Prevalence, diagnosis, and surgical management of complex ileocolic-duodenal fistulas in Crohn's disease.

BACKGROUND: The aim of the present study was to review the prevalence and surgical management of patients with Crohn's disease (CD) complicated by ileocolic-duodenal fistulas (ICDF). METHODS: We performed a retrospective chart review of CD patients who underwent surgical takedown and repair of ICDF during January 2011-December 2021 at two inflammatory bowel disease referral centers. RESULTS: We identified 17 patients with ICDF (1.3%) out of 1283 CD patients who underwent abdominal surgery. Median age was 42 (20-71) years, 13 patients were male (76%) and median body mass index was 22.7 (18.4-30.3) kg/m2. Four patients (24%) were diagnosed preoperatively and only 2 (12%) were operated on for ICDF-related symptoms. The most common procedure was ileocolic resection (13 patients, 76%) including 4 repeat ileocolic resections (24%). The duodenal defect was primarily repaired in all patients with no re-fistulization or duodenal stenosis, regardless of the repair technique. A laparoscopic approach was attempted in the majority of patients (14 patients, 82%); however, only 5 (30%) were laparoscopically completed. The overall postoperative complication rate was 65% including major complications in 3 patients (18%) and 2 patients (12%) who required surgical re-intervention for abdominal wall dehiscence and postoperative bleeding. Preoperative nutritional optimization was performed in 9 patients (53%) due to malnutrition. These patients had significantly less intra-operative blood loss (485 vs 183 ml, p = 0.05), and a significantly reduced length of stay (18 vs 8 days, p = 0.05). CONCLUSION: ICDF is a rare manifestation of CD which may go unrecognized despite the implementation of a comprehensive preoperative evaluation. Although laparoscopic management of ICDF may be technically feasible, it is associated with a high conversion rate. Preoperative nutritional optimization may be beneficial in improving surgical outcomes in this select group of patients.

Iatrogenic superior mesenteric vein injury: the perils of high ligation.

PURPOSE: The purpose of this review is to highlight the perils and pitfalls associated with high vascular ligation during right colectomies for adenocarcinoma and to identify the various mechanisms of injury to the superior mesenteric vein (SMV) and its tributaries. METHODS: This is a retrospective chart review of 304 right colectomies (159 open and 145 laparoscopic) performed over a period of 10 years (1 June 2006-31 May 2016) for right-sided colonic adenocarcinoma in an academic medical center. RESULTS: During a 10-year study period, we encountered five cases in which significant damage to the SMV and its tributaries occurred. This accounts for a total of 1.6 % of all right colectomies performed for colonic adenocarcinoma. CONCLUSIONS: Iatrogenic superior mesenteric vein injury is a rare, severe, and underreported complication of both open and laparoscopic right colectomy for colonic adenocarcinoma. We identified several mechanisms of injury such as anatomic misperception, excessive traction and pulling on the venous system, extensive tumor involvement of the mesentery, and uncontrolled suturing attempts at hemostasis. We believe that increased awareness of this complication with profound understanding of vascular anatomy and the different mechanisms of injury will allow surgeons to avoid this often devastating complication.

Current size criteria for the management of neuroendocrine tumors of the appendix: are they valid? Clinical experience and review of the literature.

We evaluated the latest pathological criteria for completion right hemicolectomy (RHC) in patients with appendiceal neuroendocrine tumors (ANETs) with emphasis on the size of the primary tumor. Data of 28 consecutive patients who underwent RHC for ANETs in three tertiary hospitals were reviewed retrospectively to assess the indications for completion RHC. 10/28 patients were found to have residual disease (36%). In 8/28 patients (29%), the tumor diameter was <1 cm (mean 0.7 ± 0.2 cm, range 0.5-0.9 cm); the indications for RHC included: tumor presence in surgical margins (1 patient), extensive mesoappendiceal invasion (EMI) (1 patient), vascular invasion (VI) (3 patients), Ki-67 ≥2% (3 patients); residual disease was present in 1 patient (3.5%). In 13/28 patients (46%), the tumor diameter was ≥1 and <2 cm (mean 1.30 ± 0.2 cm, range 1.0-1.8 cm); the indications for RHC were: EMI (2 patients), VI (2 patients), Ki-67 ≥2% (2 patients); residual disease was present in 5 patients (18%). In 7/28 patients (25%), the tumor diameter was ≥2 cm (mean 2.5 ± 0.7 cm, range 2.0-4.0 cm). In this final subgroup, RHC was an accepted practice irrespective of other pathologic findings: the tumor was present in surgical margins in 2 patients, in 5 patients VI was demonstrated, and Ki-67 ≥2% was found in 5 patients; residual disease was present in 4 patients (14%). Using the latest European Neuroendocrine Tumor Society criteria for RHC, residual disease may be missed in 18% of ANET patients.

Functional results of the double-stapled ileoanal reservoir.

BACKGROUND: The preferred method for creation of an ileoanal reservoir is still controversial. We prospectively studied the functional and physiologic outcome of our patients who underwent a double-stapled ileoanal reservoir (DSIAR). STUDY DESIGN: All consecutive patients who underwent restorative proctocolectomy with a DSIAR between 1988 and 1993 were evaluated. Functional results were assessed by questionnaires and anal manometry preoperatively and two, 12, and 24 months postoperatively. RESULTS: One hundred forty patients (90 males and 50 females) with a mean age of 40.7 (range, 12 to 71) years were evaluated. Of these, 107 patients (77 percent) had ulcerative colitis, 21 (15 percent) had familial adenomatous polyposis, six (4 percent) had indeterminate colitis, and six (4 percent) had a post-operative diagnosis of Crohn's disease. One hundred twenty-four (95 percent) of the 131 patients with closed stomas were available for functional and manometric evaluation at a mean follow-up period of 24 months. A 32 percent decline in the mean resting pressure (from 71.3 +/- 4 to 48.2 +/- 3.4 mm Hg) occurred early after DSIAR (p < 0.001) with partial recovery by 24 months. The maximal internal sphincter resting pressure showed a 39 percent decline (from 90.8 +/- 4.9 to 55.3 +/- 5.7 mm Hg, p < 0.005) with recovery after 12 months. There were no significant changes in the length of the high-pressure zone or mean or maximal squeeze pressures. A mean of 5.4 (two to 13) bowel movements occurred during the day and a mean of 1.2 (zero to four) occurred at night. Perfect or almost perfect continence was reported during the day and night, respectively, by 95 and 92 percent of the patients. Overall perioperative complications occurred in 30 patients (21 percent) including septic complications in eight (6 percent), and pouchitis in eight (6 percent). There was one postoperative death (0.7 percent). CONCLUSIONS: Double-stapled ileoanal reservoir is associated with good subjective functional and objective physiologic results and has acceptable rates of morbidity and mortality.

Malignant neuroepithelioma of the colon.

A rare case of malignant peripheral neuroepithelioma originating from the right colon is presented. The patient underwent right hemicolectomy followed by combination chemotherapy and there has been no evidence of tumour recurrence or metastases during three years of follow up. Emphasis is given to the extremely unusual location of this tumour and the favorable clinical outcome.

The use of rectal ultrasound for the correct diagnosis and treatment of rectal villous tumors.

BACKGROUND: One of the difficulties associated with surgery for rectal villous tumors (RVT) is the finding of invasive adenocarcinoma after transanal excision (TAE) and the possible need for more radical procedures or adjuvant therapy. Improved preoperative evaluation may eliminate this dilemma. The aim of our study was to evaluate the role of transrectal ultrasound (TRUS) in establishing the correct diagnosis of RVT. METHODS: All patients with biopsy proven RVT, who were referred for TAE, underwent preoperative TRUS in addition to the routine evaluation. If invasion beyond the submucosa was suspected by TRUS, multiple biopsies were taken before any surgical intervention in order to exclude invasive cancer. If no invasion was noted, biopsies were avoided and a TAE was performed. The final pathology results were compared with both the preoperative diagnosis and TRUS results. RESULTS: Thirty-five patients (19 female, 16 male; mean age 67.5 years, range 36 to 88) were studied. The mean distance of the distal extent of the lesion above the anal verge was 5.8 cm (1.5 to 6). In 27 patients, the tumor was limited to the submucosa (uT0, uT1) on TRUS and, therefore, TAE was performed. In 26 of 27 patients (96%), pathology examination confirmed the presence of RVT without evidence of malignancy. One patient was found to have invasion of the muscularis propria and required postoperative radiation therapy. In 8 patients (23%), TRUS showed extension beyond the submucosa; 3 of these patients had uT2 lesions, 4 had uT3 tumors, and 1 had perirectal nodes. These 8 patients underwent repeated biopsies with the finding of invasive adenocarcinoma in 7. Two patients underwent abdominoperineal resection, 3 had a low anterior resection, and 3 had a TAE. Final pathology confirmed the preoperative diagnosis of invasive adenocarcinoma in 7 patients. In the 1 patient with a uT2 lesion and negative biopsies, the final diagnosis was RVT with no evidence of malignancy. CONCLUSIONS: Preoperative TRUS provides an accurate diagnosis of RVT. In conjunction with TRUS-directed biopsies, directed management of these tumors could be achieved.

Pancreaticojejunostomy versus controlled pancreaticocutaneous fistula in pancreaticoduodenectomy for periampullary carcinoma.

BACKGROUND: Anastomotic leak of the pancreaticojejunostomy is a major cause of morbidity and mortality following pancreaticoduodenectomy. Reports have described a large variety of techniques for performing this anastomosis and managing the pancreatic stump. In an attempt to obviate the pancreaticojejunostomy, we prospectively studied the technique of ligating the pancreatic duct and using external drains to create a temporary controlled pancreaticocutaneous fistula. PATIENTS AND METHODS: Thirty-five consecutive patients who were to undergo pancreaticoduodenectomy for periampullary carcinoma were prospectively randomized to one of two groups: pancreaticojejunostomy (PJ) (n = 18) or controlled pancreaticocutaneous fistula (CPF) (n = 17). The groups were well matched for age, sex, coexisting medical illnesses, type of tumor, and preoperative condition. Except for the management of the pancreatic remnant, all patients in both groups underwent an identical procedure. Major morbidity, length of hospitalization, duration of the controlled pancreatic fistula, and mortality were analyzed over a mean follow-up interval of 26 months (range 5 months to 7.5 years). RESULTS: The CPF group experienced lower overall operative morbidity rates than the PJ group (24% versus 56%, P < 0.01). Two patients (11%) in the PJ group and none in the CPF group died (P = NS). Half the morbidity in the PJ group and both mortalities were related to anastomotic leak. The CPF and PJ groups left the hospital after mean stays of 26.4 and 42.2 days respectively (< 0.01). CONCLUSIONS: Compared to pancreaticojejunal anastomosis, creation of a temporary controlled pancreaticocutaneous fistula in patients who undergo pancreaticoduodenectomy for periampullary malignancy has no appreciable risk. It is associated with reduced morbidity and shorter length of hospitalization.

Laparoscopic surgery in the management of inflammatory bowel disease.

BACKGROUND: The role of laparoscopic surgery in the treatment of various upper and lower gastrointestinal disorders is still under investigation. However, a variety of laparoscopic procedures may be applied in the treatment of inflammatory bowel disease (IBD). PATIENTS AND METHODS: We present our initial results of laparoscopic and laparoscopic-assisted management of IBD in 72 consecutive patients (37 women and 35 men; mean age 36 years, range 20 to 79). The indications for surgery included: terminal ileitis in 29 patients, mucosal ulcerative colitis in 23 patients, Crohn's colitis in 11 patients, severe perianal Crohn's disease in 4 patients, duodenal Crohn's disease in 3 patients, Crohn's rectovaginal fistula in 1 patient, and rectourethral fistula in 1 patient. The procedures performed included: total abdominal colectomy (TAC) in 30 patients (22 with total proctocolectomy with ileoanal reservoir, 6 with TAC with ileorectal anastomosis, and 2 with TAC with end ileostomy), ileocolic resection in 30 patients, diverting loop ileostomy in 6 patients, closure of an end ileostomy as an ileorectal anastomosis in 3 patients who already underwent a TAC with end ileostomy, and duodenal bypass gastrojejunostomy in 3 patients. RESULTS: There were 16 complications in 13 (18%) patients: 3 enterotomies, 4 episodes of bleeding, 3 pelvic abscesses, 2 intestinal obstructions, 2 prolonged ileus, 1 anastomotic leak, and 1 efferent loop obstruction after gastrojejunostomy. However, only 3 patients required laparotomy for morbidity, and there was no mortality. In 7 (10%) patients, the laparoscopic procedure was converted to a laparotomy due to a large inflammatory mass with fistula in 4 patients, bleeding in 2 patients, and an enterotomy in 1 patient. The mean operating time was 2.9 hours (range 0.7 to 6) and the mean length of hospital stay was 6.5 days (range 3 to 19). When compared with ileocolic resection, total colectomy was associated with higher morbidity (30% versus 10%, P < 0.05) and longer hospitalization (8.7 days [range 4 to 19] versus 5.2 days [range 3 to 7], respectively; P < 0.05). CONCLUSIONS: According to this initial experience, laparoscopic surgery is a versatile and effective modality in the surgical management of inflammatory bowel disease in selected patients. However, laparoscopic total colectomy is associated with higher morbidity when compared with ileocolic resection.

Electrolyte profiles within the ileoanal pouch: measurement by an in vivo equilibrium dialysis technique.

BACKGROUND: Patients with an ileoanal pouch have high rates of fluid and electrolyte loss. These improve with pouch adaptation. There is limited information concerning secretion and absorption in the stable ileoanal pouch. A new method to measure and characterize electrolytes in the ileoanal pouch is described. METHODS: Following an in vitro study, nine patients with a stable ileoanal pouch had consecutive placement of dialysis bags consisting of a semi-permeable membrane containing 5 ml of 10% dextran in normal saline into the ileoanal pouch. These were left in place for 15, 30, 60, and 120 min. After determining that 60 min was the optimal timing for measurement of electrolyte concentrations, 12 normal volunteers underwent a similar in vivo dialysis study with dialysis bags withdrawn at 60 min. Sodium, chloride, potassium, phosphorus, calcium and magnesium concentrations in the dialysis bags were compared between the two groups. RESULTS: In the in vitro and in vivo studies, the measured electrolytes reached equilibrium within 60 min. Statistically significant differences between sodium concentrations (160.9 +/- 30.2 vs. 116.8 +/- 13.8 mmol/l, respectively) and phosphorus concentrations (6.8 +/- 5.2 vs. 1.8 +/- 0.7 mg/dl, respectively) at 60 min in ileoanal pouch patients and volunteers were found (p<0.001). There were no statistical differences in the other measured electrolytes between the two groups. CONCLUSION: An in vivo dialysis technique is described for measuring electrolyte concentrations within the ileoanal pouch. Differences in sodium and phosphate concentrations may reflect incomplete adaptation of the ileoanal pouch, and are a potential explanation for increased stool frequency in these patients.

Duodenocolic fistula: an unusual presentation of esophageal squamous cell carcinoma.

Duodenocolic fistula, one of the less common forms of entero-enteric fistulas, is usually associated with colonic malignancies at the hepatic flexure or Crohn's disease of the colon or duodenum. We report an unusual case of duodenocolic fistula caused by metastatic esophageal squamous cell carcinoma in which the primary esophageal tumor remained asymptomatic. In several collected series of clinical and autopsy studies of over 2800 patients, no similar complication of metastatic esophageal squamous cell carcinoma has been reported.

Laparoscopic cholecystectomy in octogenarians.

BACKGROUND: This study aimed to assess the outcome of laparoscopic cholecystectomy (LC) in patients 80 years old or older. METHODS: All consecutive patients 80 years old or older who underwent LC for symptomatic gallstone disease were evaluated. Data analysis included patients' age, gender, indication for surgery, comorbid condition, American Society of Anesthesiology (ASA) score, preoperative endoscopic retrograde cholangio pancreatography (ERCP), intraoperative cholangiogram, operative time, conversion to open surgery, morbidity, mortality, and length of stay. RESULTS: In this study, 67 patients (31 men and 36 women) with a mean age of 84 years (range, 80-90 years) were evaluated. Of these 67 patients, 38 (57%) underwent surgery for complicated diseases including acute cholecystitis in 15 patients (22%), gallstone pancreatitis in 17 patients (25%), cholangitis in 3 patients (4.5%), and obstructive jaundice in 3 patients (4.5%). A total of 38 patients (57%) had a preoperative ASA of 3 or 4; 23 (34%) had a preoperative ERCP; and 6 (9%) had intraoperative cholangiogram. The mean operative time was 94 +/- 20 min. Five patients (7.4%) underwent conversion to open surgery because of unclear anatomy. Complications occurred in 12 patients (18%) including pulmonary edema in 3 patients, myocardial infarction in 1 patient, atelectasis in 2 patients, common bile duct injury in 1 patient, urinary tract infection in 2 patients, wound infection in 2 patients, and intraabdominal infected hematoma in 1 patient. The mean length of stay was 5.3 days. There was no mortality. CONCLUSIONS: In octogenarians LC is safe and associated with acceptable morbidity and mortality. Therefore, it should be considered for this age group. The relatively high incidence of complicated gallstone disease in this age group may be decreased if surgery is offered to them at earlier stage of the disease, leading to further decrease in perioperative morbidity.

Laparoscopic adrenalectomy: ascending the learning curve.

BACKGROUND: Soon after its introduction, laparoscopic adrenalectomy (LA) became the procedure of choice in the surgical management of most adrenal tumors. The aim of this study was to assess the outcome and learning curve of the first 100 cases operated by the same surgical team. METHODS: Retrospective analysis of prospectively collected data of 100 consecutive LAs was performed. The parameters studied were indication for surgery, side and length of operation, intra- and postoperative complications, size of tumor, conversion to open surgery, final diagnosis, and length of stay. RESULTS: Between 1996 and 2002, 100 LAs were performed in 90 patients. The procedures included 45 left, 35 right, and 10 bilateral resections for pheochromocytoma (29), Cushings syndrome (27), Conns syndrome (16), nonfunctioning adenoma (13), and others (5). Mean tumor size was 4.16 cm (range, 0.3-11). Overall major morbidity occurred in eight patients (9%); there was one mortality due to cerebrovascular accident in an elderly patient. Five cases (5%) were converted to open surgery. The mean length of stay for the whole group was 4.7 days (range, 2-25). In order to assess the learning curve, procedures were divided into three, equal consecutive groups (n = 33, 33, and 34). Intraoperative complications in the intermediate and late groups were significantly less compared to those in the early group (2/33, 2/34, and 7/33, respectively; (p < 0.05). Similarly, the mean operating time was significantly reduced between the early (169 min) and both intermediate (116 min) and late (127 min) groups (p < 0.005). The conversion rate was reduced between the three groups (3/33, 2/33, and 0/34), but this was not significant (p = 0.06). CONCLUSIONS: As expected, the outcome of LA is associated with a steep learning curve. According to this study, it seems that performance of approximately 30 cases by an experienced laparoscopic surgeon is required to master the procedure.

Is laparoscopic appendectomy safe in pregnant women?

BACKGROUND: Because of limited laboratory and clinical data, no accepted guidelines concerning the safety of laparoscopic appendectomy (LA) in pregnancy have been established yet. In this prospective study, we evaluated the safety and outcome of LA in pregnant women as compared with the same control group of pregnant women who underwent open appendectomy (OA) during the same period. METHODS: During the years 1996 to 1999, 11 consecutive pregnant women (mean age, 27 years; range 21-39 years; gestation age range, 7-34 weeks) who underwent LA were prospectively evaluated and compared with a matched group of 11 women (mean age, 30 years; range 18-42 years; gestation age range, 11-37 weeks) who underwent OA. The following parameters were analyzed: obstetric and gynecologic risk factors, length of procedure, perioperative complications, length of stay, and outcome of pregnancy. Both groups were well matched in age and risk factors for pregnancy loss. RESULTS: There was no significant difference in the length of procedure (60 vs. 46 min) and the complications rate (one in each group) between the LA and OA groups, respectively. There was no conversion in the LA group. The length of postoperative stay was shorter in the LA group (3.6 vs 5.2 days; p = 0.05). There was no fetal loss or other adverse outcome of pregnancy in either group, and all the women in both groups had normal full-term delivery. The infants' development was normal in both groups for a mean follow-up period of 30 months. CONCLUSIONS: According to this relatively small-scale study laparoscopic appendectomy in pregnant women may be as safe as open appendectomy. This procedure is technically feasible in all trimesters of pregnancy and associated with the same known benefits of laparoscopic surgery that nonpregnant patients experience.

Laparoscopic vs open adrenalectomy for benign adrenal neoplasm.

BACKGROUND: The aim of this study was to compare the outcome of laparoscopic adrenalectomy (LA) performed for benign adrenal neoplasm to the open procedure in a similar group of patients. METHODS: All consecutive patients who underwent LA between June 1996 and February 1999 were evaluated. Data analysis included patient's age and gender, indication for surgery, histological diagnosis, size of specimen, comorbid conditions, length of stay and ileus, postoperative narcotic consumption, and time to return to normal activity. The results were compared retrospectively to a well-matched group of patients who underwent an open adrenalectomy (OA). RESULTS: Twenty-eight LA were performed in 24 patients for the following disorders: adrenocortical adenoma, 16 (four Cushing's syndrome, 12 Conn's syndrome); pheochromocytoma, 10; and nonfunctioning tumor, two. These cases were compared with a well-matched group of 28 patients who underwent OA in the same department. There were two conversions to open surgery (7%) in the laparoscopic group and no deaths in either group. Of all the evaluated parameters, the following statistically significant differences between the two groups were noted: The mean operative time was longer in the LA group (188 vs 139 min, p < 0.001.); however, this became insignificant in the last 10 cases of LA, when the mean length of surgery was reduced to 130 min. The overall morbidity was lower in the LA group (16% vs 39%, p = 0.05), as was the mean time to tolerate a regular diet (2 vs 3.9 days), mean meperidine consumption (mg) (109 vs 209), mean length of stay (4 vs 7.5 days), and mean time to return to normal activity (2.2 vs 5.2 weeks), (p < 0.001 for all). CONCLUSION: LA for benign adrenal disorders is a safe procedure that is associated with significantly lower morbidity, shorter ileus and hospitalization, reduced postoperative pain, and a faster return to normal activity than the open procedure.

Model extraction from magnetic resonance volume data using the deformable pyramid.

A general framework for automatic model extraction from magnetic resonance (MR) images is described. The framework is based on a two-stage algorithm. In the first stage, a geometrical and topological multiresolution prior model is constructed. It is based on a pyramid of graphs. In the second stage, a matching algorithm is described. This algorithm is used to deform the prior pyramid in a constrained manner. The topological and the main geometrical properties of the model are preserved, and at the same time, the model adapts itself to the input data. We show that it performs a fast and robust model extraction from image data containing unstructured information and noise. The efficiency of the deformable pyramid is illustrated on a synthetic image. Several examples of the method applied to MR volumes are also represented.

Outcome of laparoscopic colorectal surgery in older patients.

The object of this study was to assess the outcome of laparoscopic colorectal surgery in patients >60 years of age and compare it to a younger group of patients who underwent similar procedures. All consecutive patients who underwent a laparoscopic or laparoscopic-assisted procedure were evaluated. The parameters analyzed included gender, indication for surgery, procedure, complications, conversions, length of ileus, length of hospitalization, and comorbidity. The results of patients 60 years of age or older were compared to a procedure-matched group of younger patients. Between August 1991 and August 1995, 165 patients underwent a laparoscopic or laparoscopic-assisted colorectal procedure. Thirty-six patients were 60 years of age or older [mean age, 73 (60-88) years; 17 males and 19 females] and were compared with 36 younger patients [mean age, 44 (20-58) years; 13 males and 23 females]. The indications for surgery included Crohn's disease in 14 patients, polyps in 23, diverticular disease in 15, carcinoma in 11, fecal incontinence in 4, rectal prolapse in 2, radiation proctitis in 2, and sigmoidocele in 1. Identical procedures were performed in each group including right colectomy or ileocolic resection in 17 patients, sigmoidectomy in 14, loop ileostomy in 3, loop colostomy in 1, and abdominoperineal resection in 1 patient. Fourteen patients (38%) in the elderly group had comorbid conditions including ischemic heart disease (3), chronic obstructive pulmonary disease (3), hypertension (2), chronic renal failure (2), atherosclerotic vascular disease (2), congestive heart failure (1), and diabetes (1). All patients were cleared for surgery by their respective specialists. There were no statistically significant differences between the younger and older groups relative to the incidence of complications (11 vs 14%, respectively) and conversion (8 vs 11%, respectively) or the length of ileus (2.8 vs 4.2 days, respectively) or hospitalization (5.2 vs 6.5 days, respectively) (P = NS for all). There was no mortality in either group. The outcome of laparoscopic colorectal surgery in older patients is similar to that noted in younger patients. Advanced age should not be a contraindication to laparoscopic colorectal surgery.

Reconstruction of replaced right hepatic artery, to implant a single-catheter port for intra-arterial hepatic chemotherapy.

Intra-arterial hepatic chemotherapy using an implantable subcutaneous port with a catheter inserted into the gastroduodenal artery is an acceptable treatment for patients with isolated, nonresectable liver metastases from colorectal cancer. Because of the common variations of hepatic arterial anatomy occurring in about one-half of the patients, this technique will result in complete perfusion of both hepatic lobes only in those with "classical" arterial anatomy (Michels type I). Many techniques have been described in these situations, usually using a dual-catheter port with the attendant risk of hepatic misperfusion and arterial thrombosis. We herein describe an alternative technique applicable to patients with a right hepatic artery arising from the superior mesenteric artery. In this technique the right hepatic artery is anastomosed end-to-end with the gastroduodenal artery, followed by implantation of a single-catheter port that is inserted into the splenic artery.

Functional outcome of the double stapled ileoanal reservoir in patients more than 60 years of age.

Total proctocolectomy with creation of an ileoanal reservoir (IAR) is currently the preferred surgical treatment of mucosal ulcerative colitis and familial adenomatous polyposis. However, the creation of an IAR on older patients is controversial and commonly avoided because of anticipated poor functional results and increased morbidity. We prospectively studied 140 consecutive patients who underwent a double stapled IAR (DSIAR) between 1988 and 1993. We compared the outcome of 14 patients (Group I) 60 years of age or older (mean 65, range 60-71 years; 10 males and 14 females), to 126 patients (Group II) under the age of 60 (mean 37, range 12-59 years; 80 males and 14 females). Mucosal ulcerative colitis and indeterminate colitis were noted, respectively, in 12 (93%) and 1 (7%) patients in Group I and in 94 (75%) and 5 (4%) patients in Group II. In Group II, 21 (16%) patients had familial adenomatous polyposis, and 6 (5%) had a postoperative diagnosis of Crohn's disease. Subjective functional results and anal manometry were assessed in all 14 patients in Group I (100%) and in 110 of the 117 patients in Group II (94%) whose stomas were closed at a mean followup of 24 (3-60) months. Manometry was per- formed before, and 2 and 12 months after surgery. Patients in Groups I and II reported a mean of 6.2 and 5.2 bowel movements during the day (P=NS), and 2 and 1.1 at night, respectively (P<0.05). A total of 12 (86%) patients in Group I and 104 (95%) in Group II reported perfect or almost perfect continence at night (P=NS), and 12 (93%) patients in Group I and 104 (95%) in Group II reported perfect or almost perfect continence during the day (P=NS). The preoperative mean and maximal resting pressures were similar in both groups (71.7 mmHg and 94 mmHG in Group I and 71.6 and 88 mmHg in Group II respectively; P=NS). Postoperative resting pressure changes were also similar in both groups P=NS), with a similar significant decline 2 months after surgery, which recovered by 12 months after surgery in both groups. There were no significant changes between the pre- and postoperative mean and maximal squeeze pressures in either group. The overall morbidity and mortality rates in Groups I and II were 21 and 0 per cent, and 21 and 0.8 per cent, respectively (P=NS). DSIAR in patients 60 years of age or older is as safe and is associated with as good functional and physiologic results as it is in younger patients. Thus, this procedure may be offered to older patients with expectation of good outcome.

Is complete laparoscopic colectomy superior to laparoscopic assisted colectomy?

Much debate has centered around what constitutes a true laparoscopic colon resection. Purists argue that intracorporeal division of the mesentery and anastomosis confer a benefit over a "laparoscopic assisted" procedure. The aim of this study was to further examine this issue. Data were prospectively collected on 102 consecutive laparoscopic colon resections. Five procedures were converted to open cases and were excluded from analysis. Procedures were divided into two groups. Group 1 (n = 34) consisted of complete laparoscopic procedures (no abdominal incision was made): abdominoperineal resection (3), Hartmann's reversal (3), end colostomy (7), low anterior resection (5), proctectomy (1), sigmoid colectomy (15). Group 2 (n = 63) consisted of laparoscopic "assisted" procedures (i.e., an incision was made to facilitate anastomosis, division of the mesentery, and/or specimen retrieval): Ileocolic resection (6), restorative proctocolectomy (26), right colectomy (19), subtotal colectomy/end ileostomy (5), subtotal colectomy/ileorectal anastomosis (7). Length of hospitalization and duration of postoperative ileus were compared. A subset analysis of right colectomy (intracorporeal mobilization and extracorporeal division of the mesentery and anastomosis) versus sigmoid colectomy (intracorporeal mobilization, division of the mesentery and anastomosis) was also performed. There were no statistically significant differences in length of hospital stay (Group 1, 7.47 +/- 2.75 days; Group 2, 7.78 +/- 5.55 days) or duration of postoperative ileus (Group 1, 3.24 +/- 1.56 days; Group 2, 3.68 +/- 1.58 days). Similarly, in the sigmoid colectomy versus right colectomy subset analysis, there were no statistically significant differences in length of hospital stay (sigmoid colectomy, 7.92 +/- 2.90 days; right colectomy, 6.40 +/- 1.50 days) or duration of postoperative ileus (sigmoid colectomy, 3.36 +/- 1.39 days; right colectomy, 3.18 +/- 1.07 days). Our data demonstrate that intracorporeal division of the mesentery and anastomosis confer no advantage over the laparoscopic assisted procedures. Data were prospectively collected on 102 consecutive laparoscopic colon resections. There were no statistically significant differences in length of hospital stay or duration of postoperative ileus regardless of whether intracorporeal or extracorporeal mesenteric division and anastomosis were undertaken. These data demonstrate that a completely laparoscopic procedure does not appear to offer any advantage as compared to a laparoscopic assisted one.

Hyperbaric oxygenation combined with nifedipine treatment for recent-onset retinal artery occlusion.

We describe the results of early hyperbaric oxygenation combined with nifedipine treatment for central retinal artery occlusion, and explain the results pathophysiologically. We report four cases in which hyperbaric oxygenation therapy was applied in combination with nifedipine, eyeball massage, and glycerol for the treatment of central retinal artery occlusion. In two of the cases in which therapy was started less than 100 minutes after the acute onset of visual loss and one case in which therapy was started during the course of central arterial occlusion, considerable improvement in visual acuity was observed, while in the fourth case in which therapy was started six hours after the acute onset of visual loss, no improvement appeared. We conclude from these results that hyperbaric oxygenation therapy has a beneficial effect on the final visual outcome of central retinal artery occlusion, provided it is applied early enough. Further investigation is needed to fully define the nature and terms of this beneficial effect.