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The role of strictureplasty in the management of Crohn's disease: How safet is it?
April 1995
SSAT
• A NEW TOOL TO MEASURE OUTCOME OF THERAPY SHOWS IMPROVED QUALrrY OF LIFE Ab-TER LAPAROSCOPIC NISSEN FUNDOPLICATION. M. O'Toole. C. Pooe. R.A. Devo. C.A. Pellegrini. Departments of Medicine and Surgery, University of Washington. Traditionally, the outcome of therapy for gastroesophageal reflux (GER) has been assessed objectively, using manometry, 24-h pH studies and endoscopy, or subjectively, measuring the response of selected GER symptoms to therapy. While these measures indicate the effects of treatment on the disease process, they do not always reflect accurately how the patient feels, i.e., quality of life (QOL). We developed a thorough, easy to use questionnaire to explore GER and other foregut symptoms (17 items), mood status (8 items) and functional status (7 items) and tested our new tool on 40 consecutive patients operated on for abnormal GER by one surgeon over a 9 month period. All patients were tested before and 3 months after laparoscopic Nissen fundoplication. Each patient served as its own control. Each question was entered in Systat FPU5.2.1. as a variable with a value of 6 to 4. Groups of related questions were summed as scale scores. T-tests were performed on individual variables and Spearmann correlations were done to measure internal consistency of questions and scales. Maximum possible score (best scenario) was 132. The results were as follows: SCALE Symptoms Mood Function OOL t~ range. * p
Pre-opt 20.35 (7-33) 14.20 (1-31) 10.30 (1-19) 54.50 ( 1 0 - 9 0 ) < 0.05
Post-Opt 46.90 (17-64) 21.60 (5-33) t3.25 (2-20) 91.7S(29-128~
Change* 26.6(5-52) 7.4(16-28) 3.0(-6-12) 37.3(6-95~
The highest correlation was between mood and function scales (r=0.88), followed by symptoms vs. mood (r=0.80). Thus, with this new tool it is possible to measure the effects of GER symptoms on the patient's QOL (which may help define indications for medical or surgical therapy,) and the effects of a given treatment on QOL (which may help compare treatment modalities). Furthermore, our study shows that in patients with GER, symptoms, mood and function are intertwined and respond similarly to treatment and that laparoscopic Nissen fundoplication dramatically improves the patients' overall QOL.
LAPAROSCOPIC INCISIONAL HERNIA REPAIR - ONGOING EXPERIENCE. A Park*, M Gaqner+, A Pomp+, * D e p a r t m e n t of Surgery, St. J o s e p h ' s Hospital, M c M a s t e r University, Hamilton, Ontario. + D e p a r t m e n t of Surgery, Hotel D i e u de Montreal, Montreal, Quebec. L a p a r o s c o p i c incisional h e r n i a repair has b e e n d e v e l o p e d to try to a d d r e s s the issues of p a i n f u l p o s t op r e c o v e r y and d e l a y e d return to normal a c t i v i t i e s a s s o c i a t e d w i t h c o n v e n t i o n a l m e s h repair. We h a v e d e s c r i b e d a t e c h n i q u e of l a p a r o s c o p i c incisional h e r n i a repair and n o w r e v i e w our e x p e r i e n c e w i t h 25 cases. Using a 3 or 4 t r o c h a r (2,10 m m & 1 or 2 5 nun) a p p r o a c h and a 3 ~ laparoscope, a d h e s i o n s w e r e lysed and m e s h p o s i t i o n e d to o v e r l a p fascial m a r g i n s b y at least 2 cms. The h e r n i a sac was not excised. The m e t h o d of s e c u r i n g the m e s h is described. 25 h e r n i a s in 23 p a t i e n t s ~ 9 women, 14 men) r a n g i n g in size f r o m l0 cm to 420 cm ~ (mean 104 cm L ) w e r e r e p a i r e d u s i n g PTFE p a t c h (12) and P r o l e n e m e s h (13). OR time r a n g e d from 1 to 3 hrs (mean 1.8 hrs). Post op s t a y ranged from 1 to 17 days (median 3 days, m e a n 4.3 days). F o l l o w up n o w extends to 20 m o n t h s w i t h a range of 1 to 20 m o n t h s (mean 9 months). Post op c o m p l i c a t i o n s include ileus (3), t r o c h a r site i n f e c t i o n (i) and u r i n a r y r e t e n t i o n (2). Most p a t i e n t s d e v e l o p a t r a n s i e n t r e s o l v i n g seroma, n o n e i n f e c t e d nor r e q u i r i n g drainage. There has b e e n 1 h e r n i a r e c u r r e n c e to date (67 yo man, 2 m o n t h s p o s t op). Although prospective c o m p a r i s o n w i t h c o n v e n t i o n a l repair and longer follow up are needed, our e x p e r i e n c e w i t h the l a p a r o s c o p i c repair of incisional h e r n i a s r e v e a l s it to be t e c h n i c a l l y f e a s i b l e a l l o w i n g p a t i e n t s p r o m p t r e s u m p t i o n of regular activities. This is a c c o m p l i s h e d w i t h m i n i m a l m o r b i d i t y and a r e c u r r e n c e rate of 4% to date.
T H E R O L E OF S T R I C T U R E P L A S T Y IN T H E M A N A G E M E N T OF CROHN'S DISEASE: H O W SAFE IS IT? G. Ozuner, MD and V.W. Fazio, MD, D e p a r t m e n t of C o l o r e c t a l Surgery, C l e v e l a n d Clinic Foundation. Cleveland, Ohio. Strictureplasty (SXPL) is a w e l l accepted t e c h n i q u e in the m a n a g e m e n t of s e l e c t e d patients w i t h Crohn's disease. To d e t e r m i n e t h e safety, applicability, perioperative complications, e f f e c t i v e n e s s and l o n g - t e r m r e s u l t s of SXPL in Crohn's disease; the e x p e r i e n c e at a single institution was reviewed. A retrospective analysis of all p a t i e n t s u n d e r g o i n g SXPL between 6/84 and 7/94 was performed. D u r a t i o n of Crohn's disease, associated m e d i c a l and s u r g i c a l history, indications for SXPL, m e d i c a t i o n s and lab data, intraoperative findings, c o m p l i c a t i o n s and long t e r m outcome was analyzed. One h u n d r e d fifty two patients (82 M, 70 F) u n d e r w e n t 178 operations for a total of 654 s t r i c t u r e p l a s t i e s (HeinekeMikulicz 589; Finney 65). M e d i a n n u m b e r of SXPL was three and the m e d i a n age of the p a t i e n t s was 36 years. No m o r t a l i t y occurred. Median hospital stay was eight days. Perioperative septic complications (intra-abdominal abscess, fistula, leak) w e r e noted in eight p a t i e n t s (5%), and reoperation for sepsis w a s n e e d e d in three patients. Post strietureplasty hemorrhage r e q u i r i n g t r a n s f u s i o n was n o t e d in 20 p a t i e n t s (13%) of which two required nonoperative intervention. Relief of o b s t r u c t i v e s y m p t o m s was a c h i e v e d in 98% of the patients. R a t e of restricture or new s t r i c t u r e / p e r f o r a t i v e d i s e a s e was observed in 4% and 18% r e s p e c t i v e l y d u r i n g a 39 month median follow-up. SXPL is a safe and effective p r o c e d u r e for small bowel C r o h n ' s d i s e a s e in certain patients; p a r t i c u l a r l y t h o s e w i t h multiple obstructions and those v u l n e r a b l e to short bowel syndrome. P e r i o p e r a t i v e c o m p l i c a t i o n s are few and long-term results are gratifying.
Q L A P A R O S C O P I C S P L E N E C T O M Y BY LATERAL A P P R O A C H O N G O I N G EXPERIENCE. A Park*, M Gaqner+,_AA Pomp+, * D e p a r t m e n t of Surgery, St. Joseph~s Hospital, M c M a s t e r University, Hamilton, Ontario. + D e p a r t m e n t of Surgery, Hotel Dieu de Montreal, Montreal, Quebec. L a p a r o s c o p i c s p l e n e c t o m y compared w i t h conventional s p l e n e c t o m y has b e e n shown to reduce p o s t o p e r a t i v e h o s p i t a l stay and result in m o r e rapid return to work. H a v i n g tried the anterior, 5 t r o c h a r a p p r o a c h we d e v e l o p e d a 4 trochar lateral a p p r o a c h and n o w p r e s e n t our experience w i t h 18 cases. All p a t i e n t s were placed in the right lateral d e c u b i t u s position. An Ii mm trochar is i n s e r t e d in the left subcostal region, two I0 m m t r o c h a r s in the flank and a 5 m m trochar dorsally. A 30 ~ laparoscope is used. The t e c h n i q u e is described. S p l e n e c t o m y was p e r f o r m e d for I.T.P.(6), T.T.P.(2), Evan's Syndrome(l), H a i r y Cell L e u k e m i a (i), H e r e d i t a r y Spherocytosis(1), H e m o l y t i c A n e m i a (2), Lymphoma(4), H y p e r s p l e n i s m ~ to Portal Hypertension(l, o n l y case w h e r e splenic artery e m b o l i z e d pre-op). Overall OR times ranged from 75 to 310 mins w i t h a m e d i a n of 160 mins and a m e a n of 161.4 mins. S p l e e n size varied from 7 to 27 cms w e i g h i n g 70 to 4313 grams (mean 676.5 grams). Post op stays ranged from 2 to 22 days. (Median 3 days, m e a n 6.3 days). 1 patient was c o n v e r t e d (Portal H y p e r t e n s i o n ) . No post op abscesses, b l e e d i n g nor p a n c r e a t i c injury o c c u r e d in these l a p a r o s c o p i c cases. The lateral a p p r o a c h a f f o r d s superior visualization of and access to s p l e n i c hilar structures. Superb a n a t o m i c e x p o s u r e allows easier dissection, even w i t h large spleens the tail of p a n c r e a s can be seen and avoided. Over a w i d e range of pathology, s p l e e n size and patient habitus this a p p r o a c h has b e e n d e m o n s t r a t e d to be feasible and reliable, the a p p r o a c h of choice for l a p a r o s c o p i c splenectomy.
A1237
SSAT
• A NEW TOOL TO MEASURE OUTCOME OF THERAPY SHOWS IMPROVED QUALrrY OF LIFE Ab-TER LAPAROSCOPIC NISSEN FUNDOPLICATION. M. O'Toole. C. Pooe. R.A. Devo. C.A. Pellegrini. Departments of Medicine and Surgery, University of Washington. Traditionally, the outcome of therapy for gastroesophageal reflux (GER) has been assessed objectively, using manometry, 24-h pH studies and endoscopy, or subjectively, measuring the response of selected GER symptoms to therapy. While these measures indicate the effects of treatment on the disease process, they do not always reflect accurately how the patient feels, i.e., quality of life (QOL). We developed a thorough, easy to use questionnaire to explore GER and other foregut symptoms (17 items), mood status (8 items) and functional status (7 items) and tested our new tool on 40 consecutive patients operated on for abnormal GER by one surgeon over a 9 month period. All patients were tested before and 3 months after laparoscopic Nissen fundoplication. Each patient served as its own control. Each question was entered in Systat FPU5.2.1. as a variable with a value of 6 to 4. Groups of related questions were summed as scale scores. T-tests were performed on individual variables and Spearmann correlations were done to measure internal consistency of questions and scales. Maximum possible score (best scenario) was 132. The results were as follows: SCALE Symptoms Mood Function OOL t~ range. * p
Pre-opt 20.35 (7-33) 14.20 (1-31) 10.30 (1-19) 54.50 ( 1 0 - 9 0 ) < 0.05
Post-Opt 46.90 (17-64) 21.60 (5-33) t3.25 (2-20) 91.7S(29-128~
Change* 26.6(5-52) 7.4(16-28) 3.0(-6-12) 37.3(6-95~
The highest correlation was between mood and function scales (r=0.88), followed by symptoms vs. mood (r=0.80). Thus, with this new tool it is possible to measure the effects of GER symptoms on the patient's QOL (which may help define indications for medical or surgical therapy,) and the effects of a given treatment on QOL (which may help compare treatment modalities). Furthermore, our study shows that in patients with GER, symptoms, mood and function are intertwined and respond similarly to treatment and that laparoscopic Nissen fundoplication dramatically improves the patients' overall QOL.
LAPAROSCOPIC INCISIONAL HERNIA REPAIR - ONGOING EXPERIENCE. A Park*, M Gaqner+, A Pomp+, * D e p a r t m e n t of Surgery, St. J o s e p h ' s Hospital, M c M a s t e r University, Hamilton, Ontario. + D e p a r t m e n t of Surgery, Hotel D i e u de Montreal, Montreal, Quebec. L a p a r o s c o p i c incisional h e r n i a repair has b e e n d e v e l o p e d to try to a d d r e s s the issues of p a i n f u l p o s t op r e c o v e r y and d e l a y e d return to normal a c t i v i t i e s a s s o c i a t e d w i t h c o n v e n t i o n a l m e s h repair. We h a v e d e s c r i b e d a t e c h n i q u e of l a p a r o s c o p i c incisional h e r n i a repair and n o w r e v i e w our e x p e r i e n c e w i t h 25 cases. Using a 3 or 4 t r o c h a r (2,10 m m & 1 or 2 5 nun) a p p r o a c h and a 3 ~ laparoscope, a d h e s i o n s w e r e lysed and m e s h p o s i t i o n e d to o v e r l a p fascial m a r g i n s b y at least 2 cms. The h e r n i a sac was not excised. The m e t h o d of s e c u r i n g the m e s h is described. 25 h e r n i a s in 23 p a t i e n t s ~ 9 women, 14 men) r a n g i n g in size f r o m l0 cm to 420 cm ~ (mean 104 cm L ) w e r e r e p a i r e d u s i n g PTFE p a t c h (12) and P r o l e n e m e s h (13). OR time r a n g e d from 1 to 3 hrs (mean 1.8 hrs). Post op s t a y ranged from 1 to 17 days (median 3 days, m e a n 4.3 days). F o l l o w up n o w extends to 20 m o n t h s w i t h a range of 1 to 20 m o n t h s (mean 9 months). Post op c o m p l i c a t i o n s include ileus (3), t r o c h a r site i n f e c t i o n (i) and u r i n a r y r e t e n t i o n (2). Most p a t i e n t s d e v e l o p a t r a n s i e n t r e s o l v i n g seroma, n o n e i n f e c t e d nor r e q u i r i n g drainage. There has b e e n 1 h e r n i a r e c u r r e n c e to date (67 yo man, 2 m o n t h s p o s t op). Although prospective c o m p a r i s o n w i t h c o n v e n t i o n a l repair and longer follow up are needed, our e x p e r i e n c e w i t h the l a p a r o s c o p i c repair of incisional h e r n i a s r e v e a l s it to be t e c h n i c a l l y f e a s i b l e a l l o w i n g p a t i e n t s p r o m p t r e s u m p t i o n of regular activities. This is a c c o m p l i s h e d w i t h m i n i m a l m o r b i d i t y and a r e c u r r e n c e rate of 4% to date.
T H E R O L E OF S T R I C T U R E P L A S T Y IN T H E M A N A G E M E N T OF CROHN'S DISEASE: H O W SAFE IS IT? G. Ozuner, MD and V.W. Fazio, MD, D e p a r t m e n t of C o l o r e c t a l Surgery, C l e v e l a n d Clinic Foundation. Cleveland, Ohio. Strictureplasty (SXPL) is a w e l l accepted t e c h n i q u e in the m a n a g e m e n t of s e l e c t e d patients w i t h Crohn's disease. To d e t e r m i n e t h e safety, applicability, perioperative complications, e f f e c t i v e n e s s and l o n g - t e r m r e s u l t s of SXPL in Crohn's disease; the e x p e r i e n c e at a single institution was reviewed. A retrospective analysis of all p a t i e n t s u n d e r g o i n g SXPL between 6/84 and 7/94 was performed. D u r a t i o n of Crohn's disease, associated m e d i c a l and s u r g i c a l history, indications for SXPL, m e d i c a t i o n s and lab data, intraoperative findings, c o m p l i c a t i o n s and long t e r m outcome was analyzed. One h u n d r e d fifty two patients (82 M, 70 F) u n d e r w e n t 178 operations for a total of 654 s t r i c t u r e p l a s t i e s (HeinekeMikulicz 589; Finney 65). M e d i a n n u m b e r of SXPL was three and the m e d i a n age of the p a t i e n t s was 36 years. No m o r t a l i t y occurred. Median hospital stay was eight days. Perioperative septic complications (intra-abdominal abscess, fistula, leak) w e r e noted in eight p a t i e n t s (5%), and reoperation for sepsis w a s n e e d e d in three patients. Post strietureplasty hemorrhage r e q u i r i n g t r a n s f u s i o n was n o t e d in 20 p a t i e n t s (13%) of which two required nonoperative intervention. Relief of o b s t r u c t i v e s y m p t o m s was a c h i e v e d in 98% of the patients. R a t e of restricture or new s t r i c t u r e / p e r f o r a t i v e d i s e a s e was observed in 4% and 18% r e s p e c t i v e l y d u r i n g a 39 month median follow-up. SXPL is a safe and effective p r o c e d u r e for small bowel C r o h n ' s d i s e a s e in certain patients; p a r t i c u l a r l y t h o s e w i t h multiple obstructions and those v u l n e r a b l e to short bowel syndrome. P e r i o p e r a t i v e c o m p l i c a t i o n s are few and long-term results are gratifying.
Q L A P A R O S C O P I C S P L E N E C T O M Y BY LATERAL A P P R O A C H O N G O I N G EXPERIENCE. A Park*, M Gaqner+,_AA Pomp+, * D e p a r t m e n t of Surgery, St. Joseph~s Hospital, M c M a s t e r University, Hamilton, Ontario. + D e p a r t m e n t of Surgery, Hotel Dieu de Montreal, Montreal, Quebec. L a p a r o s c o p i c s p l e n e c t o m y compared w i t h conventional s p l e n e c t o m y has b e e n shown to reduce p o s t o p e r a t i v e h o s p i t a l stay and result in m o r e rapid return to work. H a v i n g tried the anterior, 5 t r o c h a r a p p r o a c h we d e v e l o p e d a 4 trochar lateral a p p r o a c h and n o w p r e s e n t our experience w i t h 18 cases. All p a t i e n t s were placed in the right lateral d e c u b i t u s position. An Ii mm trochar is i n s e r t e d in the left subcostal region, two I0 m m t r o c h a r s in the flank and a 5 m m trochar dorsally. A 30 ~ laparoscope is used. The t e c h n i q u e is described. S p l e n e c t o m y was p e r f o r m e d for I.T.P.(6), T.T.P.(2), Evan's Syndrome(l), H a i r y Cell L e u k e m i a (i), H e r e d i t a r y Spherocytosis(1), H e m o l y t i c A n e m i a (2), Lymphoma(4), H y p e r s p l e n i s m ~ to Portal Hypertension(l, o n l y case w h e r e splenic artery e m b o l i z e d pre-op). Overall OR times ranged from 75 to 310 mins w i t h a m e d i a n of 160 mins and a m e a n of 161.4 mins. S p l e e n size varied from 7 to 27 cms w e i g h i n g 70 to 4313 grams (mean 676.5 grams). Post op stays ranged from 2 to 22 days. (Median 3 days, m e a n 6.3 days). 1 patient was c o n v e r t e d (Portal H y p e r t e n s i o n ) . No post op abscesses, b l e e d i n g nor p a n c r e a t i c injury o c c u r e d in these l a p a r o s c o p i c cases. The lateral a p p r o a c h a f f o r d s superior visualization of and access to s p l e n i c hilar structures. Superb a n a t o m i c e x p o s u r e allows easier dissection, even w i t h large spleens the tail of p a n c r e a s can be seen and avoided. Over a w i d e range of pathology, s p l e e n size and patient habitus this a p p r o a c h has b e e n d e m o n s t r a t e d to be feasible and reliable, the a p p r o a c h of choice for l a p a r o s c o p i c splenectomy.
A1237