Money well spent: a comparison of hospital operating margin for laparoscopic and open colectomies.

BACKGROUND: Cost analysis after laparoscopic colectomy has been examined, although reports evaluating the effects of laparoscopy on hospital operating margin are lacking. We compared several cost/revenue measures, including hospital operating margin, between open and laparoscopic colectomies at an academic center. METHODS: Our cost-accounting database was queried for laparoscopic partial (LPC) and total colectomies (LTC), and open partial (OPC) and total colectomies (OTC) to analyze net revenue, total costs, and total hospital operating margin over a 4-year period. Laparoscopic and open colectomy cases were compared, with mean operating margin as the primary outcome. RESULTS: From July, 2002 through May, 2006, 842 patients were included for analysis with 138 undergoing laparoscopic colectomy. Net revenue was higher in the LTC group compared with open (US dollars 30,300 vs US dollars 26,800 [P = .02]), and lower in the LPC group (US dollars 15,300 vs US dollars 21,300 open [P < .0001]). Total costs were reduced in both the LPC and LTC groups compared with open [US dollars 11,700 vs US dollars 17,600 [P < .0001] and US dollars 18,000 vs US dollars 19,400 [P = .0019], respectively). LPC resulted in a similar HOM (US dollars 3,602) compared with OPC (US dollars 3,647; P = .35). LTC resulted in a higher HOM (US dollars 12,300) compared with OTC (US dollars 7,400; P = .02). CONCLUSIONS: LTC generates a significantly higher hospital operating margin than an OTC, although the margins are similar for LPC and OPC.

Effects of University of Wisconsin and Euro-Collins solutions on interstitial pulmonary edema in isolated rat lungs.

Macromolecules are present in lung preservation solutions to limit liquid filtration out of the pulmonary circulation and minimize pulmonary edema. We tested the effectiveness of these molecules by measuring interstitial edema in rat lungs perfused with macromolecular solutions (University of Wisconsin [UW] solution and Euro-Collins solution supplemented with modified pentastarch [pentafraction, PEN]) or with solutions that lacked macromolecules (UW solution with PEN and Euro-Collins solution.) The lungs were inflated with air and perfused with one of the test solutions, then rapidly frozen and prepared for histological analysis. From tissue sections, we measured cross-sectional areas of pulmonary arteries and veins, and also measured cross-sectional areas of the interstitial spaces surrounding arteries and veins. We then calculated the interstitium-to-vessel cross-sectional area ratio. In lungs perfused with macromolecular solutions these ratios were 0.09+/-0.15 and 0.53+/-0.56 (mean +/- SD) for UW solution and Euro-Collins solutions solution with PEN, respectively (P

Giant colonic mucocele after diversion colostomy for ulcerative colitis.

We report an unusual complication occurring after diversion transverse loop colostomy in a patient with long-standing ulcerative colitis. The formation of a giant colonic mucocele resulted from distal stomal and rectal stenosis, with subsequent accumulation of mucus in the obstructed segment over many years. The pathophysiologic features of this case, which are similar to mucocele of the appendix, are discussed. To our knowledge, this is the first report in the literature of a giant colonic mucocele after diversion colostomy.

Modified quadruple-loop (W) ileal reservoir for restorative proctocolectomy.

Reconstructive ileal pouch procedures are well-accepted alternatives to a permanent ileostomy in select patients requiring proctocolectomy for ulcerative colitis and familial polyposis. Double-, triple-, and quadruple-loop and lateral isoperistaltic designs have been described; however, the ideal pouch capacity and configuration are still debatable. Evidence has been reported that improved functional results and lower stool frequency with less antidiarrheal medication can be achieved with larger volume reservoirs. We describe a new modification of a quadruple-loop pouch that has been successfully performed in 10 patients. This new approach to pouch construction produced excellent functional results 6 to 12 months after ileostomy takedown and was easier to construct and engage into the muscular cuff of the distal rectum than quadruple-loop pouches of equal length loops.

The W ileal reservoir: long-term assessment after proctocolectomy for ulcerative colitis and familial polyposis.

BACKGROUND: This report examines the viability of the W reservoir as a reliable option for the treatment of ulcerative colitis and familial polyposis and studies W reservoir adaptation as reflected by changes in compliance and stool frequency. METHODS: Since 1984, 109 patients have undergone proctocolectomy with W reservoir reconstruction. Ileal reservoir static compliance was measured in 70 and 57 patients at 2 and 12 months after ileostomy takedown and in 25 patients at 3 years. Compliance was calculated as the change in volume over change in pressure. RESULTS: Twenty-four-hour stool frequency decreased from 7.3 +/- 0.2 at 2 months to 4.9 +/- 0.2 at 1 year for patients with ulcerative colitis and from 6.3 +/- 0.4 to 3.4 +/- 0.4 for patients with familial polyposis (p less than or equal to 0.05). Compliance increased from 12.7 +/- 0.6 ml/mm Hg to 14.3 +/- 0.6 ml/mm Hg between 2 months and 1 year. No significant increase in compliance occurred after 1 year. Ninety-six percent of patients were continent during the day at 12 months although 10% experienced occasional minor leakage at night. Average postoperative morbidity (for example, small-bowel obstruction, anastomotic complications) was 35%. No operative deaths, pelvic sepsis, or reservoir loss occurred. CONCLUSIONS: We conclude that W ileal reservoirs (1) are an excellent option for ileal reservoir reconstruction, (2) have optimal functional and compliance properties versus lower capacity designs and straight ileoanal pull-through procedures, and (3) maintain stable compliance characteristics and functional reservoir volume after the initial year of adaptation.

Absence of maladaptive neuronal plasticity after genitofemoral-ilioinguinal neurectomy.

BACKGROUND: Pain (neuralgia) and paresthesia in the inguinal region after lower abdominal surgery is rare. Historically, treatment consisted of neurolysis, local injections, and administration of various medications. The management of chronic pain syndromes is often coordinated by anesthesiologists. Neurolytic therapy is seldom recommended, on the basis of the theory of maladaptive neuronal plasticity. METHODS: Twenty-three patients underwent genitofemoral neurectomy at our institution between 1981 and 1990. Records were reviewed to determine preoperative symptoms, evaluation, and treatment. Patients were contacted and questioned about current symptoms and disability. RESULTS: All records were reviewed. Sixteen (70%) of the patients were located for long-term follow-up. Patients were symptomatic for an average of 3.3 years and underwent 3.1 operations before referral. Inguinal herniorrhaphy was the most common initial surgery (14 of 16 patients). All patients underwent multidisciplinary evaluation. Fifteen underwent L1-2 paraspinous nerve block, and 13 had total pain relief. Postoperative follow-up ranged from 36 to 144 months. Ten patients reported significant pain relief, and three patients reported slight improvement. Three of the six patients who had persistent neuralgia had significant orchialgia. None of the patients who had significant relief had preoperative testicular pain. CONCLUSIONS: Genitofemoral neurectomy provided long-term relief in 62.5% of patients with genitofemoral neuralgia. Severe testicular pain indicated a less favorable outcome. These data do not support the maladaptive neuronal plasticity theory but do support early referral of some patients for neurectomy.

The effects of hypoproteinemia and volume expansion on lung and soft tissue transvascular fluid filtration.

Resuscitation from major trauma or replacement of major operative blood loss frequently results in varying levels of protein depletion and alterations in plasma volume. To assess the importance of these factors on pulmonary and soft tissue transvascular fluid filtration, we compared the effects of hypoproteinemia and plasma volume expansion on the rate of lung and soft tissue transvascular fluid filtration in unanesthetized adult sheep. Ten animals were surgically prepared with chronic lung and soft tissue lymph fistulas. Lung (QL) and soft tissue (Qs) lymph flow rates were used to determine changes in transvascular fluid filtration. Initially, lactated Ringer's solution (LR) was infused to elevate pulmonary arterial wedge pressure of normoproteinemic animals (Norm/LR) 5 mm Hg for 2 1/2 hours. After a plasmapheresis-induced protein depletion of 30% to 35%, similar volume expansions with LR (Hypo/LR) and fresh frozen plasma (Hypo/Plas) were performed. Plasma, lung lymph, and soft tissue lymph oncotic pressures were determined, and transvascular oncotic gradients were calculated. Plasma volume expansion during Hypo/Plas conditions limited (p less than or equal to 0.05, 3 hours after infusion) Qs elevations compared with Hypo/LR expansion. However, there appeared to be no significant advantage with fresh frozen plasma over LR infusion in limiting QL. During fresh frozen plasma infusion, a distinct 10- to 12-hour lag in protein transport into the interstitium was observed in the soft tissue but not the lung microcirculation. The resultant differences in fluid filtration properties were in part the result of significant widening of the oncotic gradient in soft tissue. Plasma protein infusion appeared not to be beneficial over LR in limiting lung transvascular fluid filtration during hypoproteinemic states but significantly decreased soft tissue transvascular fluid flux.

Fatal gastric artery dissection and rupture occurring as a paraesophageal mass: a case report and literature review.

Gastric artery aneurysms are rare, and the majority occur as life-threatening hemorrhage with few premonitory signs or symptoms. We report an unusual hemorrhagic manifestation of a ruptured gastric artery aneurysm, occurring as a pleural effusion and an apparent paraesophageal mass. Acute intraperitoneal and mediastinal bleeding from the extravisceral portion of the left gastric artery resulted in hemorrhagic shock, prompting an emergency laparotomy. Extensive medial degeneration in the gastric artery probably contributed to dissection and rupture.

Effects of pentafraction and hetastarch plasma expansion on lung and soft tissue transvascular fluid filtration.

BACKGROUND: Hetastarch and pentafraction are high molecular weight starch solutions designed to augment plasma oncotic pressure. Although clinical utilization of hetastarch has been limited by reported coagulation abnormalities, pentafraction is a newer derivative that appears to have few adverse hemostatic effects. We examined the ability of pentafraction to modulate lung and soft tissue transvascular fluid filtration under hypoproteinemic conditions compared with hetastarch and Ringer's lactate (LR). METHODS: Awake, protein-depleted sheep (n = 19) were prepared with lung and soft tissue lymph fistulas, and comparable infusions of 5% pentafraction (n = 6), 6% hetastarch (n = 6), or LR (n = 7) were administered. Plasma and lymph samples were collected during 24-hour period to determine changes in protein concentrations, plasma-to-lymph oncotic gradients, and lung (QL) and soft tissue (QS) lymph flows. RESULTS: QL and QS rose nearly twofold after protein depletion alone. LR infusion increased QL and QS to 8.7 +/- 1.7 and 3.1 +/- 0.6 times normoproteinemic baseline, respectively (p < 0.05). In contrast, hetastarch and pentafraction infusion limited the increase in QL to 4.2 +/- 1.1 and 4.0 +/- 0.8 times normoproteinemic baseline, respectively (p < 0.05 versus LR) and did not significantly increase QS. Hetastarch and pentafraction infusions increase plasma oncotic pressure by nearly 6 mm Hg, which significantly widened the plasma-to-lymph oncotic pressure gradients above preinfusion baseline by 4.7 +/- 0.7 and 3.4 +/- 0.4 mm Hg in lung and 4.6 +/- 0.7 and 3.2 +/- 0.4 mm Hg in soft tissue, respectively (p < 0.05). CONCLUSIONS: Both hetastarch and pentafraction limit transvascular fluid filtration under hypoproteinemic conditions by augmenting plasma oncotic pressure and the plasma-to-lymph oncotic pressure gradient. Because of fewer adverse hemostatic effects pentafraction may be an improvement over current therapies in critical care fluid management.

Quadruple-loop (W) ileal pouch reconstruction after proctocolectomy: analysis and functional results.

This report analyzes experience with a modified four-limb W-shaped ileal pouch that has a larger initial capacity than do J- or S-shaped pouch designs. Fifteen patients (median age: 35 years) underwent W pouch reconstruction after proctocolectomy for ulcerative colitis and familial adenomatous polyposis. Follow-up on each patient averaged 14 months (range: 6 to 24 months). All procedures were performed without death and with minimal morbidity. Assessment of functional results showed 24-hour stool frequency (mean +/- SEM) decreasing from 6.0 +/- 0.39 initially to 4.8 +/- 0.43 at 1 year (p less than 0.005). Night evacuation decreased from 1.1 +/- 0.2 at 1 month after surgery to 0.25 +/- 0.12 at 1 year (p less than 0.025), with 10 of 15 patients having no nocturnal pouch evacuation. Continence was excellent in all patients with the exception of three of 15 patients who had occasional minimal nighttime seepage. Pouch volume determined at surgery by saline solution infusion was 200 +/- 21 ml. Pouch volume and compliance (pressure/volume) were measured before ileostomy closure and at 6 months after surgery via a special pressure-monitored balloon catheter. Maximal pouch volume increased from 190 +/- 21 ml (at time of ileostomy takedown) to 470 +/- 85 ml at 6 months. Ileal reservoir construction with a W pouch design resulted in a low 24-hour and nighttime stool frequency and excellent compliance and evacuation characteristics.

Diagnosis and treatment of genitofemoral and ilioinguinal entrapment neuralgia.

During the past 7 years 30 patients were diagnosed as having either ilioinguinal or genitofemoral entrapment neuralgia. A multidisciplinary approach (surgeon, neurologist, and anesthesiologist), as well as local blocks of the ilioinguinal nerve and/or paravertebral blocks of L-1 and L-2 (genitofemoral nerve), were essential to determine accurately which nerve was specifically involved. Fifteen of the 17 patients (88%) diagnosed as having ilioinguinal neuralgia after previous inguinal herniorrhaphy are pain free after resection of the entrapped portion of the nerve. Thirteen patients were diagnosed as having genitofemoral neuralgia after previous inguinal herniorrhaphy, blunt abdominal trauma, or other surgery. Neurectomy of the genitofemoral nerve proximal to the entrapment controlled the persistent pain in 10 of 13 (77%) of these patients. Ilioinguinal or genitofemoral nerve entrapment neuralgias are rare complications of surgery in the inguinal region. When accurately diagnosed, neurectomy of the specific nerve is highly successful in relieving severe pain and paresthesia without significant morbidity.

Thoracic versus lumbar epidural anesthesia's effect on pain control and ileus resolution after restorative proctocolectomy.

BACKGROUND: Epidural anesthesia as a perioperative adjunct has been shown to provide superior pain control and has been implicated in more rapid ileus resolution after major abdominal surgery, possibly through a sympatholytic mechanism. Studies suggest that the vertebral level of epidural administration influences these parameters. METHODS: One hundred seventy-nine patients (120 male, 59 female; average age, 36 years) underwent restorative proctocolectomy for ulcerative colitis or familial polyposis between 1989 and 1995. Patients were grouped according to type of anesthesia. Group THO (n = 53) received thoracic (T6 to T10) epidurals. Group LUM (n = 51) received lumbar (L2 to L4) epidurals, and group PCA (n = 75) received patient-controlled intravenous narcotic analgesia. Patients were compared for complications, perioperative risk factors, postoperative pain, and ileus resolution. RESULTS: Epidural narcotics, alone or combined with local anesthetics, were administered for an average of 2 (LUM) to 4 (THO) days without significant complications. Infrequent problems related to the epidural catheters included self-limited headaches or back pain (four) and site infections (two). Epidural failure, as measured by conversion to PCA for inadequate pain control, was not significantly greater for LUM (25%) than THO (23%). Average pain scores, rated daily on a visual analog scale, were significantly higher (indicating more pain) for PCA patients (4.2) during postoperative days 1 through 5 than for LUM (3.5) (p < 0.05) and for THO (2.4) (p < 0.05). Ileus resolution, as determined by stool output and return of bowel sounds, was significantly faster in THO than in LUM or PCA (p < 0.05). Resolution of ileus was not significantly different between PCA and LUM (p > 0.05). CONCLUSIONS: Thoracic epidural analgesia has distinct advantages over both lumbar epidural or traditional patient-controlled analgesia in shortening parameters measuring postoperative ileus and in reducing surgical pain. The procedure is safe and associated with low morbidity. Thoracic epidural anesthesia is also economically justifiable and may prove to impact significantly on future postoperative management by reducing length of hospitalization. Our data and those of others are most striking in these regards for patients with thoracic catheters, indicating the importance of vertebral level in epidural drug administration.

Effects of interleukin-2 on pulmonary and systemic transvascular fluid filtration.

Interleukin-2 (IL-2) therapy for patients with advanced cancer may be compromised by dose-limiting and life-threatening pulmonary and systemic edema. We studied the effects of bolus IL-2 infusion on lung and soft-tissue transvascular fluid and protein filtration in six sheep with chronic lung and soft-tissue lymphatic cannulation. Changes in lung (QL) and soft-tissue (QS) lymph flow were used as indicators of transvascular fluid filtration. A dose of 100,000 U/kg IL-2 was administered every 8 hours for 3 days. A significant increase (p less than or equal to 0.05) in both QL and QS was observed after each IL-2 infusion, with maximal flow occurring 2 to 3 hours after infusion. After 72 hours of IL-2 infusion, a fourfold maximal increase in QL occurred, which recovered to near-baseline values within 24 hours. Elevations in QL and QS were not associated with increases in pulmonary arterial or pulmonary arterial wedge pressures, but these elevations were associated with significant (p less than or equal to 0.05) increases in cardiac output (7.7 +/- 0.5 to 11.4 +/- 0.4 L/min) and a consistent decrease in systemic vascular resistance. A significant increase in lung lymph/plasma protein ratio (0.49 +/- 0.06 to 0.93 +/- 0.04 for albumin) revealed a marked increase in pulmonary microvascular porosity. This change, however, was not observed in the systemic microcirculation. Serum concentrations of tumor necrosis factor did not increase with the observed changes in pulmonary microvascular porosity. We conclude that IL-2 increases both pulmonary and systemic microvascular fluid flux. In addition, there is a marked increase in pulmonary, but not systemic, protein permeability that is not a consequence of changes mediated by tumor necrosis factor.

Pulmonary and systemic fluid filtration after continuous versus bolus interleukin-2 infusion.

Interleukin-2 has been widely investigated as adjuvant therapy for advanced cancer and is administered by either bolus or continuous infusion. We compared the effects of bolus and continuous interleukin-2 infusion on pulmonary (QL) and systemic microvascular fluid filtration in 11 adult sheep prepared with chronic lung and soft-tissue lymph fistulas. Interleukin-2 was administered as a bolus infusion (100,000 units/kg) every 8 hours for 3 days or as a continuous infusion at the same dose for 3 days. No significant changes in pulmonary hydrostatic pressures or pulmonary vascular resistance were noted after either bolus or continuous interleukin-2 infusion. However, significantly decreased (p less than or equal to 0.05) systemic vascular resistances were observed in both groups. QL increased steadily throughout the infusion period in both groups, peaking at three times baseline on the third infusion day. The plasma/interstitial protein clearance (QL X lymph/plasma protein ratio) rose similarly in both groups, indicating increased barrier permeability. Increased lymphocyte clearance into lung lymph occurred by day 3 but was not associated with lymphocytic sequestration in the lung interstitium. We conclude that pulmonary and systemic microvascular fluid and protein flux exhibit similar changes after bolus or continuous interleukin-2 infusion. These changes are associated with increased clearance of lymphocytes into lung lymph that are not sequestered in the pulmonary interstitium after infusions of shorter duration.

Relationships between sclerosing cholangitis, inflammatory bowel disease, and cancer in patients undergoing liver transplantation.

BACKGROUND: Liver transplantation has emerged as the definitive treatment for primary sclerosing cholangitis (PSC). Its relationships to inflammatory bowel disease and cholangiocarcinoma were evaluated in this series. METHODS: Fifty-three liver transplantations were performed in 41 patients with PSC at the University of Wisconsin from 1986 through 1994. Fourteen of the patients underwent colectomies for inflammatory bowel disease, eight before transplantation and six after transplantation. Five patients had cholangiocarcinoma on the hepatectomy specimen, and another two had been diagnosed before transplantation. RESULTS: Patient survival for PSC without cholangiocarcinoma was 85% and 62% at 2 and 9 years, respectively. No patient with PSC and cholangiocarcinoma has survived 2 years, although two patients were free of disease 11 and 20 months after transplantation. Despite maintenance immunosuppression seven patients with liver transplants had reactivation of inflammatory bowel disease and colon carcinoma developed in three after liver transplantation. CONCLUSIONS: Liver transplantation should be performed early in the course of PSC to avoid the lethal complications of cholangiocarcinoma. Careful colonoscopic follow-up is necessary in patients undergoing transplantation for PSC because immunosuppressive therapy does not necessarily cause inflammatory bowel disease to be quiescent, nor does it reduce the risk of colon carcinoma developing.

Perfusion of alveolar septa in isolated rat lungs in zone 1.

The combination of high inflation and low vascular pressures in zone 1 lungs is assumed to collapse alveolar vessels, making them inaccessible to vascular liquid. To test this assumption, we perfused isolated rat lungs in zone 1 (n = 5) with fluorescent albumin solution (inflation pressure = 25 cmH2O, pulmonary arterial pressure = 10 cmH2O, left atrial pressure = 0 cmH2O; flow = 0.11 +/- 0.06 ml.100 g body wt-1 x min-1) and rapidly froze them. Histologically, 33 +/- 19% (SD) of alveolar septa fluoresced, demonstrating that the perfusate had not been excluded. However, we could not resolve whether the fluorescence originated in the septal microvascular lumen or in the adjacent perimicrovascular interstitial space. To address this issue, we perfused an additional lung with horseradish peroxidase (HRP) and examined it by transmission electron microscopy. HRP filled interstitial spaces around septal vessels and extraseptal alveolar corner vessels, but because the septal vascular lumina were too compressed, we were unable to determine whether they also contained HRP. Therefore we perfused two additional lungs with particles of colloidal gold (0.05 microns diam). Using transmission electron microscopy, we found gold particles in 15-25% of septal vascular lumina, demonstrating that septal vessels were at least partially accessible in zone 1. Our interpretations is that filtration in zone 1 may occur from septal vessels and extraseptal alveolar vessels. Furthermore, results of the HRP study suggest that the perimicrovascular interstitial space is less compressible than the septal vascular lumen.

Acellular hemoglobin solution enters compressed lung capillaries more readily than red blood cells.

High lung inflation pressures compress alveolar septal capillaries, impede red cell transit, and interfere with oxygenation. However, recently introduced acellular hemoglobin solutions may enter compressed lung capillaries more easily than red blood cells. To test this hypothesis, we perfused isolated rat lungs with fluorescently labeled diaspirin cross-linked hemoglobin (DCLHb; 10%) and/ or autologous red cells (hematocrit, 20). Septal capillaries were compressed by setting lung inflation pressure above vascular pressures (zone 1). Examination by confocal microscopy showed that DCLHb was distributed throughout alveolar septa. Furthermore, this distribution was not affected by adding red blood cells to the perfusate. We estimated the maximum acellular hemoglobin mass within septa to be equivalent to that of 15 red blood cells. By comparison, we found an average of 2.7 +/- 4.6 red cells per septum in zone 1. These values increased to 30.4 +/- 25.8 and 50.4 +/- 22.1 cells per septum in zones 2 and 3, respectively. We conclude that perfusion in zone 1 with a 10% acellular hemoglobin solution may increase the hemoglobin concentration per septum up to fivefold compared with red cell perfusion.

Transport properties of alveolar epithelium measured by molecular hetastarch absorption in isolated rat lungs.

To evaluate the transport properties of the alveolar epithelium, we instilled hetastarch (Het; 6%, 10 ml, 1 - 1 x 10(4) kDa) into the trachea of isolated rat lungs and then measured the molecular distribution of Het that entered the lung perfusate from the air space over 6 h. Het transport was driven by either diffusion or an oncotic gradient. Perfusate Het had a unique, bimodal molecular weight distribution, consisting of a narrow low-molecular-weight peak at 10-15 kDa (range, 5-46 kDa) and a broad high-molecular-weight band (range 46-2,000 kDa; highest at 288 kDa). We modeled the low-molecular-weight transport as (passive) restricted diffusion or osmotic flow through a small-pore system and the high-molecular-weight transport as passive transport through a large-pore system. The equivalent small-pore radius was 5.0 nm, with a distribution of 150 pores per alveolus. The equivalent large-pore radius was 17.0 nm, with a distribution of one pore per seven alveoli. The small-pore fluid conductivity (2 x 10(-5) ml. h(-1). cm(-2). mmHg(-1)) was 10-fold larger than that of the large-pore conductivity.

Diagnosis and management of genitofemoral neuralgia.

Genitofemoral neuralgia is a syndrome characterized by chronic pain and paresthesia in the region of genitofemoral nerve distribution. Genitofemoral nerve entrapment has been described after inguinal herniorrhaphy, appendectomy, and cesarean section. Failure to distinguish it from ilioinguinal nerve entrapment can result in unnecessary inguinal reexploration, or patients severely debilitated from chronic pain. We recommend that patients with persistent pain and paresthesia in the inguinal region following surgery should have a local ilioinguinal nerve block. If this is unsuccessful in affecting relief of symptoms, a paravertebral block of L-1 and L-2 should be considered. Using these two blocks, a rational decision can then be made to operate on either the ilioinguinal nerve or the genitofemoral nerve. We describe three cases of genitofemoral neuralgia treated by extraperitoneal excision of the genitofemoral nerve.

Abnormal rectal mucosa of the anal transitional zone in ulcerative colitis.

OBJECTIVE: To determine the frequency of atypia and active ulcerative colitis (UC) in rectal mucosa within the anal transitional zone (ATZ). DESIGN: Surgeons identified ATZ tissues from restorative proctocolectomy specimens for determination by surgical pathologists of specific histopathologic features in rectal mucosa of the ATZ. SETTING: Surgical referral center for restorative proctocolectomy. PATIENTS: Ninety-four patients with symptomatic UC underwent restorative proctocolectomy between January 1991 and December 1994. INTERVENTIONS: Specific histopathologic features of active UC in the ATZ were evaluated by a single reviewer who did not know the clinicopathologic details of individual study patients. MAIN OUTCOME MEASUREMENTS: Presence and coexistence of rectal mucosal dysplasia (high or low grade), mucosa classified as indefinite for dysplasia, and acute UC (crypt abscess or cryptitis) in the ATZ. RESULTS: Of 94 ATZ tissue specimens, acute intracryptic inflammation was present in 60 rectal mucosa specimens (64%). In 29 (48%) of these 60 specimens, inflammation was neither widespread nor intense. Rectal mucosal dysplasia (low grade but not high grade) was present in 15 (16%) of 94 ATZs specimens. Inflammation elsewhere in the rectal mucosa accompanied dysplasia in 11 (73%) of 15 ATZ specimens. Rectal mucosa classified as indefinite for dysplasia was present in 24 (26%) of 94 ATZ specimens and coexisted with inflammation in 15 (63%) of these 24. Thus, rectal mucosal atypia was present in 39 (41%) of 94 ATZ specimens, and in 26 (67%) of these 39, abnormal rectal mucosa coexisted with acute inflammation. CONCLUSIONS: Rectal mucosa in the ATZ can exhibit active UC and/or atypia. Long-term monitoring is advisable if the ATZ is preserved during restorative proctocolectomy.