Laparoscopic subtotal colectomy with transrectal extraction of the colon and ileorectal anastomosis

BACKGROUND

Despite the growing acceptance of laparoscopic colon surgery, an abdominal incision is needed to remove the specimen and perform an anastomosis.

METHODS

Five trocars (one 12 mm and four 5 mm) were used. The video describes the technique of performing laparoscopic subtotal colectomy, laparoscopic cholecystectomy, transrectal removal of the gallbladder and the entire colon, and intracorporeal stapled ileorectal anastomosis in a 27-year-old female with colonic inertia and biliary dyskinesia.

RESULTS

There were no intraoperative complications. The operating time was 180 min. Blood loss was 10 cc. The patient was discharged home on postoperative day 4.

CONCLUSION

Laparoscopic subtotal colectomy with transrectal removal of the colon is a safe and effective procedure that can be added to the armamentarium of surgeons performing laparoscopic colon surgery. This technique may provide both an attractive way to reduce abdominal wall morbidity and a bridge to NOTES colon surgery.

Laparoscopic subtotal colectomy for colonic inertia

Colonic inertia is an uncommon condition, usually occurring in women in the third decade of life. Severity of symptoms may lead some patients to a surgical consultation. This is a retrospective review of 14 patients who underwent laparoscopic subtotal colectomy for colonic inertia, performed by a single surgeon from August 1993 to November 2002. The mean age of the patients was 38.5 years (range 26-50 years); 93% of the patients were women. The common presenting symptoms included abdominal pain (93%), bloating (100%), constipation (100%), and nausea (57%). Median duration of symptoms before surgery was 4.5 years (range 1-30 years). Subtotal colectomy was completed laparoscopically in 13 patients. There was one conversion (7%) because of adhesions. Eleven patients (78.6%) had undergone previous abdominal surgery. The mean operating room time was 153 minutes (range 113-210 minutes). The median time to full bowel action was 2 days. One patient developed postoperative small bowel obstruction that required open exploration. Complete follow-up was available for 11 patients at a median follow-up of 18 months (range 2-96 months). Ninety-one percent of the patients reported excellent satisfaction with surgery, and their bowel movement frequency changed from 1.2 (+/-0.2) per week preoperatives to 17.2 (+/-2.9) per week postoperatively (P < 0.001). Three patients (27%) continued to report abdominal pain and 3 patients (27%) continued to require laxatives postoperatively. Laparoscopic subtotal colectomy provides excellent symptom relief in patients with colonic inertia who do not respond to medical measures.

Ileostomy for constipation: long-term postoperative outcome

BACKGROUND AND AIMS

Idiopathic constipation is a rare indication for ileostomy construction. The aim of the study was to evaluate the success of ileostomy in treatment of severe constipation. Also to analyse the surgical complications and re-operation rate to identify any factors potentially predictive of outcome.

PATIENTS AND METHODS

This retrospective study analysed the long-term outcome of 24 ileostomies constructed for constipation. The ileostomy construction was performed in 13 patients during large bowel/rectum resection, in 6 after a full laparotomy and in 5 through an abdominal wall trephine alone. We analysed the surgical complications and the re-operation rate according any factors potentially predictive of outcome.

RESULTS

One (4%) patient had persistent constipation after stoma creation. Surgical complications occurred in 11 (46%): retraction in 6 (25.0%), peristomal sepsis in 3 (12.5%) and parastomal hernia in 2 (8.1%). Refashioning of the stoma was necessary in 7 (29%) patients. Previous abdominal surgery, end ileostomy, ileostomy constructed after large bowel resection or laparotomy were associated with a significantly higher incidence of stomal complications while age, duration of follow up, major complication and ileostomy created after bowel resection were associated to a significantly higher re-operation rate (P < 0.05). Multivariate analysis identified end ileostomy and ileostomy created after bowel resection as independent risk factors for surgical complication and re-operation, respectively (P < 0.05).

CONCLUSIONS

Ileostomies were associated with a high frequency of complications, but most could be managed by minor surgical interventions. Patients who are considered for an ileostomy for severe idiopathic constipation should, where possible, have a loop ileostomy through a trephine rather than a laparotomy.

Stoma formation for functional bowel disease

OBJECTIVE

To assess the results of stoma formation for functional bowel disease.

METHODS

A retrospective study of the indications for and complications of stoma formation in this group. A quality of life questionnaire was sent to the group.

RESULTS

A very small proportion of patients with functional bowel disease have a stoma formed (< 1%). Stoma formation is often associated with problems requiring further operations. Their QOL is reported as poor and is improved upon by stoma formation. Most patients with a temporary stoma elected to keep it rather than suffer their previous problems.

CONCLUSION

Some patients with functional bowel disease can be successfully managed by stoma formation. Their treatment is difficult, emotionally demanding and labour-intensive.

Which stoma works better for colonic dysmotility in the spinal cord injured patient?

BACKGROUND

The formation of an intestinal stoma is very effective in the treatment of colonic dysmotility associated with spinal cord injury (SCI). Little is known about the difference in the long-term outcome among left-sided colostomies, right-sided colostomies, and ileostomies in this patient population.

METHODS

The records of 45 SCI patients with intestinal stomas at our institution were reviewed retrospectively. Operative details and preoperative colonic transit times (CTT) were recorded. Patients who were alive and available were interviewed using a questionnaire designed to assess the quality of life (QOL), health status, and time to bowel care before and after stoma formation.

RESULTS

Between 1976 and 2002, 45 patients underwent a total of 48 intestinal stomas. A left-sided colostomy (LC) was formed in 21 patients, right-sided colostomy (RC) in 20, and ileostomy (IL) in 7. Three of the patients in the RC group ultimately underwent total abdominal colectomy and ileostomy. The indications for stoma formation and CTT were different in the three groups. Bloating, constipation, chronic abdominal pain, difficulty evacuation with prolonged CTT was the main indication in 95% of patients in the RC group, 43% of patients in the LC group, and 29% in the IL group. Management of complicated decubitus ulcers, perineal and pelvic wounds was the primary indication in 43% of patients in the LC group, 5% in the RC group, and none in the IL group. Preoperative total and right CTTs were longer in the RC group compared with the LC group: 127.5 versus 83.1 hours (P <0.05) and 53.7 versus 28.5 hours (P <0.05), respectively. Eighty-two percent of patients (37 of 45) were interviewed at a mean follow-up of 5.5 years after stoma formation. Most patients who were interviewed were satisfied with their stoma (RC, 88%; LC, 100%; IL, 83%) and the majority would have preferred to have the stoma earlier (RC, 63%; LC, 77%; and IL, 63%). The QOL index significantly improved in all groups (RC, 49 to 79, P <0.05; LC, 50 to 86, P <0.05; and IL, 60 to 82, P <0.05), as well as the health status index (RC, 58 to 83, P <0.05; LC, 63 to 92, P <0.05; IL, 61 to 88, P <0.05). The average daily time to bowel care was significantly shortened in all groups (RC, 102 to 11 minutes, P <0.05; LC, 123 to 18 minutes, P <0.05; and IL, 73 to 13 minutes, P <0.05.).

CONCLUSIONS

Regardless of the type of stoma, most patients had functional improvement postoperatively. Patients who underwent RC had longer CTT and more chronic symptoms related to colonic dysmotility, reflecting the preoperative selection bias. The successful outcome noted in all groups suggests that preoperative symptoms and CTT studies may have been helpful in optimal choice of stoma site selection.

Systematic review: Abdominal and pelvic surgery in patients with irritable bowel syndrome

AIM

To systematically review research on the prevalence of abdominal and pelvic surgery in patients with irritable bowel syndrome.

METHODS

Computer searches of MEDLINE, EMBASE and Current Contents were performed independently by both investigators to identify appropriate studies. Primary study selection criteria included: (i) population-based samples of adult irritable bowel syndrome patients; (ii) the use of appropriate symptom-based criteria to identify irritable bowel syndrome patients; and (iii) comparison of the prevalence of abdominal and pelvic surgery in irritable bowel syndrome patients vs. control populations. Secondary analysis was performed on published studies of referral populations and case series.

RESULTS

Two population-based studies met the primary study selection criteria and revealed an increased prevalence of surgery in irritable bowel syndrome patients vs. controls for cholecystectomy (4.6% vs. 2.4%, respectively; odds ratio, 1.9; 95% confidence interval, 1.2-3.2) and hysterectomy (18% vs. 12%, respectively; odds ratio, 1.6; 95% confidence interval, 1.1-2.2). Secondary analysis revealed an increased prevalence of appendectomy and other abdominal and pelvic surgery in irritable bowel syndrome patients.

CONCLUSIONS

Irritable bowel syndrome is associated with a disproportionately high prevalence of abdominal and pelvic surgery, but most studies exhibit sub-optimal study design and do not define the factors causing the increased prevalence of surgery in these patients.

New developments in the diagnosis and treatment of irritable bowel syndrome

Irritable bowel syndrome (IBS) is a common disorder with major health status and economic effects. Symptom criteria are of paramount importance in diagnosis, but differences among the Manning, Rome I, and Rome II criteria may lead to variable identification of people with the disorder. Practice guidelines are based on evidence and, to a greater degree, on consensus; therefore, experts vary on the specifics of ordering particular diagnostic tests. There is an overlap of IBS symptoms with those of celiac sprue, and selected patients should be tested for the latter disease. Symptom confusion with biliary pain and overlap with chronic pelvic pain could contribute to the predisposition of IBS patients to undergo cholecystectomy and hysterectomy. Development and documentation of effective therapy has been difficult, but depending on the selection of subgroups, there is evidence for usefulness of smooth muscle relaxants, loperamide, and antidepressants. Various forms of psychological therapy and new serotonin-modulating agents seem especially promising. The placebo effect of the physician-patient relationship has important therapeutic benefit.

Long-term response to subtotal colectomy in colonic inertia

The purpose of this study was to determine the long-term outcome of patients who had previously undergone subtotal colectomy for severe idiopathic constipation at the University of Florida between 1983 and 1987. In addition, we aimed to determine whether preoperative motility abnormalities of the upper gastrointestinal tract are more common among those patients who have significant postoperative complications after subtotal colectomy. We evaluated 13 patients who underwent subtotal colectomy for refractory constipation between 1983 and 1987 at the University of Florida. Preoperatively, all patients exhibited a pattern consistent with colonic inertia as demonstrated by means of radiopaque markers. Each patient was asked to quantitate the pain intensity and frequency of their bowel movements before and after surgery. In seven patients an ileosigmoid anastomosis was performed, whereas in six patients an ileorectal anastomosis was used. Abdominal pain decreased after subtotal colectomy. Patients with abnormal upper gastrointestinal motility preoperatively experienced greater postoperative pain than those with normal motility regardless of the type of anastomosis. In addition, the number of postoperative surgeries was similar in those patients with abnormal upper motility compared to those with normal motility. Overall, the total number of bowel movements per week increased from 0.5 +/- 0.03 preoperatively to 15 +/- 4.5 (P < 0.007) postoperatively. The results of our study suggest that patients with isolated colonic inertia have a better long-term outcome from subtotal colectomy than patients with additional upper gastrointestinal motility abnormalities associated with their colonic inertia.

Total colonic manometry as a guide for surgical management of functional colonic obstruction: Preliminary results

BACKGROUND/PURPOSE

Functional colonic obstruction (pseudo-obstruction) encompasses a broad group of motility disorders. Medical management of colonic pseudo-obstruction is complex and often fails, leading to surgical referral. In most cases (excepting Hirschsprung's disease) the surgeon is unable to precisely localize the area of functional obstruction. Total colonic manometry can directly measure intraluminal pressures and contractile function along the entire length of the colon. The authors propose that total colonic manometry can be used by the pediatric surgeon to guide the timing and extent of surgical therapy in refractory functional colonic obstruction.

METHODS

Four patients were evaluated for functional colonic obstruction. All underwent barium enema and rectal biopsy with a diagnosis of Hirschsprung's disease in one patient. All patients underwent colonoscopy and total colonic manometry. Manometric tracings were obtained while fasting, after feeding, and after pharmacologic stimulation both preoperatively (n = 4) and postoperatively (n = 3).

RESULTS

Total colonic manometry identified an abrupt end of normal peristalsis in 2 of the non-Hirschsprung's patients (one in the proximal colon and one in the transverse colon). Medical therapy failed in both of these patients, and they underwent diverting ostomy proximal to the loss of normal peristalsis. The third non-Hirschsprung's patient essentially had normal manometry and was able to have her colon decompressed successfully on a laxative regimen. Repeat manometry after colonic decompression showed return of normal peristalsis in 2 of these patients and continued abnormal peristaltic activity in the third. Definitive surgical intervention based on the results of total colonic manometry was performed on the latter. All 3 patients achieved normal continence. A fourth patient had Hirschsprung's disease confirmed by rectal biopsy and underwent a 1-stage neonatal modified Duhamel procedure, which was complicated by postoperative functional obstruction. Manometry showed a lack of peristaltic function beginning in the right colon. An ileostomy was performed, and timing of ileostomy closure was guided by the return of normal colonic peristalsis seen on manometry.

CONCLUSIONS

These initial cases show the utility of total colonic manometry in the management of colonic pseudo-obstruction syndromes. In addition to its diagnostic utility, direct measurement of colonic motor activity can be valuable in deciding the need for and timing of diversion, the extent of resection, and the suitability of the patient for restoring bowel continuity. In Hirschsprung's disease, total colonic manometry can potentially be used to determine suitability for primary neonatal pull-through versus a staged approach. J Pediatr Surg 36:1757-1763.

Temporary transverse colostomy vs loop ileostomy in diversion: a case-matched study

HYPOTHESIS

For temporary fecal diversion, transverse colostomy (TC) has superior safety, but loop ileostomy (LI) has superior management qualities.

METHODS

Of patients with TC or LI seen between 1988 and 1997, 63 patients were matched for diagnosis, operative procedure, and date of surgery. The 2 groups were then compared for hospital/postoperative mortality and morbidity and stoma complications.

RESULTS

Mortality rates were 6.3% for the TC group and 1.6% for the LI group (P =.25). Morbidity rates for stoma creation and for stoma closure were 47.6% and 10% (P =.19), respectively, for the TC group, and 36.5% and 6.3% (P>.99), respectively, for the LI group. Most morbidity events were minor, and neither procedure-related nor other medical complications showed a significant difference between the groups. However, patients with a TC were significantly more likely to experience skin trouble around the stoma (TC vs LI, 15.9% vs 3.2%) and leakage around the stoma (TC vs LI, 12.7% vs 1.6%).

CONCLUSIONS

Regarding safety, TC and LI should be considered equivalent options for temporary fecal diversion. We recommend further study comparing the 2 procedures with regard to patient perception and quality of life.

[Multiple jejunal strictures caused by gastric heterotopia]

A case of gastric heterotopia was discovered incidentally on a jejunal resection specimen in a 42-year-old patient operated for Koenig's syndrome present for 10 years. This anomaly was responsible for seven chronic ulcers with strictures at multiple levels. Gastric heterotopia, especially in the jejunum, is a rare anomaly, except in intestinal duplications and Meckel's diverticulum. The various complications are a direct result of the activity of the gastric glands: hemorrhage, Helicobacter pylori enteritis, perforation, chronic ulcer and obstructive syndrome; malignant adenocarcinomatous degeneration has also been reported.

Long-term follow-up of patients undergoing colectomy for colonic inertia

PURPOSE

Total abdominal colectomy with ileorectal anastomosis has been the procedure of choice for patients with the established diagnosis of colonic inertia. Previous studies with a limited follow-up of only one to two years have shown acceptable results and a high rate of patient satisfaction. The aim of this study was to evaluate the long-term results of total abdominal colectomy in these patients in terms of complications, bowel function, and overall patient satisfaction.

METHODS

Access to the colorectal registry at the Cleveland Clinic Florida identified all patients who underwent total abdominal colectomy for colonic inertia between 1988 and 1993, with a minimum of five-year follow-up. Telephone interviews were designed to assess bowel function, concomitant use of any antidiarrheal medications, postoperative complications, persistence or development of preoperative symptoms such as pain or bloating, and overall satisfaction. Patients were asked to rate their outcome as excellent, good, fair, or poor.

RESULTS

Fifty patients underwent total abdominal colectomy for the diagnosis of colonic inertia. Three patients died of unrelated causes and 30 (60 percent) were available for follow-up. The mean follow-up was 106 months, ranging from 61 to 122 months. All 30 patients reported the outcome of surgery as "excellent." The average frequency of spontaneous bowel movements was 2.5 (range, 1-6) per day. During the period of follow-up, six patients (20 percent) required admission for small-bowel obstruction, three of whom (10 percent) required laparotomy. Four patients complained of mild pelvic pain, only one of whom had the onset of pelvic pain postoperatively that persisted until the time of interview. In the other three patients the pain was present preoperatively but had decreased in intensity since the operation. Two patients (6 percent) still required assistance with bowel movements, one by laxatives and the other by enemas. Only two patients (6 percent) needed antidiarrheal medications to reduce bowel frequency.

CONCLUSION

This long-term follow-up revealed a high degree of patient satisfaction and very good bowel habits, with an acceptable long-term rate of bowel obstruction. Based on these results, total abdominal colectomy can be recommended to patients with well-established colonic inertia with expectations of sustained benefit up to ten years after surgery.

Subtotal colectomy for colonic inertia

The aim of this study was to assess the outcome of subtotal colectomy for colonic inertia (idiopathic slow transit constipation) that was resistant to laxative treatment. Twenty-four patients, 19 women and 5 men, with a mean age of 37 years, underwent subtotal colectomy with ileorectal or ascendo-rectal anastomosis. All patients were available for follow-up, with a mean follow-up of 23 months. Bowel frequency was significantly increased from 1.4+/-0.9 times per week to 22.8+/-9 times per week (average 3.2/day) after surgery (P <0.0001). The incidence of abdominal pain was decreased from 75% to 17%, as well as the severity (P <0.0001). Two patients who underwent ascendo-rectal anastomosis developed recurrent constipation. Two patients used antidiarrheal medication regularly. There was no major postoperative morbidity. Five patients were re-admitted due to small bowel obstruction; four received successful conservative management, and one required enterolysis. 'Excellent' or 'good' outcomes were reported by 21 patients (87.5%). Subtotal colectomy with ileorectal anastomosis produces satisfactory results in the majority of patients with proven colonic inertia.

Operative management of severe constipation

This report investigates the concept that severe constipation requiring major abdominal surgery may result from one of three common causes: 1) colonic inertia, 2) pelvic hiatal hernia, or 3) both colonic inertia and pelvic hernia. This study evaluates the symptoms, anatomy and outcome in 201 patients with severe surgical constipation treated by a single surgeon. In 2042 patients with constipation referred to one colon and rectal surgeon, 211 major abdominal surgical procedures were performed on 201 patients for severe constipation between 1989 and 1999. There were 187 women and 14 men. Mean age was 49 years (range, 9-84). Five high-risk patients had ileostomy; 196 had major colonic surgery for anatomic or physiologic causes of constipation, excluding malignancy, diverticular disease, and inflammatory bowel disease. Pelvic hiatal hernia was defined as the herniation of bowel through the hiatus of the pelvic diaphragm seen on pelvic videofluoroscopy or physical examination. Of these 196 patients, 44 per cent had pelvic hiatal hernia repair (PHHR), 27 per cent had total abdominal colectomy and ileorectal anastomosis for colonic inertia, and 29 per cent had surgery for both colonic inertia and pelvic hiatal hernia. Of the 144 patients undergoing PHHR, 95 had Gore-Tex patch (W. L. Gore and Associates, Inc., Phoenix, AZ) sacral colpopexy. PHHR for pelvic hiatal hernia without colonic inertia included sigmoid resection, rectopexy, and Gore-Tex patch sacral colpopexy. Mean duration of follow-up was 20 months. Symptoms noted preoperatively included abdominal pain (84%), straining at stool (90%), incomplete rectal emptying (85%), painful bowel movements (74%), pelvic pain (69%), vaginal bulge (55%), digital assistance with evacuation (35%), and incontinence of stool (38%). Outcome assessed by symptom relief was successful in 89.1 per cent of patients. 8.6 per cent of patient conditions were unchanged, and 2.3 per cent were unsatisfied with the outcome. There were no postoperative deaths. The complication rate was 6.1 per cent (small bowel obstruction, 7; anastomotic leak, 2; ureteral stenosis, 2; and patch erosion, 1). In our experience, severe surgical constipation can be due to colonic inertia, pelvic hiatal hernia, or both. Careful preoperative evaluation identifies these disorders, and surgical therapy aimed at correction of anatomic and physiologic defects results in high patient satisfaction and improvement in bowel function.

[Hartmann's procedure. Institutional experience with 92 consecutive cases]

BACKGROUND

Since it's description in 1923, Hartmann's procedure is widely used for the surgical treatment of acute left colonic complications when preoperative bowel lavage is not feasible and/or there is high risk of anastomotic dehiscence.

OBJECTIVE

Analyze the results of Hartmann's operation in the surgical treatment of consecutive patients at a single institution during a 30-month interval.

TYPE OF STUDY

Prospective, non-randomized and longitudinal study.

MATERIAL AND METHODS

Patients treated with the Hartmann procedure between March 1995 and September 1998. Surgical indication, intraoperative findings, morbidity and mortality were analyzed as well as the rate of reestablishment of bowel continuity and it's morbimortality.

RESULTS

Ninety-two patients underwent a Hartmann procedure. The mean patient's age was 60 +/- 25 years (range of 21 to 88 years) and 60% were older than 65 years. An emergency operation was carried out in 91% of the cases. Most of the patients had intra-abdominal sepsis (56%) and benign colonic process (83%). The morbidity rate was 34% and mortality rate 19. During follow-up the bowel continuity was reestablished in 32% of the cases without fatalities.

CONCLUSIONS

Hartmann's procedure is a good option for non-elective surgical treatment complicated rectosigmoid pathology. The morbidity and mortality of the operation are highly dependent on the degree of preoperative sepsis and the patient's preexisting condition. The rate of reestablishment of bowel continuity was low probably because of short follow-up.

[Open surgical therapy of functional disorders of the rectum and pelvic floor]

An overview is given of common transabdominal procedures for functional disorders of the rectum and pelvic floor which are caused by degenerative morphological changes, and termed pelvic floor insufficiency. Only the transabdominal approach permits a comprehensive and pathophysiological repair of changes associated with the disorder. Own results and a review of the literature confirm a superior functional outcome and low recurrence rates with a combined procedure consisting of rectopexy, colonic resection and pelvic floor repair.

[Neurophysiologic diagnosis in proctology]

Functional diagnostic exploration in proctology is ever-expanding and becoming more differentiating. Neurophysiologic examinations can take over an essential share. They have in part already been introduced into routine diagnostic workup. Both afference and efference, as well as the muscular system can be investigated in functional neurologic disorders of the pelvic floor. The electromyogram using concentric needle electrodes constitutes the most significant tool. It provides us with a better verification of the neurogenic lesion, and enables us to discriminate between acute and chronic and comment on severity and prognosis. The diagnostic program is additionally supplemented by motor and sensory evoked potentials, electroneurography of the pudendal nerve, and measurements of vegetative nerve paths.

[Functional disorders of the rectum and pelvic floor. Ambulatory/conservative therapy]

Early diagnosed functional disorders of the ano-rectum or pelvic floor can be treated in the office by conservative treatment or out-patient surgery. The normal anatomy of the anal canal must be restituted by reducing enlarged haemorrhoids, removing a prolapse of the anterior rectal wall with rubber-band ligation, excision of chronic fissures and prolapsing tumours. The basic therapy then consists of normalisation of bowel habits and stool consistency. An anal stenosis must be dilated. Training of the sphincter, gymnastics of the pelvic floor, electrostimulation and biofeedback are the therapy for the sphincter and pelvic floor insufficiency.

[Laparoscopic therapy of functional disorders of the rectum and pelvic floor]

Within 4.5 years, 72 laparoscopic rectopexies were performed. The indications included rectal prolapse, morphologic outlet-constipation and a combination of both. Using a modified suture rectopexy (according to Sudeck), without taking any foreign material we resected the sigmoid in 39 patients. In four cases, a resection of the sigmoid colon was carried out. Conversion rate was 2% and complications that needed reoperation occurred in 9%. No patient died; laparotomy rate was only 4%. In the mean follow up period of 24.1 months (max. 50 months), no recurrent prolapse occurred. Incontinence was abolished or improved in 64% and outlet-constipation was improved in 85%. Laparoscopic rectopexy with or without sigmoid resection seems to be of benefit for the patient: quicker convalescence; less pain; small scars; no recurrence; and improvement of constipation and incontinence.

[Utilization of medical resources for patients with irritable bowel syndrome in a tertiary hospital]

BACKGROUND

The irritable bowel syndrome (IBS) produces a high cost to society in terms of work loss, consultations, medical tests, treatments and even unnecessary surgeries.

AIMS

To evaluate the use of medical resources by IBS patients in a tertiary hospital.

METHODS

Retrospective study of medical records from patients with IBS younger than 60 years old. Number of clinical studies, consultations to all specialties and number of surgeries were analyzed.

RESULTS

Between 1987 and 1996, 98 patients age (mean) 40.8 years, were identified. Follow-up time was 33.4 months (1-243), during a mean of 22.4 studies per patient (1-82) were solicited. Prior to IBS diagnosis, 5.0 studies per patient (I-II) were required. In 87% of the cases, IBS diagnosis was established during the first visit. Each patient consulted 3.6 times/year, 44.2% for gastrointestinal symptoms and 48.6% for non-gastrointestinal symptoms. The consultations with the most demand were internal medicine (53.0%), gastroenterology (38.8%), proctology (31.6%), psychiatry (21.4%), gynecology (18.4%) and urology (13.3%). Surgical history was found in 39%, 17.3% had appendectomy and 13.3% cholecystectomy, 1.02% and 2.04% respectively were done after IBS diagnosis.

CONCLUSIONS

Although the availability of the Rome criteria for the diagnosis of IBS, these patients require an excessive quantity of studies to eliminate the possibility of organic disease, and excessive number of annual medical consultations as well. IBS patients also have a high rate of appendectomies and cholecystectomies.

[Functional disorders of the rectum and pelvic floor--surgical diagnosis]

Pelvic-floor disorders present themselves as isolated entities or, often, in combination with other ano-rectal diseases. In each case, the basis for individual therapy has to be a precise diagnosis. For differentiation of pelvic-floor disorders, we use a step by step diagnostic cascade: the first step is a basic proctological evaluation, including history, scoring, inspection, palpation, proctorectoscopy and anorectal manometry. Secondary special diagnostics, such as endosonography, neurological examination, transit-time studies and defecography are also used. In special individual problems, CT scan, MRI, urological or gynecological examination complete the diagnostic route, resulting in the definite coloproctological therapy.

Investigation and surgery in irritable bowel syndrome--a cautionary series

Irritable bowel syndrome is a common problem, and, with a broad symptom complex, likely to present to a wide variety of clinicians. Lack of awareness of these manifestations may lead to inappropriate investigation, and surgery. Six patients with irritable bowel syndrome who had multiple investigations and operations are reported. There was a median of seven years delay in diagnosis, patients seeing a median of six different consultants. Over 13 years of follow-up symptoms were unchanged, but patients had undergone a median of eight (often invasive) investigations, and six operations. Several operations were for complications of, or resulted from, a previous procedure. There were far fewer operations after diagnosis, four over 33 patient-years, than prior to diagnosis, 25 over 43 patient-years (chi-squared = 8.074, 1 df, p < 0.0025). All clinicians should be aware of the diffuse symptomatology of irritable bowel, and its potential to mimic other diseases. Surgery should be avoided.

[Displacement and resection of the ascending colon in the horse: a literature review on the basis of 2 cases]

A review of displacements and surgery of the large colon is given on the basis of two cases. A four-year-old Dutch Warmblood mare was referred, one week before foaling, for colic of twelve hours duration. At rectal palpation a large uterus was found, but no cause for the colic. Laparotomy revealed a colonic volvulus and resection of about 75% of the large colon was necessary. A dead foal was born five days postoperatively, but the mare recovered well. A nine year-old Dutch Warmblood stallion with a history of frequent colic had been treated for nephrosplenic entrapment three times. Resection of the left part of the colon was performed successfully to prevent another entrapment.

[Surgical therapy of chronic constipation]

Results of the surgical treatment for conservative intractable constipation in 70 adult patients are reviewed. 49 patients with severe symptoms have been treated by partial colectomy as sigmoid colectomy (n = 23) or left hemicolectomy (n = 26). 33 patients underwent colectomy with cecorectal anastomosis (n = 25) or ileorectal anastomosis (n = 8). Out of these patients with colectomy seven had undergone previous segmental colonic resection or internal sphincterotomy. Of those patients with cecorectal anastomosis who were dissatisfied, three underwent ileorectal anastomosis. Overall, a mortality rate of 3.3% and morbidity rate of 22.5 resp. 54.5% for partial and total colectomy were observed. The most frequent occurring complication after colectomy was small bowel obstruction in 30% requiring laparotomy in 40%. Of 45 patients who underwent partial colectomy, 34 (75%) had normal bowel function or were markedly improved. In 28 of 32 patients (87.5%) treated by colectomy a successful result has been achieved. The operation of sigmoid colectomy or left hemicolectomy may be recommended as a treatment for constipation only in patients with less severe symptoms or patients with recurrent sigmoid volvulus. For those patients with severe constipation, at present, colectomy with ileorectal anastomosis seems to be the surgical procedure that offers the greatest probability of improvement. However, the significant morbidity claimed the need for a careful patient selection.

Surgical management of colonic inertia

Fourteen patients with chronic constipation due to colonic inertia were treated with total abdominal colectomy and ileorectal anastomosis at the Cleveland Clinic Foundation from 1981 to 1986. All patients were white women ranging in age from 28 to 64 years (mean 41 years). The duration of symptoms averaged 21 years (range six to 47 years) and the average time between bowel movements was ten days. The preoperative evaluation included barium enema in 12 patients and colonoscopy in five (some patients had both studies). Anorectal dysfunction was excluded by manometry in ten patients and by rectal biopsy in six. Colonic transit studies were accomplished in only two patients. The hospital stay averaged 13 days, and there was no operative mortality. Postoperative morbidity included one case of small bowel obstruction, necessitating operative correction on postoperative day 9. Follow-up ranged from three months to five years. At their last clinic visit, the patients averaged two bowel movements per day. All patients had excellent bowel control and were happy with the procedure.

[Clinico-morphologic data in decompensated colonic stasis]

The authors studied the results of surgical treatment of 97 patients with complicated form of the decompensated stage of chronic colonic stasis. The choice of the method and volume of the operation is determined by the location and spread of the stasis in the colon. Histological examination of material removed during the operation revealed predominantly dystrophic changes of the ganglionic cells of the musculo-intestinal plexus and hypertrophy and sclerosis of the muscular coat of the colon. The operation produced a good and satisfactory effect in 83.4% of patients.

Diagnosis and surgical treatment of functional obstruction of the right dorsal colon in a horse

Functional obstruction of the right dorsal colon was found at surgery in a 6-year-old American Saddlebred gelding with a history of anorexia, depression, weight loss, and intermittent colic. Side-to-side anastomosis of the right dorsal colon to the small colon was done to bypass the obstruction. Histopathologic findings of the right dorsal colon and regional colonic lymph nodes were unremarkable. Surgical treatment was successful.

[Syndrome of acute colonic pseudo-obstruction (Ogilvie's syndrome). Study of 13 cases]

Acute pseudo-obstruction of the colon involves acute colic distension without mechanical obstruction or stercoroma in a previously healthy colon. Our study is of 13 patients, all of whom presented a pre-existing extradigestive disorder, for which 12 were taking medication. Nine patients were treated by mechanical ventilation, and five of these had previously presented meteorism. Colic dilatation was maximal in the cecum, the diameter of which measured 9 to 14.5 cm. Two patients were treated by decompression colonoscopy, which completely cured meteorism in one case. Two patients treated by digestive aspiration died due to extra-abdominal causes. Operations were carried out on 6 patients: once for peritonitis due to cecal perforation five times for deterioration of meteorism. Five patients died due to postoperative complications. These observations show that the diameter of the cecum should be monitored daily. When it exceeds 9 cm, decompression colonoscopy must be performed. Surgery should only be envisaged when there are setbacks, due to the seriousness of the operation and the possibility of postoperative complications.

Precancerous changes in the anal canal epithelium in resection specimens

Systematic histological examination for precancerous changes was carried out on 139 anal canals resected for anal or colo-rectal tumours or for inflammatory bowel disease. Severe squamous dysplasia or carcinoma in situ were found in 13 of 16 anal canals harbouring variants of squamous carcinoma but not in others. The lesions were mainly or totally located to the anal transitional zone (ATZ) in 11 cases and only in 2 cases exclusively to the squamous zone below the dentate line. Dysplastic areas separate from the tumour were found in 6 of the 13 cases. Junctional melanocytic activity and atypical melanocytic hyperplasia located in the ATZ as well as the squamous zone were present in 1 of 3 cases of malignant melanoma. The findings underline the close relationship between dysplasia and invasive carcinoma in the anal canal. Further they support the concept that basaloid, mucoepidermoid and some ordinary squamous carcinomas arise in the ATZ, and that this may also be the point of origin for malignant melanoma. A search for precancerous changes for anal canal tumours should therefore include the whole ATZ, i.e. in some cases up to 2 cm above the dentate line and it should be borne in mind that the lesions may be spotty.

Ogilvie's syndrome associated with herpes zoster infection

Acute colonic pseudo-obstruction that occurs in the setting of an underlying medical condition is known as Ogilvie's syndrome. The etiology of Ogilvie's syndrome is unknown, and associated medical illnesses are varied and often extra-abdominal. While herpes zoster infection has been reported to cause constipation and hypomotility, the association with massive colonic distention has not so far been described. We present a patient with Ogilvie's syndrome in the setting of herpes zoster infection. There was no evidence of other active illnesses, and the patient has continued to do well since the resolution of the zoster. We believe that this is the first reported association of Ogilvie's syndrome and herpes zoster infection.

Nonoperative management of acute idiopathic colonic pseudo-obstruction (Ogilvie's syndrome)

In a four-year experience (35 episodes in 27 patients) with the use of medical and colonoscopic therapy for acute idiopathic colonic pseudo-obstruction, we have found that initial conservative measures followed by flexible colonoscopy in nonresponders are effective and safe. Contrary to previous reports, an initial nonoperative approach including colonscopy is frequently successful and the outcome with this approach is not adversely affected even in the few patients who eventually require surgical decompression.

[Ogilvie's syndrome--a case report and review]

Ogilvie's syndrome is caused from functional obstruction of the colon without mechanical stenosis and also termed as pseudo-obstruction of the colon. This disease is seen in patient who has other causative distress. The pathogenesis of this rare entity is unknown but it is suspected that there may be an underlying autonomic disturbance which causes non-mechanical obstruction of the colon. Most of the case reports on Ogilvie's syndrome have appeared in European and North American journals but are extremely rare in Japan. Some cases which have been categorized "spastic ileus" may be included in this syndrome. We recently experienced a patient with cerebral infarction who developed non-mechanical obstruction of the colon. This patient was treated successfully with an exploratory laparotomy and sigmoidostomy. It is considered that early diagnosis is an essential part of the initial management of this syndrome. Conservative treatment is indicated for most of the patients but a definitive surgical therapy is occasionally necessary.

Colonoscopic decompression for acute pseudoobstruction of the colon (Ogilvie's syndrome). Report of 22 cases and review of the literature

This report has described a series of 22 patients who underwent colonoscopic decompression for acute pseudoobstruction of the colon and summarizes those cases previously reported in the literature. Twenty of the 22 patients (91 percent) were successfully treated by decompression initially. Fifteen patients (68 percent) were cured with the initial procedure, and 4 patients (18 percent) experienced recurrence. Overall, in 17 patients (77 percent), the pseudoobstruction resolved completely with colonoscopic decompression. Three patients (14 percent) underwent operation because of cecal dilatation refractory to colonoscopic decompression, and in one patient (4.5 percent), the colonic dilatation resolved spontaneously after a failed colonoscopy. Complications resulted in the death of one patient (4.5 percent). Our data are similar to those in the literature and indicate that colonoscopic decompression is a safe and efficacious first line of treatment for acute pseudoobstruction of the colon.

Course and prognosis after colectomy and ileostomy for inflammatory bowel disease in childhood and adolescence

The clinical course of 32 pediatric patients with inflammatory bowel disease (ulcerative colitis--18, Crohn's disease--14) after colectomy and ileostomy was investigated. Specific indications for surgery were: ulcerative colitis (severe colitis--50%, chronic disease--50%); Crohn's disease (fistulae--28%, severe colitis--28%, chronic disease--21%, hemorrhage--14%, growth failure--7%). Proctectomy was performed at the time of colectomy in 72% of patients with ulcerative colitis and in 64% of those with Crohn's disease. Major post-operative complications (stomal dysfunction without documented recurrent disease, obstruction, abscess, bleeding) were observed in 60% of all patients regardless of diagnosis. Histologically documented recurrent disease developed in 42% of the patients with Crohn's disease (mean follow-up: 5 yr) despite removal of all affected bowel. Ileal disease at the time of surgery appeared to be a poor prognostic factor. Sexual activity was either improved or unchanged in sexually active patients. Impotence was not observed in any of the male patients. Despite complications and recurrent disease, the majority (75%) of patients viewed colectomy and ileostomy as improving the quality of their life.

[The Ogilvie syndrome. Review of literature and report of 2 cases]

Two cases of pseudo-obstruction of the colon (Ogilvie's syndrome) are presented. Increasing abdominal distension and the pain suggested surgical treatment for both patients. The operation showed in the first case a marked dilatation of the transverse colon and sigmoid, in the second the dilatation of the ascending and transverse colon, without any distal obstruction. Enterotomy was performed only in the first case, as the diameter of the colon was more then 10 cm. The authors, by review of the literature and their own experience, propose a critical revision of the syndrome, discussing the physiopathology of the rising disease.

[Neonatal necrotizing enterocolitis (author's transl)]

Authors present analysis of 31 cases of necrotizing enterocolitis, which where treated medically as well surgically. Etiology is discussed and perinatal accidents are considered. An analysis of symptomatology and radiological study is made, both being deciding factors as to whether a surgical intervention is necessary. Medical treatment is commented as well as surgical and technical aspects. Mortality is sensibly diminished due to a better knowledge of the illness and to a closer cooperation between neonatologist and surgeon. It is important to point out sequelae which appeared in patients treated medically with intestinal stenosis localized in the colon.

[Cecum perforation, complication of an acute idiopathic dilatation of the colon, or Ogilvie's syndrome. Practical interest of various pathogenic data. Apropos of one case]

The authors report a new case of caecal perforation complicating acute dilatation of the colon without organic obstruction (Ogilvie's syndrome). They recall the two characteristics of this syndrome : abdominal distension due to colonic ileus, without any organic cause, and the constant coexistence of an associated pathological condition (traumatic, post-operative, infective, cardio-vascular, respiratory or neurological). The major complication is caecal perforation, announced by a clinical and radiological preperforative syndrome. The pathogenesis of Ogilvie's syndrome remains mysterious. Two facts are worth attention : the role of the sympathetic nerve in intestinal paralysis and the direct intervention of an extra-intestinal pathological factor in the onset of this syndrome. Hence two therapeutic consequences : the favourable effect of splanchnic infiltrations on intestinal motility, and the parallel course of acute colonic dilatation and the extra-intestinal disease.

[Functional disorders of distal colon in children (author's transl)]

Functional disorders of the distal part of the colon in neonates and infants should be diagnosed by X-ray investigations (defecograms), double-suction biopsies (Erlanger children suction biopsy apparatus), anorectal and sigmoidal manometry and coloscopic functional investigations. 90% of all disorders of the distal colon can be diagnosed by manometric studies, in 40% X-ray investigations will lead to an exact diagnosis, in 12% double suction biopsies and in 10% coloscopic investigations establish the right diagnosis. The double suction biopsy is important for the exclusion of aganglionosis. Either a conservative or a surgical treatment is necessary, depending on the primary lesion. Wash outs, sphinctertraining, toilet training are necessary in cases of prolonged constipation following sigmaresection with restmegacolon, in cases of rectal inertia syndrom, and in cases of overflow incontinence. A pressure reducing operation (a sphincteromyotomy) is indicated in ultrashort aganglionic segments, in special cases of elongated sigma, in cases of prolonged constipation after sigma resection and with disturbed reflex mechanism, in cases of sphincter inhibition syndrome, and in children with paradox reflex mechanism. A resection is indicated in Hirschsprung disease, mechanical obstruction of the bowel, very large and severe cases of sigma elongatum and in cases of overflow-incontinence.

Colitis cystica profunda

Colitis cystica profunda is a benign disease characterized by variably sized mucin-filled cysts beneath the muscularis mucosae. The clinocpathologic features of five patients are described. The accumulated evidence suggests that awareness of this entity both by clinicians and pathologists with help differentiate it from carcinoma and decrease the need for radical surgery.