure except the wounds are left open. 

Exhaustive studies have been done to compare the two procedures, but little difference in outcome if any has been shown.  Both procedures are burdened with the fact that patients typically experience significant post-operative discomfort due to the rich innervation of the operative site below the dentate line. 

Initially the technique involved removing the hemorrhoids themselves but was further modified into the “stapled anopexy” which we perform with FDA approval in this country today.  Instead of circumferentially removing the hemorrhoids, we remove a ring of the mucosa and submucosa, circumferentially, 4 cm above the dentate line. This places the incision over the viscerally innervated portion of the anal canal with obvious benefit in terms of post operative pain. 

The staple line re-anastamoses the partial thickness resection similar to a DeLorme procedure performed for rectal prolapse. 

The result is a return to the native hemorrhoidal position with simultaneous partial reduction in blood supply to the hemorrhoids, limiting their potential to become engorged again.  The benefits are many and the technique is designed for prolapsing grade 3 and 4 internal hemorrhoids.  Some surgeons have stretched this indication to include grade 2 internal hemorrhoids and even patients who also have relatively asymptomatic concurrent external hemorrhoids. 

Studies have shown the stapled hemorrhoidectomy to be associated with reduced postoperative pain, earlier recovery time, earlier return to work, and similar recurrence rate compared to the excisional technique.  It can be performed as an outpatient with local, regional anesthesia, or general anesthesia.  It should also be noted that the presence of hemorrhoids is physiologically normal and felt to be at least 15% of the body’s mechanism for normal fecal continence. 

Excising them may very well compromise fecal continence over the long term.  Therefore, leaving the hemorrhoids in situ and altering their potential for engorgement, has some theoretical benefit as well.

At Colon and Rectal Care, we believe this technique to be a very valuable alternative, but only for the appropriately selected patient.  The feedback from patients has been quite positive.  Not unlike many of our laparoscopic colectomy patients, these patients have been pleased with a more comfortable option and a more rapid return to baseline functioning. Pernice LM et al., DCR 2001;44:836-841.  Ganio E et al., British Journal of Surgery 2001;88:669-674.  Hetzer FH et al., Archives of Surgery 2002; 137:337-340.  Singer MA et al., DCR 2002; 45:360-369.  Summarized by Joseph Muller, MD

Sexual function and fecal incontinence following 3rd and 4th degree perineal lacerations: The role of sphincter reconstruction on sexual function

Fecal Incontinence can effect upwards of 10% of the population with females accounting for more than 66%. The most common cause is obstetric trauma from a 3rd or 4th degree tear. Sexual functionfollowing a tear/episiotomy for some patients can be quite distressing. Studies have looked at the results of surgery for incontinence in regards to sexual function.

Signorello et al, carried out a retrospective evaluation of post-partum sexual function as it related to perineal trauma. Groups were broken down into 1st degree tear (211 patients), 2nd degree tear (336 patients) and 3rd and 4th degree tears (68). There was a 70% response rate. Factors measure were dyspareunia, sexual satisfaction, sensation and achieving orgasm. At 6 months wound with 3rd and 4thdegree tears were 270% more likely to report dyspareuniaEpisiotomy conferred the same profile of sexual outcomes as did spontaneous lacerations. In regards to this issue, Lewicky et al, evaluatedsexual function following sphincteroplasty in with women having had 3rd and 4th degree perineal tears. 32 patients were given a survey comparing pre-operative and post-operative sexual function.

Parameters measured were degree of physical sensation, sexual satisfaction, achieving orgasm, libido and physical/emotional labiality. Overall there was a 28-42% improvement in all parameters with 29% improvement in orgasm and 38% improvement in libido.

Most telling was that 31% of patients prior to surgery were emotionally and 24% physically unable to have sexual intercourse. That number fell to 0% and 6% respectively following surgery.  This study though limited by its retrospective cohort design, clearly indicated the extreme positive value of sphincter reconstruction on a patient’s physical, mental and sexual well being.

In our own series we have found a dramatic improvement in physical and mental parameters as related to sexual function and are extremely proud in the improvement in quality of life our patients have achieved. Signorello et al. Am J Obstet Gynecol. 2001. Apr; 184(5): 881-8, Lewicky et al. DCR. Oct 2004, Oct; 47(10): 1650-4 Summarized by Shekar Narayanan, MD

The role of porcine small intestine mucosa in the treatment of enterocutaneous fistulas

Enterocutaneous fistulas continue to be a problem for both surgeons and patients. Overall mortality is between 6-20% with sepsis being the most common cause of death. They can cause electrolyte imbalance, dehydration, skin excoriations and emotional distress. Between 25-80% of fistulas heal without additional surgery. Common forms of therapy include TPN, control of infection or sepsis with percutaneous drainage and the use of sandostatin.

Common causes of fistulas not healing are foreign body, radiation, distal obstruction, infection or epithelialization. Non-resectional modes of treatment include injection of fibrin glue sealant. Results have been mixed without good randomized studies. Recently, Schultz described the technique of placing a submucosal sheet into the fistula for healing.

Two patients underwent abdominal surgery for specific pathologies  (1) Crohns Disease (2) Colon Cancer). Both patients developed post-operative enterocutaneous fistulas secondary to complications from surgery. Neither healed after 2 months. A piece of porcine small intestine submucosa was placed into the tract using fluoroscopy. One patient had to have the procedure repeated. However, at one year neither had a recurrence.  Though this is small study the idea is very appealing conceptually. These same results have been applied to anorectal fistulas with promising results. We have implemented this algorithm in the rare situation of developing this type of fistula and will use the technique prior to repeat abdominal exploration in these select patients. Schultz et al. Journal American College of Surgeons. Volume 194; Issue 5, 541-543 (April 2002) Summarized by Shekar Narayanan, MD

This newsletter is produced by Doctors Rama M. Jager, Shekar Narayanan, Joseph C. Muller and Arun Gowdamarajan, specialists in Colon and Rectal Surgery. Our practice includes an onsite anorectal floor lab and ambulatory surgery center. Comments or requests to subscribe can be e-mailed to info@colonandrectalcare.com.

Colon and Rectal Watch; Vol. 3, Issue 5; November 2004

Diagnosis and treatment of perianal and anal Crohn’s disease
Colorectal Cancer Screening: Screening Patients at Average Risk, Screening High Risk Patients

Diagnosis and treatment of perianal and anal Crohn’s disease

Perianal disease occurs up to 90% of patients with Crohn’s disease and is the initial manifestation of the disease in 19% of patients even before the onset of intestinal symptoms.  Crohn's colitis was much more frequently associated with an anal lesion than small bowel Crohn's disease (52 per cent vs. 14 per cent).  The incidence of perianal lesions was higher in ileocolic Crohn’s disease than isolated colic and ileal involvement. Neither intestinal nor rectal activity of Crohn's disease noticeably affected the occurrence of an anal abscesses and fistulas.

Anal Crohn’s disease may lead to subcutaneous, peri-anal, ischiorectal, intersphincteric, and suprasphincteric abscesses and fistulas leading to slow and gradual destruction of the anal sphincters. Anal ulcerations and consequent fibrotic stenosis as well as rectovaginal fistula formation also are common.

Anal lesions can precede the onset of abdominal and intestinal problem. When an anal lesion is the heralding sign, Crohn's disease will soon develop elsewhere in the intestines. When atypical anorectal fissures and fistulas are diagnosed, one should be aware of sub-clinical Crohn’s disease and initiate proper diagnostic investigations. Crohn's disease should also be considered in patients whose anorectal wounds after surgical hemorrhoidectomy or fissurectomy fail to heal, leading to indolent necrotic wounds.

In addition to clinical evaluation in the office, examination under anesthesia, endorectal ultrasound and endoanal MRI enable detailed assessment of the anorectal lesions and predict the chances of disease control with surgical care.  Fistulography to delineate fistular tracts, on the other hand, is often non-productive, at least in our experience.

Anal Crohn’s disease is difficult to treat. Definitive surgical management such as fistulotomy or fistulectomy should be undertaken with great care and deliberation. Surgeon’s wish to treat the disease radically should be balanced against high risk of wound complications and development of anal incontinence in these patients. Anal and perirectal abscesses can be treated by surgical drainage. Low, simple anal fistulas can be managed by outpatient anal fistulotomy.  High and complex anal fistulas are safely treated by placing a Seton (drain) to avoid abscess formation, although their efficacy is moderate at best. Anal stenosis is treated by mild dilatation under sedation. Rectovaginal fistulas can be treated by mucosal advancement anoplasty although failure rate may be high.

Even severe perianal Crohn's disease does not invariably lead to total proctocolectomy. However, in a few appropriate patients with both anal and colonic Crohn’s disease, proctocolectomy and ileostomy often improves the quality of life however. A trial with temporary fecal diversion to manage severe anal Crohn’s disease is less used but was very effective in our center’s experience. Medical management is the mainstay of anal Crohn’s disease since improvement in quality of life rather than a radical cure is the treatment goal. 

Medical treatment with immunosuppressive agents such as Azathioprine and Cyclosporine combined with antibiotics such as Metronidazole and Ciprofloxacin often provide significant symptomatic improvement for our patients. Intravenous Infliximab, a monoclonal antibody preparation that targets the cytokine TN, improves symptoms in these patients quite effectively and can even lead to total if not permanent healing of the anal and rectovaginal fistulas. Complete healing of anal fistulas is reported in 46% of patients treated with 5 to 10 mg/kg of Infliximab at weeks 0, 2 and 6 weeks.

We at Colon and Rectal care feel that patients with Crohn’s disease afflicted with anorectal lesions require careful evaluation and well designed treatment plan to improve the quality of life and to minimize the treatment related morbidity. Medical and surgical management of the devastating ailment should be tailored to the patient and the severity of the affliction.   (Aliment Pharmacol Ther. 2004 20 Suppl 4:106, Gut. 2004 53:1314,  Br J Surg. 2004  91:80,   Aliment Pharmacol Ther. 2004   19:953) Summarized by Rama M. Jager MD, PhD

Colorectal Cancer Screening: Screening Patients at Average Risk, Screening High Risk Patients

Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the second leading cause of cancer deaths in the U.S.  The 5-year survival for early stage cancers is 90%, while only 10% of patients with advanced cancers survive 5 years.  As most cancers arise in polyps, and it takes on average 10 years for a small polyp to progress to a cancer, screening should lead to a decrease in CRC related deaths.

Screening Patients at Average Risk

Screening for patients at average risk for CRC should begin at age 50.  The simplest option is fecal occult blood testing (FOBT).  Patients should collect three separate stool samples at home on a yearly basis.  Since samples from digital rectal exam have a high false positive rate, they should not be used.  All positive tests mandate total colonoscopy (TC).  In prospective, randomized trials this approach has decreased CRC mortality by 15-33%.

Another option, flexible sigmoidoscopy, should be performed every 5 years.  Sigmoidoscopy is most effective when combined with yearly FOBT and with intermittent barium enemas to evaluate the right colon.  As with FOBT, all positive tests mandate TC. Double contrast barium enema (DCBE) every 5-10 years is another option.  DCBE does offer evaluation of the entire colon, but has only 83% sensitivity.  Furthermore, no studies demonstrate DCBE lowers CRC related mortality. 

TC every 10 years may be the best method for CRC screening.  TC offers the advantages of complete colonic visualization with therapeutic potential.  Although no direct studies evaluate whether screening TC reduced CRC related mortality, the National Polyp Study estimated that 76-90% of colon cancers could be prevented through routine colonoscopic screening sigmoidoscopy, and there is direct evidence sigmoidoscopy reduces CRC mortality.  TC has a sensitivity of 93% for detecting CRC.

Several recent reports have generated interest in CT colography (virtual colonoscopy) as a non-invasive method to evaluate the colon.   At this time there is no solid evidence demonstrating equivalent effectiveness at finding early cancers compared with currently recommended screening tests. More studies are needed before recommended it as a screening test for the general public.  At this time CT colonoscopy represents a promising, but experimental, approach.

Screening High Risk Patients

Individuals with a family history of CRC or adenomas in first-degree relative should undergo TC every 3-5 years beginning at an age 10 years younger than the youngest effected relative.    Hereditary non-polyposis colorectal cancers should be suspected in any patient with several relatives with CRC, especially if any of the relatives was diagnosed before age 50.  Colonoscopic evaluations should be performed in these patients every 2 years starting at age 25, or 5 years younger than the earliest diagnosis of CRC, whichever is younger.  After age 40, TC should be done annually. 

Personal history of CRC requires TC before surgery or within 12 months of resection; if negative, subsequent procedures can be deferred for 3 years.  Frequency of endoscopy in patients with a personal history of adenomatous polyps depends on the number and type of polyps initially treated.  Although therapy for these patients should be individualized, TC is the preferred method of follow-up

We believe colonoscopic screening most effectively reduces mortality from colon cancer; it is the most sensitive test and allows concurrent therapy.  Unfortunately, only 1/3 of patients actually undergo adequate screening.  In order improve this community’s screening rate, we have a program in place to allow easy, prompt scheduling of this vital exam. (Gastrointest Endosc2000 Jun;51(6):777-82.  Other sources available on request) Summarized by Arun Gowdamarajan, MD

This newsletter is produced by Doctors Rama M. Jager, Shekar Narayanan, Joseph C. Muller and Arun Gowdamarajan, specialists in Colon and Rectal Surgery. Our practice includes an onsite anorectal floor lab and ambulatory surgery center. Comments or requests to subscribe can be e-mailed to info@colonandrectalcare.com.

Colon and Rectal Watch; Vol. 3, Issue 4; October 2004

The role of Rifaximin in the management of diverticulitis
What's the latest with rectal cancer staging modalities?
Can endorectal ultrasound (ERUS) be used to assess the degree of tumor “down-staging”after preoperative chemoradiation?

The role of Rifaximin in the management of diverticulitis

Recently, Xifaxan (Rifaximin) was approved by the FDA for the treatment of Traveler’s Diarrhea. Rifaximin is a non-absorbable oral antibiotic, which inhibits RNA synthesis. Several studies have found great value in the use of Rifaximin for management of Diverticulitis. Papi et al, conducted a double blind placebo trial on 168 patients. Half received fiber only, the other half received fiber plus Rifaximin. They found at 12 months 69% of the Rifaximin group were a symptomatic vs. only 40% of the fiber group (p<.001). Iosca, showed that at six months there was improvement in symptoms and avoidance of complication related to diverticular disease. The symptoms most controlled were bloating and abdominal pain.  Tursi et al, recently added Mesalazine in comparing the effects. 218 patients were enrolled in the study, which showed statistically significant improvement in bowel habits and symptoms at 3,6,9 and 12 months in the group with both drugs. Of note, symptomatic recurrence occurred in only three patients on both Rifaximin and Mesalazine, versus 13 patients on just Rifaximin. Latella, recently reconfirmed the usefulness of Rifaximin. In a multi-center trial, 1000 patients were enrolled to receive fiber supplementation alone, or fiber and cyclical (twice daily for one week per month) Rifaximin. At 12 months, 57% of patients treated with both medications were a symptomatic versus 29% who took only fiber. The complications rate of diverticular disease (perforation, bleeding) was 1.34% in the combination group versus 3.2% in the fiber group (p<.05). 

Overall, these studies show Rifaximin to have significant impact on the morbidity of diverticular disease and encourage its use. We have implemented Rifaximin into our treatment pathway for diverticular patients who do not meet surgical criteria. We are investigating the additional use of Mesalazine to improving results. Tursi. Dig Liver Dis. 2002 Jul;34(7);

What's the latest with rectal cancer staging modalities?

Rectal cancer staging is an important part of the overall management of the disease process.  Accurate staging often determines method of treatment and, of course, the likelihood of success with that regimen.  The traditional literature in this country has compared multiple modalities to examine the depth of tumor penetration and the presence or absence of enlarged and presumably metastatic local lymph nodes.  These are the key data obtained for local tumor assessment.  They are coupled with biopsy results and imaging studies done to identify distant metastases when planning treatment. 

A recent review of ERUS(endorectal ultrasound) compared the wide range of published statistics on various other modalities.  In particular, accuracy of the depth of tumor penetration through the bowel wall and the presence of metastases to regional lymph nodes was examined.  The various tests were compared against the pathologic specimen findings postoperatively to generate the statistics.  The majority of literature seems to show ERUS T stage accuracy in the 80-90% range and lymph node status 70-80%.  Study findings however, were as shown in the table below. 

 

Digital Rectal Exam

CT scan

MRI-endocoil

ERUS

Tumor depth

58-88%

53-94%

66-92%

62-92%

Lymph nodes

N/A

54-70%

60-90%

64-88%


Interestingly, a recent prospective study from Germany looked at 92 patients with rectal cancer. 

Each patient preoperatively underwent transrectal ultrasound and a special multi-slice double contrast CT scan done with 3 dimensional reconstruction analyzed in a cine mode.  The results of both tests were then compared against the postoperative path specimen as the gold standard to compare sensitivity, specificity, positive and negative predictive values, and accuracy.  These percent values for tumor depth were as follows in the ERUS/CT scan:  (85/59, 87/63, 88/72, 84/48, 86/60).  The percent values for metastatic lymph node detection in the ERUS/CT scan were:  (75/55, 85/71, 75/50, 85/74, 81/65).  They conclude CT scan superiority for preoperative staging of rectal cancer.  It remains to be seen if, in fact, their CT technique is that different from the technique used in prior North American and if their results can be duplicated using similar technology here in this country.

At Colon and Rectal Care, we have adopted ERUS as our preferred treatment modality. Schaffzin DM,  Clin Colorectal Cancer.  2004 Jul;4(2):124-32. Kulinna C, Scheidler J Comput Assist Tomogr.  2004 Jan-Feb;28(1):123-30. Hunerbein M. Colorectal Dis. 2003 Sep;5(5):402-5. Summarized by Joseph C. Muller, MD

Can endorectal ultrasound (ERUS) be used to assess the degree of tumor “down-staging”after preoperative chemoradiation?

In the age of multimodality treatment with chemoradiation followed by surgery, the issue of “down-staging” has surfaced.  As a result, the proposed need for a reasonably sensitive, specific, and accurate method of “restaging” has been suggested.  A recent study looked at 82 patients undergoing 5-FU administration with concurrent hyperfractionated radiotherapy, followed by surgical resection for locally advanced rectal cancer.  Endorectal ultrasound was performed on all patients before and after thechemoradiation.  Ultrasound findings were compared with final pathology findings after surgery.    A complete pathologic response was seen in 20% of the patients. 

The results also showed that overall accuracy of the ultrasound for predicting accurate T-stage after chemoradiation was only 48%.  Accuracy for the N-stage was 77%.  The authors determined that theultrasound was unable to accurately distinguish postradiation changes from residual tumor and that it was an inaccurate study after chemoradiation.  For that reason, they discouraged its use for this purpose. 

Another study from Berlin evaluated the same question and found four to six weeks after radiation, similarly dismal results.   ERUS T stage accuracy was only 50% with 13% underestimation and 37% overestimation.  Lymph node involvement was only 57% accurate. 

Finally, an older study from Italy reached a similar conclusion when looking at the integrity of the ERUS.  The ultrasound was done after radiation, but before surgical resection of the rectal tumor.  When reviewing the postoperative tumor specimen and comparing it to the ERUS, they found that what theultrasound “staged” was no longer the tumor, but rather the extent of fibrosis in the rectal wall.  In summary, they determined that six to eight weeks after radiation, ERUS no longer stages the tumor, but rather the fibrosis that takes its place.  However, they do not discount the findings because, in their opinion, the extent of the fibrosis in the rectal wall is a direct indication of the depth of residual cancer.

In our practice, a pre-radiation ultrasound is done for staging purposes.  Only rarely is this done after radiation for operative anatomic assessment. Vanagunas A,  Am J Gastroenterolo. 2004 May;99(5):953-4.Rau B, Surg Endosc. 1999 Oct;13(10):980-4. Dis. Colon Rectum. 2000 Aug; 43(8):1075-83. Summarized by Joseph C. Muller, MD

Colon and Rectal Watch; Vol. 3, Issue 3; August 2004

The Management of hyperplastic polyps: a new subset
Novel approaches to the treatment of anal fistulas
Newer modes of treatment of advanced colorectal cancer

The Management of hyperplastic polyps: a new subset

Hyperplastic polyps have been traditionally viewed as non-neoplastic lesions, which do not require more frequent evaluations and follow-up. However, several recent studies have focused on the pathogenesis of colorectal cancer and the link to hyperplastic polyps. Jass et al, recently wrote that “Colorectal Cancer is not a single disease. One type of colorectal cancer (30%) shows chemical alterations in DNA and methylation, and a portion with genetic instability.” In addition, there is strong evidence that Hyperplastic polyps are not harmless and may serve as precursor to the development of colorectal cancer, especially in the proximal bowel. It may be necessary to define genetic steps and biomarkers for this subset of patients. Wynter et al,  conducted a comparison of hyperplastic polyposis with those patients with a distal colorectal cancer. They measure frequency of DNA methylation K-ras mutation. They found those patients with Hyperplastic polyposis (often described as sessile serrated adenomas) have higher percentage of DNA methylation and 7/10 had a foci of dysplasia. They concluded a subset of Hyperplastic polyp patients have a distinct morphological polyp with significant malignant potential. Finally, Hyman et al, studied prospectively thirteen patients with hyperplastic polyposis (>20 polyps and/or an polyp > 1cm in the right colon). 7/13 (54%) developed colorectal cancer with four on initial evaluation and three developing despite annual colonoscopies. They concluded patients with numerous or large hyperplastic polyps are at significant risk for colorectal cancer and aggressive surveillance or surgery may be warranted. Similar results were found by Koide, who did a retrospective review of English and Japanese literature and found 32 cases of hyperplastic polyposis with 50% developing colorectal cancer. In our experience, we find that large hyperplastic polyps or numerous hyperplastic polyps do confer a significant colorectal cancer risk. We are aggressively increasing our surveillance of these patients and some have undergone resection with excellent results. Clin Gastroenterol Hepatol. 2004 Jan;2(1):1-8, Gut 2004 Apr;53(4):573-80, Endoscopy 2002 June;34(6):499-502, ASCRS ann meet, Podium Present 2004, Dallas,TX.

Novel approaches to the treatment of anal fistulas

Anal fistulas are often complex and patients often have to undergo multiple procedures to eliminate the source of the problem. Fistulotomy continues to be the gold standard for intershpincteric and superficial fistulas. However, transphincteric and extrasphincter fistulas are not amenable to fistulotomy due to the risk of incontinence. Three papers recently shown at the American society of colon and rectal surgeons meeting,  may have application towards some of these fistulas. Ratto et al, studied the accuracy of endoanal ultrasound in accessing the track as well the internal opening of a fistula. They studied 120 patients using a standard endoanal ultrasound and a 10 MHz probe. Patients had hydrogen peroxide injection of the external opening. They found 92-98% correlation between ultrasound and surgical assessment for the primary track, internal opening, secondary opening and the presence of an abscess. Due to ultrasound guidance, no patient suffered fecal incontinence. Nunoo et al, studied whether the use of antibiotics in conjunction with abscess drainage will decrease the incidence of fistula formation. They studied 60 patients over a 6-year period. 45% received antibiotics at the time of abscess drainage with 24% developing a fistula. Of those who did not receive antibiotics, 39% developed a fistula. Though not statistically significant, this trend may change our thought processes regarding the role of antibiotics and anal fistulas. Finally, Robb et al, hypothesized that small intestine submucosa could be used to heal anal fistula due to it’s use in enterocutaneous fistulas. The small intestine submucosa was rolled and then pulled thought the fistula tract. The ends were trimmed and the internal opening was closed. 65% had closure of the tract at 51 weeks of follow-up. The average time to heal was 5 weeks. They concluded that this technique might be used for complicated recurrent fistulas as well due to healing of 4/7 of these patients. In our practice, endoanal ultrasound has become standard of care in evaluating anal fistulas. The use of topical antibiotics and small intestine submucosa is fascinating and we are beginning to implement this in select patients. Pres Am Soc Col Rec Surg .5, 2004. Dallas, TX.

Newer modes of treatment of advanced colorectal cancer

Colorectal cancer that recurs after excisional surgery is difficult to treat with chemotherapy. Also, more than 50% of all colorectal cancers diagnosed are ‘advanced’ by the time they are diagnosed and require systemic chemotherapy. Current chemotherapeutic options include 5-fluorouracil combined with agents such as irinotecan and oxaliplatin. The response rate of colorectal cancer to current drug therapy is not high. Latest chemotherapeutic agents such as Iressa (gefitinib), Avastin and Erbutux(cetuximab) improve the hitherto dismal response rate to systemic chemotherapy. These new drugs are often labeled target-directed, post-genomic sophisticated “smart drugs”.

Identification of specific biochemical and molecular differences between ‘normal’ and malignant cells is necessary for development of these ‘smart drugs’. The epidermal growth factor receptor-tyrosine kinase(EGFR-TK) is a selective target for inhibiting cancer. The epidermal growth factor receptor is a cell membrane growth factor receptor that plays a key role in cell growth and cancer progression by controlling signaling pathways affecting the cell growth, apoptosis, angiogenesis and metastatic potential of cancer cells. This receptor is aberrantly activated or over expressed in colorectal cancer cellsand impacts an autocrine growth pathway important in cancer growth yet is strictly controlled in normal cells.

The epidermal growth factor receptor (EGFR) is over- expressed in 70% of colorectal cancers in contrast to normal colocytes. In fact, higher levels of EGFR indicate and aggressive cancer and poor prognosis. Certain small molecules such as Iressa( gefitinib) inhibits EGF-R when administered orally by affecting the intrinsic tyrosine kinase pocket of the EGF-R.

Toxicity from these medications such as diarrhea and acneform folliculitis is common but tolerable. Addition of these newer agents to the older chemotherapeutic drugs such as 5-FU does not seem to increase the systemic toxicity to unacceptable levels. Surgical complications from the new medications are obviously pertinent in our surgical practice. Delayed wound healing induced medications such as Erbitux can lead to increased incidence of wound dehiscence as well as anastomotic complications in patients with colorectal cancer who require intestinal or colonic resection. Patients with intraabdominal carcinomatosis developing small bowel obstruction may have difficult time recovering uneventfully from laparotomy and intestinal bypass or resection. Occurrence of spontaneous intestinal/colonic perforations and consequent intraabdominal abscess formation has also been reported. Although these new medications are introduced not long ago, our center already cared for one patient who developed spontaneous colonic perforation following therapy with Avastin, requiring surgical repair and fecal diversion.

All the newer approaches to chemotherapy and consequent therapy induced morbidity also underscores the significance of prevention of colorectal cancer. Although a common cancer, colorectal cancer is one of the few cancers that can besuccessfully prevented. Periodic endoscopic evaluation for exclusion and excision of premalignant colorectal adenomas remains the best mode of combating this common disease.

Colon and Rectal Watch; Vol. 3, Issue 2; February 2004

Sentinel lymph node mapping and colorectal cancer
Perineal lichen sclerosus
The current role of the Malone antegrade continent enema procedure for fecal incontinence and severe constipation

Sentinel lymph node mapping and colorectal cancer

The concept of sentinel lymph node mapping suggests that metastasis from cancer occurs through specific lymphatic channels to involve the sentinel node as the first site of spread. Thus, if the sentinel node is negative, it is likely that the remainder of the nodes are negative. Data suggests a 95% identification rate with a false negative rate of 0-2%. This technique has been widely accepted for both melanoma and breast cancer. The technique involved the injection of Isosulfan Blue into the vicinity of the tumor. In addition, patients are injected with a radioisotope prior to surgery. The node is then identified by the presence of the blue dye and a radioactive reading on a gamma counter. Its usage in colorectal carcinomas is still questionable since a regional lymphadenectomy is routinely used for colonic resections. However, several authors have found the technique useful in “upstaging” patients (identifying regional tumor spread) as well as identifying non-regional lymphatic drainage. Bilchik et al, reviewed 100 patients done between 1996-2000. They found 8 patients with aberrant lymphatic drainage altering surgical resections (8%), and 18 patients (24%) where micrometastasis was found on immunohistochemical staining, which was missed on routine hematoxylin staining. In addition, polymerase chain reactions were performed on 40 patients with negative staining, 12 of which had positive micrometastasis. This study provides important implications for the use of sentinel lymph node mapping. Wong et al, found similar results for ex-vivo use of this technique. In studying 26 patients over six months, they found that four patients were upstaged by using adjuvant stains. Sentinel lymph node mapping continues to evolve in the realm of colorectal cancer. (Bilhcik et al. Eur J Cancer 38:977, 2002, Wong et al. Ann Surg 233:515, 2001).

Perineal lichen sclerosus

Lichen sclerosus is a common chronic pruritic inflammatory anogenital dermatosis which is not uncommonly misdiagnosed. It occurs mostly in elderly females and less often in males, with the male-to-female ratio of 1:6. Its underlying cause is yet to be determined. However, strong association with autoimmune diseases and a link with HLA DQ7suggests immunopathologic basis. Lichen sclerosus often appears as whitish or pink pruritic irregular patches mostly involving the labia, vulvar introitus and perianal region. Diagnosis is often made by inspection and confirmed by skin biopsy, which shows lichenoid infiltrate in the dermal-epidermal junction associated with hyperkeratosis of the stratum corneum. Skin biopsy is also helpful to exclude intraepidermal neoplasia and HPV disease associated lesions. Treatment of Lichen sclerosus includes daily application of Clobetasol 0.5% cream for up to 12 weeks and topical Tacrolimus 0.1%, Topical or systemic retinoids can also be effective. Exclusion of HPV disease before using Clobetasol is ideal to avoid stimulation of growth of condylomata in HPV positive patients. Phototherapy and laser ablation as well as topical testosterone, although used by some, are not effective in the majority of the patients. Risk of malignant transformation is a concern in addition to symptomatic burden of Lichen sclerosus. There is a 5% incidence of squamous cell carcinoma and thus all lesions suspicious of Lichen sclerosus may need long-term clinical follow-up and periodic biopsy. (Mod Pathol. 11:844,1998, J Am Acad Dermatol. 48:935, 2003, Clin Exp Dermatol. 28:128,2003 and others).

The current role of the Malone antegrade continent enema procedure for fecal incontinence and severe constipation

The Malone Antegrade Continent Enema (MACE) procedure was originally developed for treating children born with complex malformations and fecal incontinence to help improve quality of life. The procedure involves using the appendix to create a continent tube, which is brought out at skin level. The patient self-catheterizes on a schedule and wears a small dressing over the opening. Results have largely been very satisfactory. Several studies have looked at the procedure in middle-aged patients afflicted with neurogenic diseases and the role of laparoscopy in conduction of the procedure. Van Savage et al. reviewed three patients who underwent laparoscopic continent enema procedure for neurogenic bowel. The patients were fed the day of surgery and discharged the following morning. All patients resolved their fecal incontinence/constipation. Stomal stenosis occurred in some requiring dilation. Weiser at al, developed a neoappendix for those patients who had already undergone appendectomy. In 4 patients, a tube of cecum was used as a neoappendix with the creation of an anti-reflux valve. In follow up of 3 months to 8 years, all were functional, continent and without stenosis. Teichman et al, reviewed the results in six patients over a 4-year period of time. Five of six patients were continent to stool per the procedure. There were complications noted in four out of six patients, however, five out of six patients were satisfied and rated their quality of life improved. Regarding quality of life, Yerkes et al. reviewed 65 patients who had undergone the procedure over a four-year period of time. Complete or near complete continence was achieved in 77% of the patients. 89% were highly satisfied with the procedure. The only negatives were daily time commitment, pain and cramping and occasional constipation. Overall, we find this procedure attractive in patients with both intractable constipation and fecal incontinence and who have other disabilities which make more traditional approaches un-useable. Our initial set of patients has done well with limited morbidity. (Yerkes et al. J Urol.169:320, 2003, Teichman et al. Urology.61:502, 2003, Weiser et al. J Urology. 169:2321, 2002 Van Savage et al. J Urology. 164:1084, 2000).

Colon and Rectal Watch; Vol. 2, Issue 5; December 2003

Hemorrhoidal disease: Classification and treatment

Hemorrhoidal disease: Classification and treatment

There is hemorrhoidal disease and there is hemorrhoidal disease. No single treatment plan is efficacious in all patients with hemorrhoids. Unlike diseases such as acute appendicitis wherein the current most effective universally accepted treatment is surgical appendectomy, hemorrhoidal disease is heterogeneous and no one treatment cures all. Even in a single physician’s experience, the treatment has to be individualized according to the patient and the extent of the disease. While this statement seems self evident and sounds like a cliché, many physicians view hemorrhoidal disease as a monolithic entity. It is treated initially with high fiber diet, sitz baths and local anti-inflammatory medications. Those patients that don’t respond to this non-interventional treatment are recommended for surgical hemorrhoidectomy, band ligation and other invasive measures.

Some vary the treatment plan depending on the severity of hemorrhoidal disease, classifying the severity according to Grade I, II, III and IV. This classification is frequently erroneously applied to both internal and external hemorrhoids whereas the classification really only addresses the severity of internal hemorrhoidal and rectal mucosal prolapse. Even colon and rectal surgeons who are knowledgeable enough to publish textbooks skip the heterogeneity of hemorrhoidal disease and barely review the classification of hemorrhoid and the appropriate treatment based on the type of hemorrhoids. After managing thousands of patients with symptomatic hemorrhoidal disease, I believe more firmly than ever before, that the treatment plan should be dependent on the severity and especially the type of hemorrhoids.

What are hemorrhoids?

To the patient, any problem that leads to anorectal pain or bleeding and any difficulty with defecation represents hemorrhoidal disease. For some, any swelling in the perianal region associated with anorectal pain or bleeding constitutes hemorrhoidal disease. For the anorectal pathophysiologists, (Br. J. Surg. 62:542, 1975; Diverticulitis. Colon and Rectum 27:442, 1984), abnormal dilatation of the internal hemorrhoidal plexuses associated with abnormal distention of arteriovenous anastomosis in the submucosal vascular cushions and degeneration of muscularis submucosae and destruction of anchoring subcutaneous and submucosal and consequent distal fibrous tissue displacement of the anal vascular cushions constitutes hemorrhoids. For the colon and rectal surgeon in clinical practice, structural alterations of anal canal manifested by medial and distal displacement of anorectal line, increased non-circumferential engorgement of distal rectal mucosa near the anorectal line, loss of elasticity of perianal skin associated with anorectal dysfunction manifested by anorectal pain, prolapse, bleeding, pruritus, discharge, perianal soiling and sense of incomplete defecation compromise hemorrhoidal disease.

Classification of hemorrhoids and why classify?

Classification of any disease serves three of the following purposes; First, quantification of the severity of the disease, second, stratification of treatment according to the severity of disease and third, determination of efficacy of various existing treatments and new treatments for the disease.

Current classification of hemorrhoids as Grade I, II, III and IV, is based on the degree of internal hemorrhoidal and associated rectal mucosal prolapse as evident by patient’s history of prolapse and anoscopic findings. Most textbooks of colon and rectal surgery erroneously discuss the classification as describing “the severity of both internal and external hemorrhoids”. While the classification of hemorrhoids may be viewed as on of those meaningless minutiae which deserve no further attention by any intelligent human being, the ubiquitous nature of hemorrhoids, the biologic and economic costs faced by both the individual and society indicate that a more formal classification is in order which enables meaningful comparison of treatment modes. Hemorrhoids can be classified both as symptomatic and asymptomatic, the symptoms being:

  1. Anorectal pain and discomfort
  2. Anorectal bleeding
  3. Prolapse
  4. Pruritus and irritation
  5. Anorectal discharge
  6. Difficulty with anorectal hygiene associated with soiling of clothes
  7. Sense of incomplete defecation

CURRENT CLASSIFICATION OF HEMORRHOIDS

  • Grade I: Non-prolapsing hemorrhoids
  • Grade II: Prolapsing hemorrhoids that spontaneously reduce
  • Grade III: Prolapsing hemorrhoids that need manual reduction 
  • Grade IV: Prolapsing hemorrhoids that can’t be reduced

(Permanently prolapsed hemorrhoids)


Hemorrhoids can also be classified as internal hemorrhoids (those that are above the anorectal line) and external hemorrhoids (those that are below the anorectal line). External hemorrhoids fall into two categories, namely those involving the perianal skin and this distal to the anal verge and those involving the anoderm mainly the skin between the anorectal line and the anal verge. External hemorrhoids can also be fibrotic, thrombosed and edematous. Subanodermal hemorrhoids (external hemorrhoids covered by anoderm) may be associated with friable anoderm covered with superficial vasculature thus contributing to anorectal bleeding and those associated with nonfriable anoderm which may contribute to the sense of incomplete defecation and at times tenesmus. Internal hemorrhoids can be thrombosed or non-thrombosed and inflamed or non-inflamed. Internal hemorrhoids can also be classified as Grade I, II, III and IV. Grade I hemorrhoids do not prolapse and hence the patient is not aware of the prolapse. The physician who examines the patient can identify the hemorrhoidal tissue on the basis of anoscopy. The Grade I hemorrhoids may be associated with medial displacement of anorectal line, but not distal displacement. Grade II hemorrhoids prolapse during defecation, but the prolapse spontaneously reduces. These hemorrhoids are associated with medial and distal displacement of anorectal line. Grade III hemorrhoids prolapse but can be manually reduced by the patient. Grade IV hemorrhoids are permanently prolapsed and cannot be reduced. In Grade III and IV hemorrhoids, anorectal line is significantly displaced both medially and distally. In Grade IV hemorrhoids, anorectal line is visible perianally.

The current classification of hemorrhoids as Grade I, II, III and IV, is incomplete since it does not address the severity of hemorrhoidal disease other than that of internal hemorrhoids. The treatment of hemorrhoids, however, is dependent not only on the hemorrhoidal prolapse as described by the above classification, but also on the presence or absence of associated anorectal lesions such as fissures, papilla and condylomata along with the type and severity of anorectal symptoms- namely pain, prolapse, bleeding, pruritus, etc.

Hemorrhoidal disease can be an isolated anorectal abnormality or combined with associated problems such as prolapsing hypertrophic papilla, anal fissure, condylomata, anal canal carcinoma and any other non-hemorrhoidal anorectal lesion.

Recommended Treatment

The ideal treatment should be efficient in reducing the severity of symptoms, with minimal biologic (minimal pain, lack of side effects) and financial risks (cost of the treatment, cost of work loss). While all of us wait for the ultimate gadget or magic pill most of us have to manage the thousands of patients that come to see us for symptomatic relief in the mean time. I would like to outline my current treatment plan for hemorrhoidal disease.

  1. Patients even with extensive external and/ or internal hemorrhoids but no anorectal symptoms require no further treatment.
  2. If the patient has a simple thrombosed external hemorrhoid (true external hemorrhoid, the thrombus being present distal to the anal verge) and sees the physician within the first few days after the onset of symptoms, surgical excision of the thrombosed external hemorrhoid would give immediate symptomatic relief. Thrombosed hemorrhoids involving the subanodermal region, namely the tissue between the anal verge and the anorectal line, may need subanodermal dissection. Small thrombosed hemorrhoids can be treated non surgically with sitz bath and stool softening medicines.
  3. Circumferential thrombosed hemorrhoids that involve multiple external hemorrhoids, multiple internal hemorrhoids and often associated with anodermal necrosis, may require immediate formal three quadrant hemorrhoidectomy.
  4. When a patient has a painful thrombosed internal hemorrhoid, surgical excision of the internal and associated external hemorrhoidal complex may be optimal.
  5. If a patient has chronic painless rectal bleeding, and has prominent subanodermal hemorrhoids associated with friable and fragile anoderm, surgical hemorrhoidectomy may be the best treatment option. Bleeding from fragile anoderm is difficult to count without surgical excision.
    Current Available Treatment Options
    1. High fiber diet, stool softeners and sitz baths
    2. Topical anti-inflammatory agents
    3. Sclerotherapy by submucosal injection of sclerosants
    4. Band ligation of internal hemorrhoids
    5. Infrared photocoagulation
    6. Electrocoagulation with low amperage direct current (Ultroid)
    7. CO2 laser/ Argon laser/ ND-Yag laser photocoagulation
    8. Limited hemorrhoidectomy to remove the most prominent hemorrhoidal complex
    9. Formal three-quadrant outpatient hemorrhoidectomy
    10. Stapled Prolapsectomy
  6. Hemorrhoids associated with hypertrophic anal papilla and deep-seated fibrotic anal fissure may require surgical hemorrhoidectomy, fissurectomy, internal anal sphincterotomy and excision of the papilla.
  7. Patients with extensive external hemorrhoids, especially those that are fibrotic and edematous and associated with a significant problem with pruritus ani and difficulty with anorectal hygiene may require surgical hemorrhoidectomy.
  8. Patients with a significant degree of medial and distal displacement fot he anorectal line, namely those patients who have permanent hemorrhoidal prolapse or a severe degree of hemorrhoidal prolapse that requires frequent manual reduction, may benefit from surgical hemorrhoidectomy.
  9. If a patient has one isolated prominent hemorrhoid complex that is associated with permanent prolapse of rectal mucosa, a limited one-quadrant hemorrhoidectomy can be considered followed by non-excisional treatment of the remaining internal hemorrhoids.
  10. Hemorrhoids that seem to bleed profusely enough to produce anemia often require surgical hemorrhoidectomy although photocoagulation can be an initial treatment option.
  11. Patients with multiple episodes of thrombosed hemorrhoids benefit from surgical hemorrhoidectomy rather than other modes of treatment.
  12. Patients with superficial anal fissures that do not have a significant degree of fibrosis (with no exposed internal anal sphincter) often benefit from CO2 laser photocoagulation at which time the anal fissure can also be curetted and cauterized with the CO2 laser- which accomplishes ultra superficial internal anal photosphincterotomy which is not commonly associated with anal incontinence.
  13. Band ligation of internal hemorrhoids is extremely efficacious for hemorrhoids that prolapse. The risk of massive anorectal bleeding that occurs when the necrosed hemorrhoid sloughs and the of anorectal suppurative complication, need attention.
  14. The low amperage DC current electrocoagulation of internal hemorrhoids may be one option of management of internal hemorrhoids but the results have been dismal in my personal experience.
  15. Patients with internal hemorrhoids that do not prolapse, or prolapse but spontaneously reduce, can be treated initially with infrared photocoagulation or CO2 laser photocoagulation (ND-Yag or Argon, depending on the surgeon’s experience). If non-excisional photocoagulation therapy does not improve symptoms, surgical hemorrhoidectomy can then be considered.
  16. Patients with hemorrhoids and condylomata acuminata are best treated by CO2 laser management of condylomata at which time internal hemorrhoids can be photocoagulated.
  17. Most patients can benefit from infrared photocoagulation of internal hemorrhoids. At least, this can be used as an initial mode of treatment. At times, the treatment may have to be repeated multiple times especially when the patient gets symptomatic relief and does not want to consider surgical treatment. Although the multiplicity of treatments may require several visits to the physician’s office, minimal biologic risks (lack of significant side effects, lack of postoperative pain, etc.) and the cost efficiencies (decreased cost of multiple treatments compared to surgical treatment and the avoidance of the cost of work loss and cost of treatment of complications associated with surgery) make photocoagulation my choice treatment for most patients with internal hemorrhoids. Unfortunately, photocoagulation is extremely inefficient in reducing the severity of external hemorrhoidal symptoms.
  18. Sclerotherapy is still used by some physicians but can almost completely be supplanted by photocoagulation.
  19.  When rectal mucosal prolapse is extensive and severe enough to displace the anal cushions, stapled prolapsectomy may achieve symptomatic relief, although external hemorrhoidal prominence may not improve adequately.

Summary:  Treatment of hemorrhoids depends of the severity and type of hemorrhoidal disease. Surgical hemorrhoidectomy has not been completely replaced by any one mode of treatment so far. Infrared photocoagulation is probably the most commonly used treatment and probably the most efficacious initial treatment for the majority of patients, in spite of the need for multiple treatments and increased frequency of recurrence of hemorrhoidal symptoms. Sclerotherapy can be safely substituted by photocoagulation. Band ligation of internal hemorrhoids, even though extremely efficacious is associated with some risk of bleeding and sepsis.  Stapled prolapsectomy is useful in patients with significant rectal mucosal prolapse. This obviously one man’s opinion of optimal care for hemorrhoidal disease. At least in my practice, it resulted in a significant degree of patient satisfaction and reduction in morbidity from hemorrhoidal disease. This treatment plan is by no means an outcome of any controlled clinical trials although some facets such as infrared photocoagulation has been proven to be effective even in a controlled clinical trial setting and is based on my experience over the past twenty five years. It is said that experience is fallacious but inexperience is more fallacious and often erroneous.

Colon and Rectal Watch; Vol. 2, Issue 4; August 2003

Strategies in surgical repair of rectocele
Bile salt malabsorbtion and diarrhea
Recurrent Crohn's disease after the initial surgical resection

Strategies in surgical repair of rectocele

Rectocele (herniation of rectum into the vagina) is a common problem resulting in obstructive defecation. Patients often complain of incomplete evacuation and straining without the ability to expel as well as the need for digital vaginal splinting. Treatment options include dietary manipulationpelvic floor rehabilitation by biofeedback and surgical reconstruction of the posterior vaginal wall.   The transvaginal approach is the most common surgical technique. Most patients benefit from the surgical repair.  However, the dyspareunia has been reported in up to 40% of patients postoperatively. The transrectal approach also has been shown to have good results, however, the concern of having to incise the rectal mucosa has led some to shy away and presently is generally performed by select colorectal surgeons. The transperineal approach using a synthetic mesh has recently generated increased interest. Watson et al, reported symptomatic improvement in obstructed defecation in eight out of nine patients undergoing insertion of Marlex mesh into the rectovaginal septum.  Transperineal repair using collagen mesh has also been reported, with 75% of the patients noticing improvement in stool evacuation. None of the patients had complications related to the mesh implantation. Our practice finds all three methods to have merit. Choice of the surgical procedure depends on patient’s symptoms, status of patient’s perineal body and rectovaginal septum and presence of co-existing pathology. (Watson et al. J Am Coll Surg. 183:257,1996 , Altman et al. ASCRS Podium Presentation 2003. New Orleans, LA. June 2003)

Bile salt malabsorbtion and diarrhea

Patients with chronic ‘'large volume” watery diarrhea or steatorrhea showing no identifiable abnormalities on stool microbiologic evaluation, routine radiographic imaging and gastrointestinal endoscopy are often diagnosed to have Irritable Bowel Syndrome. Some of these patients may have bile salt malabsorption, which should be included in the diagnosis of patients with chronic diarrhea of undetermined origin. Intestinal reabsorption of bile salts is crucial in human health and disease by controlling enterohepatic circulation and is specific to the distal 50cm of terminal ileum. An apical sodium-dependent bile acid co-transporter controls ileal reclamation of the bile salts. Inherited mutation of this transporter can lead to congenital diarrhea from bile acid malabsorption. 

Adult-onset bile salt malabsorption may be secondary to inappropriate down regulation of the ileal bile acid transporter or defects in ileal transfer of bile acids into the portal circulation. This mechanism may explain occurrence of bile salt malabsorption in postinfective chronic diarrhea as well as Collagenous Colitis and Lymphocytic Colitis. Crohn’s ileitis and ileal resection can affect ileal absorption of bile salts. Bile salt malabsorption may also explain diarrhea and postprandial fecal urgency that most patients experience after cholecystectomy.

Bile acid malabsorption can be diagnosed by SeHCAT (75Selenium HomotauroCholic Acid Test).  This Nuclear Medicine evaluation is not commonly available in Indianapolis hospitals and in fact, in my opinion, may not be necessary in routine clinical practice. Successful therapeutic trial with bile salt sequestrants may indirectly establish the diagnosis.

Therapy with bile salt sequestrants such as Cholestyramine, Colestipol and Sucralfate to treat diarrhea produced by bile salt malabsorption is quite effective in most of the patients.  Transplantation of ileal stem cells that contain the sodium-dependent ileal bile acid transporter into the jejunum to create a functional "neoileum" to treat bile acid malabsorption has been successful in the laboratory and eventually may be feasible in clinical practice. (J Gastrointest Surg. 7:516, 2003, Dig Dis Sci. 46:2231, 2001,  Scand J Gastroenterol. 36:1077, 2001, Aliment Pharmacol Ther. 12:839:1998and others)

Recurrent Crohn's disease after the initial surgical resection

Surgical resection is the only therapeutic option in some patients with Crohn’s disease either because of drug-resistant disease activity or because of surgical complications such as stricture, enteroenteric fistulas and perforation.  Unfortunately, some degree of postoperative recurrence is highly likely. New lesions can be seen colonoscopically within weeks to months at the ileocolonic anastomosis or in the neoterminal ileum in 75% of patients.

One year after first resection in Crohn's disease, 60-80% of patients have endoscopic recurrence, 10-20% have clinical relapse, and 5% have surgical recurrence. Five years after the resection, clinical recurrence is seen in 55% of patients and 76% of patients develop clinical recurrence at 15 years after the initial surgical resection. Recurrence needing further surgical intervention develops almost 50% of patients within 10 years after the initial surgical resection and 90% of patients require surgery again at some time in their lives.

Young age, smoking, fistulizing and perforating clinical course of the disease, ileal or ileocolonic involvement, ileocolonic resection, concurrent perianal disease and end-to-end anastomosis are known to increase the risk of recurrence.

Measures to prevent recurrence are uncertain. Oral aminosalicylates such as Sulfasalazine andMesalamine, antibiotics such as Metronidazole, immunosuppressants such as Azathioprine are mildly effective in preventing recurrence.  Oral systemic glucocorticoids are not useful. Poorly absorbed oral steroids such as Budesonide may be helpful in patients who had surgical resection for severe disease activity and not so much in patients who had internal-fistulizing or perforating Crohn’s disease. Fish oil supplements also can be helpful in reducing the rate of recurrence.

Understanding the multifactorial etiology along with the clinical heterogeneity of Crohn’s disease and proper stratification of patients in deciding the drug treatment after surgical resection are important in reducing the morbidity from postoperative recurrent Crohn’s disease. Our practice in managing patients with Crohn’s disease after the initial resection includes oral Metronidazole along withaminosalicylates, advise to cease smoking and endoscopic evaluation of the neoterminal ileum 6 to 12 months after the surgical resection to obtain prognostic information regarding further clinical course. (Aliment Pharmacol Ther. 17: 38, 2003; Best Pract Res Clin Gastroenterol. 17:63, 2003; Gastroenterology. 118:264, 2000; and others)

Colon and Rectal Watch; Vol. 2, Issue 3; June 2003

Radiation proctitis
Treatment options for pruritis ani
Laparoscopic management of colonoscopically nonresectable colonic polyps

Radiation proctitis

Symptoms from radiation proctitis such as tenesmus, diarrhea, pain, bleeding and incontinence usually improve within a few weeks of the last radiation treatment. However, the symptoms do not clear up in 10%-20% of the patients, resulting in chronic radiation proctitis (proctopathy). Radiation proctitis can be manifested from months to years after the radiation treatments. Severe bleeding that leads to anemia requiring blood transfusions is not uncommon. At the present time, there is no recommended standardmanagement and most medical treatments are not universally effective.

For proctitis, Sucralfate enemas lead to clinical improvement greater than topical anti-inflammatory medications such as glucocorticoidal or 5 ASA enemas. Oral Metronidazole improves the response rate and reduces rectal bleeding, diarrhea, erythema and ulcerations. Rectal Hydrocortisone may be more effective than rectal Betamethasone. Short chain fatty acid enemas and rectal butyrate enemas can also lead to symptomatic improvement in some patients. Vitamin E and Vitamin C three times per day for 8 weeks has been used in patients with radiation proctitis with symptomatic improvement. Topical application of Formalin has been very effective in controlling symptoms of radiation proctitis. Use of a heater probe, bipolar electrocautery, Argon-Plasma coagulation and YAG Laser coagulation all help to control active bleeding but may not control the problem on a long-term basis. Recent studies have shown that rectal instillation of Amifostine (500 to 2500 mg) before radiation therapy may decrease the incidence of radiation proctitis.

If none of the measures help to control the symptoms and patient is losing blood to the degree that blood transfusions are needed or the lifestyle is impacted significantly, outpatient laparoscopic ileostomy to promote gut rest and healing of radiation proctitis is a worthwhile consideration.  Treatment for radiation proctitis is multifaceted.  Our institution noted excellent results from using topical Formalin with minimal to no side effects. We have also had excellent results with outpatient laparoscopic temporary ileostomy in a handful of patients. (Intern J Radiat Oncol Biol Phys 53:1160, 2002)

Treatment options for pruritis ani

Pruritis Ani is derived from the Latin word “Prurire” meaning itch. Anal itching affects up to 5 % of the population with the majority of the patients being males in the fifth and sixth decades of life. Causal factors include poor hygiene, neoplasms, dermatologic conditions, chronic skin infections, anal lesions (fistulas, hemorrhoids and fissures) and anal incontinence; these are often referred to as the “Eight D’s of Diagnosis of Pruritis”.

Currently, treatment options include dietary modifications (avoidance of caffeine, alcohol and cola ), topical medications, keeping the area clean and dry with cotton pads, treatment of internal hemorrhoids with infrared photocoagulation or rubber band ligation, and perianal injection of Methylene blue. Studies at St. Louis University have shown that 75% of patients presenting with pruritis ani have an associated colorectal pathology (cancer, polyps, inflammatory bowel disease) and treatment of the proximal colorectal pathology resulted in significant improvement in the pruritis symptoms. Farouk et al, has demonstrated that in a series of 23 men with pruritis, anorectal manometry revealed internal sphincter relaxation resulting in occult fecal leakage and thus causing irritation. In these patients, biofeedback therapy of anal incontinence would seem to be reasonable to improve sphincteric function. Topical Doxepin or Phenylephrine also can improve internal anal sphincter tone.

Patients with pruritus ani may also be suffering from an underlying skin infection. A group in the United Kingdom, which took 40 patients and presented them in combination to both colorectal and dermatologic specialists, substantiated this theory. They found that 34 (83%) of the patients haddermatosis, which responded to appropriate therapy, and thus suggested a combined specialty approach in the treatment of pruritis. Finallyhypnosis has been used in select cases of intractable pruritis with one patient receiving substantial relief. Overall, pruritis is a challenging problem for both the physician and patient. However, with appropriate physiology testingpatient counselingdietary modification and select medical and surgical options, the majority of patients can improve their quality of life. We have found evaluating anal sphincteric structure and function, as well as treatment of internal hemorrhoids with office mucosal fixation therapy using office infrared photocoagulation or band ligation has resulted in improvement in pruritic symptoms. (Dasan et al. . Br J. Surg. 86:1337,1999; Farouk et al, Brit J. Surg 81:603, 1994)

Laparoscopic Management of Colonoscopically Nonresectable Colonic Polyps

Laparoscopic management of colonoscopically nonresectable colonic polyps

Colonic neoplastic polyps are encountered in approximately 3 to 10% of patients undergoing colonoscopic evaluation.  Most of these polyps can be removed during colonoscopy.  However, large sessile polyps, especially those in the right colon may not be colonoscopically resectable and frequently require transabdominal surgical resection.

Since most the polyps are benign, limiting surgical morbidity should be a primary concern. Laparoscopic techniques may be helpful to reduce the surgical morbidity. Under laparoscopic guidance and continuous serosal visualization, colonoscopic polypectomy could be done with reasonable degree of safety.  If full thickness excision occurs, suturing of the mural defect under laparoscopic guidance can be done.  If intraoperative frozen section shows carcinomatous tissue, segmental resection or hemicolectomy can be completed under laparoscopic guidance. The cited publication reports feasibility and safety of this technique in 47 patients over 9 years with a single complication of port site seroma.Our center found this approach very encouraging and implementing it in treating large sessile colonic polyps that cannot be colonoscopically excised. (Dis Col Rect43:1246, 2000).

This newsletter is produced by Doctors Rama M. Jager and Shekar Narayanan, specialists in Colon and Rectal Surgery with special emphasis on diseases of colon and rectum. Our practice includes an onsite anorectal floor lab and ambulatory surgery center. Comments or requests to subscribe can be e-mailed to info@colonandrectalcare.com

Colon and Rectal Watch; Vol. 2, Issue 2; April 2003

When does your patient with sigmoid diverticulitis need surgical resection?
What's new in Hemorrhoid Surgery?
Rectal Cancer Reconstruction

When does your patient with sigmoid diverticulitis need surgical resection?

What used to be a rarity is now a common disease. Sigmoid diverticulitis was almost unknown or rarely reported in the 19th century. However, the current rate of prevalence of perforated sigmoid diverticulitis is about 3.8 per 100,000 and is increasing even compared to the rate a few decades ago. Sigmoid diverticulosis, the precursor for diverticulitis is the most common endoscopic and radiographic finding in patients over age 50. About 1% of patients with diverticulosis develop sigmoid diverticulitis. Most patients (76%) can be treated successfully by bowel rest with liquid diet and antibiotic therapy (common choice being a quinoline and Metronidazole). CT of the abdomen with oral and rectal contrast establishes the diagnosis and also provides prognostic information regarding need for surgical treatment. Sigmoid colectomy is not needed to manage the initial episode of sigmoid diverticulitis. The first attack can be managed with oral antibiotics except in immunosuppressed patients. Elective sigmoidectomy is often necessary following a second attack. Patients younger than 50, and especially those with severe diverticulitis on CT scan (abscess, extraluminal air or contrast) benefit from aggressive surgical management. The severity of diverticulitis on CT predicts the risk of medical treatment failure during the acute phase and the need for eventual sigmoid colectomy. When sigmoid diverticulitis is a multiple recurrent, elective sigmoid colectomy is the best treatment option. Recent reports of peritoneal lavage without sigmoidectomy and fibrin glue sealing of perforated diverticulitis await duplication before inclusion into clinical practice.

It is essential to exclude concomitant sigmoid cancer in patients with diverticulitis. However, endoscopic exclusion of cancer should be done only after resolution of the acute infective episode. Sigmoid diverticulitis rarely recurs after the initial sigmoidectomy. Resecting the sigmoid colon all the way down to the sacral promontory avoids the risk of recurrent sigmoid diverticulitis. In our center’s experience over the past 28 years, sigmoid diverticular disease managed by elective sigmoidectomy yielded excellent clinical results and has never recurred. (Dis Colon Rectum 45:962, 2002; Eur Radiol 12:1145; 2002; Dis Colon Rectum 41:1523, 1998; Dis Colon Rectum 45:955, 2002; Surg 67: 458, 2001; Langenbecks Arch Surg 385:143, 2000; Panminerva Med 43:289, 2001).

What's new in Hemorrhoid Surgery?

Hemorrhoidal problems affect over millions of people per year. In addition, hundreds of thousands of dollars in medications are prescribed each year for this common human malady. Common treatment options involve dietary modifications, fiber agents and stool softeners. Office procedures such asinfrared photocoagulation (IPC) and rubber band ligation are used with great success in the treatment of grade 1 and 2, and occasional grade 3 internal hemorrhoids. However these modalities are often unsuccessful and surgical hemorrhoidectomy is necessary. The results of hemorrhoidectomy are excellent and have resulted in good outcomes. However, the level of pain is usually significant along with complications of incontinence and stricture.

In 1997 Longo and Pescatori, published data regarding a technique known as stapled rectal mucosectomy, now commonly referred to as “Stapled Hemorrhoidectomy”. This technique involves the use of a circular stapler to suspend the internal hemorrhoids and prolapsing mucosa. The premise behind this idea is that internal hemorrhoids lie within in a high pressure zone and an area of increased blood flow. When a patient bears down, this exerts an increase in both pressure and blood flow resulting in prolapse and/or bleeding of the internal hemorrhoids. Using the stapling technique (Procedure for Prolapsing Hemorrhoids), the internal hemorrhoids and the prolapsing mucosa are suspended well above the dentate line after removal of a portion of mucosa, therefore decreasing both blood flow and removing them from an area of potential prolapse.

A U.S. trial was recently conducted by two different centers comparing outcomes of the PPH technique. The trial involved a total of 68 patients treated with this technique. The procedure was done as anoutpatient, taking an average of 22 minutes. 93% of patients remained asymptomatic at 9 months duration. 99% of patients recovered completely by one week. There were no mortalities, incontinence, or persistent pain. The most common complication was urinary retention (12%). Retroperitoneal and pelvic sepsis are rare complications described in European literature, which may require antibiotic therapy. Stapled Hemorrhoidectomy, mucosal fixation therapy (IPC or Banding), and hemorrhoidectomy are individually selected based on morphologic stratification of hemorrhoidal disease to render the best possible care. We have found Stapled Hemorrhoidectomy to be a valuable tool in the hemorrhoidal armamentarium and have found it to be extremely successful in those patients that fit the appropriate criteria. (Singer et al. Early Results of Stapled Hemorrhoidopexy in the United States. Podium Presentation. ASCRS Annual Meeting. June 2002)

Rectal Cancer Reconstruction

Colorectal cancer is the 2nd most common cause of cancer death in the U.S. In 2000, there were36,400 new cases of rectal cancer. The use of staging ultrasound and neoadjuvant chemotherapy/radiation has improved local control of rectal cancer while preserving sphincter function. Recently the “Coloplasty” was introduced to augment the Colonic J-Pouch to improve continence in patients undergoing a colo-anal anastomosis for rectal cancer. A study comparing manometric and functional results of Coloplasty, colon J Pouch and straight colo-anal anastomosis found the first two had decreased incontinent episodes and fewer bowel movements. We have found both the Colonic J-pouch and Coloplasty to be valuable surgical techniques in maximizing continence while preserving sphincter function. (Mantyh et al. Dis Colon Rectum 2001 Jan;44(1):37-42)

Colon and Rectal Watch; Vol. 2, Issue 1; Feb. 2003

Immunologic markers for Crohn's Disease and Ulcerative Colitis: Is Indetermininte Colitis a Distinct Clinical Entity?
Current management of perianal Hidradenitis Suppurativa

Immunologic markers for Crohn's Disease and Ulcerative Colitis: Is Indetermininte Colitis a Distinct Clinical Entity?

Crohn’s disease can be distinguished from Ulcerative colitis by the endoscopic appearance and distribution of the inflammatory lesions in the lower g.i. tract in majority of patients afflicted with debilitating disease. In about 10% of patients, the diagnosis is not clear-cut and these patients are diagnosed with “Indeterminate colitis”. Most of the treatment options are similar for Crohn’s disease and Ulcerative Colitis. However, prognosis, surgical options and response to various immunosuppressive agents may depend on the specific diagnosis. For example, ileal pouch to anal canal anastomosis will be curative in Ulcerative Colitis but often fails in patients with Crohn’s Disease, making it necessary to exclude Crohn’s Disease.

Immunologic tests such as ASCA(Anti-Saccharomyces cerevisiae antibodies) and pANCA (perinuclear Anti-Neutrophil Cytoplasmic Autoantibodies) through commercial laboratories(Prometheus) can help distinguish Crohn’sdisease from Ulcerative colitis. ASCA, directed against oligomannosidic epitomes in the cell wall of Saccharomyces cerevisiae are more common in patients with Crohn's disease in contrast to patients with ulcerative colitis or healthy controls. ASCA IgG antibodies are found in 80% of Crohn’s Disease patients and 20% of Ulcerative Colitis patients, whereas ASCA IgA antibodies are found in 35% of Crohn’s Disease patients but less than 1% of Ulcerative Colitis patients. The presence of IgG or IgA ASCA has been shown to have a high specificity for Crohn's disease, especially in patients with small bowel Crohn’s disease. There are published reports of 95-100% specificity for diagnosing Crohn’s disease when both IgG and IgA ASCA are positive.

P-ANCA is found in 70% of Ulcerative Colitis patients, but in only 20% of patients with Crohn’s Disease.ASCA-/pANCA+ can be 100% specific for Ulcerative Colitis. The presence of ASCA combined with the absence of ANCA is highly diagnostic of Crohn's disease. Agglutinin antibodies to anaerobic coccoid rods are also reported in Crohn’s disease. This test however is not commercially available.

Up to 48% of patients with Inflammatory bowel Disease have no antibodies against ASCA or pANCA. Most of these patients also have endoscopic findings that are nonspecific. These patients remain diagnosed with Indeterminate Colitis which may represent a distinct disease etiologically and immunologically different from Ulcerative colitis and Crohn’s disease.

Immunologic tests including ASCA are approaching the needed specificity to exclude Crohn’s disease and thus may be useful to diagnose Crohn’s disease and exclude Ulcerative Colitis in the near future.Specificity of these two tests for IBD is high, but, currently, the low sensitivity limits their screening utility. Also, commercial availability and insurance coverage for immunologic diagnosis of Inflammatory Bowel Disease is not optimal at this time. Endoscopic and radiographic evaluation still remains the golden standard for establishing the diagnosis of Inflammatory Bowel Disease. (Eur J Gastroenterol Hepatol. 14:1013, 2002; Intern Med J 32:349, 2002; Inflame Bowel Dis 7:192, 2001; Am J Gastroenterol 96:730, 2001; Eur J Gastroenterol Hepatol 14:129, 2002; Gastroenterology 122:1242, 2002; Dis Colon Rectum 45:1062, 2002)

Current management of perianal Hidradenitis Suppurativa

Perianal Hidradenitis suppurativa or Verneuil's disease or is a recurrent, chronic inflammatory and suppurative disease often leading to perianal subcutaneous abscesses, sinuses, fistulas and fibrosis. In some patients, autosomal dominant inheritance is noted. Hyperandrogenism, obesity, smoking may affect the gene expression of variable gene penetrance of this disease. Until recently, hidradenitis was felt to be a disease of the apocrine glands, the primary event being apocrine follicular occlusion followed by bacterial infection. Current research shows the disease to be a defect of follicular epithelium. The problem starts with hyperkeratosis and inflammation of the infundibulum in terminal hair follicles of the intertrigal skin. Subsequent segmental rupture of the follicular epithelium spreads inflammatory reaction leading to infundibulofolliculitis. Secondary bacterial involvement of the apocrine and eccrine sweat produces the clinical lesion. Hidradenitis suppurativa may thus be a misnomer and acne inversa is a more accurate term to describe this debilitating disease.Perianal hidradenitis in its early stages is difficult to distinguish from atypical anal fistulas.

Hidradenitis rarely resolves spontaneously. Dapsone, retinoids such as Accutane, antiandrogens, and systemic antibiotics although used often do not uniformly control the disease. Potential complications of hidradenitis include scarring, local or systemic infection, systemic amyloidosis, arthropathy, andsquamous cell carcinomaEarly definitive surgical intervention by wide local excision and healing by secondary intention as well as subcutaneous fistulotomy may avoid progressive infection-induced morbidity. Hidradenitis suppurativa (HS) can be associated with Crohn’s disease. Infliximab, a monoclonal antibody against the lymphokine TNF alpha has been to be effective in controlling hidradenitis in these patients.

Colon and Rectal Watch; Vol. 1, Issue 2; Dec. 2002

Chemoprevention of Colon Cancer
Dyschezia

Chemoprevention of Colon Cancer

Taking a pill to prevent colorectal cancer, the second most common malignancy, is an attractive proposition and most patients will ask measures they can take to prevent colon cancer and colon polyps. Apart from dietary modifications such asavoidance of animal fats and alcohol and adequate exercise in addition to periodic colonoscopic identification and removal of colorectal adenomas, there are no proven measures that reduce the risk of colorectal neoplasia. However, various dietary supplements have been purported to be oncoprotective, some based on in vitro or animal cancer models and others on clinical and epidemiological studies.

Diet high in fresh fruits and vegetables, low in calories, alcohol and animal fat is cancer protective although the presumed protective effects of fiber per se is doubted by recent trials Calcium, Folate, and Selenium may help in colon cancer prevention. Folate modulates carcinogenesis. Intracellular Folate deficiency alters gene-specific DNA methylation and affect DNA stability by production of DNA strand breaks or misincorporation of Uracil. Folate supplementation slows cryptal colocyte proliferation in patients at high risk for colon cancer. Low dietary Folate and Methionine and high alcohol consumption increase risk of colon cancer, possibly by modulating methylation. The inverse association of Folic acid consumption with colon cancer risk was greater in women with a family history. More practically, Folate seems to abolish the undesirable effect of family history of colon cancer, which increases the risk of colorectal carcinogenesis.

A deficiency of micronutrients such as Folic acid, Vitamin B12, Vitamin B6, Niacin, Vitamin C, or Vitamin E damages DNA by causing single- and double-strand breaks and oxidative lesions. This damage is similar to radiation induced DNA damage. This may explain high colon cancer risk associated with low Folate intake. Vitamin B12 and B6 deficiencies, common in elderly population also lead to chromosome breaks. Micronutrient deficiency may explain why the quarter of the population that eats the fewest fruits and vegetables has about double the cancer rate for most types of cancer when compared to the quarter with the highest fruit consumption. Correcting the micronutrient deficiency by dietary supplementation can have noticeable cancer-preventive benefits.

Epidemiologically, dietary Calcium and Vitamin D intake are inversely related to incidence of colon cancer. Dietary Calcium supplements lower epithelial cell proliferation indexes from a higher- to a lower risk pattern, indicating oncoprotective benefit. Yogurt and Lactobacilli suppress carcinogen-induced preneoplastic and neoplastic lesions in animal models. Yogurt and the lactic acid producing bacteria (probiotics) may decrease the ability of colonic microflora to produce carcinogens. Prebiotics such as non-digestible oligosaccharides alter colonic microflora by selectively augmenting the growth of Lactobacilli in the colon. Evidence for cancer-preventing properties of pro- and prebiotics is also based on fecal enzyme activities in humans as well as in vivo and in vitro inhibition of genotoxicity of carcinogens. The combination of pro- and prebiotics (synbiotics) is more effective than either of the categories.

Cox-2 inhibitors may also be candidates in chemoprevention of colon cancer. Carcinoigenesis is a complex process associated with over expression of prostaglandins. Incidence of colon cancer inversely correlates with the use of nonsteroidal anti-inflammatory drugs (NSAIDs), which inhibit prostaglandin synthesis. The NSAIDs inhibit cyclooxygenases (COX), which are active in prostaglandin production. Cyclooxygenase-2 (COX-2) is usually not expressed in normal tissue but over-expressed in premalignant lesions and neoplasms. Early clinical data suggest that COX-2 inhibitors may protect against colon cancer. Prostaglandin E2 acts by binding to the membrane receptor EP1. EP1 receptor is believed to be important in colon carcinogenesis and selective EP1 receptor antagonists may prove to be oncoprotective.

There is no one prescription that you can suggest to your patients when they ask you about colon cancer prevention. Secondary prevention by identification and removal of premaligant colorectal adenomas by periodic colonoscopy is currently the best measure of prevention of colorectal neoplasia. [ Mason JB, Semin Gastrointest Dis 13:143, 2002; Khosraviani K. et al, Gut 51:195, 2002; Fuchs CS. Et al Cancer Epidemiol Biomarkers Prev 11:227, 2002; (Dang CT et al Oncology (Huntingt) 16:30, 2002; Kawamori T, Wakabayashi K, . J Environ Pathol Toxicol Oncol 21:149, 2002; Holt PR, Wolper C, Moss SF, Yang K, Lipkin M . Nutr Cancer 41:150, 2001; Wu K et al, J Natl Cancer Inst 94:437, 2002; Ames BN. Mutat Res 475:7, 2001; Burns AJ, Rowland IR. Curr Issues Intest Microbiol 1:13, 2000]

Dyschezia

“Dyschezia” is defined as difficulty with defecation. It may be associated with pain during and after bowel movement depending on the etiology. It is usually a consequence of long continued voluntary suppression of the urge to defecate. It affects thousand of people each year with the majority being women. Common causes for dyschezia include rectocoele (protrusion of the rectum into the vagina),internal intussusception with or without full thickness rectal prolapse, solitary rectal ulcer syndrome, levator spasmrectal neoplasiaendometriosis and thrombosed internal hemorrhoids. There are also several pelvic floor abnormalities such aspelvic floor dyssnergia (disturbance of muscle coordination), ansimus (failure of muscular relaxation or paradoxical contraction) and rectal akinesia. Physical examination findings are variable. Often, findings such as rectocoeles and levator spasm are evident. However, in a number of patients, no definable cause can be found. Diagnostic evaluation includes anorectal manometry, non-invasive EMG,anorectal US and occasionally, defecography. These tests help to elucidate the mechanism and treatment options for a patient’s dyschezia. Initial management should be medical in most situations except for rectal neoplasia, rectal prolapse and thrombosed hemorrhoids. This includes reassurance, hormonal therapy,topical Nifedipine or Nitroglycerin, oral DiltiazemGabapentin or Tamsulosin. Skeletal muscle relaxants such as Benzodiazapenes and finally injection ofBotulinum Toxin may also be of some benefit. In addition, biofeedback has been shown to improve many of the situations with no morbidity. Some mild improvement with electrogalvanic stimulation and steroid caudal blocks can be obtained. Surgical treatment is less commonly employed and involves the repair of rectocoeles, enterocoeles, and treatment of intussusception or rectal ulcers. With appropriate evaluation, reassurance and medical treatment the majority of patients can improve their quality of life. Major emphasis on management of dyschezia should be on exclusion of correctable abnormalities and symptomatic management of incurable problems. [Wie sel et al Patient satisfaction after biofeedback for constipation and pelvic floor dyssnergia, Swiss. Medication. Wkly 2001 Mar 24;131 (11-12: 152-156]

Colon and Rectal Watch; Vol. 3, Issue 6; Oct. 2002

Management of Anal Fissure
Newer Treatments for Anal Incontinence
New Advances in Laparoscopic Colon Surgery

Management of Anal Fissure

Anal fissure, a painful longitudinal disruption of the anoderm, is a common anorectal problem. Midline anterior or posterior anal canal fissures are more common than lateral fissures. Since the fissure is often associated with increased tone of the internal anal sphincter, the most common surgical treatment involves internal anal sphincterotomy with or without fissurectomy. Anal incontinence following partial internal anal sphincterotomy is reported to be as high as 35% limiting its use as the primary mode of fissure treatment. “Chemical” sphincterotomy can be attempted initially before surgical sphincterotomy.Topical 0.2% Nitroglycerin,a nitric oxide donor, applied perianally can heal up to 60% of anal fissures but associated with a high incidence of headaches which precludes its use in many patients. Calcium channel blockers such as Diltiazem and Nifedipine relax the internal anal sphincter and also improve the micro vascular circulation in the anal canal. Topical 2% Diltiazem or 0.2% Nifedipine cream can heal 60% of anal fissures. Oral Diltiazem (60mg po bid) may also be beneficial but associated with more side effects than topical Diltiazem. Topical 0.1% Bethenechol, a cholinergic agent inhibits internal anal sphincteric tone through the muscarininc receptors, healing anal fissures. Botulinum toxin produced by Clostridium Botulinum is a potent neuromuscular blocker agent that inhibits acetylcholine release from presynaptic nerve endings. Botulinum toxin injections into the internal anal sphincter can heal up to 80%of anal fissures although the cost of toxin and insurance coverage are practical issues that impact its use. In vitro studies show that adenosine 3', 5'-cyclic monophosphate and guano sine 3', 5’-cyclic monophosphate affect myogenic tone of the internal anal sphincter and Phosphodiesterase inhibitors such as Dipyridamole may be effective in decreasing internal anal sphincter tone. In our experience, office curettage and cauterization with Silver Nitrate as well as cauterization with a CO2 Laser (which probably destroys the superficial layers of the internal anal sphincter thus decreasing internal anal sphincteric hypertonia) can benefit some patients with the anal fissures. Treatment options should be tailored to each individual patient, based on response to medical treatment. [Briel J.W. et al, Brit J. Surg. 89:1193,2002]

Newer Treatments for Anal Incontinence

Fecal incontinence is the inability to defer the call to defecate to a socially acceptable location or simply “the loss of sphincter control”. It affects 5% of the population with 65% being female and less than 65 years of age. A full diagnostic workup is needed to identify the reason for a patient’s incontinence. This includes anorectal manometry (measurement of sensation and pressures within the rectum), EMG(measurement of nerve innervation), Pudendal nerve latency and endoanal ultrasound (evaluation of sphincter disruption). Upon completing some or all of the above evaluation, most patients will benefit from medical, surgical or combination therapy. In addition, many patients will benefit from the use ofbiofeedback (neural-sensory stimulation program) showing 70% improvement. Surgical therapy traditionally involved colostomies (rarely done now), anal cerclage and anal sphincteroplasty (either a re-approximation or overlap of the disrupted muscles). Sphincteroplasty has a 70-80% success rate and is still the most common operation employed. However, not all patients are candidates for a sphincteroplasty. Continent ostomies (appendix or ileum) has recently regained interest. Laparoscopically the appendix or ileum is brought out to the skin level and an “antegrade enema” can be used to promote continence.Sacral nerve stimulationis a technique in which stimulating wires are attached to the S2-S4 nerve roots. This is useful in those patients with incontinence, no demonstrable sphincter disruption and significant neuropathy. In European studies, this has been shown to have 65-80% improvement. The “SECCA Procedure” involves the use of radio frequency waves to fibrose the anoderm. This is an outpatient procedure and is ideally suited for the elderly who cannot tolerate more aggressive procedures. Preliminary US studies show a 60% improvement at 6 months with minimal morbidity. Injection of Bioplastique material into the internal sphincter is an evolving entity with preliminary data showing 50% improvement. Finally, the artificial anal sphincter continues to evolve. This involves the implantation of an artificial sphincter that allows the patient to gain anal continence. A recent study showed 50% of the patients gaining continence. A 20% infection rate continues to be troublesome.Overall, in our practice we offer several options for patients with anal incontinence, which can improve their quality of life. [Takahashi T. et al, Dis. Colon Rectum 45:915, 2002]

New Advances in Laparoscopic Colon Surgery

Laparoscopic colorectal surgery was introduced in 1991. Even today, there is a great deal of debate regarding its employment in clinical practice. Laparoscopic techniques decrease hospital stay, decrease pain, decrease ileus rate and promote faster return to work. Concerns about cost andequivalency to traditional surgery have limited its use. However, recent trials support the advantage of laparoscopic colorectal surgery. A study done in Orlando by Dr. Narayanan demonstrated equivalent oncologic outcome for patients undergoing laparoscopic versus open surgery for adenocarcinoma, with no difference in morbidity or mortality. This was substantiated by two recent European trials. Lesions in the right colon, sigmoid colon and rectal cancer in which a stoma cannot be avoided are ideally suited for laparoscopy. In addition, benign lesions such as unresectable polyps, diverticular disease and small bowel masses are ideal candidates for laparoscopic treatment. Technical advances in laparoscopy include the use of aheated CO2 system for pneumoperitoneum. This decreases the incidence of shoulder pain and hypothermia. “Laparoscopic stitching” devices are able to both suture and tie tissue together especially helpful in laparoscopic treatment of rectal prolapse by proctopexy. Lighted ureteral stents placed preoperatively flash like a “neon sign” decreasing operative time and risk of ureteral injury.Laparoscopic colorectal surgery continues to evolve and in our practice, it appears to have significant advantages, including minimal morbidity compared to “open” techniques. [Patankar S., Narayanan S. et al, “Prospective Comparison of Laparoscopic vs. Open Resections for Colorectal Adenocarcinoma at Ten Year Follow-up” ASCRS anual meeting 2002]



These newsletters are produced by Doctors Rama M Jager and Shekar Narayanan, specialists in Colon and Rectal Surgery with special emphasis on diseases of colon and rectum. Our practice includes an onsite anorectal floor lab and ambulatory surgery center. Comments can be e-mailed to info@colonandrectalcare.com