Bio

Bio


Pelvic floor and functional bowel disorders refer to a series of symptoms and anatomic findings that effect men and women of all ages. These may include: constipation, difficult evacuation, fecal incontinence, irritable bowel disorders, diarrhea, pelvic organ prolapse, urinary and sexual dysfunction and pain. Although not life threatening, these disorders can severely affect quality of life and individual performance.

Over the past two decades I have dedicated my career to working with other specialists for comprehensive care for individuals with pelvic floor disorders. In July 2017, I joined The Department of Surgery, Division of Colorectal Surgery at Stanford University as the Medical Director of the Pelvic Health Center. I previously spent the prior decade at Cleveland Clinic running a multidisciplinary clinic and performing over 200 combined procedures in conjunction with colleagues in urology and urogynecology. We developed a robotic surgical approach to woman with vaginal and rectal prolapse and performed many surgeries to repair intestinal and rectal fistula (abnormal communications between the intestine and vagina).

Prior to that I established a Pelvic Floor Center at Maimonides Medical Center received a Jahnigan Career Development Award looking at multicompartment prolapse in elderly women. In addition to performing surgery and teaching throughout my career, I have maintained a commitment to long-term follow up of patients after surgery.
Although my training and focus is around surgical techniques and solutions for anorectal disorders and pelvic health, I believe that prevention, non-surgical alternatives, diet, exercise, and behavior management are vitally important to patient success.

One of my many goals is to educate patients, health care providers, and trainees about pelvic floor disorders.
When I am not at work I enjoy quality time with my three teenagers, dog, friends and I practice yoga.

Clinical Focus


  • General Surgery
  • Rectal Prolapse
  • Pelvic Floor Dysfunction
  • Fecal incontinence
  • Slow transit constipation
  • Obstructed defecation syndrome
  • Colovaginal fistula
  • Rectal vaginal fistula
  • Hemorrhoids
  • Anal fistula
  • Robotic Surgery

Academic Appointments


Administrative Appointments


  • Surgery Department Wellness Department, Stanford (2020 - 2022)

Professional Education


  • Fellowship: Cleveland Clinic Colon and Rectal Surgery Fellowship (2001) OH
  • Medical Education: Drexel University College of Medicine Orthopaedic Surgery Program (1994) PA
  • Residency: Icahn School of Medicine at Mount Sinai Hospital General Surgery Residency (2000) NY
  • Board Certification: American Board of Colon and Rectal Surgery, Colon and Rectal Surgery (2003)
  • Board Certification: American Board of Surgery, General Surgery (2001)

Publications

All Publications


  • A Collaborative Approach to Multicompartment Pelvic Organ Prolapse CLINICS IN COLON AND RECTAL SURGERY Gurland, B., Mishra, K. 2020
  • RECTAL PROLAPSE REPAIR IN MALES: IS ROBOTIC VENTRAL MESH RETROPEXY THE RIGHT CHOICE? Gurland, B., Sceats, L. WILEY. 2020: S182?S183
  • Crohn's disease: failure of a proprietary fluorescent in situ hybridization assay to detect M. avium subspecies paratuberculosis in archived frozen intestine from patients with Crohn's disease. BMC research notes Greenstein, R. J., Su, L., Fam, P. S., Gurland, B., Endres, P., Brown, S. T. 2020; 13 (1): 96

    Abstract

    OBJECTIVES: Although controversial, there is increasing concern that Crohn's disease may be a zoonotic infectious disease consequent to a mycobacterial infection. The most plausible candidate is M. avium subspecies paratuberculosis (MAP) that is unequivocally responsible for Johne's disease in ruminants. The purpose of this study was to evaluate a proprietary (Affymetrix RNA view) fluorescent in situ hybridization (FISH) assay for MAP RNA. Non-identifiable intestine from patients with documented Crohn's disease was assayed according to the manufacturer's instructions and with suggested modifications. Probes were custom designed for MAP and human beta-actin (as the eukaryotic housekeeping gene) from published genomes.RESULTS: Repetitively, false positive signal was observed in our "No-Probe" negative control. Attempts were made to correct this according to the manufacturer's suggestions (by modifying wash solutions, using recommended hydrochloric acid titration and different fluorescent filters). None prevented false positive signal in the "No-Probe" control. It is concluded that when performed according to manufactures instruction and with multiple variations on the manufactures recommended suggestions to correct for false positive signal, that the Affymetrix RNA view cannot be used to detect MAP in pre-frozen resected intestine of humans with Crohn's disease.

    View details for DOI 10.1186/s13104-020-04947-0

    View details for PubMedID 32093770

  • Trends in management of combined rectal and vaginal pelvic organ prolapse Speed, J., Zhang, C., Gurland, B., Enemchukwu, E. WILEY. 2020: S83?S84
  • Do preoperative demographics or symptoms predict recurrence in patients following combined surgical repair for pelvic organ prolapse and rectal prolapse? Syan, R., Wallace, S., Gurland, B., Enemchukwu, E. WILEY. 2020: S174?S175
  • Patient satisfaction improved when patients seen by multiple providers at a multidisciplinary pelvic health center Speed, J., Montalvo, C., Cuevas, J., Gurland, B., Enemchukwu, E. WILEY. 2020: S179?S180
  • Measuring Pelvic Floor Disorder Symptoms Using Patient-Reported Instruments: Proceedings of the Consensus Meeting of the Pelvic Floor Consortium of the American Society of Colon and Rectal Surgeons, the International Continence Society, the American Urogynecologic Society, and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction Bordeianou, L. G., Anger, J. T., Boutros, M., Birnbaum, E., Carmichael, J. C., Connell, K. A., De, E. B., Mellgren, A., Staller, K., Vogler, S. A., Weinstein, M. M., Yafi, F. A., Hull, T. L., Bernstein, M., Bhullar, J., Elkadry, E., Garrett, K., Gurland, B., Ahmed, K., Lee, P., Lipetskaia, L., Lucia, O., Rogers, R., Thorsen, A., Zutshi, M., Bharucha, A. E., Brenner, D., Kaiser, A., Ogilvie, J., Neto, A., Speranza, J., Stein, S., Brown, H., Cotterill, N., Elkadry, E., Garfinkle, R., Gupta, A., Harmanli, O., Hutchinson-Colas, J., Kobashi, K., McNevin, S., Murphy, M., Naranjo Ortiz, C., Warren, G., Bleier, J., Paquette, I., Richter, L., Singla, A., Oliver, J., Wakamatsu, M., Jaffi, F., Bennett, N. E., Hinkle, N. M., Jenkins, L., Mantilla, N., Savitt, L. R., Towe, M., Wexner, S. D., Ky, A., Bonnette, H., Hall, C., Keller, D., Lewicky-Gaupp, C., Rogers, R., Schizas, A., Umanskiy, K., Varma, M., Pelvic Floor Disorders Consortium LIPPINCOTT WILLIAMS & WILKINS. 2020: 1?15

    View details for DOI 10.1097/SPV.0000000000000817

    View details for Web of Science ID 000506388300002

    View details for PubMedID 31833996

  • Trends in the Diagnosis and Management of Combined Rectal and Vaginal Pelvic Organ Prolapse. Urology Speed, J. M., Zhang, C. A., Gurland, B., Enemchukwu, E. 2020

    Abstract

    To examine the rates of surgical repair of comorbid rectal prolapse (RP) and pelvic organ prolapse (POP) over time in a large population-based cohort.We queried Optum®, a national administrative claims database, from 2003-2017. We evaluated female patients age 18 or older with a diagnosis of POP and/or RP. Sociodemographic characteristics, comorbidities, and rates of procedures were collected.We identified 481,051 women diagnosed with RP and/or POP. Only 2.0% of women in the cohort had comorbid POP and RP. While 29.9% of women with RP had dual prolapse, only 2.1% of women with POP had both diagnoses. Overall, 25.8% of women had one or more surgical repairs. Surgical repairs were done in 26.0% of women with POP, 15.0% of women with RP, and 48.2% of women with comorbid POP/RP, though only 19.8% of patients with dual diagnoses had both RP and POP repairs. Over the study period, the rate of multidisciplinary surgical repairs increased by 2.7-fold.The prevalence of comorbid RP and POP among women in our cohort is low (2.0%). Rates of multidisciplinary surgery have increased possibly due to the increased use of imaging, laparoscopic surgery, and awareness of the shared pathophysiology of the disease.

    View details for DOI 10.1016/j.urology.2020.05.010

    View details for PubMedID 32439552

  • Surgical approach, complications, and reoperation rates of combined rectal and pelvic organ prolapse surgery. International urogynecology journal Wallace, S. L., Syan, R., Enemchukwu, E. A., Mishra, K., Sokol, E. R., Gurland, B. 2020

    Abstract

    Our primary objective was to determine rectal prolapse (RP) and pelvic organ prolapse (POP) reoperation rates and postoperative < 30-day complications after combined RP and POP surgery at a single institution.This was an IRB-approved retrospective cohort study of all female patients who received combined RP and POP surgery at a single tertiary care center from 2008 to 2019. Recurrence was defined as the need for subsequent repeat RP or POP surgery at any point after the index surgery. Surgical complications were separated into Clavien-Dindo classes.Sixty-three patients were identified, and 18.3% (12/63) had < 30-day complications (55% Clavien-Dindo grade 1; 27% Clavien-Dindo grade 2; 18% Clavien-Dindo grade 4). Of patients undergoing combined abdominal RP and POP repair, no postoperative < 30-day complications were noted in the MIS group compared to 37.5% of those patients in the laparotomy group (p?

    View details for DOI 10.1007/s00192-020-04394-2

    View details for PubMedID 32577789

  • Measuring pelvic floor disorder symptoms using patient-reported instruments: proceedings of the consensus meeting of the pelvic floor consortium of the American Society of Colon and Rectal Surgeons, the International Continence Society, the American Urogynecologic Society, and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction Bordeianou, L. G., Anger, J., Boutros, M., Birnbaum, E., Carmichael, J. C., Connell, K., De, E. B., Mellgren, A., Staller, K., Vogler, S. A., Weinstein, M. M., Yafi, F. A., Hull, T., Bernstein, M., Bhullar, J., Elkadry, E., Garrett, K., Gurland, B., Fraz, A., Lee, P., Lipetskaia, L., Lucia, O., Rogers, R., Thorsen, A., Zutshi, M., Staller, K., Bharucha, A. E., Brenner, D., Kaiser, A., Ogilvie, J., Neto, A., Speranza, J., Stein, S., Brown, H., Cotterill, N., Garfinkle, R., Gupta, A., Hutchinson-Colas, J., Kobashi, K., McNevin, S., Murphy, M., Naranjo Ortiz, C., Warren, G., Birnbaum, E., Connell, K., Bleier, J., Paquette, I., Richter, L., Singla, A., Oliver, J., Wakamatsu, M., Jaffi, F., Bennett, N. E., Hinkle, N. M., Jenkins, L., Mantilla, N., Savitt, L. R., Towe, M., Wexner, S. D., Weinstein, M., Ky, A., Bonnette, H., Hall, C., Keller, D., Lewicky-Gaupp, C., Rogers, R., Schizas, A., Umanskiy, K., Varma, M., Pelvic Floor Disorders Consortium SPRINGER-VERLAG ITALIA SRL. 2020: 5?22

    View details for DOI 10.1007/s10151-019-02125-4

    View details for Web of Science ID 000514318200002

    View details for PubMedID 31823193

  • Effect of a Multimodal Prehabilitation Program Prior to Colorectal Surgery on Postoperative Pain and Pain Medication Use Lee, A., Shelton, E., Bidwell, S., Shelton, A., Gurland, B., Morris, A. M., Kin, C. J. ELSEVIER SCIENCE INC. 2019: S58?S59
  • Surgical Decision-Making for Rectal Prolapse: One Size Does Not Fit All. Postgraduate medicine Lee, A., Kin, C., Syan, R., Morris, A., Gurland, B. 2019

    Abstract

    Background: Surgery remains the only known treatment option for rectal prolapse. Although over 100 abdominal and perineal procedures are available, there is no consensus as to which intervention is best suited for an individual. This retrospective cohort study describes the patient- and disease-related factors involved in making surgical recommendations around rectal prolapse in a single surgeon experience. Methods: 91 consecutive patients ?18 years old diagnosed with external and/or high grade internal rectal prolapse were assessed and were prospectively entered into an IRB approved registry. Information on patient symptoms, comorbidities, exam findings, surgeon judgement and patient preference was collected. Treatment recommendations (abdominal, perineal, or no operation) were analyzed and compared. Results: Surgical intervention was recommended to 93% of patients. Of those, 66% were recommended robotic abdominal procedures: 75%, robotic ventral mesh rectopexies; 16%, resection rectopexies; and 9%, suture rectopexies. On univariate analysis, patients with older age, higher ASA scores, presence of cardiopulmonary morbidity, pain as a primary rectal prolapse symptom, rectal prolapse always descended, and surgeon concern for frailty and general anesthesia were associated with recommendations for perineal operations (p<0.05 for all). However, on multivariate analysis, only age and concern over prolonged anesthesia remained correlated with recommendation for perineal surgery. Of patients >80 years of age, 15% were recommended an abdominal approach. Conclusions: With multiple options available for treatment of rectal prolapse, treatment recommendations remain surgeon-dependent and may be influenced by many factors. In our practice, robotic ventral mesh rectopexy was the most commonly recommended operation and was offered to carefully selected patients of advanced age. Although robotic surgery and ventral mesh rectopexy may not be accessible to all patients and surgeons, this represents a single surgeon's practice bias. This study reinforces the importance of perineal procedures for higher-risk individuals.

    View details for DOI 10.1080/00325481.2019.1669330

    View details for PubMedID 31525304

  • SURGICAL APPROACH, COMPLICATIONS AND RECURRENCE AFTER COMBINED RECTAL PROLAPSE AND PELVIC ORGAN PROLAPSE SURGERY AT A SINGLE TERTIARY CARE CENTER FROM 2008 TO 2019 Wallace, S. L., Syan, R., Tran, A., Mishra, K., Sokol, E. R., Gurland, B. H. SPRINGER LONDON LTD. 2019: S262
  • TRENDS IN THE SURGICAL MANAGEMENT OF COMBINED VAGINAL AND RECTAL PROLAPSE FOLLOWING THE INITIATION OF A MULTI-DISCIPLINARY PELVIC FLOOR CENTER Syan, R., Wallace, S. L., Gurland, B. H., Rogo-Gupta, L. SPRINGER LONDON LTD. 2019: S345
  • Clinical phenotypic presentation of rectal prolapse varies with age Neshatian, L., Lee, A., Wallace, S., Enemchukwu, E., Rogo-Gupta, L., Mishra, K., Garcia, P., Nguyen, L. B., Gurland, B. WILEY. 2019
  • SURGICAL APPROACH, COMPLICATIONS AND RECURRENCE AFTER COMBINED RECTAL PROLAPSE AND PELVIC ORGAN PROLAPSE SURGERY AT A SINGLE TERTIARY CARE CENTER FROM 2008 TO 2019 Wallace, S., Syan, R., Tran, A., Gurland, B., Sokol, E., Mishra, K. WILEY. 2019: S324?S326
  • Long-Term Outcomes After Ventral Rectopexy With Sacrocolpo- or Hysteropexy for the Treatment of Concurrent Rectal and Pelvic Organ Prolapse. Female pelvic medicine & reconstructive surgery Jallad, K., Ridgeway, B., Paraiso, M. F., Gurland, B., Unger, C. A. ; 24 (5): 336?40

    Abstract

    The primary objective is to describe the long-term anatomic and subjective outcomes in women undergoing ventral rectopexy with sacrocolpo- or hysteropexy. The secondary objective is to describe the perioperative adverse events.This is a retrospective cohort of women who underwent ventral rectopexy with either concurrent sacrocolpo- or hysteropexy at a tertiary care center between 2009 and 2015. A composite outcome for recurrent pelvic organ prolapse and rectal prolapse was defined as subjective failure (vaginal or rectal prolapse symptoms), objective failure (prolapse to or beyond the hymen or full thickness rectal prolapse), or any retreatment for prolapse. Patient's Global Impression of Change was recorded at baseline and at all follow-up visits. Perioperative adverse events were defined a priori and collected up to 6 weeks after surgery.A total of 59 patients underwent a ventral rectopexy, either a sacrocolpopexy (48/59, 81.3%) or sacrohysteropexy (11/59, 18.6%). The median follow-up after surgery for all patients was 17 months (range, 1-76) with a composite success rate for both pelvic organ prolapse and rectal prolapse (estimated by Kaplan-Meier method) of 57.4%. Forty (91%) of 44 patients reported a Patient's Global Impression of Change score of 6 or 7, indicating significant improvement after surgery. Of the patients, 15 (25.4%) experienced a perioperative adverse event. Use of biologic graft was associated with a higher rate of adverse event (40.0% [95% confidence interval, 24.6-57.5] vs 10.3% [95% confidence interval, 3.6-26.3]; P < 0.01).Ventral rectopexy with sacrocolpo- or hysteropexy is associated with significant improvement in anatomic and subjective outcomes. One in 4 women experienced a perioperative adverse event.

    View details for PubMedID 28657998

  • Expert Commentary on Surgical Evaluation and Management of Constipation DISEASES OF THE COLON & RECTUM Gurland, B. 2019; 62 (6): 665?66
  • Expert Commentary on Surgical Evaluation and Management of Constipation. Diseases of the colon and rectum Gurland, B. 2019; 62 (6): 665?66

    View details for PubMedID 31094959

  • Mindfulness-Based Training Improves Technical Skills and Emotional Regulation for Surgical Residents. JAMA network open Gurland, B. 2019; 2 (5): e194087

    View details for DOI 10.1001/jamanetworkopen.2019.4087

    View details for PubMedID 31125093

  • Editorial: Botox for levator ani. Techniques in coloproctology Gurland, B. H., Neshatian, L. 2019

    View details for PubMedID 30993476

  • Editorial: Botox for levator ani TECHNIQUES IN COLOPROCTOLOGY Gurland, B. H., Neshatian, L. 2019; 23 (3): 199?200
  • First Reported Case of Intussusception Caused by Escherichia coli O157:H7 in an Adult: Literature Review and Case Report SURGICAL INFECTIONS Cha, P. I., Gurland, B., Forrester, J. D. 2019; 20 (1): 95?99
  • Resection Rectopexy Is Still an Acceptable Operation for Rectal Prolapse AMERICAN SURGEON Carvalho e Carvalho, M., Hull, T., Zutshi, M., Gurland, B. H. 2018; 84 (9): 1470?75

    Abstract

    The aim of this study was to compare resection rectopexy (RR) with ventral mesh rectopexy (VMR). This institutional review board-approved retrospective study compared patients with rectal prolapse, who underwent RR or VMR from 2009 to 2016. The primary end point was the comparison of complications and prolapse recurrence rates. Seventy-nine RR and 108 VMR patients qualified. Using propensity score matching, the two groups were not significantly different (P = 0.818). There were no differences regarding gender (female 103 vs 72; P = 0.4) and age (59.3 vs 53.9; P = 0.054). Patients in the VMR group had a greater body mass index (25.5 vs 22.9; P = 0.001) and poorer physical status (American Society of Anesthesiologists 3 57.4% vs 41.8%; P = 0.04). The VMR group had more: robotic approaches (69.4% vs 8.9%; P < 0.001), concomitant urogynecological procedures (63 vs 19; P < 0.001), and longer operative time (269 vs 206 minutes; P < 0.001) but a reduced length of stay (2 vs 5 days; P < 0.001). The median follow-up (16 vs 26 months; P = 0.125) and the median time of recurrence (14 vs 38 months; P = 0.163) were similar. No differences were observed for complications or recurrence (10.2% vs 10.1%; P = 0.43). We failed to identify superiority based on surgical technique.

    View details for Web of Science ID 000445896600052

    View details for PubMedID 30268178

  • Levator ani syndrome: transperineal botox injections TECHNIQUES IN COLOPROCTOLOGY Bolshinsky, V., Gurland, B., Hull, T. L., Zutshi, M. 2018; 22 (6): 465?66

    View details for PubMedID 29850943

  • First Reported Case of Intussusception Caused by Escherichia coli O157:H7 in an Adult: Literature Review and Case Report. Surgical infections Cha, P. I., Gurland, B., Forrester, J. D. 2018

    Abstract

    Intussusception is the process by which one segment of intestine "telescopes" into another segment. Escherichia coli O157:H7 is a rare cause of intussusception that uncommonly requires a surgical procedure.Case report and literature review.We reviewed 25 cases of infection with E. coli O157:H7 that resulted in intussusception, all of which involved minors. Our case identifies the first reported adult with intussusception secondary to E. coli infection necessitating surgical intervention. In total, two (8%) required operation. Hemolytic uremic syndrome did not develop in any patient, and there were no deaths.E. coli O157:H7-associated intussusception is rare and does not commonly require operation. If conservative management fails, a surgical procedure may be necessary to resect the pathologic lead point.

    View details for PubMedID 30359547

  • Should we offer ventral rectopexy to patients with recurrent external rectal prolapse? INTERNATIONAL JOURNAL OF COLORECTAL DISEASE Gurland, B., Carvalho e Carvalho, M., Ridgeway, B., Paraiso, M. R., Hull, T., Zutshi, M. 2017; 32 (11): 1561?67

    Abstract

    For patients with rectal prolapse undergoing Ventral Rectopexy (VR), the impact of prior prolapse surgery on prolapse recurrence is not well described.The purpose of this study was to compare recurrence rates after VR in patients undergoing primary and repeat rectal prolapse repairs.This study is a prospective cohort study.IRB-approved prospective data registry of consecutive patients undergoing VR for full-thickness external rectal prolapse between 2009 and 2015.Rectal prolapse recurrence was defined as either external prolapse through the anal sphincters or symptomatic rectal mucosa prolapse warranting additional surgery. Preoperative and postoperative morbidity and functional outcomes were analyzed. Actuarial recurrence rates were calculated using the Kaplan-Meier method.A total of 108 VRs were performed during the study period. Seventy-two were primary and 36 repeat repairs. Seven cases were open, 23 laparoscopic, and 78 robotic. Six cases were converted from laparoscopic/robotic to open. In 63 patients, VR was combined with gynecological procedures. There were no statistical differences between primary or recurrent prolapse for the following: demographics, operative time, concomitant gynecologic procedures, complications, blood loss, and graft material type. Length of stay was longer in patients with a history of prior prolapse surgery (p = 0.01). Prolapse recurrence rates for primary repairs were reported at 1.4, 6.9, and 9.7% and for recurrent prolapse procedures 13.9, 25, and 25% at 1, 3, and 5 years (p = 0.13). Mean length of follow-up was similar between groups. Time to recurrence was significantly shorter in patients undergoing repeat prolapse surgery 8.8 vs 30.7 months (p = 0.03).VR is a better option for patients undergoing primary rectal prolapse repair.

    View details for PubMedID 28785819

  • Rectovaginal fistula repair with episioproctotomy and sphincteroplasty - a video vignette. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland Aytac, E., Gurland, B. 2017; 19 (3): 305

    View details for PubMedID 28160386

  • Sacral neuromodulation for the treatment of faecal incontinence following proctectomy. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland Mizrahi, I., Chadi, S. A., Haim, N., Sands, D. R., Gurland, B., Zutshi, M., Wexner, S. D., da Silva, G. 2017; 19 (5): O145?O152

    Abstract

    This study assessed the effectiveness of sacral neuromodulation (SNM) for faecal incontinence (FI) following proctectomy with colorectal or coloanal anastomosis.An Institutional Review Board (IRB)-approved database identified patients treated for FI following proctectomy (SNM-P) for benign or malignant disease, who were matched 1:1 according to preoperative Cleveland Clinic Florida Faecal Incontinence Scores (CCF-FIS) with patients without proctectomy (SNM-NP). Primary outcome was change in CCF-FIS.Twelve patients (seven women) were in the SNM-P group and 12 (all women) were in the SNM-NP group. In the SNM-P group, six patients underwent proctectomy for low rectal cancer and five received neoadjuvant chemoradiation. Five patients had handsewn anastomosis, and one had stapled coloanal anastomosis. One lead explantation occurred after a failed 2-week SNM percutaneous trial. Six patients underwent proctectomy for benign conditions. Within-group analyses revealed significant improvement in CCF-FIS in the SNM-P group (reduction from a score of 18 to a score of 14; P = 0.02), which was more profound for benign disease (reduction from 14.5 to 8.5) than for rectal cancer (reduction from 19.5 to 15). SNM was explanted in 66% and 33% of patients after proctectomy for malignant and benign conditions, respectively. In the SNM-NP group, 41% underwent overlapping sphincteroplasty. One patient received chemoradiation for anal cancer. Within-group analysis for the SNM-NP group showed significant improvement in CCF-FIS (a reduction from 17.5 to 4.0; P = 0.003). There was significant improvement in CCF-FIS in patients without previous proctectomy (mean delta CCF-FIS: 11.1 vs 4.7; P = 0.011). Analysis of covariance (ANCOVA) reaffirmed that controls outperformed proctectomy patients (P = 0.006).SNM for FI after proctectomy appears less effective than SNM in patients without proctectomy, with high device explantation rates, particularly after neoadjuvant chemoradiation and proctectomy for low rectal cancer.

    View details for PubMedID 27885800

  • Faecal incontinence in patients with a sphincter defect: comparison of sphincteroplasty and sacral nerve stimulation. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland Rodrigues, F. G., Chadi, S. A., Cracco, A. J., Sands, D. R., Zutshi, M., Gurland, B., Da Silva, G., Wexner, S. D. 2017; 19 (5): 456?61

    Abstract

    Sphincteroplasty (SP) is used to treat faecal incontinence (FI) in patients with a sphincter defect. Although sacral nerve stimulation (SNS) is used in patients, its outcome in patients with a sphincter defect has not been definitively evaluated. We compared the results of SP and SNS for FI associated with a sphincter defect.Patients treated by SNS or SP for FI with an associated sphincter defect were retrospectively identified from an Institutional Review Board approved prospective database. Patients with ultrasound evidence of a sphincter defect were matched by age, gender and body mass index. The main outcome measure was change in the Cleveland Clinic Florida Faecal Incontinence Score (CCF-FIS).Twenty-six female patients with a sphincter defect were included in the study. The 13 patients in each group were similar for age, body mass index, initial CCF-FIS and the duration of follow-up. No differences were observed in parity (P = 1.00), the rate of concomitant urinary incontinence (P = 0.62) or early postoperative complications. Within-group analysis showed a significant reduction of the CCF-FIS among patients having SNS (15.9-8.4; P = 0.003) but not SP (16.9-12.9; P = 0.078). There was a trend towards a more significant improvement in CCF-FIS in the SNS than in the SP group (post-treatment CCF-FIS 8.4 vs 12.9, P = 0.06). Net improvement in CCF-FIS was not significantly different between the groups (P = 0.06).Significant improvement in CCF-FIS was observed in patients treated with SNS but not SP patients. A trend towards better results was seen with SNS.

    View details for PubMedID 27620162

  • Optimizing Treatment for Rectal Prolapse. Clinics in colon and rectal surgery Hrabe, J., Gurland, B. 2016; 29 (3): 271?76

    Abstract

    Rectal prolapse is associated with debilitating symptoms and leads to both functional impairment and anatomic distortion. Symptoms include rectal bulge, mucous drainage, bleeding, incontinence, constipation, tenesmus, as well as discomfort, pressure, and pain. The only cure is surgical. The optimal surgical repair is not yet defined though laparoscopic rectopexy with mesh is emerging as a more durable approach. The chosen approach should be individually tailored, taking into account factors such as presence of pelvic floor defects and coexistence of vaginal prolapse, severe constipation, surgical fitness, and whether the patient has had a previous prolapse procedure. Consideration of a multidisciplinary approach is critical in patients with concomitant vaginal prolapse. Surgeons must weigh their familiarity with each approach and should have in their armamentarium both perineal and abdominal approaches. Previous barriers to abdominal procedures, such as age and comorbidities, are waning as minimally invasive approaches have gained acceptance. Laparoscopic ventral rectopexy is one such approach offering relatively low morbidity, low recurrence rates, and good functional improvement. However, proficiency with this procedure may require advanced training. Robotic rectopexy is another burgeoning approach which facilitates suturing in the pelvis. Successful rectal prolapse surgeries improve function and have low recurrence rates, though it is important to note that correcting the prolapse does not assure functional improvement.

    View details for PubMedID 27582654

    View details for PubMedCentralID PMC4991961

  • Is Botox for anal pain an effective treatment option? Postgraduate medicine Bibi, S., Zutshi, M., Gurland, B., Hull, T. 2016; 128 (1): 41?45

    Abstract

    The aim of this study was to evaluate the efficacy of Botulinum toxin-A (Botox) in relieving anal pain associated with anal fissure (AF) and Levator ani syndrome (LS).All patients with medically refractory AF or LS from 2005 to 2012 and treated with Botox injections were included.One hundred and three patients [66 patients (53 female) with AF and 37 patients (26 female) with LS] were evaluated. The minimum/maximum dose of Botox was 20/100 units for AF and 50/200 units for LS. Thirteen (19.7%) patients with AF and 14 (38%) patients with LS received > 1 Botox treatment. The time interval between injections varied from 1 to 12 months. Mean follow-up was 6.4 months for AF and 9 months for LS. Relief of anal pain was noted in 59% of AF and 43% of LS patients. Significant changes in pre- and post-op pain scores were noted in both groups. Nine out of 12 patients with failed sphincterotomy were relieved after Botox treatment. Temporary fecal incontinence was reported in 2/66 (3%) AF patients and 4/37 (10%) of LS patients. Overall, 66% patients' recommended Botox treatment and 72% were happy with the treatment as per telephone interview results.Botox relieves pain more effectively in AF than in LS. It is an effective option in medically refractory cases of LS. Higher doses of Botox are safe to use in LS; however, this needs to be evaluated. Botox injections have an overall low complication rate.

    View details for PubMedID 26308909

  • Outcomes of Sacral Neurostimulation Lead Reimplantation for Fecal Incontinence: A Cohort Study. Diseases of the colon and rectum Cracco, A. J., Chadi, S. A., Rodrigues, F. G., Zutshi, M., Gurland, B., Wexner, S. D., DaSilva, G. 2016; 59 (1): 48?53

    Abstract

    Adverse events and complications have been reported after sacral neurostimulation for fecal incontinence, which may result in surgical revision and device explantation. Lead reimplantation may be feasible; however, available data regarding outcomes are less robust.The aim of this study was to determine the outcomes of sacral neurostimulation lead reimplantation for fecal incontinence.This was a retrospective review of prospectively collected data.The study was conducted at 2 clinical sites from a single institution.Patients with fecal incontinence who underwent sacral neurostimulation implantation or reimplantation between 2011 and 2014 were included in the study.Sacral neurostimulation reimplantation was the included intervention.Change in the Cleveland Clinic Florida Fecal Incontinence Score (0 best; 20 worst) in reimplantation as compared with index implantation controls was the main measure. Secondary outcomes included the frequency and type of adverse events and complications.A total of 112 patients underwent either sacral neurostimulation implantation or reimplantation between 2011 and 2014. Ninety-seven patients underwent an index percutaneous nerve stimulation trial, 93 of whom also underwent a stimulator implantation. Fifteen patients underwent lead reimplantation, with 5 performed before stimulator implantation and 10 after stimulator implantation. The index implanted and reimplanted groups had similar demographics, comorbidities, and complication profiles including explantation rates. The most common reason for reimplantation was lead related (6/15), including 4 lead migrations, 1 lead fracture, and 1 lead erosion. Significant decreases in the incontinence score were achieved in each group (index implantation: p < 0.001; reimplantation: p = 0.006). When comparing the efficacy of sacral neurostimulation therapy in decreasing the fecal incontinence score from baseline in each group, patients with an index implantation were found to have a more significant improvement in their incontinence score as compared with the reimplantation group (p = 0.047).This was a retrospective study. A large number of patients with incomplete functional assessment data were excluded from analysis.The improvements in fecal incontinence are significantly better after index implantation than after reimplantation.

    View details for PubMedID 26651112

  • Multidisciplinary Approach to the Treatment of Concomitant Rectal and Vaginal Prolapse. Clinics in colon and rectal surgery Jallad, K., Gurland, B. 2016; 29 (2): 101?5

    Abstract

    Rectal prolapse and vaginal prolapse have traditionally been treated as separate entities despite sharing a common pathophysiology. This compartmentalized approach often leads to frustration and suboptimal outcomes. In recent years, there has been a shift to a more patient-centered, multidisciplinary approach. Procedures to repair pelvic organ prolapse are divided into three categories: abdominal, perineal, and a combination of both. Most commonly, a combined minimally invasive abdominal sacral colpopexy and ventral rectopexy is performed to treat concomitant rectal and vaginal prolapse. Combining the two procedures adds little operative time and offers complete pelvic floor repair. The choice of minimally invasive abdominal prolapse repair versus perineal repair depends on the patient's comorbidities, previous surgeries, preference to avoid mesh, and physician's expertise. Surgeons should at least be able to identify these patients and provide the appropriate treatment or refer them to specialized centers.

    View details for PubMedID 27247534

    View details for PubMedCentralID PMC4882172

  • Rectal Prolapse in Octogenarians: Does Surgery Impact Daily Activity? The American surgeon Bibi, S., Zutshi, M., Gurland, B., Hull, T. 2015; 81 (11): E371?2

    View details for PubMedID 26672569

  • Does Stool Leakage Increase in Aging Pouches? Diseases of the colon and rectum Kim, H., Sun, L., Gurland, B., Hull, T., Zutshi, M., Church, J. 2015; 58 (12): 1158?63

    Abstract

    Restorative proctocolectomy with IPAA is the standard surgical option for patients with ulcerative colitis. Although ileal pouches have been shown to have acceptable functional outcomes, some patients experience fecal incontinence.The purpose of this study was to evaluate the incidence of fecal leakage and the way it may change over time in patients with an ileoanal pouch.This study used a retrospective design.The study was conducted at a tertiary care center.Patients who received an IPAA for ulcerative colitis between 1983 and 2008 were accessed from a prospectively maintained database. We excluded patients with cancer, colonic dysplasia, and missing record of ileostomy closure and without long-term functional data.We defined fecal leakage as leakage of stool more than once per day. Univariate and multivariate analyses were performed to identify associations with and possible risk factors for fecal leakage.A total of 1228 patients were included in this study. There were 656 men, with a mean age of 38.7 years. The median follow-up time was 158 months. The fecal leakage rates at 5, 10, and >15 years were 24.6%, 25.7%, and 27.4% (p = 0.66). Patients with fecal leakage were significantly older at the time of surgery (p < 0.001), had longer disease duration before surgery (p = 0.04), underwent more 2-stage surgery (p = 0.04), included more women (p < 0.01), and showed lower preoperative maximum anal squeeze pressure (p = 0.008). On multivariate analysis, the only significant factor predisposing to fecal leakage was older age at the time of pouch surgery (OR = 1.07 (95% CI, 1.02-1.12); p = 0.005).The study was limited by its retrospective and non-randomized nature.The occurrence of fecal leakage in patients with IPAA does not change with time. However, increased age at the time of surgery may increase the chances of patients with IPAA having fecal leakage.

    View details for PubMedID 26544813

  • Case-matched Comparison of Robotic Versus Laparoscopic Colorectal Surgery: Initial Institutional Experience. Surgical laparoscopy, endoscopy & percutaneous techniques Gorgun, E., Aytac, E., Gurland, B., Costedio, M. M. 2015; 25 (5): e148?51

    Abstract

    Robotic colorectal surgery is an emerging technique. In this study, we aimed to compare outcomes of robotic colorectal operations to laparoscopy. Patients undergoing robotic colorectal surgery between November 2010 and July 2013 were case matched to laparoscopic counterparts based on diagnosis and operation type. Perioperative and short-term postoperative outcomes were compared. There were 57 patients who underwent robotic colorectal surgery. American Society of Anaesthesiologists score was higher in patients who underwent robotic surgery (2 vs. 3, P=0.01). Blood loss (200 vs. 300 mL, P=0.27) and conversion rate to open surgery (6 vs. 5, P=0.75) were similar between the groups. Operating time was longer in robotic surgery (172 vs. 267 min, P<0.0001). Time to first bowel movement (3 vs. 3 d, P=0.38), hospital stay (5 vs. 6 d, P=0.22), and postoperative complications were comparable between the groups. In the early learning curve period, robotic colorectal surgery shows similar short-term outcomes with longer operating time compared with conventional laparoscopy.

    View details for PubMedID 26429057

  • Comparing perineal repairs for rectal prolapse: Delorme versus Altemeier. Techniques in coloproctology Elagili, F., Gurland, B., Liu, X., Church, J., Ozuner, G. 2015; 19 (9): 521?25

    Abstract

    Data comparing surgical outcomes and quality of life (QOL) following perineal repair of rectal prolapse are limited. The aim of our study was to compare the short-term outcome and QOL of two perineal procedures in patients with rectal prolapse.All patients with full-thickness rectal prolapse admitted to our institution and undergoing Delorme and Altemeier procedures from 2005 to 2013 were identified using an institutional, IRB-approved rectal prolapse database. Short-term outcomes and QOL were compared.Seventy-five patients (93% female) underwent rectal prolapse surgery: 22 Altemeier and 53 Delorme, mean age 72 ± 15 years. Sixty-six percentage of patients were ASA grade III or IV (Table 1). The median hospital stay was longer in Altemeier?s group [4 (1?44) days vs. 3 (0?14) days; p = 0.01]. After a median follow-up of 13 (1?88) months, the rate of recurrent prolapse was 14% (n = 11) [Altemeier 2 (9%) vs. Delorme 9 (16%) p = 0.071]. Postoperative complication rate was 12% (n = 9) [Altemeier 5 (22%) vs. Delorme 4 (7%), p = 0.04]. There was no mortality. The Cleveland Global Quality of Life scores in each group were 0.6 ± 0.2 and 0.5 ± 0.3, respectively (p = 0.59), and were not changed by the surgery.In patients where abdominal repair of rectal prolapse is judged to be unwise, a Delorme procedure offers short-term control of the prolapse with low risk of complications and with reasonable function. In addition, patients that recur after a Delorme procedure can undergo another similar transanal procedure without compromising the vascular supply of the rectum.

    View details for PubMedID 26341686

  • Actual versus estimated length of stay after colorectal surgery: which factors influence a deviation? American journal of surgery Ahmed Ali, U., Dunne, T., Gurland, B., Vogel, J. D., Kiran, R. P. 2014; 208 (4): 663?69

    Abstract

    The aim of this study was to determine factors associated with deviation in length of hospital stay (LOS) from that determined by diagnosis-related groups.A cohort study from a prospectively collected database was conducted, including consecutive patients undergoing surgery in a high-volume colorectal surgery department in 2009.For 1,461 included patients, average expected and actual LOS were 8.17 days (interquartile range, 4.7 to 11.9 days) and 8.31 days (interquartile range, 4 to 10 days), respectively. The most prominent factors associated with an increase of LOS from expected were parenteral nutrition (5.11 days), emergency room admittance (3.67 days), and ileus (3.45 days) (P ? .001 for all). Other independently associated factors included blood transfusion, anastomotic leak, sepsis, pulmonary embolism, and surgeon. Patients with higher severity illness indexes and longer postoperative intensive care stay had lower than expected LOS.After colorectal surgery, several modifiable factors are associated with deviation of LOS from expected. An opportunity hence exists to reduce both LOS and financial burden for hospitals in an era of pay for performance.

    View details for PubMedID 25241954

  • An electronic safety screening process during inpatient computerized physician order entry improves the efficiency of magnetic resonance imaging exams. Academic radiology Schneider, E., Ruggieri, P., Fromwiller, L., Underwood, R., Gurland, B., Yurkschatt, C., Kubiak, K., Obuchowski, N. A. 2013; 20 (12): 1592?97

    Abstract

    Delays between order and magnetic resonance (MR) exam often result when using the conventional paper-based MR safety screening process. The impact of an electronic MR safety screening process imbedded in a computerized physician order entry (CPOE) system was evaluated.Retrospective chart review of 4 months of inpatient MR exam orders and reports was performed before and after implementation of electronic MR safety documentation. Time from order to MR exam completion, time from MR exam completion to final radiology report, and time from first order to final report were analyzed by exam anatomy. Length of stay (LOS) and date of service within the admission were also analyzed.We evaluated 1947 individual MR orders in 1549 patients under an institutional review board exemption and a waiver of informed consent. Implementation of the electronic safety screening process resulted in a significant decrease of 1.1 hours (95% confidence interval 1.0-1.3 hours) in the mean time between first order to final report and a nonsignificant decrease of 0.8 hour in the median time from first order to exam end. There was a 1-day reduction (P = .697) in the time from admission to the MR exam compared to the paper process. No significant change in LOS was found except in neurological intensive care patients imaged within the first 24 hours of their admission, where a mean 0.9-day decrease was found.Benefits of an electronic process for MR safety screening include enabling inpatients to have decreased time to MR exams, thus enabling earlier diagnosis and treatment and reduced LOS.

    View details for PubMedID 24200487

  • Colectomy with ileorectal anastomosis has a worse 30-day outcome when performed for colonic inertia than for a neoplastic indication. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland Reshef, A., Gurland, B., Zutshi, M., Kiran, R. P., Hull, T. 2013; 15 (4): 481?86

    Abstract

    Whether bowel related dysfunction adversely affects postoperative recovery after total colectomy with ileorectal anastomosis (C + IRA) for colonic inertia (CI) has not been previously well evaluated. This study compared the early postoperative outcome of C + IRA for CI and for other noninflammatory indications.Patients undergoing elective C + IRA from 1999 to 2010 were identified from a prospectively maintained database. Since inflammation in the rectum or small bowel may influence the outcome, patients with inflammatory bowel disease were excluded. Patients undergoing surgery for CI (group A) were compared with patients having the operation for other benign noninflammatory diseases (group B). Demographics, American Society of Anesthesiologists (ASA) score, body mass index (BMI), surgical procedure and 30-day complications were assessed.The study population consisted of 333 patients undergoing elective C + IRA (99 men, mean age 39 ± 16 years). The procedure was laparoscopic in 163 (49%) patients. Groups A (n = 131) and B (n = 202) had similar age and ASA score (39 ± 11 vs 39 ± 19 years, P = 0.4; 2.2 ± 0.5 vs 2.4 ± 0.7). Group A patients had lower BMI (25 ± 5 vs 28 ± 8 kg/m(2) , P = 0.002), more women (99 vs 51%, P < 0.001) and fewer laparoscopic procedures (43 vs 53%, P = 0.04). Compared with group B, group A had a greater incidence of postoperative ileus (32 vs 19%, P = 0.009), higher overall morbidity (36 vs 15%, P < 0.001) and increased length of stay (8.4 ± 6 vs 7.2 ± 5 days, P < 0.006). These differences persisted when subgroups of patients who underwent laparoscopic or open surgery were compared.Although CI is considered a 'benign' condition, patients undergoing C + IRA for this indication have significant morbidity compared with patients having the operation for other noninflammatory benign conditions.

    View details for PubMedID 23061597

  • Surgical complications impact patient perception of hospital care. Journal of the American College of Surgeons Gurland, B. H., Merlino, J., Sobol, T., Ferreira, P., Hull, T., Zutshi, M., Kiran, R. P. 2013; 217 (5): 843?49

    Abstract

    Public reporting of the Hospital Consumer Assessment of Healthcare Providers and Systems survey is designed to produce data on patients' perceptions of the quality of hospital care. The aim of this study was to assess the impact of complications on patient responses to Hospital Consumer Assessment of Healthcare Providers and Systems "top-box" (most favorable) scores.All patients who underwent a colorectal procedure from October 2009 to June 2012 at a single center were included. Patient complications were categorized as major, minor, or no complications and "surgical technique" or "medical." Chi-square and Wilcoxon rank sum tests were used to compare binary and ordinal top-box scores, respectively.One thousand four hundred and nine surveys were collected for 1,233 patients (mean age 53 ± 15.7 years; 701 [52.2%] females) who underwent 955 (67.8%) major abdominal, 114 (8.1%) anorectal, and 340 (24.1%) stoma-related operations. There were 195 (13.8%) major and 396 (28.1%) minor complications. There were 159 (11.3%) technique complications and 411 (29.2%) medical complications. Patients without any complications were more likely to recommend the hospital than those with complications (p = 0.023) irrespective of type of complication (minor vs major; p = 0.72 or technique vs medical; p = 0.5). Responsiveness of hospital staff was also reported as higher for patients without complications (p = 0.0003) and the type of complication did not influence this assessment (minor vs major; p = 0.71 and technique vs medical; p = 0.95).The occurrence of any complication after colorectal surgery adversely impacts patients' self-reported perceptions of hospital care as measured by Hospital Consumer Assessment of Healthcare Providers and Systems. An instrument that more accurately reflects patients' assessment of quality in the context of variations in patient, disease, and surgical factors is required.

    View details for PubMedID 24035448

  • Colectomy for slow transit constipation: effective for patients with coexistent obstructed defecation. International journal of colorectal disease Reshef, A., Alves-Ferreira, P., Zutshi, M., Hull, T., Gurland, B. 2013; 28 (6): 841?47

    Abstract

    Patient selection is a crucial step when considering total abdominal colectomy and ileorectal anastomosis (TAC/IRA) for refractory constipation.This study aimed to evaluate the results of short- and long-term outcomes for patients with pure slow transit constipation (STC) compared to those with slow transit and features of obstructive defecation (STC + OD).This study included all patients who underwent TAC/IRA for constipation from 1999-2010. Patients were divided into two groups: group A (STC) and group B (STC + OD) based on abnormal physiology or motility testing in addition to the surgeon's clinical impression of symptomatic obstructive defecation. Demographics, operative variables, and short-term outcomes were collected by retrospective chart review and were compared between groups. Long-term functional outcomes were assessed by telephone survey. This included: number of bowel movements, use of laxatives, antidiarrheal medications, and surgery satisfaction. Validated questionnaires were collected postoperatively.One hundred forty-four patients (143 females; mean age, 40 (18-68) years old) underwent TAC/IRA by either laparoscopic (63 (44 %)) or open (81 (56 %)) techniques. One hundred three patients had pure STC and 41 had STC + OD. Four patients underwent TAC with end ileostomy at first procedure. Seven patients underwent surgery after a trial of diverting ileostomy. One patient died unexpectedly, 2 days after uneventful surgery. Median follow-up was 43 (IQR, 16-75) months. Five (5 %) patients in group A and two (5 %) in group B underwent subsequent ileostomy for poor functional outcomes. Eighty-eight (68 %) patients were available by telephone. Short- and long-term outcomes were equivalent in both groups as well as patient satisfaction (89 vs. 85 %, p?=?0.7).Total abdominal colectomy can be offered to selective patients with slow transit constipation and obstructive defecation with equivalent long-term results.

    View details for PubMedID 23525467

  • Ventral rectopexy for rectal prolapse and obstructed defecation. Clinics in colon and rectal surgery Cullen, J., Rosselli, J. M., Gurland, B. H. 2012; 25 (1): 34?36

    Abstract

    Ventral rectopexy has gained popularity in Europe to treat full-thickness rectal external and internal prolapse. This procedure has been shown to achieve acceptable anatomic results with low recurrence rates, few complications, and improvements of both constipation and fecal incontinence. The authors review the principles, techniques, and outcomes of ventral rectopexy.

    View details for PubMedID 23449032

    View details for PubMedCentralID PMC3348728

  • Anal encirclement with sphincter repair (AESR procedure) using a biological graft for anal sphincter damage involving the entire circumference. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland Zutshi, M., Hull, T., Gurland, B. 2012; 14 (5): 592?95

    Abstract

    The effect of a biological material to support an overlapping sphincter repair was investigated in patients with damage to the entire circumference of the external sphincter due to radiation or trauma.A tunnel is created under the damaged external anal sphincter muscle to encircle the anal canal. A biological graft (Surgisis?; 6 ply, 2×20 cm) is then inserted through the tunnel and sutured to the muscle after being pulled firmly to close the patulous anus. An overlapping repair is then carried out. Between January 2009 and June 2010, 13 patients underwent this procedure.The average age at surgery was 68.6 years. The mean follow up was 16.3 (range 6-24) months. The average length of stay was 1 day. No complications were reported. Postoperatively, incontinence severity scores and quality of life scales [39.22 (±16.1) to 9.66 (±11.9)] showed improvement. Incontinence episodes were markedly decreased to one per week.Anal encirclement using a biological graft with sphincter augmentation may achieve continence in patients with circumferential anal sphincter damage.

    View details for PubMedID 21689344

  • Biological implants in sphincter augmentation offer a good short-term outcome after a sphincter repair. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland Zutshi, M., Ferreira, P., Hull, T., Gurland, B. 2012; 14 (7): 866?71

    Abstract

    Long-term results of the overlapping sphincter repair (OSR) have been disappointing, attributed to poor tissue quality that deteriorates with time. Biological grafts enforce tissues. The aim was to compare functional outcome and quality of life at 1 year with and without Permacol reinforcement to evaluate short-term benefit.From November 2007 to November 2008, women undergoing OSR using Permacol (group 1, n = 10) under institutional review board approval (safety trial) were age matched with patients from an institutional review board approved database (group 2, n = 10) who underwent the traditional OSR. Permacol mesh was placed under the two overlapped muscles. Group 2 underwent traditional repair. Preoperative and postoperative management of the groups was similar. The Fecal Incontinence Severity Index (FISI), the Cleveland Clinic Incontinence Score (CCFIS) and the Fecal Incontinence Quality of Life (FIQL) scale were used preoperatively and 1 year post-surgery.No significant differences in demographics, symptom duration, number of vaginal deliveries, comorbidities and symptom severity were noted. Group 2 underwent concomitant procedures. Group 1 reported no complications. Group 2 reported urinary retention and dehiscence. A significant difference was found in preoperative and postoperative FIQL subscales of coping/behaviour between groups. However, comparing the pre and post scores, significant improvements on FISI (P = 0.02), the CCFIS (P = 0.005) and two subscales of FIQL (coping/behaviour, P = 0.02, and embarrassment, P = 0.01) were found in group 1. Patient satisfaction was higher in group 1.Biologic tissue enhancers (Permacol) do not add morbidity. Sphincter augmentation results in significant improvement in continence and quality of life scores compared with the preoperative scores in the short term over traditional repair. Long-term studies are needed to determine if this effect is sustained.

    View details for PubMedID 21895926

  • Functional outcomes and quality of life after anorectal surgery. The American surgeon Grucela, A., Gurland, B., Kiran, R. P. 2012; 78 (9): 952?56

    Abstract

    There is a paucity of information examining quality of life (QOL) and functional results after anorectal surgery. We aim to prospectively evaluate postoperative QOL, pain, functional outcomes, and satisfaction for a large cohort of patients undergoing anorectal surgery. Data were prospectively accrued for consecutive patients undergoing anorectal operations from June 2009 to September 2010. Preoperative and postoperative electronic questionnaires were completed. QOL was evaluated by the European QOL index (EQ-5D) and functional results with the Fecal Incontinence Severity Index (FISI). Satisfaction was assessed: 1) Are you satisfied with surgery? 2) Would you recommend surgery to others? Responses were reported: 1 to 5 (1 = not at all; 5 = a lot). Pain was scored: 1 (no pain) to 10 (worst). One hundred ninety-five patients, 111 (56.9%) females, median age 44 years (range, 18 to 93 years), underwent anorectal surgery for abscess, condyloma, fissure, fistula, hemorrhoids, incontinence, pilonidal disease, pouch problems, tumors, and prolapse. Overall, pain improved significantly with improved QOL (P = 0.03). This correlated with overall postoperative satisfaction (92.4%). A total of 87.7 per cent of patients would recommend their surgery to others. The FISI was similar pre- and postoperatively (P = 0.18) and did not worsen postoperatively irrespective of surgical indication and procedure. Most patients were satisfied after anorectal surgery, which correlated with improved pain and QOL. Functional outcomes did not worsen. This will help counsel patients preoperatively and allay anxiety about postoperative function.

    View details for PubMedID 22964203

  • Overlapping sphincter repair: does age matter? Diseases of the colon and rectum El-Gazzaz, G., Zutshi, M., Hannaway, C., Gurland, B., Hull, T. 2012; 55 (3): 256?61

    Abstract

    The predictors of the outcomes following anal sphincteroplasty have not been well documented.The aim was to evaluate age as a predictor of functional outcome and quality of life after overlapping sphincter repair.This study is a retrospective review of chart review followed by a prospective evaluation by the use of validated questionnaires.Patients were assigned to group A (? 60 years old) or group B (>60 years).Included were patients with obstetric sphincter injuries who underwent overlapping sphincteroplasty between 1996 and 2007.The Fecal Incontinence Quality of Life Scale, Fecal Incontinence Severity Index, the Cleveland Global Quality of Life scale, and a patient satisfaction questionnaire were used to assess outcome.Three hundred twenty-one women underwent sphincteroplasty and 197 responded to this study, 146 (74.1%) patients in group A and 51 (25.9%) patients in group B. Median follow-up was 7.7 years (range, 4.7-10.0). The mean overall Fecal Incontinence Quality of Life Scale was 11.0 ± 3.5. Median Fecal Incontinence Severity Index score was 29.8 ± 15.9. Mean Cleveland Global Quality of Life scale was 0.7 ± 0.2. The 2 groups were comparable for BMI (p = 1.0), ethnic background (p = 0.8), smoking (p = 0.8), and follow-up duration (p = 0.9). Intergroup comparison showed no significant difference in the Fecal Incontinence Quality of Life Scale scores (p = 0.5) in all subscales: lifestyle (p = 0.8), coping behavior (p = 0.5), depression and self-perception (p = 0.2), and embarrassment (p = 0.1). No significant differences were noted in Fecal Incontinence Severity Index (p = 0.2), Cleveland Global Quality of Life scale (p =1.0), or postoperative satisfaction (p = 0.6).The study was limited by its retrospective nature.Comparable long-term Fecal Incontinence Severity Index score and Fecal Incontinence Quality of Life Scale scores following overlapping sphincter repair suggest that age is not a predictor of outcome for overlapping sphincter repair. This procedure can be offered to both young and older patients.

    View details for PubMedID 22469791

  • Perineal descent does not imply a more severe clinical disorder. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland Alves-Ferreira, P. C., Gurland, B., Zutshi, M., Hull, T. 2012; 14 (11): 1372?79

    Abstract

    There is poor consensus in the literature about measuring perineal descent. We aimed to assess symptoms and quality of life in constipated patients with abnormal perineal descent.Constipated patients were categorized into those with obstructed defaecation, colonic inertia, mixed disorders and irritable bowel syndrome constipation types. Anal physiology was performed. KESS score, Irritable Bowel Syndrome Quality of Life and SF-12 questionnaires were completed. The position of the perineum was measured by defaecography. Patients were divided into two groups according to the position of the perineal descent at rest: group 1 (normal < 3.5 cm) and group 2 (abnormal > 3.5 cm).Fifty-eight patients were identified, 23 (40%) in group 1 and 35 (60%) in group 2. Patients in group 2 were older (P = 0.007), had a higher body mass index (BMI; P = 0.003), a higher rate of hysterectomy (P = 0.04) and more vaginal deliveries (P = 0.001). Obstructed defaecation was the predominant subtype of constipation. Group 1 had more difficulty in initiating defaecation and group 2 presented more cases with intussusception and enterocele (P = 0.03 for both). Group 2 had a lesser degree of perineal descent between rest and straining. Rectal compliance was greater in group 2 (P = 0.03). Symptoms and quality of life scores were similar between the groups.Radiologically determined excessive perineal descent is not indicative of worse symptoms or quality of life. This radiological finding does not warrant further investigation.

    View details for PubMedID 22390340

  • Total abdominal colectomy has a similar short-term outcome profile regardless of indication: data from the National Surgical Quality Improvement Program. The American surgeon Alves-Ferreira, P. C., de Campos-Lobato, L. F., Zutshi, M., Hull, T., Gurland, B. 2011; 77 (12): 1613?18

    Abstract

    The purpose of this study was to evaluate the 30-day postoperative complications rate in patients undergoing elective total abdominal colectomy (TAC) for chronic constipation, neoplastic disorders, and inflammatory bowel disease (IBD) using the American College of Surgeons National Quality Improvement Database (ACS-NSQIP). The 2007 ACS-NSQIP sample was used to identify the Current Procedural Terminology codes for TAC and International Classification of Diseases, 9th Revision codes for chronic constipation, neoplasia, and IBD. Preoperative and intraoperative variables and postoperative complications were compared among the three diagnosis groups. Wilcoxon rank sum and Fisher exact tests were used for analysis. P < 0.05 was considered significant. Seven hundred forty-four patients were identified; chronic constipation was found in 107 (14.4%) patients, neoplasia in 312 (42.3%), and IBD in 322 (43.3%). Patients with constipation were predominantly females (85.2%). The neoplastic group was older and had greater body mass index when compared with the other groups. Patients with IBD presented greater use of steroids, lower albumin and hematocrit levels, and higher morbidity probability. Constipated patients had more neurologic and renal complications when compared with the IBD group (P = 0.01). None of the other categories of complications were statistically different among the diagnosis groups. With the exception of urinary tract infection being higher in the constipation patients compared with IBD (10 vs 4%, P = 0.03), there were no statistically significant differences among the other short-term specific complications. The 30-day complication rate after TAC is similar for chronic constipation, neoplasia, and IBD.

    View details for PubMedID 22273218

  • Surgeons should not hesitate to perform episioproctotomy for rectovaginal fistula secondary to cryptoglandular or obstetrical origin. Diseases of the colon and rectum Hull, T. L., El-Gazzaz, G., Gurland, B., Church, J., Zutshi, M. 2011; 54 (1): 54?59

    Abstract

    Closure of rectoanovaginal fistula from a cryptoglandular or obstetrical origin can be difficult. Multiple techniques exist and none are perfect. Although episioproctotomy offers the advantage of a simultaneous repair of the sphincter complex, it is a more extensive procedure. A rectal-advancement flap appears less traumatic and divides no perineal tissue or sphincter. The aim of this study was to evaluate the results of episioproctotomy and rectal-advancement flap on healing, postoperative continence, and sexual function.Data were retrospectively collected regarding 87 women with cryptoglandular or obstetrical rectoanovaginal fistula treated from June 1997 to 2009, who underwent episioproctotomy or rectal-advancement flap at the discretion of the treating surgeon. Healing, use of seton or stoma, number of previous procedures, smoking, age, body mass index, dyspareunia, SF-12 health survey, the IBD Quality of Life, and the Fecal Incontinence Quality of Life, and the Female Sexual Function Index were obtained from our database and via telephone interviews. The Fisher exact probability and ? tests were used.The mean age of these 87 women was 42.8 ± 10.5 years. Mean follow-up was 49.2 ± 39.2 months. Fifty (57.5%) patients underwent episioproctotomy and 37 (42.5%) underwent rectal-advancement flap. Thirty-nine (78%) patients healed after episioproctotomy vs 23 (62.2%) patients after rectal-advancement flap (P = .1). Episioproctotomy was associated with significantly better fecal (P < .001) and sexual (P = .04) function. There was no significant difference in other studied variables between the 2 techniques.Despite episioproctotomy being a more extensive procedure, healing rates were comparable between episioproctotomy and rectal-advancement flaps. In this select population, episioproctotomy may provide better continence and may confer better sexual function compared with rectal-advancement flap. In appropriate patients surgeons should not hesitate to perform episioproctotomy on cryptoglandular or obstetrical-associated rectoanovaginal fistula.

    View details for PubMedID 21160314

  • Robotic sacrocolpoperineopexy with ventral rectopexy for the combined treatment of rectal and pelvic organ prolapse: initial report and technique. Journal of robotic surgery Reddy, J., Ridgeway, B., Gurland, B., Paraiso, M. F. 2011; 5 (3): 167?73

    Abstract

    The objective of our study is to describe the peri-operative and early postoperative surgical outcomes following robotic sacrocolpoperineopexy with ventral rectopexy for the combined treatment of rectal and pelvic organ prolapse. This was a retrospective cohort study of ten women with symptomatic Stage 2 or greater pelvic organ prolapse and concomitant rectal prolapse who desired combined robotic surgery, at a single institution. The mean age of the subjects was 55.3 ± 19.2 years (range 19-86)  and the mean body mass index was 25.8 ± 5.7 kg/m(2). Preoperatively, the women had Stage 2 or greater pelvic organ prolapse and the average length of rectal prolapse was 2.1 ± 1.9 cm. There were no conversions to conventional laparoscopy or laparotomy. The mean operating room time was 307 ± 45 min with an estimated blood loss of 144 ± 68 ml. The average length of stay was 2.4 ± 0.8 days. Preliminary data suggest that robotic sacrocolpoperineopexy with ventral rectopexy is a feasible procedure with minimal operative morbidity for the combined treatment of rectal and pelvic organ prolapse. Longer follow-up is needed to ensure favorable long-term subjective and objective outcomes.

    View details for PubMedID 27637703

  • Doppler-guided hemorrhoidal artery ligation: the experience of a single institution. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract Szmulowicz, U. M., Gurland, B., Garofalo, T., Zutshi, M. 2011; 15 (5): 803?8

    Abstract

    This study aims to review the short-term recurrence and complications of Doppler-guided hemorrhoidal artery ligation (DG-HAL) with mucopexy.Approval was obtained for a retrospective chart review of patients who underwent DG-HAL from January 2007 to June 2009. A treatment failure was recorded if internal hemorrhoids were noted at follow up or symptoms persisted. All recurrences were assessed for predictive factors.The procedures were performed by four surgeons. Ninety-six patients were included. The average age was 63.5 years (21-81 years). The mean follow up was 15 months (3-35 months). Of the patients, 93 (96.8%) reported bleeding pre-operatively. Mucopexy accompanied DG-HAL in 87 (90.6%). Postoperative complications occurred in nine (9%) patients. Residual hemorrhoids were evident in 20 (21%) patients, 13 of whom required further management for symptomatic disease, five with DG-HAL. Fifty percent (10/20) and 70% (9/13) of the recurrences necessitating further treatment transpired during the first 20 procedures of each surgeon. All 13 symptomatic recurrences demonstrated large, circumferential internal hemorrhoids.DG-HAL is a simple procedure with a low complication rate. Recurrences are more frequent during the learning curve. Patients with large, circumferential internal hemorrhoids should be counseled about a possible higher rate of recurrence. DG-HAL can be effectively repeated for recurrences.

    View details for PubMedID 21359596

  • A primer on endoscopic electronic medical records. Clinics in colon and rectal surgery Atreja, A., Rizk, M., Gurland, B. 2010; 23 (1): 5?9

    Abstract

    Endoscopic electronic medical record systems (EEMRs) are now increasingly utilized in many endoscopy centers. Modern EEMRs not only support endoscopy report generation, but often include features such as practice management tools, image and video clip management, inventory management, e-faxes to referring physicians, and database support to measure quality and patient outcomes. There are many existing software vendors offering EEMRs, and choosing a software vendor can be time consuming and confusing. The goal of this article is inform the readers about current functionalities available in modern EEMR and provide them with a framework necessary to find an EEMR that is best fit for their practice.

    View details for PubMedID 21286284

    View details for PubMedCentralID PMC2850160

  • Using technology to improve data capture and integration of patient-reported outcomes into clinical care: pilot results in a busy colorectal unit. Diseases of the colon and rectum Gurland, B., Alves-Ferreira, P. C., Sobol, T., Kiran, R. P. 2010; 53 (8): 1168?75

    Abstract

    Patient-reported outcomes are traditionally collected through paper questionnaires. This process is labor intensive and costly. The aim of this study was to assess the feasibility of using tablet computing technology to streamline the questionnaire intake process and integrate patient-reported outcomes into electronic health records for access at the point of care.Response-driven electronic questionnaires for patients with colorectal disorders were designed. The impact of this technology on clinical workflow and questionnaire response rates was assessed. Historical data on paper questionnaire response rates over a similar time period were compared with the electronic data.From June through July 2009, data from 103 patient visits to 2 surgeons over 8 clinic days were included. Females comprised 69.7% of the sample with a median age of 49 (range, 18-84) years. When patients checked in 30 minutes early, 82% completed the forms by their scheduled visit time. The questionnaires response rate was 96%. Scores were calculated automatically and included in the electronic health record. Median questionnaire completion time was 15 (interquartile range, 8-21) minutes. Conversely, collection rates of historical data for the same surgeons over a 2-month period revealed that 152 patient visits yielded 38 paper questionnaires, a response rate of 25%.Collection of patient-reported outcomes by use of tablet technology and automatic transmission into the electronic chart with data storage for later use is feasible. This process can overcome many of the inefficiencies associated with paper questionnaires.

    View details for PubMedID 20628281

  • Obstetric and cryptoglandular rectovaginal fistulas: long-term surgical outcome; quality of life; and sexual function. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract El-Gazzaz, G., Hull, T. L., Mignanelli, E., Hammel, J., Gurland, B., Zutshi, M. 2010; 14 (11): 1758?63

    Abstract

    Rectovaginal fistula (RVF) repair can be challenging. Additionally, women may experience sexual dysfunction and psychosocial ramifications even after a successful repair. The aim of this study was to investigate variables looking for predictors of healing/failure and examine long-term quality-of-life (QOL) and sexual function in women with low RVF from obstetrical or cryptoglandular etiologyFrom June 1997-2009, 268 women underwent RVF repair. Of those, 100 with obstetric or cryptoglandular etiology agreed to participate in this study. Healing, type of procedure, use of seton or stoma, number of previous procedures, smoking, age, body mass index (BMI), dyspareunia, QOL using SF-12, FIQL, IBS-QOL, and female sexual function index was obtained from our prospective database and telephone contact. Fisher's exact test, chi-square test, and multivariable-logistic-regression model were used to identify the variables associated with healing/failure.Mean follow-up was 45.8 ± 39.2 months; mean age 42.8 ± 10.5 years; and BMI was 28.8 ± 7.6. Sixty (60%) fistulas were obstetric and 40 (40%) cryptoglandular and 68/100 patients (68%) healed. On multivariate analysis, treatment failure was related to a heavier BMI (p = 0.001) and number of repairs (p = 0.02). Looking at each type of repair, episioproctotomy had significant healing compared to the other choices (but was not significant on multivariate analysis). Forty-seven women were sexually active at follow-up and 12/47 (25.5%) reported dyspareunia. Fecal incontinence was reported preoperatively in 42 women, more often in those with obstetric-related RVF (76% vs. 24% p < 0.05). Healing was not affected by age, smoking, co-morbidities, preoperative seton, or stoma use. Fecal and sexual function and QOL were comparable between women with healed and unhealed RVF.Patients with higher BMI and more repairs had a decreased healing rate following RVF repair. Despite surgical outcome, QOL and sexual function were surprisingly similar regardless of fistula healing.

    View details for PubMedID 20593308

  • Transvaginal sacrospinous rectopexy: initial clinical experience. Techniques in coloproctology Gurland, B., Garrett, K. A., Firoozi, F., Goldman, H. B. 2010; 14 (2): 169?73

    Abstract

    There is a wide range of surgical procedures available to treat rectal prolapse that differ in approach as well as in principle. The current perineal approaches available involve mucosal or full thickness resection. There are currently no accepted procedures combining rectal fixation without resection using the perineal approach. We present our initial report of transvaginal sacrospinous rectopexy for the treatment of rectal prolapse.A longitudinal incision was made in the posterior wall of the vagina. The rectum and sacrospinous ligament were identified. Two sutures were placed in the sacrospinous ligament and brought through a piece of Surgisis mesh previously anchored to the anterior surface of the rectum. This was performed bilaterally. These sutures were tied to complete the rectal suspension, and the posterior wall of the vagina was closed.Transvaginal sacrospinous rectopexy was performed in all seven cases. In the first two cases, a Delorme procedure was performed concurrently. Two patients had rubber band ligation for symptomatic internal hemorrhoids, one patient had a sphincter plication, and one patient had an anal encirclement procedure with Surgisis. Six of the seven patients had concomitant urologic procedures. The average operative time was 163 min, and the average blood loss was 107 mL. None of the cases required conversion to an open procedure. There was one full thickness recurrence at 18 weeks.Transvaginal sacrospinous rectopexy is a safe, minimally invasive, technically feasible technique for the treatment of rectal prolapse.

    View details for PubMedID 20309717

  • Analysis of function and predictors of failure in women undergoing repair of Crohn's related rectovaginal fistula. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract El-Gazzaz, G., Hull, T., Mignanelli, E., Hammel, J., Gurland, B., Zutshi, M. 2010; 14 (5): 824?29

    Abstract

    Crohn's-related rectovaginal fistulae have significant impact on quality of life including sexual function. The aim of this study was to obtain long-term follow-up of Crohn's related rectovaginal fistulae to assess variables that influence surgical success and determine its effects on quality of life and sexual function.All women with Crohn's-related rectovaginal fistulas who underwent surgical repair from 1997 to 2007 were contacted for long-term follow-up. Variables assessed were age, body mass index, smoking, presence of active Crohn's disease, type of surgical procedure performed, use of perioperative seton or stoma, number of previous procedures, time interval between last repair and current repair, use of immunomodulators, and steroids. SF-12, Fecal Incontinence Quality-of-Life Scale, and Female Sexual Function Index were used to assess quality of life and sexual function. Multivariable logistic regression model was used to identify variables associated with surgical failure.Sixty-five women were identified at median follow-up of 44.6 months (interquartiles, 13.1-79.1) of which 30 patients (46.2%) were successfully healed. Methods of repair included advancement flap (n = 47), episioproctotomy (n = 8), colo-anal anastomosis (n = 7), and fibrin glue or plug (n = 3). Twenty-eight women (43.1%) were sexually active at follow-up, and of those, nine complained of dyspareunia, all within the unhealed group of patients. On multivariate analysis, only immunomodulators were associated with successful healing (p = 0.009). Smoking and steroids were associated with failure (p = 0.04). Sexual function and quality-of-life scores were comparable between healed and unhealed groups.Crohn's-related rectovaginal fistulae are difficult to treat. Healing increased with use of immunomodulators; however, smoking and steroids were predictors of failure. Dyspareunia was higher in unhealed women.

    View details for PubMedID 20232172

  • Transrectal ultrasound, manometry, and pudendal nerve terminal latency studies in the evaluation of sphincter injuries. Clinics in colon and rectal surgery Gurland, B., Hull, T. 2008; 21 (3): 157?66

    Abstract

    Fecal incontinence may be due to postpartum anal sphincter injuries or neurological damage even in the absence of obvious perineal trauma. Anal physiologic testing with transrectal ultrasound, manometry, and pudendal nerve terminal latency studies help to identify those patients with anal sphincter injuries who might benefit from anal sphincter repair. In this article, the authors discuss the specific tests that are available and how to interpret them.

    View details for PubMedID 20011414

    View details for PubMedCentralID PMC2780206

  • Does rectal wall tumor eradication with preoperative chemoradiation permit a change in the operative strategy? Diseases of the colon and rectum Zmora, O., Dasilva, G. M., Gurland, B., Pfeffer, R., Koller, M., Nogueras, J. J., Wexner, S. D. 2004; 47 (10): 1607?12

    Abstract

    Preoperative chemoradiation may downstage locally advanced rectal cancer and, in some cases, with no residual tumor. The management of complete response is controversial and recent data suggest that radical surgery may be avoided in selected cases. Transanal excision of the scar may determine the rectal wall response to chemoradiation. This study was designed to assess whether the absence of tumor in the bowel wall corresponds to the absence of tumor in the mesorectum, known as true complete response.A retrospective review of the medical records of patients who underwent preoperative chemoradiation for advanced mid (6-11 cm from the anal verge) and low (from the dentate line to 5 cm from the anal verge) rectal cancer (uT2-uT3) followed by radical surgery with total mesorectal excision was undertaken. Patients in whom the pathology specimen showed no residual tumor in the rectal wall (yT0, "y" signifies pathologic staging in postradiation patients) were assessed for tumoral involvement of the mesorectum.A total of 109 patients underwent preoperative, high-dose radiation therapy (94 percent with 5-fluorouracil chemosensitization), followed by radical surgery for advanced rectal cancer. Preoperatively, 47 patients were clinically assessed to have potentially complete response. After radical rectal resection, pathology did not reveal any residual tumor within the rectal wall (yT0) in 17 patients. In two (12 percent) of these patients, the mesorectum was found to be positive for malignancy: one had positive lymph nodes that harbored cancer; one had tumor deposits in the mesorectal tissue.Compete rectal wall tumor eradication does not necessarily imply complete response, because the mesorectum may harbor tumor cells. Thus, caution should be exercised when considering the avoidance of radical surgery. Reliable imaging methods and clinical predictors for favorable outcome are important to allow less radical approaches in the future.

    View details for PubMedID 15540288

  • Is routine pouchogram prior to ileostomy closure in colonic J-pouch really necessary? Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland da Silva, G. M., Wexner, S. D., Gurland, B., Gervaz, P., Moon, S. D., Efron, J., Nogueras, J. J., Weiss, E. G., Vernava, A. M., Zmora, O. 2004; 6 (2): 117?20

    Abstract

    Colonic J-pouch with coloanal anastomosis has gained popularity in the surgical treatment of middle and lower rectal pathologies. If a diverting ileostomy is performed, a pouchogram is frequently performed prior to ileostomy closure. The aim of this study was to assess the routine use of pouchogram prior to ileostomy closure in patients with colonic J pouch-anal anastomosis.All patients who underwent a colonic J pouch-anal anastomosis between 1990 and 2000 were retrospectively reviewed. Patients with temporary loop ileostomy who had pouchogram prior to ileostomy closure were included. Pouchogram results were compared to the patient's post ileostomy closure clinical outcome. Sensitivity, specificity and predictive values of pouchogram were assessed.Eighty-four patients had a pouchogram prior to ileostomy closure. Radiological abnormalities were evident in 6 patients, including 4 strictures, 1 pouch-vaginal fistula and 1 leak. Of these findings, 4 were false positives (3 strictures and 1 leak) and two were true positives (1 stricture and 1 pouch-vaginal fistula). The actual rate of pouch complications was 9.5% (8 complications) including 3 anastomotic leaks, all with normal pouchogram, 3 strictures requiring dilatation under anaesthesia, only one detected by pouchogram, and 2 pouch-vaginal fistulas, only one diagnosed by pouchogram. The sensitivity and specificity of pouchogram, respectively, was 0 and 98% for anastomotic leak, 33 and 96% for stricture, and 50 and 100% for pouch-vaginal fistula. Overall, pouchogram changed the management in only 1 of 84 patients.Pouchogram has a low sensitivity in predicting complications following ileostomy closure in patients after colonic J-pouch anal anastomosis and rarely changes the management of these patients. The use of pouchogram prior to ileostomy closure may be unnecessary and should be reserved in cases of clinical suspicion of complications.

    View details for PubMedID 15008910

  • Laparoscopic surgery for inflammatory bowel disease: results of the past decade. Inflammatory bowel diseases Gurland, B. H., Wexner, S. D. 2002; 8 (1): 46?54

    Abstract

    Laparoscopic colectomy is one of the most difficult laparoscopic procedures. Surgeons attempting to perform laparoscopic surgery for inflammatory bowel disease (IBD) must have significant experience with IBD and advanced laparoscopic skills. Surgical management for IBD may be treated with a range of laparoscopic procedures that vary in complexity. After 10 years of experience, studies comparing laparoscopy versus laparotomy are favoring laparoscopy when evaluating reduction in postoperative ileus, pain, and length of hospitalization, disability, and cosmesis. The indications and contraindications for laparoscopic surgery for IBD are evolving as surgical expertise and equipment improve.

    View details for PubMedID 11837938

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