ASCRS ANNUAL MEETING UPDATES:
The annual meeting of the American Society
of Colon and Rectal surgeons drew over 1,200 colon and rectal specialists
from 28 countries to discuss diagnosis, treatment and surgery for problems
in the colon, rectum and anus. I have included below a few changes in
treatment or surgery of common conditions.
Anal Intraepidermal Neoplasm (AIN)
This is the same lesion we used to call Bowen’s disease and used to
excise radically. With increased perineal evaluation of HIV patients the
presence of AIN has been found in more asymptomatic patients. Examination
techniques similar to those used for vaginal and cervical intraepithelial
neoplasm, using acetic acid and magnification reveal lesions not visible
to routine examination.
What to do with these lesions remains controversial.
Mark Welton, colorectal surgeon at Stanford and UCSF, advocates local
ablation with cautery of AIN-3 lesions. Bard Cosman at UCSD recommends
only diligent surveillance with local excision of lesions that become T1
invasive cancers. Neither has follow up evidence yet to suggest that one
policy is better than the other. More study is needed, but less radical
surgery seems to be the immediate answer.
These studies have also shown that intra-anal condyloma are NOT routinely
associated with receptive anal intercourse. In fact, anal pap smears in
heterosexual women with cervical condyloma routinely reveal viral
particles in normal appearing anal epithelium.
Crohn’s Colitis And Pouch Surgery
Experience at many centers over the last 50 years has confirmed that
80% of patients with Crohn’s disease confined to the colon |
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are cured with proctocolectomy. Patients who
undergo ileo-anal pouch for ulcerative colitis or indeterminate
colitis and subsequently are found to have Crohn’s disease have the same
rate of cure – 80%. Since 80% are cured with proctocolectomy and 80% do
well, should Crohn’s colitis patients be offered restorative
proctocolectomy with ileo-anal pouch? Results from the University of
Louisville indicate that in the absence of ileal disease an ileo-anal
pouch can be safely offered to Crohn’s colitis patients. There is a higher
rate of pouchitis but the pouch loss rate is not increased.
Chronic Constipation
Over $500 Million is spent in America on non-prescription laxatives
for constipation. Inadequate fiber and water intake, sedentary lifestyle
and medications account for most of these problems but up to 1/3 have a
surgically correctable cause for constipation (slow transit constipation
or pelvic outlet obstruction). Subtotal colectomy has shown to reliably
correct the constipation in most patients with slow transit but improved
BM frequency may mot improve quality of life. A recent study found that
many still have abdominal pain but 93% would still have decided for
surgery. In patients with normal transit, defecography can identify pelvic
obstruction from rectocele, puborectalis contraction or internal rectal
prolapse.
Anal Fissure
Fissure is one of the most common causes of anal pain and bleeding,
especially in young patients. Up to 2/3 will heal with topical application
of ½ ml of 0.2% nifedipine ointment twice daily for 8 weeks. This can be
compounded at the Medicine Shoppe or Poulsbo Drug. Lateral internal anal
sphincterotomy achieves healing in 98% in those not healed with
conservative measures. Complication rate is quite low and symptoms,
especially pain, are relieved rapidly.
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Medicare will now cover a screening colonoscopy
every ten years for average risk patients
Kitsap ColoRectal Surgery, Johnny B. Green, MD, FACS, FASCRS
Eastwood Building, 2528 Wheaton Way, #103, Bremerton, WA 98310
(360) 377-4717 -- (360) 377-4134 fax
www.kitsapcolorectal.com
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