Thermal imaging in the detection of bowel ischemia

PURPOSE

The aim of this study was to introduce thermal imaging in the intraoperative detection of bowel ischemia by comparing thermal imaging with conventional techniques in detecting acutely ischemic bowel, using histologic evidence for intestinal necrosis as the standard.

METHODS

A prospective study was performed using a porcine model. Laparotomy was performed on four pigs under general anesthesia. A 25-cm segment of mid jejunum was tagged with proximal and distal sutures, and its mesentery was ligated and divided. Thermal imaging, visual inspection, Doppler ultrasound, and fluorescence with Wood's lamp after fluorescein were used to estimate the extent of bowel ischemia five minutes after ligation of the mesentery. Measurements were taken in reference to both the proximal and distal tags to obtain two data points per animal for each method. After two hours of warm ischemia, the jejunum was harvested and sectioned longitudinally. Comparisons were made between the estimated region of necrosis for each method and microscopic evidence of necrosis.

RESULTS

Visual inspection was the only method unable to detect a difference between vascularized and devascularized bowel for each of the eight data points. Fluorescein dye missed 3 cm of ischemic bowel. Doppler ultrasound and thermal imaging were 100 percent sensitive for necrotic bowel, with thermal imaging overestimating necrosis to a greater extent than Doppler ultrasound. The positive predictive value of fluorescein dye, Doppler ultrasound, and thermal imaging for determining nonviable bowel was 91.8, 80.8, and 69.5 percent, respectively.

CONCLUSIONS

Thermal imaging has the potential to be a useful adjunct in the intraoperative determination of bowel ischemia. Further studies are indicated to study this technique.

Diaphragm-like strictures of the ileum associated with NSAID use: a rare complication

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed for many conditions including arthritis. A rare complication of their use is diaphragm-like strictures of the small and large intestines. A 65-year-old woman with a 12-year history of arthritis came to us with a 35-pound weight loss and anorexia. She had been taking piroxicam for 3 years. Evaluation including enteroclysis revealed multiple mid-ileal diaphragm-like strictures and proximal small bowel dilatation. The symptoms persisted despite discontinuance of the drug. Abdominal exploration with intraoperative enteroscopy revealed five ileal strictures within a short segment of bowel. Resection was done and completion enteroscopy showed no other strictures. The patient recovered uneventfully and had full resolution of the symptoms. We discuss the difficulties in diagnosis and management of this drug complication and briefly review the literature.

Combination therapy for epidermoid carcinoma of the anal canal

PURPOSE

This study was designed to assess results of chemoradiation therapy for epidermoid carcinoma of the anal canal.

METHODS

A retrospective review of records of the prospective database revealed 35 patients who had been diagnosed with anal canal carcinoma and treated with chemoradiotherapy at Wilford Hall USAF Medical Center (tertiary referral hospital) from 1981 to 1991.

RESULTS

Patients ranged in age from 35 to 80 (mean, 59) years, and 63 percent were women. Primary tumors ranged from 1 to 8 cm in diameter (mean, 3 cm). The first six patients had an abdominoperineal resection (APR) after chemoradiotherapy, and no residual tumor was identified in the specimens. In the subsequent 29 patients who did not have APR, 5 had moderate problems with anal continence, and one required a diverting colostomy for incontinence. Follow-up ranged from 4 months to 12.9 years (mean, 5.2 years). There were two pelvic recurrences, and three patients developed distal metastasis. Eight patients died during follow-up, including three with recurrent or persistent disease. Five-year survival using life-table analysis was 89 percent.

CONCLUSION

Long-term follow-up confirms that chemoradiation remains the preferred therapy for epidermoid carcinoma of the anal canal.

Laparoscopic-assisted full-thickness endoscopic polypectomy

PURPOSE

To describe the procedure for endoscopically removing sessile colonic polyps with laparoscopic assistance.

METHODS

Technique description and retrospective review of experience.

RESULTS

The technique has been used to successfully remove polypoid colonic lesions in three patients.

CONCLUSIONS

Laparoscopic-assisted polypectomy allows complete excision of moderate-sized sessile polyps and may spare selected patients a colonic resection.

Nonfunctioning parathyroid carcinoma

Parathyroid carcinoma is a rare clinical entity accounting for only 4 per cent of all cases of parathyroid neoplasia. Nonfunctioning parathyroid carcinoma is even rarer. Previously, virtually all patients with these lesions were treated for a nonspecific neck mass. However, in the present case, a preoperative diagnosis of nonfunctioning parathyroid carcinoma was made based on the technetium pertechnetate/thallium 201 subtraction scan. The authors report on the 14th case of nonfunctioning parathyroid carcinoma, a review of the literature, and guidelines for the preoperative and operative evaluation of neck masses suspected to be parathyroid carcinoma.

Anorectal physiology testing. A survey of availability and use

Survey forms were sent to all members of the Coloproctology Section of the Royal Society of Medicine and the American Society of Colon and Rectal Surgeons to obtain their opinions of the availability, actual use, and perceived helpfulness of different methods for the evaluation of the physiology of the colon and rectum. Responses revealed a similarity in age and practice patterns in both groups. Of the 19 methods surveyed, greater than 90 percent of respondents in both groups rely on three traditional methods of patient evaluation: patient history, digital examination, and sigmoidoscopy. Four other methods have gained acceptance by the majority of respondents in both groups: colon transit studies, defecography, perfused-catheter manometry, and rectal compliance. The three methods ranked lowest in availability, actual use, and helpfulness by both groups were single-fiber electromyography, use of a perineometer, and evoked potential studies. Our study provides a baseline for future surveys on the investigative efforts of physicians studying the physiology of the colon, rectum, and anus.