Discontinuous appendiceal involvement in ulcerative colitis: pathology and clinical correlation.

Continuous mucosal involvement from the rectum proximally is one of the hallmarks of ulcerative colitis. However, recent pathologic series report appendiceal ulcerative colitis in the presence of a histologically normal cecum, representing a "skip" lesion. The clinical significance of this finding has not been established. Eighty patients, 54 males and 26 females, average age 37.9 years (range 14 to 82 years) who underwent proctocolectomy for ulcerative colitis from January 1990 to September 1995 were examined to determine the rate of discontinuous appendiceal involvement. Excluded were 12 patients with prior appendectomy and 11 with fibrotic obliteration of the appendiceal lumen. Of the remaining 57 patients, seven (12.3%) had clear appendiceal involvement in the presence of a histologically normal cecum. These seven patients clinically were indistinguishable from the 50 patients without skip involvement of the appendix in terms of age at surgery, pretreatment medications, type of surgery, interval from diagnosis to definitive procedure, complications, functional results, and clinical course. Discontinuous appendiceal involvement was found in 12.3% of patients undergoing proctocolectomy for ulcerative colitis, and clinically these patients behave as those without this feature.

Calcified mucocele of the appendix presenting as ureteral obstruction.

Mucocele of the appendix, a rare lesion, occurs in 0.3% of patients undergoing appendectomy. Only 46 cases of calcified mucocele have been reported. Complications reported include appendiceal intussusception, rupture resulting in acute abdomen, and infection. We report the case of a 74-year-old man with a calcified mucocele of the appendix that was discovered in the evaluation of a ureteral obstruction. During exploratory surgery, the patient was found to have a 6 x 5 cm appendiceal tumor and underwent a right ileocolectomy. Pathologic examination showed calcified mucous cystadenoma of the appendix. Calcification of a mucocele is believed to denote chronicity. Our case is the first report of ureteral obstruction secondary to calcified mucocele and the second calcified mucocele to be seen on computerized tomography. Calcified mucocele should be included in the differential diagnosis of any calcified tumor in the right lower quadrant.

Simultaneous transmission of Borrelia burgdorferi and Babesia microti by individual nymphal Ixodes dammini ticks.

Nymphal Ixodes dammini ticks, selected from a group of ticks in which 22 of 31 (71%) contained dual Borrelia burgdorferi and Babesia microti infections, simultaneously transmitted B. burgdorferi and B. microti to 4 of 7 (57%) hamsters exposed to individual ticks.

Resuscitation and transfer of trauma patients: a prospective study.

Improved outcome for trauma patients is closely linked to adequate early resuscitation and timely transfer of selected patients to trauma treatment centers. To document adequacy of early care of patients transferred to a regional trauma center, we analyzed 100 consecutive patients transferred after early care in a licensed emergency department by a medical doctor. Patients were evaluated in four injury categories: 1) neurologic, 2) chest, 3) abdominal, and 4) orthopedic. Standards promulgated by the American College of Surgeons Committee on Trauma and the American College of Emergency Physicians were applied in each injury category, and percentage of noncompliance with these accepted standards was calculated. Dangerous levels of noncompliance with accepted standards of trauma care were documented. On the average, major departures from accepted standards of early care were found in more than 70% of cases, particularly in the potentially lethal areas of airway acquisition and volume replacement. Implications of these data and an evaluation of corrective measures are discussed.

Complications associated with ileal pouch-anal anastomosis.

Seventy-three patients underwent total colectomy, rectal mucosectomy, creation of J or S ileal reservoir, and ileal pouch-anal anastomosis from 1982 to 1989. Mean follow-up was 38 months, with a minimum of 3 months in 15 patients being followed long-term at another institution. Forty-eight (66%) patients had histologically proven ulcerative colitis and 25 (34%) patients had familial polyposis. Thirty-eight J reservoirs and 35 S reservoirs were constructed. There were no perioperative deaths. The failure rate (loss of pouch) was 3%. Thirty-six complications in 34 (47%) patients were reported, 14 (19%) patients required surgery. Bowel obstruction was the most common postoperative complication (16%), followed by pouchitis (15%), and cuff infection (5%). Seventy-eight percent of the complications were associated with the J pouch. Average stool frequency at 1 year was 4 per 24-hour period. Other complications included postoperative pneumonia (1), peroneal nerve palsy (1), and temporary sexual dysfunction (1). Seven of 15 complications requiring surgical intervention occurred in the first 2 years of the study period, illustrating the learning curve associated with the procedure. Blood loss, transfusion requirements, and length of operation were not associated with higher complication rates. Use of the J pouch and experience of the individual surgeon affected morbidity.

Significance of a normal surveillance colonoscopy in patients with a history of adenomatous polyps.

PURPOSE: The aim of this study was to determine the appropriate surveillance for patients with a history of adenomatous polyps whose last colonoscopic examination was normal. METHODS: This was a retrospective review of a database of 7,677 colonoscopies (1990 to 1996). In patients under colonoscopic surveillance, we reviewed cases of patients who had received three colonoscopies (an index (initial) colonoscopy positive for adenomas and 2 follow-up colonoscopies (interim and final)). The risk of adenomas and cancers at final follow-up colonoscopy was compared between patients having a normal interim colonoscopy and those with a positive interim colonoscopy. The risk at final colonoscopy was also stratified by time interval and the size and number of adenomas at the initial index colonoscopy. RESULTS: Two hundred four patients undergoing surveillance for adenomas met inclusion criteria. At index colonoscopy the median polyp size was 1 cm and median frequency was three polyps. At all follow-up colonoscopies, we detected 493 adenomas and one cancer (median follow-up, 55 months). At 36 months patients with a normal interim colonoscopy (n = 91) had significantly fewer polyps than patients with a positive interim colonoscopy (n = 113; 15 vs. 40 percent; P = 0.0001). By 40 months, adenomas were detected in more than 40 percent of patients in both groups. The risk after a normal interim colonoscopy was not affected by time interval or number or size of polyps. Adenomas found subsequent to a normal interim colonoscopy were dispersed throughout the colon in 28 patients and isolated to the rectosigmoid in 6 patients. CONCLUSIONS: In patients with a history of adenomas, a normal follow-up colonoscopy is associated with a statistically but not clinically significant reduction in the risk of subsequent colonic neoplasms. These patients require follow-up surveillance colonoscopy at a four-year to five-year interval.

The natural history of isolated rectosigmoid adenomatous polyps: is flexible sigmoidoscopy a safe alternative for surveillance?

PURPOSE: Colonoscopic surveillance is recommended for patients with adenomatous polyps. Significant cost savings would result from identification of subgroups of patients in whom less costly surveillance would suffice. This study was performed to determine the natural history of patients undergoing removal of isolated rectosigmoid adenomas and to establish whether flexible sigmoidoscopy might be adequate for follow-up. METHODS: A retrospective review of a database of 7,677 colonoscopies, from 1990 to 1996, identified patients who had a minimal follow-up of two years after removal of adenomatous polyps isolated to the rectosigmoid. Polyps detected on surveillance colonoscopy were categorized as distal (< or =60 cm from anal verge), proximal (>60 cm from anal verge), and diffuse (proximal plus distal). The risk of polyp formation was determined by actuarial analysis using the Kaplan-Meier method. RESULTS: Sixty-two patients undergoing surveillance for adenomas met inclusion criteria. At the index colonoscopy, 124 isolated rectosigmoid polyps were identified. The median polyp size was 1 cm and median frequency was one polyp. The median follow-up time for the entire cohort (N = 62) was 53 months. At follow-up surveillance colonoscopy, 105 additional adenomas were discovered and removed in 40 patients. No malignant polyps were detected. The pattern of polyps detected were proximal (n = 19), rectosigmoid (n = 16), and diffuse (n = 5). CONCLUSIONS: The majority (65 percent) of patients with isolated rectosigmoid polyps have additional polyps on long-term surveillance, and 60 percent of patients will have these polyps located proximal to the reach of a sigmoidoscope. Therefore, flexible sigmoidoscopy is not a safe alternative for surveillance of patients with isolated rectosigmoid polyps.

Total pelvic exenteration with or without sacral resection in patients with recurrent colorectal cancer.

Pelvic recurrence from colorectal cancer produces significant morbidity. Radiation can help palliate the pain produced by this recurrence. Frequently patients with recurrent colorectal cancer will progress to a constant unrelenting pain and obstructive uropathy with sacral and bladder involvement. These patients can be candidates for an aggressive surgical resection with the hope of significant palliation and prolonged survival. From October 1988 to December 1991, six patients had total pelvic exenteration at our institution. Of these six patients, two had en bloc sacral resection at levels S1-S2 and one at S2-S3. Two patients had residual disease at the time of primary surgery, and in the other four patients, recurrence occurred 7 to 48 months after primary resection. One patient died with disease at 7 months, and five patients are alive at 9, 25, 25, 37, and 37 months since the pelvic resection; four have no evidence of disease. The present Karnofsky performance status is 80% or greater in all patients. There were no operative deaths. Of the five living patients, the survival from diagnosis of the primary lesion is 25 to 97 months. Total pelvic exenteration and abdomino-sacral exenteration can produce significant palliation and prolong survival in a selected group of patients with pelvic recurrence from colorectal cancer.

Restorative proctocolectomy: Ochsner Clinic experience.

BACKGROUND: Restorative proctocolectomy, a standard operation for ulcerative colitis and familial adenomatous polyposis has significant complications, even in experienced hands. METHODS: We studied surgical outcome by retrospectively reviewing cases of restorative proctocolectomy done at Ochsner Foundation Hospital from 1982 to 1995. Demographic and clinical data from two periods (1982 to 1989 and 1989 to 1995) were compared to determine factors associated with improved outcome. RESULTS: We performed 145 ileal pouch-anal procedures. In 56 patients, 104 complications occurred. The more recent group had a greater incidence of inflammatory bowel disease, steroid use, and staged operations; reduced operative times and hospital stays; more general but fewer pouch-related complications. Pouch failures were similar for both groups. CONCLUSIONS: Perioperative outcome appeared to be associated with technical experience, improved perioperative care, exclusion of patients with Crohn's disease,judicious surgical reoperation for pouch complications, and use of a 3-stage procedure in malnourished patients or those with acute or toxic colitis.

Surgical management of anorectal fistulas in Crohn's disease.

A retrospective review of patients with Crohn's disease treated at our institution from 1973 to 1986 revealed 35 patients operated upon for anorectal fistulas. Twenty-nine had low intermuscular fistulas (multiple in seven), and six had high intermuscular (supralevator) fistulas. Fistulotomy alone was performed in 19 patients, and eight underwent partial fistulotomy and seton insertion. Five additional patients had proximal fecal diversion before fistulotomy. Three patients with severe colonic and anorectal disease underwent proctocolectomy as the initial procedure. Of the 32 patients who had fistulotomy performed, complete healing occurred in 30. Seven patients who healed required more than one operation for fistula. One patient was left with an asymptomatic fistula, and one required proctectomy for persistent symptomatic fistula and proctitis. Success of operation correlated with absence of rectal disease and quiescent disease elsewhere in the gastrointestinal tract. Aggressive medical treatment is required to control bowel disease preoperatively. In the majority of patients, subsequent surgery is justified and healing can be anticipated.

Results of operation for rectovaginal fistula in Crohn's disease.

A retrospective review of patients with Crohn's disease treated at our institution from 1973 to 1986 revealed 12 patients operated on for rectovaginal fistula. Disease involved the large intestine in 10 patients. Primary fistula repair was performed in four patients and four others had staged repair with preliminary fecal diversion. Four patients with severe colonic and anorectal disease had proctocolectomy performed as the first procedure. Of eight patients who underwent fistula repair, complete healing occurred in six. One patient has a persistent fistula, which is minimally symptomatic, and the other required proctocolectomy after three unsuccessful repairs. Success of operation correlated with quiescent intestinal disease and absence of rectal involvement. In selected patients with symptomatic fistulas, surgical repair is indicated and healing can be anticipated.

Outpatient bowel preparation for elective colon resection.

To determine the safety and cost-effectiveness of outpatient preoperative bowel preparation with polyethylene glycol-electrolyte lavage solution, we retrospectively analyzed 726 cases of colectomy done by colon and rectal surgeons between July 1987 and July 1991. Included were 319 patients who had elective segmental or total abdominal colectomy with primary anastomosis. Patients who required protective proximal stoma were excluded. Patients requiring emergency surgery, colostomy closure, and restorative proctocolectomy were excluded. Patients were separated into two groups equally matched by age, sex, procedure done, and comorbidity: 145 had bowel preparation as outpatients and 174 as inpatients. Both groups had similar numbers of days hospitalized, days receiving nothing by mouth, and days requiring nasogastric intubation or gastrostomy tube, as well as similar postoperative complications. There was one wound infection, one anastomotic leak, and one death in each group. Cost of outpatient preparation was approximately $40. Cost of inpatient preparation, including a semiprivate room, was approximately $400. Outpatient preparation with polyethylene glycol-electrolyte lavage solution and oral antibiotics before elective colon resection can be done with equivalent safety and at a substantial cost savings.

Colonoscopic screening of asymptomatic patients with a family history of colon cancer.

The records of 201 asymptomatic patients who underwent colonoscopy based solely on a family history of colon cancer were reviewed. Eighty-five patients (42 percent) had a total of 166 lesions. Fifty-four (27 percent) patients of the screened population had neoplastic lesions, while 31 (15 percent) patients had nonneoplastic polyps. Four carcinomas were found. Twenty-five of the patients with polyps (29 percent) had no polyps distal to the splenic flexure; these proximal polyps (and two carcinomas) would have been missed on screening with fiberoptic sigmoidoscopy. Nineteen of these 25 patients had polyps smaller than 0.5 cm, which likely would have been missed with contrast enemas. Almost one half (47 percent) of all polyps discovered at screening colonoscopy were proximal to the descending colon. Only one patient younger than 40 years old had adenomas. The yield of polyps and cancer in patients with familial risk indicates screening colonoscopy should be considered after age 40.

Colonoscopic follow-up of adenomas and colorectal cancer.

Increasing experience with colonoscopy has altered recommendations for the frequency of follow-up surveillance examinations for adenomatous polyps and colorectal cancer. Current recommendations include a follow-up colonoscopy at 1 year for patients with more than two adenomatous or highly suggestive polyps and after curative surgery for colorectal cancer. Other patients can safely receive a follow-up colonoscopy at longer intervals of 3 years. Published data and a review of the Ochsner Clinic experience are presented to support these recommendations.

Rectal carcinoids: the most frequent carcinoid tumor.

One hundred seventy patients with gastrointestinal carcinoid tumors were treated at Ochsner Clinic from 1958 to 1990. Ninety-four rectal carcinoid tumors were diagnosed and treated during this time. Carcinoid tumors of the rectum represented the most frequent primary site (55 percent), followed by carcinoids of the ileum (12 percent), appendix (12 percent), colon (6 percent), stomach (6 percent), jejunum (2 percent), pancreas (2 percent), and other (5 percent). One-half of rectal carcinoids were discovered during anorectal examination of asymptomatic patients. The remainder were found primarily by examination of patients for symptoms of benign anorectal conditions. The diagnosis of rectal carcinoid was made at the time of initial examination in 61 patients. This allowed definitive treatment in a single session by local excision and fulguration in 48 patients. The remainder were treated by repeat biopsy and fulguration (25 patients) or by transanal excision (12 patients). Overall, 85 carcinoid tumors of the rectum measuring less than 2 cm were treated by local excision and fulguration or by transanal excision, with an average five-year follow-up. There were no local recurrences. Ten patients with metastasizing rectal carcinoids averaging 4 cm were treated. All were symptomatic at presentation and fared poorly despite radical surgery. Three were alive at three years but only one survived five years. At our institution, rectal carcinoids were the most frequently detected carcinoid tumor. Small carcinoids of the rectum were adequately treated by local excision and fulguration or by transanal excision, with no local recurrence. The true incidence of rectal carcinoids is detected only with careful and complete rectal examination of the asymptomatic screening population by experienced surgeons. With more widespread screening of the well population, rectal carcinoids may become recognized as the most frequent human carcinoid tumor.

Diminutive colonic polyps: an indication for colonoscopy.

A prospective study investigated the significance of solitary diminutive colonic polyps discovered during screening flexible sigmoidoscopy. Eighty-two patients with a solitary diminutive polyp (less than or equal to 5 mm) underwent colonoscopy after cold biopsy of the index polyp. Of the patients with adenomatous index polyps, 42.5 percent had proximal neoplastic polyps. Of the patients with hyperplastic index polyps, proximal neoplastic polyps were found in 38.9 percent. These data suggest that diminutive polyps identified during flexible sigmoidoscopy, whether adenomatous or hyperplastic, place the patient in the intermediate risk group for colorectal neoplasia. We recommend that any patient with polyps seen during screening sigmoidoscopy, regardless of histopathology, should undergo colonoscopy.

Colostomy closure. Ochsner Clinic experience.

PURPOSE: We retrospectively reviewed the records from our past five years of experience with colostomy closure at a large multispecialty hospital to determine postoperative morbidity. RESULTS: From March 1988 to April 1993, 46 patients underwent colostomy closure. Patients ranged in age from 24 to 87 (mean, 41.8) years, and 25 (54 percent) were women. Stomas had been created during emergency operations in 40 patients (87 percent); most operations (54 percent) were for complications of acute diverticulitis. Of the 46 procedures, 40 (87 percent) were end colostomies, and 6 were loop colostomies. Stomas were closed at a range of 11 to 1,357 days after creation (mean, 207 days; median, 116 days). Twenty-six patients (57 percent) underwent colostomy closure alone, and the remainder underwent additional procedures ranging from appendectomy to hepatic lobectomy. Duration of operations ranged from 1 to 9.5 (mean, 4.2) hours, and estimated blood loss averaged 400 ml. Overall hospital stay for closure was 6 to 62 (mean, 11.5) days. Inpatient complications occurred in 15 percent of patients, including congestive heart failure (2 percent), cerebrovascular accident (4 percent), pneumonia (2 percent), enterocutaneous fistula (2 percent), and pulmonary embolus with death (2 percent). The most common long-term complication was midline wound hernia, which occurred in 10 percent of surviving patients. Overall, complications occurred in 24 percent. CONCLUSIONS: Colostomy closure is a major operation; however, with good surgical judgement and technique, associated morbidity and mortality can be minimized.

Postpolypectomy colonic hemorrhage.

PURPOSE: This study was undertaken to evaluate the incidence, diagnostic methods, and treatment of hemorrhage occurring after colonoscopic polypectomy. METHODS: A retrospective chart review was conducted of 12,058 patients who underwent colonoscopy at an academic referral center between January 1989 and July 1993. Of these, 6,365 patients required polypectomies or biopsies. RESULTS: After these procedures, 13 patients (0.2 percent) developed lower gastrointestinal hemorrhage requiring hospitalization. All bleeding episodes occurred within 12 days of polypectomy or biopsy (mean = 8 days). Twelve patients (92 percent) underwent technetium-tagged red blood cell scintigraphy, which localized bleeding in four patients (31 percent). In the eight patients with normal scintigrams, hemorrhage did not recur, and no further evaluation was performed. Five patients (38 percent) underwent arteriography. Arteriogram was positive in two of four patients with positive scintigrams, and bleeding was controlled with selective vasopressin infusion. The fifth patient had arteriography without prior diagnostic studies because of massive hemorrhage; the bleeding site was identified and controlled with selective vasopressin infusion. Three patients had lower gastrointestinal endoscopy, with endoscopic identification of bleeding site in two patients, and endoscopic electrocautery controlled the bleeding in one patient. In the 13 patients with hemorrhage, cessation of bleeding occurred with intestinal rest and hydration in nine patients (69 percent), selective vasopressin infusion in three patients (23 percent), and endoscopic electrocautery in one patient (8 percent). Eight patients (62 percent) required blood transfusion with a mean of 4.8 units (excluding one patient on warfarin sodium who required 14 units of blood). No patient required surgical intervention. CONCLUSIONS: Incidence of hemorrhage after colonoscopic polypectomy or biopsy is low, and in our series, hemorrhage resolved without the need for surgical intervention. Management includes initial stabilization followed by diagnostic evaluation. Technetium-tagged red blood cell nuclear scintigraphy identifies ongoing bleeding and identifies patients in whom additional invasive procedures (arteriography lower gastrointestinal tract endoscopy) are warranted.