Use of the surgical towel in colorectal hand-assisted laparoscopic surgery (HALS).

The use of laparotomy pads or towels to displace the small intestine away from the operative site is a well-established technique in open surgery; however, its application is unfeasible or extremely challenging in standard laparoscopic surgery. We describe the use of standard surgical towels in hand-assisted laparoscopic surgery (HALS). A Pfannenstiel incision is made and a Gelport hand-access device is assembled. A sterilized surgical towel, 65 x 44 cm in size, is inserted via the Gelport, unfolded, and placed over the bowel loops laparoscopically with the assistance of the hand. The bowel loops are then housed gently in the towel and displaced away from of the operative site. HALS enables the easy insertion and handling of a large surgical towel inside the peritoneal cavity. The towel successfully retracts the small intestine, enabling the surgeon to concentrate the use of his or her hand on the targeted structures. This practical and inexpensive tip adds another advantageous component to the practice of colorectal HALS.

Surgical treatment of hemorrhoids: prospective, randomized trial comparing closed excisional hemorrhoidectomy and the Harmonic Scalpel technique of excisional hemorrhoidectomy.

PURPOSE: The object of this study was to evaluate technique using the ultrasonically activated scalpel as an alternative to closed hemorrhoidectomy in an unbiased evaluation of this new technology. METHODS: Thirty patients with Grade 2 or 3 symptomatic hemorrhoids were prospectively randomized to undergo closed hemorrhoidectomy assisted by electrocautery or hemorrhoidectomy with the ultrasonically activated scalpel, i.e., the Harmonic Scalpel. We evaluated the difference between techniques in operative time, postoperative pain, incontinence, and quality of life (using the Short Form-36 survey), as well as complications. RESULTS: Mean operative time for closed hemorrhoidectomy with electrocautery was 35.7 +/- 3 minutes; for Harmonic Scalpel patients, it was 31.7 +/- 2 minutes (P < 0.37). There was no statistical difference in operative time for two- or three-column hemorrhoidectomy. There was no significant difference in pain measurements reported on Day 1 (5.8 +/- 0.4 for electrocautery and 5.6 +/- 0.6 for Harmonic Scalpel, P < 0.82). On postoperative Day 7, the difference in pain between groups approached significance, with pain reported as 3.7 +/- 0.3 for electrocautery and 5.1 +/- 0.7 for Harmonic Scalpel(R) (P < 0.06). At six weeks, both groups were pain free. There was a significant decrease in pain between postoperative Days 1 and 7 in the electrocautery patients that was not seen in the Harmonic Scalpel patients. Incontinence measured preoperatively, at postoperative Day 7, and at postoperative Week 6 was similar for both groups and reflected occasional incontinence of gas. When the various items of the Short Form-36 survey were compared, there was no significant difference between posttreatment and preoperative values. There was no difference in the number of complications between patient groups. CONCLUSION: Although the Harmonic Scalpel is an effective tool in the treatment of hemorrhoidal disease, we found no specific advantage in postoperative pain, fecal incontinence, operative time, quality of life, or complications compared with traditional closed hemorrhoidectomy.

Acute diverticulitis in heart- and lung transplant patients.

Significant gastrointestinal complications have been observed in patients following heart- and lung transplantation. These complications can occur in the immediate post-operative period or remote from the time of transplantation. We retrospectively reviewed the medical records of 268 consecutive patients who received either heart- or lung transplants at Henry Ford Hospital between 1985 and 1998. Two hundred and thirty-three patients received heart transplants and 35 underwent lung transplantation. Two patients developed acute diverticulitis post transplant, both requiring surgery. Management of acute diverticulitis in the heart- and lung transplant population requires a high index of suspicion. Early and aggressive diagnosis is mandatory. Surgical intervention must be prompt when indicated, with meticulous attention to surgical technique. With appropriate intervention, reasonable outcomes can be expected.

Acute colonic perforation associated with colorectal cancer.

Our purpose was to evaluate long-term outcome in patients presenting with acute colonic perforation in the setting of colorectal cancer. We conducted a retrospective review of 48 consecutive patients presenting with acute colonic perforation associated with colorectal cancer at a single institution. Patients presented either with free air or acute peritonitis. No patients with colonic obstruction were included. Forty-eight patients presented with colon perforation. Thirty-six had perforation at the tumor, 11 proximal to the tumor, and one distal to the primary tumor. Patients who perforated proximal to the tumor were older (74.5 +/- 2 vs 64.7 +/- 3; P < 0.04) and had a longer length of stay (46.8 +/- 17 vs 11.6 +/- 1 P < 0.001). Fourteen patients had stage II disease, 19 stage III, and 15 stage IV. Thirty-day mortality was 14 per cent (n = 7) with nine in-hospital deaths. Of 30-day survivors 29 (60%) had curative resection (21 with local perforation and nine with proximal perforation). Of these 14 received adjuvant chemotherapy. Eleven patients (33%) had either unresectable or metastatic disease on exploration. Mean follow-up was 21.5 months. Ten patients developed metastatic disease after potentially curative resections. Of these nine patients had perforations of the primary tumor. Three patients developed local recurrence and all had local tumor perforations. One-year survival was 55 per cent (n = 16). Five-year disease-free survival was 14 per cent (n = 4). There were no long-term survivors after perforation proximal to the tumor, although disease stage was comparable in both groups. We conclude that perforation proximal to a cancer is associated with a higher perioperative mortality and worse long-term outcome when compared with acute perforations at the site of the tumor. Long-term survival requires both aggressive management of the concomitant sepsis and definitive oncologic surgery.

Perineal repair of colorectoanal intussusception. Report of a case and review of the literature.

Colorectoanal intussusception is a rare and distinct entity that differs from the more common rectal prolapse. Typically intussusception occurs with tumor at the apex of the intussuscepted segment acting as a lead point. Only 26 adult cases of this entity have been reported in the literature. All have been associated with a benign or malignant tumor. Here we present a case and review the literature of colorectoanal intussusception. The case presented is that of an elderly woman with a large circumferential villous tumor at its apex. Perineal resection was performed in a single stage with intravenous sedation without complication (figures). This represents only the second reported case in the English literature of a colorectoanal intussusception treated in this manner.

Endoscopic examination of the colon and rectum distal to a colostomy.

We report results of the endoscopic examination of the colon distal to a colostomy in 85 patients. Almost half had symptoms related to the excluded bowel. Whereas severe colitis or tumor may be asymptomatic, many patients had discomfort, pain, bleeding, and discharge. Endoscopic examination revealed abnormal findings in 80% of the patients. These were as uncomplicated as mucous plugs or as serious as polyps or carcinoma. We found a high incidence of diversion colitis in the excluded colon. Because of these abnormal findings, endoscopy of the bowel distal to a colostomy at regular intervals is recommended. Mucous plugs and scybala should be treated by irrigation, while polyps and carcinoma should be treated as they would in the nondiverted colon. Diversion colitis can be treated medically with local steroids, or surgically. In most cases, even in severe colitis, we recommend closure of the colostomy. Removal of the excluded colon is seldom necessary.