Medical

PURPOSE: Biofeedback treatment is often offered to patients in colorectal centers; however, standards of treatment are still lacking. A dedicated team approach is desirable but difficult to coordinate. We present our three-year experience of electromyographic-based biofeedback treatment offered within a multicenter, statewide organization. METHODS: Between October 1992 and October 1995, 188 patients completed a biofeedback treatment program in one of five coordinated centers within a 200-mile radius. A unified common database was established and continuously updated. A colorectal surgeon served as statewide director, and dedicated teams were established at each location. Each local team included the medical director and a certified biofeedback therapist and had access to a dietitian and a nurse data coordinator. Electromyographic-based biofeedback sessions were given weekly, and a home trainer program was established. RESULTS: A total of 116 patients with chronic constipation had a mean of eight (range, 2–14) weekly sessions. A total of 72 patients with fecal incontinence had a mean of seven (range, 2–11) weekly sessions. A total of 84 percent of the constipated and 85 percent of the incontinent patients had significant improvement with biofeedback treatment. Patient compliance and satisfaction were high. Constipated patients increased the mean number of weekly unassisted bowel movements from 0.8 to 6.5. Incontinent patients decreased the mean number of weekly gross incontinence episodes from 11.8 to 2. CONCLUSIONS: Biofeedback treatment can be extremely successful in both incontinent and constipated patients. A large geographic area can be covered with coordinated centers in which each dedicated team uses a unified treatment protocol, and a common database is established.

PURPOSE: This study was undertaken to assess the accuracy and ability of endorectal ultasound (ERUS) to predict changes in rectal tumor stage after a preoperative chemoradiation protocol. METHODS: Since December 1990, all rectal malignancies at our institution have been preoperatively staged with ERUS. ERUS has been an essential tool in preoperative staging of rectal cancer patients, possessing an overall accuracy of 84 percent for T stage and 81 percent for lymph node status in our hands (Williamson PR, unpublished data). Beginning in July 1992, all patients staged with T3 or T4 lesions on initial ERUS have been entered into a protocol consisting of preoperative chemoradiation therapy (CRT). This protocol consists of patients receiving 4,500 to 5,040 rads for five to eight weeks and concomitantly receiving sensitizing doses of 5-fluorouracil and/or leucovorin. All patients were scheduled for sphincter-saving or abdominoperineal resections six to eight weeks following completion of CRT. A repeat ERUS was performed on each patient one week before surgery. RESULTS: The study group consisted of 15 patients who completed CRT, including 12 males and 3 females. Evidence of tumor shrinkage via ERUS measurement was seen in all patients. Average tumor shrinkage as assessed by ERUS was 16 percent by width and 32 percent by depth of invasion. Sonographic level of invasion and nodal status were each downstaged in 38 percent of patients. Pathologic evaluation comparison revealed that the level of invasion was downstaged in 47 percent and nodal status in 88 percent compared with initial ERUS staging. Of those patients downstaged, 4 of 11 (36 percent) revealed no tumor in the pathology specimen. CONCLUSIONS: We conclude from our early experience that although ERUS offers a method for assessing degree of shrinkage and downstaging of T3 and T4 lesions after CRT, presently it does not closely predict the pathologic results. Results are strongly related to the experience of the ultrasonographer. The ability to distinguish tumor from radiation-induced changes to perirectal tissues is under continued investigation, and a new method of interpreting the data obtained by ERUS after CRT will need to be established.

PURPOSE: Many anorectal procedures are currently being performed on an outpatient basis, hemorrhoidectomy being the exception because of the need for parenteral narcotics postoperatively. We investigated the effectiveness of a subcutaneous morphine pump (SQMP) for outpatient posthemorrhoidectomy pain control. METHODS: In Phase 1 of our study, 22 patients undergoing radical hemorrhoidectomy were started on an SQMP protocol postoperatively. Twenty-nine patients received conventional postoperative narcotic dosing. In Phase 2, 19 patients enrolled in an SQMP protocol underwent hemorrhoidectomy in an ambulatory setting. Length of hospitalization, catheterization rate, and pain control were evaluated. RESULTS: In Phase 1, zero patients in the study group and two in the control group required additional hospitalization beyond 23 hours for pain control. The rates of catheterization were similar between the two groups. Pain control was considered satisfactory in 21 of 22 study patients. There was no correlation between pain level and morphine dose. Eighteen of 22 patients experienced minor side effects, necessitating pump removal in two patients. In Phase 2, 18 of 19 patients on the SQMP were discharged from the recovery room. Cost analysis shows the combination of outpatient hemorrhoidectomy and the SQMP to be cost-effective in comparison with an inpatient stay. CONCLUSIONS: The SQMP enables hemorrhoidectomy to be done on an outpatient basis. It provides effective pain control, enjoys high patient acceptance, and is cost-effective.

PURPOSE: The aim of this study was to test if the techniques learned during our early learning experience have proved to be effective in reducing the complications specifically related to the laparoscopic technique of colorectal surgery. METHODS: From October 1991 until July 1996, 195 laparoscopic operations were performed on the colon and the rectum. These data were divided into “early” and “latter” groups. The conversion reasons and early and late postoperative complications were analyzed and compared. RESULTS: Incidence of conversions required because of iatrogenic injuries showed a decline from 7.3 percent in the early group to 1.4 percent in the latter group. Sixty-six postoperative complications were observed in 59 (30.3 percent) patients. Complications specifically related to the technique of laparoscopic surgery occurred in nine (4.6 percent) patients. These were postoperative bleeding in three patients, port site hernias in five patients, and left ureteric stricture in one patient. Eight (6.5 percent) of these complications occurred in the early group, whereas one (1.4 percent) occurred in the latter group. Analyzing the conversions caused by intraoperative iatrogenic injuries and the specific postoperative complications together reveals that the incidence of 13.8 percent (17/123) in the early group has been reduced significantly to 2.8 percent (2/72) in the latter group. CONCLUSIONS: On the basis of our experience, we have identified techniques, which are discussed in detail, to make laparoscopic colorectal surgery safe. Strict adherence to these techniques has significantly reduced the incidence of complications, specifically those related to the laparoscopic technique.

Pain after hemorrhoidectomy is widely feared by many patients who are mostly still treated with oral/intramuscular narcotics to control their pain postoperatively. PURPOSE: In an effort to decrease posthemorrhoidectomy pain by applying newer methods of analgesia, a prospective trial was conducted to investigate the postoperative analgesic effect of Toradol® (ketorolac tromethamine; Syntex Labs, Palo Alto, CA) injected into the sphincter muscle at the time of hemorrhoidectomy and taken orally during a five-day postoperative period in a group of 24 patients (Toradol® group). Results were compared with two other groups of matching patients: one group (narcotics, n=18) treated with standard postoperative narcotic intramuscular/oral analgesics after overnight hospital stay, and a group (SQMP, n=21) previously treated by one of us with outpatient, subcutaneous infusion of morphine sulfate (Roxane Laboratories, Columbus, OH) via a home infusion pump. METHOD: The length of hospitalization, severity of postoperative pain and complications, costs, and side effects were analyzed by patient questionnaire at the time of the first postoperative visit and hospital and clinic records were reviewed. Differences between groups were analyzed using Student's t-test withP<0.05 being significant. RESULTS: Subjective pain response and hospitalization cost were significantly less in the SQMP group; however, this was at the expense of increased postoperative complications (urinary retention) and side effects (day until first bowel movement, nausea) although without a decrease in satisfaction rating. The Toradol® group had pain control equivalent to that of the narcotics group, a higher satisfaction rating, and suffered no increase in complications relative to either group. Significantly, there was no urinary retention in the Toradol® group. CONCLUSION: Postoperative pain after hemorrhoidectomy can be safely controlled as an outpatient using newer methods of pain control. These include both constant-infusion pain pump or supplemental use of the nonsteroidal analgesic ketorolac, both of which allow early release of the patient the day of surgery by diminishing postoperative pain. An important advantage of local injection of ketorolac is the elimination of urinary retention in our study group, probably by blunting the pain reflex response facilitated by prostaglandins, thus allowing safe same-day discharge.

Laparoscopic colorectal surgery is an established safe procedure with demonstrated benefits. Proficiency in this specialty correlates with the volume of cases. We examined training in this surgical field for both general surgery and colon and rectal surgery residents to determine whether the number of cases needed for proficiency is being realized. We examined the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Colorectal Surgeons (ABCRS) operative statistics for graduating general surgery and colon and rectal surgery residents. Although the number of advanced laparoscopy cases had increased for general surgery residents, there was still a significant gap in case volume between the average number of laparoscopic colorectal operations performed by graduating general surgery residents (21.6) and those performed by graduating colon and rectal surgery residents (81.9) in 2014. There is a gap between general surgery and colon and rectal surgery residenc...