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Canadian Surgery Forum Canadien De Chirurgie Vol. 44, Suppl., August / août 2001 ISSN 0008-428X ABSTRACTS RÉSUMÉS of presentations to the des communications présentées Annual Meetings of the aux congrès annuels de la Canadian Society of Colon Société canadienne and Rectal Surgeons des chirurgiens du côlon et du rectum Canadian Association of General Surgeons Association canadienne des chirurgiens généraux Canadian Association of Thoracic Surgeons Association canadienne des chirurgiens thoraciques CANADIAN SURGERY FORUM CANADIEN DE CHIRURGIE Québec, QC September 6 to 9, 2001 Québec (QC) du 6 au 9 septembre 2001 Abstracts Résumés Canadian Surgery Forum canadien de chirurgie 2001 Canadian Society of Colon and Rectal Surgeons Société canadienne des chirurgiens du côlon et du rectum 1 2 ARTIFICIAL BOWEL SPHINCTER IMPLANTATION COMPARISON OF DELORME AND ALTEMEIER IN THE MANAGEMENT OF SEVERE FECAL IN- PROCEDURES FOR RECTAL PROLAPSE. E.C. McKe- CONTINENCE — EXPERIENCE FROM A SINGLE vitt, B.J. Sullivan, P.T. Phang. Department of Surgery, St. INSTITUTION. A.R. MacLean, G. Stewart, K. Sabr, M. Paul’s Hospital, University of British Columbia, Vancou- Burnstein. Department of Surgery, St Michael’s Hospital, ver, BC University of Toronto, Toronto, Ont. We wish to compare the outcomes of 2 perineal operations for The purpose of this study was to evaluate the safety and effi- rectal prolapse: rectal mucosectomy (Delorme’s operation) cacy of artificial bowel sphincter (ABS) implantation in the and perineal rectosigmoidectomy (Altemeier’s operation). management of severe fecal incontinence (FI). We reviewed all 34 patients who had a perineal repair of Ten patients (6 males), with a mean age of 40.6 years, un- rectal prolapse at our hospital from July 1997 to June 2000. derwent ABS implantation between April 1998 and November Ten patients had the Delorme operation and 24 patients had 1999. The etiology of FI was imperforate anus (6), obstetrical the Altemeier operation. Mean age was 44.7 years (22–77) for trauma (3) and trauma (1). All patients failed previous opera- Delorme and 67.1 years (23–87) for Altemeier operations. tive and/or nonoperative therapy. One patient had a stoma at Follow-up telephone interviews were conducted for 25 pa- the time of ABS implantation. Preoperative evaluation in- tients (8 Delorme; 17 Altemeier) at a mean of 12.8 and 19.3 cluded calculation of the Fecal Incontinence Severity Score months, respectively. (FISS) and anal manometry. Manometry was repeated at acti- Recurrence of prolapse occurred in 50% patients who had vation of the ABS, and both manometry and FISS were per- the Delorme (2 full-thickness, 2 mucosal) versus 0% for the formed at 6- and 12-month follow-up visits. Differences in the Altemeier operation, p = 0.006. Incontinence to solid stool measures were tested with the repeated measures ANOVA to changed from 30% to 38%, preop. to postop., for the Delorme determine if a difference existed over time, and if ANOVA was compared with a change of 65% to 29% for the Altemeier op- significant, further paired comparisons were conducted using a eration, p = 0.2. Incontinence scores (Jorge and Wexner, Student’s t-test. 1993) changed from 7.9 ± 7.0 to 6.7 ± 7.7, p = 0.45, for the Mean operating time was 2 hours 22 minutes (range: 1 h Delorme, and 14.7 ± 6.4 to 10.8 ± 8.0, p = 0.01, for the Alte- 30 min–2 hr 50 min), and mean length of stay was 7 days meier operation. (range 5–13). Two patients have required explantation at 5 Complications occurred in 2 Delorme versus 6 Altemeier and 8 months, because of erosion of the device, and reopen- patients with 1 anastomotic stricture in each group, p = 0.68. ing of a rectourethral fistula, respectively. The remaining 8 pa- Hospital stay was 3.0 ± 0 days for Delorme versus 4.6 ± 2.0 tients had significant improvement in manometry and FISS. days for the Altemeier operation, p = 0.01. Patient satisfaction Mean preoperative resting anal pressure (RAP) was 20 was rated as excellent or good by 50% of Delorme and 64% of mm Hg; mean RAP was 56.6 mm Hg at activation (p < Altemeier patients, p = 0.3. 0.001), 50.7 mm Hg at 6 months (p < 0.001) and 55.3 We conclude that perineal rectosigmoidectomy had fewer mm Hg at 12 months (p = 0.001). Mean preoperative FISS recurrences and improved incontinence scores compared with was 102.4; mean FISS was 53.4 at 6 months (p = 0.011) and rectal mucosectomy for the treatment of rectal prolapse. 55.3 at 12 months (p = 0.002). ABS implantation results in a significant increase in RAP 3 and a significant decrease in FISS. Serious complications ANAL ADVANCEMENT FLAP FOR CHRONIC ANAL leading to explantation were seen in 2 of our 10 patients. FISSURE: A RETROSPECTIVE REVIEW. M.J. Raval, ABS implantation is an effective tool in the management of J.A. Heine, D.R.E. Johnson, W.D. Buie. Department of severe FI. Surgery, University of Calgary, Calgary, Alta. Canadian Journal of Surgery, Vol. 44, Suppl., August 2001 — Abstracts 3 CSCRS The aim of this study was to evaluate anal advancement flap 5 (AAF) for the treatment of chronic anal fissure (CAF). HOME TPN — AN ALTERNATIVE TO EARLY A retrospective chart review from December 1993 to No- SURGERY IN PATIENTS WITH COMPLICATED IBD. vember 2000 identified 21 patients (11 female, 10 male; age J.P. Evans, A. Steinhart, Z. Cohen, R.S. McLeod. Depart- 19–72) who underwent AAF for CAF. ment of Surgery and Department of Medicine, Mount Sinai Twelve flaps were lateral and 9 were midline covering the fis- Hospital, University of Toronto, Toronto, Ont. sure. Indications for AAF repair of the fissure included patient preference (8), poor sphincter function (previous surgery [4], A small number of patients undergoing surgery for inflamma- trauma [3], idiopathic [4]), and associated anal stenosis (2). tory bowel disease require short-term parenteral nutrition ei- There was no mortality. Morbidity included perianal sepsis (1) ther pre- or postoperatively. Some of these patients will require and flap tip necrosis (1). Two patients required overnight re- definitive surgery to correct the underlying cause of intestinal admission for pain control. One patient with anal stenosis had failure. Delaying surgery may make a difficult procedure easier, constipation, which resolved conservatively. Following primary and sometimes surgery may even be avoided. Traditionally pa- AAF, 20 patients were healed, while 1 required a second AAF tients remain in hospital while they receive this nutritional sup- for cure. No patient reported incontinence. port. This paper examines the safety and feasibility of providing Anal advancement flap for chronic anal fissure is a viable short-term, home TPN for IBD patients for whom the alterna- surgical alternative to lateral internal sphincterotomy for se- tive is prolonged hospitilization or early surgery. A review of all lected patients, especially those at high risk for postoperative IBD patients receiving temporary home parenteral nutrition incontinence. from our hospital pharmacy from June 1996 to July 2000 was performed. A quality-of-life phone questionnaire was con- 4 ducted at the time of review. Fifteen patients (11 males, 4 fe- FACTORS AFFECTING OUTCOMES FOR THE males) were identified, average age 35 years. The underlying PELVIC POUCH PROCEDURE IN ONTARIO. E.D. diagnosis was Crohn’s disease in 10 and ulcerative colitis in 5. Kennedy, D.M. Rothwell, D.V. Mukraj, H. MacRae, Indications for TPN varied. Two patients received preoperative Z. Cohen, R.S. McLeod. Department of Surgery, Mount home TPN for complex internal fistulae and resolving sepsis. Sinai Hospital, the Institute for Clinical Evaluative Sci- Twelve patients received home TPN after undergoing surgery ences and the University of Toronto, Toronto, Ont. during that admission. Five developed septic complications (anastomotic leak/enterocutaneous fistula), 4 had high-output The objective of this study was to determine what clinical vari- proximal stomas and 3 had prolonged ileus/partial obstruc- ables are predictive of length of hospital stay (LOS) and 30- tion. One patient received home TPN for a spontaneous ente- day readmission, reoperation and excision rates following rocutaneous fistula to an old surgical wound. TPN was given pelvic pouch procedure (PPP) using population based data. to 7 patients with the intention of performing delayed surgery. Two population based, administrative databases were used Five patients were given a trial of nonoperative management, to obtain all demographic, surgical and hospital data for pa- with a plan to perform surgery for non-healing fistulas. The av- tients undergoing the PPP in Ontario between 1992 and erage duration of TPN prior to discharge was 19.6 days and for 1998. Logistic regression was used to determine if age, gen- home TPN was 75 days (range 7–240). Two (13%) patients der, PPP staging (1, 2 or 3 stage), year of PPP or hospital vol- failed home TPN (1 with uncontrolled sepsis; 1 with dehydra- ume (high [HV] >100 PPP; medium [MV] 11–100 PPP; low tion) and were readmitted to hospital. Home TPN was [LV] ≤10 PPP) were predictive of LOS, 30-day readmission, stopped in 1 patient whose enterocutaneous fistula failed to reoperation and excision rates. heal with nonoperative treatment. Home TPN was successful Overall, 1285 PPP were performed. Mean LOS for all in 12 (80%) patients, 8 (53%) who underwent planned defini- stages of the PPP decreased from 21.0 to 18.5 days (p = tive surgery and in 4 (27%) patients who settled without re- 0.002) while 30-day readmission rate decreased from 12.8% quiring surgery. No patient developed deterioration in any of to 9.9% (p = 0.5). One- and 2-stage PPP had shorter LOS the nutritional indices (weight, hemoglobin, transferrin, albu- than 3-stage; however, lower stage was also associated with a min, lymphocyte count) used to monitor therapy.
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