Prospective, randomized study comparing clinical results between small and large colonic J-pouch following coloanal anastomosis.

PURPOSE: Improved functional results can be obtained by construction of a colonic J-pouch after coloanal anastomosis. Variability in pouch size following coloanal anastomosis is prevalent in current literature. In this study, the authors compare clinical bowel function after complete rectal excision with coloanal anastomosis for patients with rectal carcinoma using either a small 6-cm or a large 10-cm colonic J-pouch anastomosis. The clinical outcome is assessed both at short-term and long-term follow-up. METHODS: Fifty-nine consecutive patients with rectal cancers 4 to 8 cm from the anal verge were recruited into the study. Patients were randomized intraoperatively to either a 6-cm J-pouch group or a 10-cm J-pouch group. Clinical assessments were performed prospectively at 3, 6, 12, and 24 months postoperatively, following colostomy closure. Clinical parameters such as frequency, urgency, continence, and laxative and enema use were assessed and compared between the two groups. RESULTS: There was no statistical differences in the mean defecation frequency, urgency, and fecal continence between the two groups at 3, 6, 12, and 24 months. In the first year, laxative and enema use between the two groups was negligible; however at two years, 30 percent of patients with a large reservoir compared with 10 percent of patients in the small-pouch group required laxative and/or enema for constipation and evacuation of bowels. CONCLUSION: Similar clinical results can be expected from patients with either small or large reservoirs at one year. However, with long-term follow-up, patients with a large reservoir are more likely to require medication for constipation and evacuation. To avoid these inconveniences a small reservoir is advocated for patients undergoing coloanal anastomosis.

[Voluminous inguinal hernias can also be treated under local anesthesia]. / Les volumineuses hernies inguinales peuvent aussi être traitées sous anesthésie locale.

In patients with a large inguinal hernia, surgeons are usually reluctant to use a local anesthesia as described in the Shouldice technique. The purpose of this study was to appreciate the efficiency of such a technique. Routine local anesthesia used 200 cc of 0.5% lidocaine injected subcutaneously in the groin area and more deeply, near the anterior superior iliac spine in order to achieve a nerve block of the genital branches of the ilioinguinal and genitofemoral nerves. If necessary, the peritoneal sac is injected with lidocaine: it is usually not opened, just pushed back into the abdomen. At the end of the procedure, the estimated size of the peritoneal sac, the presence of pain, the necessity of converting the local anesthetic technique into an other procedure and the use of a prosthesis were recorded in the patient's charts. From January 1986 to December 1992, all patients with an inguinal hernia more than 6 cm in diameter, were included in the study. 111 consecutive patients were defined as having a large hernia and were operated by one of the authors. 3 patients were excluded, following general anesthesia as the first approach, males leaving 108 cases. The mean age was 59.8 years (range: 21 to 92). There were 103 males and 5 females, 60 right hernias, 37 left and 11 bilateral of which 4 were bilateral and large, giving a total of 112 large hernias. The mean diameter of the sac was 8.6 cm (range: 6 to 30). 7 patients were operated for recurrent large hernia. During the procedure, 9 patients reported pain which necessitated repeated injections of local anesthetic. The local procedure never had to be converted into general anesthesia. All patients had a Shouldice repair and none required the use of a prosthesis. Patients were reviewed after a mean of 36 months of postoperative course (from 5 to 79 months). No hernia recurrence was observed, five patients had "residual" pain.

[Local antibiotic prophylaxis for repair of inguinal hernia]. / Antibioprophylaxie locale pour cure de hernie inguinale.

A controlled randomized trial was carried out in 324 patients with inguinal hernia. Efficacy was evaluated of a single injection of cefamandole (n = 162) administered at operative site during local anesthesia, using an untreated group as control (n = 162), as prophylaxis against post-operative local infection. Seven patients in the control group developed abscesses at the operative site after discharge, 6 of the 7 during one-month follow up, compared with none in the treated group (n = 0.07). No side effects were reported due to the antibiotic therapy. The cost of the antibiotic treatment was 10 times less than that for treating the suppurations in the control group.

[Inguinal hernia. The Shouldice parietal repair]. / Hernie inguinale. Réparation pariétale de Shouldice.

Parietal repair according to the Shouldice technique consists of a double line of sutures on each of three musculo-aponeurotic layers of the groin, i.e. successively: plicature of the transverse muscle and attachments; aponeuroplasty by back-to-back suture of the internal and external oblique muscles, and plicature of the aponeurosis of the external oblique muscle. Parietal repair of this kind is only possible after wide dissection of the inguinal region. It can be performed under local anaesthesia during a short hospitalization period. Normal activity is rapidly resumed, and in the experience of those who favour this technique, the recurrence rate is a mere 1%.