Sexually transmitted diseases of the colon, rectum, and anus. The challenge of the nineties

During the past two decades, an explosive growth in both the prevalence and types of sexually transmitted diseases has occurred. Up to 55 percent of homosexual men with anorectal complaints have gonorrhea; 80 percent of the patients with syphilis are homosexuals. Chlamydia is found in 15 percent of asymptomatic homosexual men, and up to one third of homosexuals have active anorectal herpes simplex virus. In addition, a host of parasites, bacterial, viral, and protozoan are all rampant in the homosexual population. Furthermore, the global epidemic of AIDS has produced a plethora of colorectal manifestations. Acute cytomegalovirus ileocolitis is the most common indication for emergency abdominal surgery in the homosexual AIDS population. Along with cryptosporidia and isospora, the patient may present to the colorectal surgeon with bloody diarrhea and weight loss before the diagnosis of human immunodeficiency virus (HIV) disease. Other patients may present with colorectal Kaposi's sarcoma or anorectal lymphoma, and consequently will be found to have seropositivity for HIV. However, in addition to these protean manifestations, one third of patients with AIDS consult the colorectal surgeon with either condylomata acuminata, anorectal sepsis, or proctitis before the diagnosis of HIV disease. Although aggressive anorectal surgery is associated with reasonable surgical results in some asymptomatic HIV positive patients, the same procedures in AIDS (symptomatic HIV positive) patients will often be met with disastrous results. It is incumbent upon the surgeon, therefore, to recognize the manifestations of HIV disease and diagnose these conditions accordingly.

The ileoanal reservoir

One hundred nine men and 71 women with a mean age of 31 years had construction of 164 S, 2 J, and 14 other ileoanal reservoirs. Postoperative gastrointestinal complications included small bowel obstruction in 11 percent and ileus, hemorrhage, and sepsis in 6 percent, 5 percent, and 11 percent, respectively. There was a 13 percent incidence of miscellaneous postoperative complications. Pouch perianal fistulas developed in 5 percent of patients, and pouch vaginal and other pouch fistulas developed in an additional 4 percent. During long-term follow-up, small bowel obstruction developed in 27 percent of patients, and enterolysis or enterectomy was required in 15 percent of patients. One hundred fourteen patients who were followed for a mean length of 5 years after ileostomy closure (range 16 to 88 months) were evaluated for functional outcome. Function improved with time in 63 percent of patients and remained stable in another 33 percent; only 4 percent had long-term deterioration. Ninety-five percent of patients would again choose an ileoanal reservoir over a permanent ileostomy. This long-term assessment shows that although the ileoanal reservoir is a viable option in the management of mucosal ulcerative colitis, it should not be recommended to every patient.

Ileal pouch vaginal fistulas: incidence, etiology, and management

Some of the initial problems associated with the ileoanal reservoir have been solved. In their place, other complications have been recognized. Among these, the ileal pouch vaginal fistula stands out as a recently recognized difficult management problem. This multicenter study was undertaken to gain insight into the causes for, and treatment of, pouch vaginal fistulas. Cases were gathered from 11 surgical practices throughout North America, in which the ileoanal reservoir procedure is frequently performed. Overall, 304 females had undergone ileoanal reservoir procedures by these surgical groups. Twenty-one patients developed 22 pouch vaginal fistulas for an overall incidence of 6.9 percent. Five additional patients with pouch vaginal fistulas, whose restorative proctocolectomies were done elsewhere, were referred to these surgeons for treatment. The courses of these 26 patients form the basis of this report. This study details the risk factors which predispose in the development of a pouch vaginal fistula, as well as the various treatment options available.

Long-term functional analysis of the ileoanal reservoir

Since November 1980, 180 patients underwent abdominal colectomy, rectal mucosectomy, ileoanal reservoir construction, and ileoanal anastomosis at the authors' institutions. One hundred twenty-nine patients had restoration of intestinal continuity before the end of 1986. One hundred fourteen of these patients (88 percent) were available for follow-up at a mean length of time of 5.0 years from ileostomy closure (range, 16 to 88 months). The mean number of pouch evacuations was 5.4 +/- 2.5 during the day (range, 1 to 12) and 1.5 +/- 1.0 at night (range, 0 to 6). Ninety-one percent of patients reported perfect or almost perfect daytime continence, and 74 percent found this true at night. Sixty-three percent of patients believed their pouch function continued to improve over many years. Ninety-five percent of patients questioned would choose an ileoanal reservoir again instead of a permanent ileostomy. This long-term assessment of the function of the ileoanal reservoir confirms that it is a viable, although not perfect, option in the management of ulcerative colitis and familial adenomatous polyposis.

Emergency colectomy for cytomegalovirus ileocolitis in patients with the acquired immune deficiency syndrome

The charts of all patients with the acquired immune deficiency syndrome (AIDS) who underwent emergency intra-abdominal surgery between January 1981 and July 1987 were reviewed. Eleven AIDS patients underwent 13 emergency laparotomies. Seven of these patients (64 percent) had cytomegalovirus (CMV) ileocolitis as the pathologic process requiring emergent surgical intervention. Four patients had hemorrhagic CMV proctocolitis and three had perforations of CMV ulcers of the ileum or rectosigmoid. The operations performed included three subtotal colectomies, two segmental resections, and two diverting stomas. The postoperative mortality rate in the CMV group was 28 percent at one day, 71 percent at one month, and 86 percent at six months. Furthermore, CMV ileocolonic pathology was directly responsible for 70 percent of the deaths in AIDS patients who underwent emergent exploratory laparotomy.

The demographics of anal cancers are changing. Identification of a high-risk population

One hundred fifty-six consecutive cases of carcinoma of the anal canal and margin diagnosed between 1959 and 1986 were reviewed. There were 27 cases between 1959 and 1967, 41 between 1968 and 1976, and 88 between 1977 and 1986. Although the female-to-male ratio remained constant at 1.5:1, a high-risk group emerged, consisting of male patients with admitted homosexuality, bisexuality, or a history of anal condylomata acuminata. During the earliest period, 8 percent of male patients were in this group; this subset rose to 72 percent during the latest period (P less than .05). While the number of anal margin cancers has decreased, there has been a steady rise in the number of anal canal and in situ carcinomas, especially in the high-risk group.

Mesenteric panniculitis of the sigmoid colon. Report of two cases

Mesenteric panniculitis is an extremely rare disease in which the normal fatty architecture of the mesentery is replaced by fibrosis, necrosis, and calcification. Grossly, the mesentery is massively thickened and rubbery, with irregular areas of reddish-brown to pale yellow foci resembling fat necrosis scattered throughout. Microscopically, inflammatory involvement of the fibroadipose tissue shows round cells, foam cells, and giant cells. Macrophages that have ingested fat, also called lipophages, are the hallmark of the diagnosis. One hundred twenty-two cases of mesenteric panniculitis have been described in the literature; only three of these involved the large-bowel mesentery. This paper presents a review of the literature and two new cases that involve exclusively the mesentery of the sigmoid colon.

The surgical management of anorectal diseases in AIDS and pre-AIDS patients

The charts of 340 patients with Acquired Immunodeficiency Syndrome (AIDS), AIDS-related complex (ARC), or AIDS-prodrome (AIDS-P), treated between January 1982 and April 1986 at the Roosevelt Division of the St. Luke's-Roosevelt Hospital Center, were reviewed. The incidence of anorectal disease was 34 percent. Fifty-two patients (15 percent) presented with anorectal complaints prior to the diagnosis of AIDS, ARC, or AIDS-P. Over 50 percent of these patients were dead within 7.4 months. Fifty-one patients (15 percent) underwent 73 anorectal surgical procedures. Twenty-two of these patients (43 percent) were dead within six months, and only six patients had satisfactory wound healing 30 days after surgery. In addition to an 88 percent rate of poor healing, there was a 16 percent rate of major complications. Identification of these high-risk groups prior to any anorectal surgery is imperative to avoid unacceptable surgical complications. Aggressive surgical intervention should be reserved only for patients who did not fall into the high-risk groups presented.

The initial management of left lower quadrant peritonitis

The majority of patients admitted to the hospital with left lower quadrant peritonitis and suspected acute diverticulitis are treated empirically without colon radiography either for the duration of their hospital course, or until such time as it is deemed safe to perform a barium enema to confirm this diagnosis. Unlike barium, a water-soluble contrast agent such as Gastrografin can be used safely and accurately immediately on hospitalization. Early establishment of an accurate diagnosis can help eliminate complications, morbidity, mortality, and lengthy hospitalizations. Seventy-one patients admitted with left lower quadrant peritonitis, temperatures above 99.5 degrees F, and leukocytosis were evaluated. Treatment either was based on a diagnosis established by results of a barium enema or water-soluble contrast enema, or was empiric in nature. The early use of a water-soluble contrast enema in the elucidation of the cause of left lower quadrant peritonitis proved to be the most accurate and also the most cost-effective means of diagnosis.

The diagnosis and treatment of acute appendicitis in the aged

Since the turn of the century, the elderly population, particularly those over the age of 80, has been increasing steadily. Consequently, the surgeon will be confronted frequently with the diagnostic challenge of acute appendicitis in this population. Over the past ten years, 13 patients over the age of 80 were treated for acute appendicitis at the St. Lukes-Roosevelt Hospital Center. The mean duration of symptoms was 2.4 days; all patients complained of abdominal pain, with 72 percent of patients having right lower quadrant involvement. Ninety-two percent had perforated prior to surgery, and 23 percent did not survive the disease. This high mortality rate is attributed to both a delay in presentation to the physician and a further delay in proper treatment due to misdiagnosis. This is a disease with which every physician must be familiar and be continually vigilant, as correct diagnosis and prompt treatment are the keys to averting high morbidity and mortality rates.

Sensitivity of hemoccult testing in patients with colorectal carcinoma

This paper is a retrospective study of 100 sequentially selected cases of colorectal carcinoma treated at The Roosevelt Hospital between 1978 and 1983. In 44 of these patients, the admitting physical digital rectal examination was hemoccult-negative (HN). This group of patients showed no significant difference in tumor location, stage, size, or in presenting symptoms when compared with the 56 patients who were found to be hemoccult-positive (HP). It is concluded that a negative stool hemoccult examination should not alter the course of the patient's work-up if any suspicion of colorectal carcinoma exists. Furthermore, hemoccult sensitivity does not appear to be affected by the size, location or Dukes' classification of a colorectal neoplasm.