Short- and long-term surgical outcomes in patients undergoing proctocolectomy with ileal pouch-anal anastomosis in the setting of primary sclerosing cholangitis.

BACKGROUND: Primary sclerosing cholangitis occurs in approximately 10% of patients with ulcerative colitis, but studies involving IPAA in patients with cholangitis have been reported in limited numbers. OBJECTIVE: This study aimed to examine surgical outcomes in patients with ulcerative colitis and sclerosing cholangitis undergoing total proctocolectomy with IPAA and to identify variables associated with surgical complications. DESIGN: This is a retrospective cohort study. SETTINGS: This study was conducted at a single tertiary referral institution. PATIENTS: Included were all patients with cholangitis and ulcerative colitis who underwent proctocolectomy with IPAA from 1994 to 2005. MAIN OUTCOME MEASURES: Perioperative morbidity, long-term pouch function, and pouch survival were the main outcome measures. RESULTS: One hundred patients (62 male) were studied. Forty-three percent were on steroids. There was no perioperative mortality, and 51 30-day complications occurred in 39 patients (39%). Median follow-up time was 5.9 years (range, 0.14-16.2 y). Pouch failure occurred in 3 patients (3%). The single variable that predicted 30-day morbidity was previous abdominal surgery (P = .03). Prednisone use, body mass index, age, ASA score, preoperative Model for End Stage Liver Disease score, and year of surgery were not significantly associated with short-term complications. CONCLUSIONS: IPAA can be performed safely in the setting of sclerosing cholangitis. The preoperative Model for End-stage Liver Disease Score and the use of preoperative immunosuppressive agents are not associated with an increased risk of complications. The likelihood of long-term pouch survival is excellent.

Malignant adrenal neoplasm masquerading as worrisome adrenal hemorrhage.

BACKGROUND: Adrenal hemorrhage (AH) associated with adrenal neoplasm is rare. This study assesses the clinical and pathological impact of AH in the setting of malignant adrenal neoplasm to establish management strategies. MATERIALS AND METHODS: Patients admitted over a 25-year period with a diagnosis of AH and malignant adrenal neoplasm were retrospectively reviewed. RESULTS: Malignant adrenal neoplasms were reported in 14 of 217 patients (6.4%) presenting with AH. Of these, 4 were women. Mean age was 56 years. The most common presenting symptom was abdominal pain (n = 6), followed by altered mental status and shock (2) and hypercortisolism (1). Five patients were asymptomatic. In 10 patients the adrenal tumor was metastatic. Four patients had adrenocortical carcinoma (ACC). All primary adrenal tumors were unilateral. Risk factors for AH were identified in 5 patients (anticoagulation, 3; trauma, 1; and recent surgery, 1). Computed tomography (n = 12) demonstrated adrenal masses ranging in size from 6.8 to 11.0 cm (mean, 9 cm). Nine patients were managed by surgical resection (adrenalectomy, 4; radical nephrectomy, 2; adrenalectomy/splenectomy, 1; adrenalectomy/bowel resection, 1; and laparotomy and packing, 1) Actual survival time ranged from 9 days to 7.8 years (median 329 days). CONCLUSION: Most patients with AH in the setting of malignant adrenal neoplasm had metastatic tumors to the adrenal glands. These patients do not typically present in hemorrhagic shock, allowing for adequate preoperative evaluation for function and assessment for primary tumors. Long-term survival of these patients is rare.

Diagnosis and treatment of Mirizzi syndrome: 23-year Mayo Clinic experience.

BACKGROUND: Mirizzi syndrome (MS) is characterized by extrinsic compression of the common hepatic duct by stones impacted in the cystic duct or gallbladder neck. Open cholecystectomy (OC) has been the standard treatment; however, laparoscopy has challenged this approach. STUDY DESIGN: The objective of this study was to review our clinical experience with MS since the introduction of laparoscopic cholecystectomy (LC) and determine the impact of alternative approaches. We conducted a retrospective review of patients with MS from January 1987 to December 2009. RESULTS: There were 36 patients with MS among 21,450 cholecystectomies (frequency 0.18%). Seventeen were women. The most common presenting symptoms were abdominal pain (n = 23) and jaundice (n = 19). Preoperative diagnostic studies included ultrasonography (n = 27), CT (n = 24), and endoscopic retrograde cholangiopancreatography (n = 32). Cholecystectomy was performed in 35 patients; LC was initiated in 15 and OC in 21. Conversion rate from LC to OC was 67%. Five patients who had successful LC had type I MS. Of the patients who underwent LC with conversion or OC, 14 had type I and 16 had type II MS. The cystic duct for type I and the bile duct for type II MS were managed diversely according to surgeon's preference. There was no operative mortality. Morbidity was 31% with Clavien class I in 2, IIIa in 4, IIIb in 1, and IV in 3 patients. Mean hospitalization was 9 days (range 2 to 40 days). Mean follow-up was 37 months (range 1 to 187 months). CONCLUSIONS: Low incidence and nonspecific presentation of MS precludes referral and substantive individual experience. Although LC may be applicable in selected patients with type I MS, OC remains the standard of care.

Patterns of accidental genital trauma in young girls and indications for operative management.

BACKGROUND/PURPOSE: The aim of this study was to define the injury patterns of accidental genital trauma (AGT) in female patients and examine the indications and outcomes of operative intervention. METHODS: Review of patients younger than 16 years with AGT from 1980 to 2007 excluding sexual- and obstetric-related injuries. RESULTS: One hundred sixty-seven patients met the criteria. Mean (+/-SEM) age was 6.9 (0.2) years. There were 70.5% straddle injuries, followed by nonstraddle blunt injuries (23.5%) and penetrating injuries (6.0%). Injuries to the labia were most frequent (64.0%). Injuries to the posterior fourchette (7.8%) and hymenal disruption (8.4%) were less frequent. There was 87.9% of AGT that was managed expectantly without further sequelae. Twenty patients (12.1%) were managed operatively. Penetrating injuries were more likely to require operative management (P