Elective and emergent operative management of ulcerative colitis

Surgical therapy of ulcerative colitis is effective, safe, and provides an improved quality of life in those whose disease cannot be managed medically. In the elective setting, widespread acceptance of restorative proctocolectomy has made surgical therapy an attractive option in the overall management of ulcerative colitis. Enthusiasm for this procedure should be tempered by the acknowledgment of the significant incidence of pouchitis in the long term, however. Proctocolectomy with ileostomy remains a good surgical option for patients who are unsuitable for restorative procedures. The standard therapy for fulminant colitis or toxic megacolon remains subtotal colectomy with ileostomy. Patients undergoing subtotal colectomy are candidates for conversion to restorative procedures.

Anal fissure

Anal fissure is a common condition with a characteristic presentation. Despite increased pharmaceutical options in the medical management of anal fissures, surgical therapy is not in danger of becoming obsolete. Lateral internal sphincterotomy remains an attractive option for many patients suffering from this painful condition.

Laparoscopic colectomy

The unique challenges of a laparoscopic approach to colorectal surgery have delayed its widespread adoption into clinical practice. Advances in instrumentation, modifications of technique, and an unequivocal demonstration of its safety undoubtedly will increase its popularity in the future.

Fabricating a gold occlusal platform on a removable partial denture to help prevent extrusion of mandibular incisors

A clinical procedure is presented in which a maxillary removable partial denture replacing anterior teeth was fabricated with a cast gold anterior occlusal platform. This treatment is indicated to correct abrasion caused by extruded mandibular anterior teeth on the maxillary removable partial denture. The advantages compared to prosthetic teeth supported by an acrylic resin base or metal-backed facings are discussed. This technique allows for development of optimal esthetics, strength, and durability while preventing further extrusion and excessive wear of the teeth occluding against prosthesis.

Fabricating a gold occlusal platform on a removable partial denture to help prevent extrusion of mandibular incisors

A clinical procedure is presented in which a maxillary removable partial denture (RPD) replacing anterior teeth was fabricated with a cast gold anterior occlusal platform. This treatment is indicated to correct abrasion caused by extruded mandibular anterior teeth on the maxillary RPD. The advantages compared with prosthetic teeth supported by an acrylic resin base or metal-backed facings are discussed. This technique allows for development of optimal esthetics, strength, and durability, while preventing further extrusion and excessive wear of the teeth occluding against prosthesis.

Incarcerated rectal prolapse--rupture and ileal evisceration after failed reduction: report of a case

We report a case of incarcerated rectal prolapse that could not be reduced after using the previously described application of ordinary table sugar. Gentle pressure caused the prolapsed rectum to perforate, and the small bowel herniated through the tear. This is only the second case reported in the literature of an ileal herniation through a perforated rectum after an attempted reduction of an incarcerated prolapse. It is the only reported case occurring after sugar application and the 42nd case of ileal herniation through the rectum from all causes.

Laparoscopic appendectomy and the management of gynecologic pathologic conditions found at laparoscopy for presumed appendicitis

A laparoscopic approach to patients with possible appendicitis has increased in popularity. In this article it is compared to the traditional open appendectomy, and the management of frequently found gynecologic pathology masquerading as appendicitis is described.

Risk of dysplasia in anal condyloma

BACKGROUND

Recent studies suggest an alarming incidence of dysplasia in homosexuals with anal condyloma. The purpose of our study was to determine the incidence of dysplasia in anal condyloma in our male patients and to determine risk factors for premalignant or malignant change.

METHODS

Between 1986 and 1994, 103 male patients were referred to our colorectal clinic for evaluation of anal condyloma. Ninety-one patients had biopsy for pathology and form the basis of this report. All charts were reviewed and results analyzed using the chi-squared test with the Yates correction factor.

RESULTS

Mean patient age was 31 +/- 11 years (range, 13 to 78 years) and mean duration of disease was 20 +/- 26 months (range, 2 to 120 months). There were 59 heterosexuals and 32 homosexuals/bisexuals. Two heterosexuals (3%) had invasive squamous cell carcinoma and four (6%) had dysplasia. One homosexual/bisexual (3%) had squamous cell carcinoma in situ and nine (28%) had dysplasia (p < 0.05). Statistical analysis revealed that HIV seropositive status and disease location above the dentate line also predicted increased risk of dysplasia, whereas duration of disease, previous topical therapy, substance abuse, and other sexually transmitted diseases were not significant risk factors.

CONCLUSIONS

Homosexual orientation, disease above the dentate line and HIV seropositivity increase the risk of dysplasia in perianal condyloma. The incidence of dysplasia in perianal condyloma is significant enough to warrant consideration of biopsy in all patients.

Development of invasive adenocarcinoma following colectomy with ileoanal anastomosis for familial polyposis coli. Report of a case

PURPOSE

Proctocolectomy with ileoanal anastomosis has gained increasing acceptance for the prophylactic treatment of patients with familial polyposis coli. Long-term surveillance of the ileal pouch and the pouch-anal anastomosis has not been emphasized despite concern regarding retained rectal mucosa following the procedure.

METHODS

A 34-year-old patient with a strong family history of familial polyposis coli was treated at 14 years of age by single-stage proctocolectomy with straight ileoanal anastomosis. Follow-up proctoscopic examinations revealed development of adenomatous changes at the ileoanal anastomosis.

RESULTS

This report presents a patient with familial polyposis coli who developed invasive adenocarcinoma at the ileoanal anastomosis 20 years after proctocolectomy with ileoanal anastomosis.

CONCLUSIONS

We stress the need for lifelong proctoscopic surveillance in patients with familial polyposis coli treated by proctocolectomy with ileoanal anastomosis.

Spinal epidural abscess complicating an ileal J-pouch-anal anastomosis. Report of a case

A 42-year-old man developed recurrent epidural abscesses from an enteroepidural fistula arising from a J pouch. Lower-extremity neurologic deficit in patients with an ileal pouch-anal anastomosis should alert the physician to this rare complication.

Preoperative screening with ultrasonography for laparoscopic cholecystectomy: an alternative to routine intraoperative cholangiography

BACKGROUND

Laparoscopic management of choledocholithiasis is not routinely successful. A prospective study was undertaken to determine if preoperative screening with ultrasonography and liver function tests (LFTs) could minimize the incidence of unsuspected choledocholithiasis.

METHODS

One hundred twenty-one patients were studied. Patients with a common bile duct greater than 6 mm and either clinical symptoms or elevated LFT results were referred for preoperative endoscopic retrograde cholangiopancreatography (ERCP).

RESULTS

Ten patients (8%) were referred for preoperative ERCP, of whom seven had choledocholithiasis, two had papillary stenosis, and one had a normal examination (90% positive ERCPs). One hundred eight patients underwent successful laparoscopic cholecystectomy. Nine patients underwent postoperative ERCP dictated by increasing common bile duct size, elevated enzyme levels, or symptoms. Four patients (3%) had choledocholithiasis that was successfully treated endoscopically. One patient had papillary stenosis, one had oriental cholangitis, and three had normal results on examination.

CONCLUSIONS

In this study ultrasonography and LFTs identified patients at high risk for choledocholithiasis, allowing preoperative referral for endoscopic stone extraction.

A psychophysiological study in humans using phasic colonic distension as a noxious visceral stimulus

Psychophysiological experiments were performed in 9 humans using constant-pressure, phasic, graded distention (30 sec, 20-70 mm Hg) of the sigmoid colon as a visceral stimulus. Reliable cardiovascular (pressor), respiratory and visceromotor responses in addition to reports of pressure/pain sensations were evoked by colonic distension in 8 of the 9 subjects. The pressure/pain sensations were referred to the lower abdomen, lower back and perineum and their intensity quantified using a visual analogue scale. Responses to colonic distension were graded and increased with repeated distensions at the same intensity (60 mm Hg). The area of referral as indicated by subject drawings increased with repeated distensions as did the intensity of the subjects' sensory and affective descriptors of the sensation. Five of the subjects differentiated between 'pressure' and 'pain' sensations evoked by colonic distension; the intensity of the 'pain' sensation accelerated during the distending stimulus whereas the 'pressure' sensation was typically stable or adapting during the distending stimulus.

A psychophysiological study in humans using phasic colonic distension as a noxious visceral stimulus

Psychophysiological experiments were performed in 9 humans using constant-pressure, phasic, graded distention (30 sec, 20-70 mm Hg) of the sigmoid colon as a visceral stimulus. Reliable cardiovascular (pressor), respiratory and visceromotor responses in addition to reports of pressure/pain sensations were evoked by colonic distension in 8 of the 9 subjects. The pressure/pain sensations were referred to the lower abdomen, lower back and perineum and their intensity quantified using a visual analogue scale. Responses to colonic distension were graded and increased with repeated distensions at the same intensity (60 mm Hg). The area of referral as indicated by subject drawings increased with repeated distensions as did the intensity of the subjects' sensory and affective descriptors of the sensation. Five of the subjects differentiated between 'pressure' and 'pain' sensations evoked by colonic distension; the intensity of the 'pain' sensation accelerated during the distending stimulus whereas the 'pressure' sensation was typically stable or adapting during the distending stimulus.

Post-discharge care planning and rehabilitation of the elderly surgical patient

Successful discharge planning, home care, and rehabilitation for surgical patients can be very satisfying. However, everyone involved should be aware that it can also be frustrating when, despite careful plans and organization, everything falls apart, often because the patient's disease course is different from that expected or the patient or family are not satisfied with the services. There are multiple other reasons for plans to fail, but with experience the failures should become less frequent. All too often in life we take success for granted and weigh failures twice as much. The danger of this type of thinking becomes especially important in discharge planning--successfully discharged patients may be "invisible" but the failures are back very quickly. Everyone involved in discharge planning should be made aware of the successes in order to prevent "burn out." Certain predictable complications can often be prevented or rapidly reversed, and rehabilitation is achieved by a team of varied health care providers. A home visit is often very helpful before discharge of an elderly surgical patient.

Anorectal manometry in active and quiescent ulcerative colitis

Anorectal function was measured in 11 patients with active medically intractable ulcerative colitis, seven patients with quiescent ulcerative colitis, and 18 healthy subjects. The anal resting pressure, squeeze pressure, and ability to defecate a balloon were similar in all groups. Significantly lower rectal distention volumes were required for rectal sensation, critical volume, and to induce rectal contractility in patients with active disease compared to controls or patients with quiescent disease. Rectal compliance was significantly reduced in patients with active and quiescent disease. The increased rectal sensitivity and contractility in patients with active colitis appear to be related to active mucosal inflammation and ulceration. Episodes of mucosal inflammation may be responsible for chronic changes in the rectal wall resulting in fibrosis and decreased compliance in patients with quiescent disease. The frequency and urgency of defecation and the fecal incontinence may be due to a hypersensitive, hyperactive, and poorly compliant rectum.

Rectosigmoid motility in patients with quiescent and active ulcerative colitis

We studied the pathophysiology of diarrhea in ulcerative colitis by evaluating and comparing rectosigmoid motility before, during, and after a 900-cal meal in healthy subjects, patients with quiescent ulcerative colitis, and patients with active ulcerative colitis. Three intraluminal pressure transducers were used for recording of rectosigmoid motility. Motility during fasting, eating, and after eating a meal was similar in patients with quiescent disease and controls. Motility increased significantly during eating in controls, but not in patients with quiescent disease. In patients with active colitis, motility was significantly reduced during fasting, eating, and after eating, compared with controls. Motility increased significantly during eating in patients with active disease. Propagated activity was similar in the three study groups; therefore, the decreased motility was due to decrease in segmental contractions. These findings suggest that diarrhea in patients with active colitis may be related to the loss of normal segmental contractions which delay distal stool transport.

Primary perianal actinomycosis. Report of a case and review of the literature

A case of primary perianal actinomycosis presenting as recurrent perianal abscesses is reported. Although this is a rare presentation of actinomycosis, it is easily recognized when encountered and should be treated with surgical drainage, examination under anesthesia, and long-term antibiotic therapy.

Anorectal function and defecation dynamics in patients with rectal prolapse

Seven female patients with clinical rectal prolapse and nine healthy female control subjects were studied with anorectal manometry, external sphincter electromyography, and a saline continence test. Resting anal tone, maximum voluntary squeeze, and rectal functional capacity were significantly decreased in the rectal prolapse patients (p less than 0.02). During defecation attempts, external sphincter or pelvic floor electromyographic activity decreased in all of the control subjects, whereas six prolapse patients showed increased electromyographic activity and one had no change in activity (p less than 0.01). Continence to saline solution was also significantly impaired in prolapse patients (p less than 0.001). Postoperative studies in three patients who underwent repair revealed persistence of abnormal anorectal function and defecation dynamics. Patients with rectal prolapse have impaired resting and voluntary sphincter activity, decreased functional rectal capacity, and impaired continence. The failure of normal relaxation of the external sphincter or pelvic floor during defecation attempts, as demonstrated in the patients described herein, may contribute to the development of prolapse and denervation sphincter injury seen in such patients.

Anal canal pressure and motility after ileoanal anastomosis

This study was done to determine the effect of mucosal rectectomy and ileal pouch to anal anastomosis (IAA) on pressure and motility of the anal canal. Fifty patients, 22 +/- 2 months after operation (mean plus or minus standard error of the mean), and 30 healthy control volunteers were studied. Twenty-eight patients had excellent continence, while 22 had episodic minor incontinence. The maximum resting pressure in the anal canal was reduced in patients with episodic incontinence compared with continent patients and control volunteers. The increase in pressure with squeeze was slightly greater in continent than in incontinent patients. The frequency of the anal slow waves was less after IAA than in control volunteers and the amplitude of the waves was greater. The frequency and amplitude, however, were not related to continence or resting pressure. In conclusion, decreased anal canal resting and squeeze pressures after ileal pouch to anal anastomosis are associated with episodic minor incontinence, while altered motility patterns in the anal canal are not.

High-resolution sonography of acute appendicitis

During a 7-month period high-resolution sonography was used in the evaluation of 68 patients with an equivocal clinical diagnosis of acute appendicitis. The sonographic findings were correlated with surgical-pathologic outcome in 32 cases and with clinical follow-up in the remainder. This technique was found to be accurate in the diagnosis of acute appendicitis with a specificity of 95%, a sensitivity of 80%, and an accuracy of 90%. The predictive value of a positive test was 91%; that of a negative test was 89%. The results show that high-resolution sonography is indicated to establish the diagnosis of acute appendicitis in patients with equivocal clinical findings.

The surgical risk of colectomy in patients with cirrhosis

The records of 54 patients with documented cirrhosis who underwent colectomy between January 1970 and January 1984 were studied to assess the operative risk and to determine the preoperative predictive risk factors. In-hospital mortality was 24 percent (13 patients), and postoperative complications occurred in 48 percent (26 patients). The risk of surgical intervention was significantly increased if encephalopathy, ascites, anemia, or hypoalbuminemia was present before operation. A simple operative risk index involving the presence of encephalopathy and ascites and the levels of hemoglobin and albumin is proposed to help distinguish a low-risk subgroup in whom postoperative mortality was 12.8 percent from a high-risk subgroup in whom postoperative mortality was 53.3 percent.

Simplified assessment of segmental colonic transit

Transit times of radiopaque markers through the human gut were measured by published techniques and compared with a simplified method. Three sets of distinctive markers were ingested by 24 healthy persons on 3 successive days. In the first part of the study, daily abdominal x-rays were taken and individual stools were collected for radiography. Mouth-to-anus transits were assessed from the fecal output of markers and mean colonic and segmental colonic transits were calculated from the daily radiographs. These established methods were then compared with estimates of total colonic and segmental transits based on a single abdominal film, taken on the fourth day. The single-film technique correlated well with values obtained from the previous, but more inconvenient, methods. Using the simpler approach, colonic transit was assessed in 49 additional healthy subjects, for a total group of 73. Total colonic transit was 35.0 +/- 2.1 h (mean +/- SE); segmental transits was 11.3 +/- 1.1 h for the right colon, 11.4 +/- 1.4 h for the left colon, and 12.4 +/- 1.1 h for the rectosigmoid. Men had significantly shorter transits for the whole colon than did women (p less than 0.05), and this difference was apparent to some extent in the right (p = 0.06) and left colon (p = 0.07) but not in the rectosigmoid. Age did not influence transit significantly nor did a small dose of supplemental fiber. The technique is simple, convenient for clinical usage, and reduces the exposure to radiation to acceptable levels. There should be a role for this approach in the evaluation of colonic transit in selected patients.

Sexual function in women after proctocolectomy

One hundred women who had undergone proctocolectomy with a continence-preserving procedure (50 Kock pouches, 50 ileoanal anastomoses) for ulcerative colitis or polyposis coli were interviewed regarding their preoperative and postoperative sexual function. Frequency of intercourse increased and the incidence of dyspareunia decreased after operation in both groups. Patients who had a Kock pouch had a greater incidence of persistent postoperative dyspareunia than patients who underwent an ileoanal procedure (38% vs. 18%, p less than 0.02). Only one patient in each group reported a postoperative disturbance in ability to achieve orgasm. Most women reported no change in their menstrual cycle, but patients with a Kock pouch had more episodic vaginal discharge than patients with an ileoanal anastomosis (18% vs. 0%, p less than 0.001). Postoperative fertility was minimally impaired. Overall, the majority of women in this study who underwent proctocolectomy for benign diseases experienced enhanced sexual function after operation, which they attributed mainly to improved health.

Temporary ileostomy for ileal pouch-anal anastomosis. Function and complications

The function and complications associated with temporary ileostomies were reviewed in patients undergoing ileal pouch-anal anastomosis. A series of 180 patients had temporary ileostomies established (157 loop, 23 Brooke). Patients with incomplete fecal diversion had a significantly higher incidence of pouch-anal anastomotic complications (44 percent) than did those with complete diversion (14 percent). Patients with loop ileostomies were more likely than patients with Brooke ileostomies to develop technique-related complications (18 percent vs. 13 percent) and peristomal irritation (54 percent vs. 26 percent). The most frequent complications after take-down of the ileostomy were transient bowel obstruction (13 percent) and peritonitis (7 percent). These complications could not be related to the type of stoma used or the interval to closure. Temporary diversion of a pouch-anal anastomosis decreased the incidence of anastomotic complications. These ileostomies, however, are associated with a significant risk of complications, which can be minimized by meticulous surgical technique.

Ileal pouch-anal anastomosis without temporary, diverting ileostomy

Of two hundred patients undergoing proctocolectomy with ileal pouch-anal anastomosis, all but nine have had temporary diverting ileostomies. Of these nine patients, eight had successful results. One patient developed abdominal sepsis due to jejunal volvulus and perforation after she had returned home, and at surgery the pouch was excised. Ileal pouch-anal anastomosis without a temporary diverting ileostomy can be performed safely by surgeons experienced with this procedure in carefully selected patients.

Ileal "J" pouch-anal anastomosis. Clinical outcome

One hundred eighty-eight patients undergoing abdominal colectomy with distal mucosal proctectomy and endorectal ileal pouch-anal anastomosis were reviewed to assess long-term functional results and to identify factors that might influence them. There was no postoperative mortality, but 10 patients (5.3%) required permanent ileostomy because of postoperative complications or the development of unsuspected Crohn's disease. Immediate postoperative complications, including pelvic sepsis, small bowel obstruction requiring surgery, anastomotic stricture, and ileostomy dysfunction, were observed in 11%, 9%, 14% and 9% of patients, respectively. No males were impotent but nine (9%) developed retrograde ejaculation. Pouchitis occurred in 8% of patients. Among 157 patients assessed at least 60 days after ileostomy closure (mean +/- SD, 375 +/- 216 days), all evacuated their neorectum spontaneously, and stool frequency was 6.0 +/- 2.6 daily and 1.2 +/- 1.3 nightly. While continence was generally good, 2.5% of patients during waking hours and 4.5% during sleep had occasional frank soilage. Moreover, seepage was noted in 25 and 47% of patients during daytime and nighttime, respectively. Both stool frequency and degree of continence improved with time. Patients less than 50 years of age and those with polyposis coli had fewer stools and better continence than those older than 50 or those with ulcerative colitis. It is concluded that ileal "J" pouch-anal anastomosis can be performed safely and will provide acceptable anorectal function without late deterioration.