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Early colectomy in steroid-refractory acute severe ulcerative colitis improves operative outcome
a p o l l o m e d i c i n e 1 2 s ( 2 0 1 5 ) S10–S29
uation, colonoscopy showed rectal growth with multiple colonic polyps. Patient underwent total proctocolectomy with end ileostomy. Histopathology showed well differentiated papillary adenocarcinoma rectum(T2N0M0), multiple sessile colonic polyps (>100) and pedunculated dysplastic polyps. Patient has no family history of malignancy. We report this rare case of synchronous periampullary and rectal malignancy with FAP presenting with obstructive jaundice. http://dx.doi.org/10.1016/j.apme.2015.11.072 Early colectomy in steroid-refractory acute severe ulcerative colitis improves operative outcome Sujeet Kumar Saha, Ameet Kumar, Rajesh Panwar, Sujoy Pal, Nihar Ranjan Dash, Vineet Ahuja, Peush Sahni Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India Background: Up to a third of patients with acute severe ulcerative colitis (ASUC) fail to respond to intensive steroid therapy and eventually require a salvage colectomy. We have previously reported a retrospective audit and shown that the mortality of emergency colectomy can be decreased by offering it within the first week of intensive medical therapy.1 We implemented this policy and report the results of our experience. Methods: The clinical records of all patients with ASUC who had failed intensive steroid-based medical therapy and undergone emergency colectomy between 2005 and 2015 were extracted from a prospectively maintained database. The data were analysed with regard to duration of intensive medical therapy, timing of surgery and in-hospital mortality. Results: Eighty-eight patients underwent emergency surgery for ASUC after failed medical therapy. Of these 84 (95.5%) had ASUC alone and 4 (4.5%) had toxic megacolon. Of these 75 (85.2%) were operated within 7 days of initiation of intensive medical therapy (58%; n = 51 were operated <5 days). One patient who was operated on day 8 following steroid therapy died postoperatively. The current postoperative mortality of 1.1% (1/88) was significantly lower than the mortality noted in the previously recorded retrospective case series (15.6%; 8/51; p = 0.006). Conclusion: The policy of early colectomy, within 7 days, in patients who fail to respond to intensive steroid-based therapy improves perioperative outcomes with significantly low in-hospital mortality.
reference
1. Pal S, Sahni P, Pande GK, Acharya SK, Chattopadhyay TK. Outcome following emergency surgery for refractory severe ulcerative colitis in a tertiary care centre in India. BMC Gastroenterol. 2005;5:39.
http://dx.doi.org/10.1016/j.apme.2015.11.073
S25
Complex fistula in ano: Fistulotomy (laying open) with or without setons – Our experience Sunil Kumar Aims and objectives: Anorectal abscess and fistula continue to be common problems encountered in surgical practice. The basic principles over the decades continues to be the same, namely eradication of sepsis and preventing incontinence resulting in satisfactory outcome. Materials and methods: Consecutive patients with proven complex anorectal fistulas operated by a single Colorectal surgeon over the last 20 months were included. All had telephonic follow up. Complex fistulas are those with more than a single tract, multiple openings and those extending towards the levators and associated with IBD. Results: Some 46 patients were operated during the study period. The average age was 37 years, 12 females and 34 males. 12 were operated elsewhere for the same problem and presented with recurrence. 15 patients had transrectal ultrasound (TRUS) before surgery and 3 patients had both MRI and TRUS. The rest were operated based on clinical findings and proctoscopy. All patients had fistulotomy (laying open), followed by the use of cutting setons wherever required. There were 3 patients with complex perianal sinuses. Loose seton was used in only 1 patient with Crohn’s. There were 2 patients with rectovaginal fistulas, 1 had collagen plug repair while the other had mucosal advancement flap. There were 3 recurrences. 3 patients needed repeat surgery to remove the cutting setons. Conclusions: Simple fistulotomy (laying open) along with selective use of cutting setons has provided satisfactory outcome in our patients with complex fistula in ano. http://dx.doi.org/10.1016/j.apme.2015.11.074 Incidence of the LAR syndrome after surgery for rectal cancer A. Thapa, D.K. Maharjan, T.Y. Tamang, P.B. Thapa, S.K. Shrestha Colorectal Unit, Department of Surgery, Kathmandu Medical College Teaching Hospital, Sinamangal, Kathmandu, Nepal Aims and objectives: With improving survival of rectal cancer, functional outcome has become increasingly important. Following sphincter-preserving LAR for rectal cancer often results in severe bowel dysfunction with incontinence, urgency, and frequent bowel movements, a major problem for many surviving rectal cancer patients. Low Anterior Resection Syndrome (LARS) has been reported in up to 50–75% of patients on a long-term basis. Material and methods: This is a descriptive study conducted at Colorectal Unit, Department of Surgery, Kathmandu Medical College and Teaching Hospital, Kathmandu, Nepal. Our objective is to study the incidence of LARS after surgery for rectal cancer. All patients who had undergone low and ultra low anterior resection for middle and low rectal cancer respectively were included after reversal of diverting ileostomy.
uation, colonoscopy showed rectal growth with multiple colonic polyps. Patient underwent total proctocolectomy with end ileostomy. Histopathology showed well differentiated papillary adenocarcinoma rectum(T2N0M0), multiple sessile colonic polyps (>100) and pedunculated dysplastic polyps. Patient has no family history of malignancy. We report this rare case of synchronous periampullary and rectal malignancy with FAP presenting with obstructive jaundice. http://dx.doi.org/10.1016/j.apme.2015.11.072 Early colectomy in steroid-refractory acute severe ulcerative colitis improves operative outcome Sujeet Kumar Saha, Ameet Kumar, Rajesh Panwar, Sujoy Pal, Nihar Ranjan Dash, Vineet Ahuja, Peush Sahni Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India Background: Up to a third of patients with acute severe ulcerative colitis (ASUC) fail to respond to intensive steroid therapy and eventually require a salvage colectomy. We have previously reported a retrospective audit and shown that the mortality of emergency colectomy can be decreased by offering it within the first week of intensive medical therapy.1 We implemented this policy and report the results of our experience. Methods: The clinical records of all patients with ASUC who had failed intensive steroid-based medical therapy and undergone emergency colectomy between 2005 and 2015 were extracted from a prospectively maintained database. The data were analysed with regard to duration of intensive medical therapy, timing of surgery and in-hospital mortality. Results: Eighty-eight patients underwent emergency surgery for ASUC after failed medical therapy. Of these 84 (95.5%) had ASUC alone and 4 (4.5%) had toxic megacolon. Of these 75 (85.2%) were operated within 7 days of initiation of intensive medical therapy (58%; n = 51 were operated <5 days). One patient who was operated on day 8 following steroid therapy died postoperatively. The current postoperative mortality of 1.1% (1/88) was significantly lower than the mortality noted in the previously recorded retrospective case series (15.6%; 8/51; p = 0.006). Conclusion: The policy of early colectomy, within 7 days, in patients who fail to respond to intensive steroid-based therapy improves perioperative outcomes with significantly low in-hospital mortality.
reference
1. Pal S, Sahni P, Pande GK, Acharya SK, Chattopadhyay TK. Outcome following emergency surgery for refractory severe ulcerative colitis in a tertiary care centre in India. BMC Gastroenterol. 2005;5:39.
http://dx.doi.org/10.1016/j.apme.2015.11.073
S25
Complex fistula in ano: Fistulotomy (laying open) with or without setons – Our experience Sunil Kumar Aims and objectives: Anorectal abscess and fistula continue to be common problems encountered in surgical practice. The basic principles over the decades continues to be the same, namely eradication of sepsis and preventing incontinence resulting in satisfactory outcome. Materials and methods: Consecutive patients with proven complex anorectal fistulas operated by a single Colorectal surgeon over the last 20 months were included. All had telephonic follow up. Complex fistulas are those with more than a single tract, multiple openings and those extending towards the levators and associated with IBD. Results: Some 46 patients were operated during the study period. The average age was 37 years, 12 females and 34 males. 12 were operated elsewhere for the same problem and presented with recurrence. 15 patients had transrectal ultrasound (TRUS) before surgery and 3 patients had both MRI and TRUS. The rest were operated based on clinical findings and proctoscopy. All patients had fistulotomy (laying open), followed by the use of cutting setons wherever required. There were 3 patients with complex perianal sinuses. Loose seton was used in only 1 patient with Crohn’s. There were 2 patients with rectovaginal fistulas, 1 had collagen plug repair while the other had mucosal advancement flap. There were 3 recurrences. 3 patients needed repeat surgery to remove the cutting setons. Conclusions: Simple fistulotomy (laying open) along with selective use of cutting setons has provided satisfactory outcome in our patients with complex fistula in ano. http://dx.doi.org/10.1016/j.apme.2015.11.074 Incidence of the LAR syndrome after surgery for rectal cancer A. Thapa, D.K. Maharjan, T.Y. Tamang, P.B. Thapa, S.K. Shrestha Colorectal Unit, Department of Surgery, Kathmandu Medical College Teaching Hospital, Sinamangal, Kathmandu, Nepal Aims and objectives: With improving survival of rectal cancer, functional outcome has become increasingly important. Following sphincter-preserving LAR for rectal cancer often results in severe bowel dysfunction with incontinence, urgency, and frequent bowel movements, a major problem for many surviving rectal cancer patients. Low Anterior Resection Syndrome (LARS) has been reported in up to 50–75% of patients on a long-term basis. Material and methods: This is a descriptive study conducted at Colorectal Unit, Department of Surgery, Kathmandu Medical College and Teaching Hospital, Kathmandu, Nepal. Our objective is to study the incidence of LARS after surgery for rectal cancer. All patients who had undergone low and ultra low anterior resection for middle and low rectal cancer respectively were included after reversal of diverting ileostomy.