Direct measurements of Ab and Ac using vertex and kaon charge tags at the SLAC detector.

Exploiting the manipulation of the SLAC Linear Collider electron-beam polarization, we present precise direct measurements of the parity-violation parameters A(c) and A(b) in the Z-boson-c-quark and Z-boson-b-quark coupling. Quark-antiquark discrimination is accomplished via a unique algorithm that takes advantage of the precise SLAC Large Detector charge coupled device vertex detector, employing the net charge of displaced vertices as well as the charge of kaons that emanate from those vertices. From the 1996-1998 sample of 400 000 Z decays, produced with an average beam polarization of 73.4%, we find A(c)=0.673+/-0.029(stat)+/-0.023(syst) and A(b)=0.919+/-0.018(stat)+/-0.017(syst).

Improved direct measurement of the parity-violation parameter Ab using a mass tag and momentum-weighted track charge.

We present an improved direct measurement of the parity-violation parameter A(b) in the Z boson-b-quark coupling using a self-calibrating track-charge technique applied to a sample enriched in Z-->bb events via the topological reconstruction of the B hadron mass. Manipulation of the Stanford Linear Collider electron-beam polarization permits the measurement of A(b) to be made independently of other Z-pole coupling parameters. From the 1996-1998 sample of 400,000 hadronic Z decays, produced with an average beam polarization of 73.4%, we find A(b)=0.906+/-0.022(stat)+/-0.023(syst).

Improved direct measurement of A(b) and A(c) at the Z(0) pole using a lepton tag.

The parity violation parameters A(b) and A(c) of the Zb(b) and Zc(c) couplings have been measured directly, using the polar angle dependence of the polarized cross sections at the Z(0) pole. Bottom and charmed hadrons were tagged via their semileptonic decays. Both the electron and muon analyses take advantage of new multivariate techniques to increase the analyzing power. Based on the 1993-1998 SLD sample of 550,000 Z(0) decays produced with highly polarized electron beams, we measure A(b) = 0.919+/-0.030(stat)+/-0.024(syst), and A(c) = 0.583+/-0.055(stat)+/-0.055(syst).

Using quality of life scores to help determine treatment: is restoring bowel continuity better than an ostomy?

OBJECTIVE: In colorectal surgery, evaluation of heath-related quality of life (HRQL) has been relatively minimal when compared to other medical specialties. Would the performance of such HRQL evaluations change our decision-making in patient care? In familial adenomatous polyposis (FAP), procedures that restore bowel continuity (i.e. Ileorectal anastomosis or ileal pouch anal anastomosis) are routinely preferred to ileostomy because of the perceived, but unproven, better HRQL. This study evaluates FAP patients who underwent prophylactic colectomy with either permanent ileostomy or 'restored bowel continuity' reconstruction. The functional outcomes of both groups are reported, and the HRQL assessments are compared. METHODS: All FAP patients who underwent (procto) colectomy resection with reconstruction, either restored bowel continuity (BC) or permanent ileostomy (OST), between 1980 and 1998 were studied. Functional data were obtained by questionnaire and medical record review. HRQL was assessed by 2 validated instruments - the SF-36 Physical and Mental Health Summary Scales and the SF-36 Health Survey - which measure physical summary (PSF) and mental summary functioning (MSF) as well as eight separate health quality dimensions including health perception (HP), physical (PF) and social functioning (SF), physical (PR) and emotional role limitations (ER), mental health (MH), bodily pain (BP), and energy level (E). RESULTS: Results were obtained in 54 patients; bowel continuity (44), ileostomy (10). Mean patient age was 39 years, mean follow up time was 10.5 years. Mean patient age at operation was 28 years. Functional results for BC included number of bowel movements/day (6.7), leakage (30%), having to wear a pad (11%), perianal skin problems (25%), food avoidance (68%), and inability to distinguish gas (27%). Functional results for OST were routinely excellent. Results of the HRQL surveys reveal no significant differences for BC vs OST (HP: 67 +/- 28 vs 79 +/- 39; PF: 91 +/- 14 vs 90 +/- 17; SF: 86 +/- 23 vs 97 +/- 5; PR: 79 +/- 34 vs 83 +/- 40; ER: 86 +/- 28 vs 88 +/- 27; MH: 77 +/- 19 vs 82 +/- 14; BP: 78 +/- 24 vs 71 +/- 32; E 60 +/- 21 vs 58 +/- 18, respectively). CONCLUSION: Although the perceived quality of life for ileostomy patients is generally worse than the 'restored bowel continuity' group, the measured HRQL is the same for both groups. These results suggest that a permanent ileostomy should be included as a viable and appropriate first line treatment option for FAP patients after resection. This study also suggests that HRQL should play a greater role in the evaluation of care and treatment in colorectal surgery.

First symmetry tests in polarized Z0 decays to bbg.

We have made the first direct symmetry tests in the decays of polarized Z0 bosons into fully identified bbg states, collected in the SLD experiment at SLAC. We searched for evidence of parity violation at the bbg vertex by studying the asymmetries in the b-quark polar- and azimuthal-angle distributions, and for evidence of T-odd, CP-even or CP-odd, final-state interactions by measuring angular correlations between the three-jet plane and the Z0 polarization. We found results consistent with standard model expectations and set 95% C. limits on anomalous contributions.

Improved direct measurement of leptonic coupling asymmetries with polarized Z bosons.

We present final measurements of the Z boson-lepton coupling asymmetry parameters A(e), A(mu), and A(tau) with the complete sample of polarized Z bosons collected by the SLD detector at the SLAC Linear Collider. From the left-right production and decay polar angle asymmetries in leptonic Z decays we measure A(e) = 0.1544+/-0.0060, A(mu) = 0.142+/-0.015, and A(tau) = 0.136+/-0.015. Combined with our left-right asymmetry measured from hadronic decays, we find A(e) = 0.1516+/-0.0021. Assuming lepton universality, we obtain a combined effective weak mixing angle of sin (2)theta(eff)(W) = 0.230 98+/-0.000 26.

High-precision measurement of the left-right Z Boson cross-section asymmetry.

We present a measurement of the left-right cross-section asymmetry ( A(LR)) for Z boson production by e(+)e(-) collisions. The measurement includes the final data taken with the SLD detector at the SLAC Linear Collider during the period 1996-1998. Using a sample of 383 487 Z decays collected during the 1996-1998 runs we measure the pole value of the asymmetry, A(0)(LR), to be 0.150 56+/-0.002 39 which is equivalent to an effective weak mixing angle of sin (2)straight theta(eff)(W) = 0.231 07+/-0.000 30. Our result for the complete 1992-1998 data set comprising approximately 537 000 Z decays is sin (2)straight theta(eff)(W) = 0.230 97+/-0.000 27.

Safety and efficacy of dynamic graciloplasty for fecal incontinence: report of a prospective, multicenter trial. Dynamic Graciloplasty Therapy Study Group.

PURPOSE: Dynamic graciloplasty has been used for intractable fecal incontinence, and good results have been reported. The aim of this study was to assess prospectively the safety and efficacy of dynamic graciloplasty for intractable fecal incontinence in a prospective, multicenter trial. METHODS: A total of 123 adults were treated with dynamic graciloplasty at 20 institutions. Continence was assessed preoperatively and postoperatively by use of 14-day diaries. RESULTS: There was one treatment-related death. One hundred eighty-nine adverse events occurred in 91 patients (74 percent). Forty-nine patients (40 percent) required one or more operations to treat complications. One hundred seventy (90 percent) events were resolved. Sixty-three percent of patients without pre-existing stomas recorded a 50 percent or greater decrease in incontinent events 12 months after dynamic graciloplasty, and an additional 11 percent experienced lesser degrees of improvement. Twenty-six percent were not improved, worsened, or exited. In patients with pre-existing stomas, 33 percent achieved successful outcomes at 12 months. This number increased to 60 percent at 18 months. Seventy-eight percent of patients had increased enema retention time, and mean anal canal pressures improved significantly at 12 months. Significant changes in quality of life were also observed. CONCLUSIONS: Objective improvement can be demonstrated in the majority of patients with end-stage fecal incontinence treated with dynamic graciloplasty. Reduction in incontinence episodes can be correlated with improved quality of life. Adverse events are frequently encountered, but most resolve with treatment.

Does better functional result equate with better quality of life? Implications for surgical treatment in familial adenomatous polyposis.

PURPOSE: The main impetus for a patient with familial adenomatous polyposis to choose colectomy with ileorectal anastomosis over ileal pouch-anal anastomosis is the better functional result. However, does better functional result necessarily translate into better overall quality of life? Previous studies of other diseases have demonstrated no such correlation. This study was performed to determine whether any relationship exists between functional result and quality of life in patients with familial adenomatous polyposis after ileorectal anastomosis and ileal pouch-anal anastomosis. METHODS: All patients with familial adenomatous polyposis who underwent colectomy with ileorectal anastomosis or proctocolectomy with ileal pouch-anal anastomosis from 1980 to 1998 were studied. Functional data were obtained by questionnaire. Health-related quality of life was assessed by two validated instruments, the SF-36 Physical and Mental Health Summary Scales and the SF-36 Health Survey, which measure physical and mental functioning and eight separate health-quality dimensions, including health perception, physical and social functioning, physical and emotional role limitations, mental health, bodily pain, and energy or fatigue. RESULTS: Data were obtained in 44 of 68 patients, 14 with ileorectal anastomosis and 30 with ileal pouch-anal anastomosis. No differences were demonstrated between the two groups for patient age, mean follow-up time, and mean patient age at operation. Functional results were worse for the ileal pouch-anal anastomosis group vs. the ileorectal anastomosis group in number of bowel movements per day (7.5 vs. 5.2; P < 0.05), leakage (43 vs. 0 percent; P < 0.01), pad usage (17 vs. 0 percent; P < 0.01), perianal skin problems (33 vs. 7 percent; P < 0.01), food avoidance (80 vs. 43 percent; P < 0.01), and inability to distinguish gas (37 vs. 7 percent; P < 0.01). Results of the health-related quality-of-life surveys, however, demonstrated no difference between the ileal pouch-anal anastomosis and ileorectal anastomosis groups. The Physical and Mental summary scales for the ileal pouch-anal anastomosis and ileorectal anastomosis groups were not significantly different (Physical Health Scale, 50.3 vs. 50.9; Mental Health Scale, 51.7 vs. 49.6), and none of the eight dimensions of the SF-36 health survey demonstrated statistical differences between the ileal pouch-anal anastomosis and ileorectal anastomosis groups. CONCLUSION: Better functional results were not equated with better quality of life in this pilot study. Although patients with the ileorectal anastomosis have better functional results than those with ileal pouch-anal anastomosis, the measured health-related quality of life as determined by a validated generic health-related quality-of-life instrument is the same for both groups. These results suggest that all patients with familial adenomatous polyposis might be optimally treated with an ileal pouch-anal anastomosis. More importantly, this study suggests that health-related quality of life should play a greater role in the evaluation of care and treatment in colon rectal surgery.

Laparoscopic colectomy: indications for conversion to laparotomy.

HYPOTHESIS: Although experience with laparoscopic colectomy continues to accumulate, criteria for patient selection for the procedure have yet to be developed. We propose that review of indications for conversion to laparotomy during laparoscopic colectomy should define some of the current technical limitations of the procedure. This information may facilitate development of selection criteria for laparoscopic colon and rectal surgery. DESIGN: Single-institution retrospective medical records review. SETTING: Tertiary referral center. PATIENTS: Two hundred patients who underwent laparoscopic colon surgery, in 47 (23.5%) of whom the procedure was converted to laparotomy. INTERVENTIONS: A registry of 200 patients who have undergone laparoscopic colon surgery was analyzed. Medical records of 47 patients whose procedure was converted were reviewed to assess indications for conversion and identify factors contributing to the need for conversion. RESULTS: Between July 1, 1991, and September 30, 1998, 200 laparoscopic colon procedures were performed: 78 ascending colectomies, 74 descending or sigmoid colectomies, 14 diverting stomas, and 34 "other procedures." The 200 patients were divided into 4 cohorts of 50 consecutive patients to analyze changes with time. The conversion rate was statistically greater in the first quarter (18 patients [36.0%]) than in subsequent quarters (16.0%; P <.05). The rate of conversion to laparotomy for segmental resection of the ascending and descending colon (31/153 [20.3%]) has been equivalent and less than the conversion rate for other procedures (16/33 [48.5%]; P <.05). The distribution of patients by operative indication has been fairly constant. The indication for operation has not influenced the need for conversion. The indications for conversion were technical problems in 15 patients (hypercarbia, unclear anatomy, and stapler misfire), laparoscopic complications in 9 patients (bleeding, cystotomy, and enterotomy), and problems that exceeded the limits of laparoscopic dissection in 23 patients (phlegmon, adhesions, obesity, and adjacent organ involvement by cancer). CONCLUSIONS: Our conversion rate has decreased during our experience, and currently the need for conversion to laparotomy is most frequently caused by situations such as excessive tumor bulk, adhesions, and diverticular phlegmon that exceed the technical limitations of laparoscopic dissection. Colorectal reanastomosis following a Hartmann resection and procedures involving resection of the distal rectum are unlikely to be successfully completed. Although obesity accentuates the technical limitations of laparoscopic dissection, it is an infrequent cause for conversion to laparotomy.

Functional results after perineal complications of ileal pouch-anal anastomosis.

PURPOSE: This study investigated the functional significance of perineal complications after ileal pouch-anal anastomosis. METHODS: Review of a prospective registry of 628 patients was undertaken. Bowel function was assessed by detailed functional questionnaire. Statistical analyses were performed using chi-squared and Fisher's exact probability tests. RESULTS: Of 628 patients, 153 (24.4 percent) had 171 perineal complications. The 277 control patients had no complications. Complications included 66 (10.5 percent) anastomotic strictures, 28 (4.5 percent) anastomotic separations, 36 (5.7 percent) pouch fistulas, 41 (6.5 percent) episodes of pelvic sepsis, and 18 (2.9 percent) patients with multiple complications. After these complications were addressed, the pouch failure rate was low (10 percent); in 90 percent of patients, the pouch could be salvaged. Most pouch failures were the result of pouch fistulas, and most occurred in patients ultimately diagnosed with Crohn's disease. Functional results after cure of these perineal complications revealed no significant functional differences between control patients and those cured of anastomotic separations, anastomotic strictures, and pouch fistulas. Only a few minor differences were demonstrated in function after an episode of pelvic sepsis. The major deterioration in function occurred after treatment for multiple perineal complications. CONCLUSIONS: An appreciable number of perineal complications occur after ileal pouch-anal anastomosis. Pouch-perineal fistulas are associated with the highest pouch failure rate. The majority of these fistulas occur in patients ultimately diagnosed with Crohn's disease or indeterminate colitis. Although there is no substitute for good technique and sound clinical judgment in the success of ileal pouch-anal anastomosis, if perineal complications are successfully treated, functional outcome is equivalent to that in patients without perineal complications.

Fatigue rate index as a new measurement of external sphincter function.

PURPOSE: Assessment of sustained voluntary contraction of the external sphincter is helpful in evaluating the patient who has a defecation disorder on presentation. A new index of external sphincter function is described. METHOD: A prospective registry of patients referred for computerized anal manometry using standard protocols was reviewed. Patients were grouped by primary symptoms; those with overlapping complaints were excluded. The rate of fatigue, defined as the change in stationary squeeze over a 40-second period of voluntary contraction, was calculated by linear regression analysis. Fatigue rate index, a calculated measure of time necessary for the external sphincter to become completely fatigued, was determined to permit comparison of external sphincter fatigue in patients with different complaints. RESULTS: Twenty-six healthy volunteers (15 women; mean age, 45 years), 33 patients with a primary complaint of anal seepage (13 women; mean age, 53 years), 75 patients with gross incontinence (61 women; mean age, 53 years), and 49 patients with severe constipation (41 women; mean age, 45 years) were evaluated. Mean resting and squeeze pressures were 55 mmHg and 107 mmHg for volunteers, 37 mmHg and 97 mmHg for patients with seepage, 30 mmHg and 49 mmHg for incontinent patients, and 56 mmHg and 93 mmHg for constipated patients. Pudendal neuropathy, as evidenced by a prolonged pudendal nerve terminal motor latency (> 2.4 ms), was identified in 13 percent of volunteers, 32 percent of patients with seepage, 54 percent of incontinent patients, and 38 percent of constipated patients. Mean fatigue rate index was 3.3 minutes for volunteers, 2.3 minutes for seepage patients, 1.5 minutes for incontinent patients, and 2.8 minutes for constipated patients. Compared with volunteers and patients with seepage, the incontinent patients had a significantly shorter fatigue rate index (P < 0.05; Student's t-test), which was independent of the variations in resting pressure (P < 0.05; two-way analysis of variance). CONCLUSION: The external anal sphincter is normally subject to fatigue. Patients with worsening degrees of incontinence have a predictably lower fatigue rate index. Fatigue rate index is a simple measure of external sphincter integrity, which may be used in assessment of sphincter function and future treatment protocols.

Pudendal neuropathy is the only parameter differentiating leakage from solid stool incontinence.

PURPOSE: Fecal incontinence may occur in several forms. Although some patients are grossly incontinent, other patients experience only leakage. In patients with gross incontinence, severity can range from the mildest forms (limited to loss of control of flatus) to the most severe forms (involving loss of solid stool). This study was undertaken to determine which physiologic parameters differentiate female patients with incontinence of solid stool from patients with control of formed stool and incontinence limited to seepage. METHODS: Thirty-eight consecutive female patients with a primary complaint of seepage or solid stool incontinence were evaluated using water perfusion manometry, balloon inflation assessment of rectal sensitivity, and pudendal nerve terminal motor latency. A prospectively maintained database was used for collection of data. The findings in the two patient groups were compared with patients in a group of normal control individuals. Ages of the women in the three groups were similar. RESULTS: Both groups of patients demonstrated statistically significant (P < 0.05) decreases in rest and squeeze sphincter lengths, pressures, and pressure volumes compared with normal volunteers. The patients also had significantly more asymmetric high-pressure zones and hypersensitive rectums. No significant difference between the two groups of incontinent patients could be identified using any of these parameters. Significant differences between the groups were found in pudendal nerve function. The distal rectoanal excitatory reflex was abnormal in 58.1 percent of grossly incontinent women compared with 28.6 percent of patients with leakage (P < 0.05). The majority of patients with leakage alone (65 percent) had normal pudendal nerve terminal motor latency, whereas only 22.6 percent of women with gross fecal incontinence had normal pudendal nerve terminal motor latency bilaterally (P = 0.01). CONCLUSIONS: Normal bilateral pudendal nerve function can partially compensate for abnormal sphincter symmetry and function, permitting women with grossly abnormal parameters to maintain control of bowel movements. It remains to be seen whether, with advancing age, patients with leakage will have development of slowed pudendal nerve conduction and, if so, whether their condition will progress to gross incontinence.

"Ideal" length of stay after colectomy: whose ideal?

PURPOSE: In response to external pressure to achieve an idealized length of stay after colon resection, a study was designed to define perioperative factors that significantly impact average length of stay (ALOS). METHODS: We retrospectively reviewed the records of 226 patients undergoing open colon resection from 1988 to 1995 to determine the effects of age, type of procedure, nature of the procedure (elective vs. emergency), and postoperative course on ALOS. Statistics were calculated by Student's t-test, chi-squared analysis, and analysis of variance. RESULTS: Average length of stay was 10 (range, 4-34) days, with a significant trend toward lower ALOS in recent years; ALOS in 1988 averaged 11 days, whereas in 1994, ALOS averaged 9 days (r2 = 0.118; P < 0.001). Patients younger than 65 years of age had an ALOS of 9 days vs. 11 days in patients older than 65 years (P = 0.0024). Patients with anastomoses on the right and left side had similar ALOS (8.5 vs. 9.1 days), whereas creation of a stoma was associated with a significantly higher ALOS (12.1 days; P < 0.00001). The need for postoperative nasogastric intubation (14.9 vs. 9.3 days) and the performance of emergency operations (12.2 vs. 6.5 days) were also associated with a significantly higher ALOS (P < 0.00001). CONCLUSIONS: Caution must be exercised in accepting rigid criteria for length of stay for patients undergoing colorectal resections, as uncontrollable clinical variables are involved in defining the "ideal" patient.

Intraoperative colonic lavage in nonelective surgery for diverticular disease.

BACKGROUND: Staged resection of the sigmoid colon has been the traditional strategy for treating patients who require nonelective surgery to manage complications of diverticular disease. Resection and primary anastomosis has not generally been recommended when the clinical setting is compromised by contiguous inflammation or inadequate mechanical cleansing of the colon because of concerns regarding the potential risk of anastomotic dehiscence. Although many reports have confirmed that intraoperative colonic lavage (ICL) is a safe method for relieving fecal loading of the colon to facilitate primary intestinal anastomosis in patients with mechanical obstruction of the distal colon, there is very limited experience with the use of this technique in treating acute inflammatory disorders of the colon. In this report, we present our results with ICL in the nonelective treatment of patients with complications of diverticulitis. METHODS: Records of all patients undergoing urgent operations at the Lahey Clinic to treat complications of diverticular disease from July 1987 to January 1996 were reviewed. RESULTS: Of 62 patients who required nonelective operations, 33 underwent ICL in an attempt to perform primary anastomosis. In five patients, the operation included creation of a colostomy. The indication for surgery was obstruction in 13 patients (39 percent), persistent abscess or phlegmon in 13 (39 percent), perforation in 6 patients (18 percent), and hemorrhage in 1 patient (3 percent). According to Hinchey's classification system, 18 patients had Stage I disease, 10 had Stage II, and 5 patients had Stage III disease. There were no patients with Stage IV disease. The single anastomotic complication in the series was responsible for the sole operative mortality. The morbidity rate of 42 percent, included three intraoperative complications (2 splenic injuries and 1 ureteral laceration), two intra-abdominal abscesses (6 percent), and six wound infections (18 percent). CONCLUSION: In our experience, ICL has proven to be a safe method for accomplishing single-stage resection of the colon in selected patients with diverticulitis who require an urgent operation. When there is no evidence of diffuse purulent or feculent peritonitis, we believe this is the preferred method for treating patients who are hemodynamically stable.

Afferent limb obstruction complicating ileal pouch-anal anastomosis.

PURPOSE: Small-bowel obstruction is a common complication after ileal pouch-anal anastomosis (IPAA). Acute angulation of the afferent limb at the pouch inlet is the cause of obstruction in a subset of patients requiring laparotomy. METHODS: Patients were identified from the Lahey Clinic ileoanal pouch registry, a prospective computerized database of all patients who have undergone IPAA since 1980. Records of patients who were identified as having afferent limb obstruction as a cause of bowel obstruction after IPAA were reviewed. RESULTS: A total of 567 patients had undergone total proctocolectomy and ileoanal J-pouch at time of the study. Of 122 patients with one or more episodes of obstruction after IPAA, 48 required operative intervention. Afferent limb obstruction was identified as the cause of obstruction in six patients (12 percent). The most common presentation was recurrent partial obstruction (4 of 6 patients). Contrast small-bowel series and enemas were suggestive of obstruction in four of six patients, the most consistent radiographic finding being small-bowel dilation to the level of the pouch inlet. All patients underwent laparotomy for unresolved obstruction. Intraoperatively, the afferent limb was found to be adherent posterior to the pouch, causing acute angulation at the pouch inlet. Rather than risk injury to the pouch or its mesentery, the obstruction was bypassed by side-to-side anastomosis of the afferent limb to the pouch (enteroenterostomy) in five of six patients. One patient underwent ileostomy only because of technical considerations. Two patients required re-exploration and pexy of the afferent limb to the pelvic sidewall (pouchopexy) to relieve recurrent afferent limb obstruction. CONCLUSION: Afferent limb obstruction should be suspected in patients with recurrent obstruction after IPAA. Bypass of the obstructed segment from distal ileum to the pouch is safe and effective treatment. Because of the risk of recurrent afferent limb angulation, concurrent pouchopexy should be considered.

Evolutionary changes in the pathologic diagnosis after the ileoanal pouch procedure.

PURPOSE: Inadequate initial differentiation between ulcerative colitis and Crohn's disease may lead to a diagnosis of indeterminate colitis. Construction of an ileoanal pouch in these patients may result in significant morbidity and pouch failure when the ultimate diagnosis is Crohn's disease. METHOD: We prospectively studied 543 patients with idiopathic inflammatory bowel disease to determine whether a patient's pathologic diagnosis changed with time and how it affected outcome. RESULTS: Preoperative diagnosis was ulcerative colitis in 499 patients, indeterminate colitis in 42 patients, and Crohn's disease in 2 patients. Prior colectomy was performed in 58 percent of patients with ulcerative colitis and in all patients with indeterminate colitis and Crohn's disease. Postoperatively, the diagnosis changed in 20 patients with ulcerative colitis (13 to indeterminate colitis, 7 to Crohn's disease). Another two patients with indeterminate colitis showed evidence of Crohn's disease in the resected rectal specimen. As patients were followed up, an additional 13 patients were found to have Crohn's disease (5 indeterminate colitis, 8 ulcerative colitis). With the current diagnosis, perineal complications and pouch failure occurred, respectively, in 23 and in 2 percent of patients with ulcerative colitis, in 44 and in 12 percent of patients with indeterminate colitis, and in 63 and in 37 percent of patients with Crohn's disease. Pathologic diagnosis was altered in 35 patients (6 percent) overall, with a 12-fold increase in the diagnosis of Crohn's disease. Only 3 percent of patients with ulcerative colitis compared with 13 percent of patients with indeterminate colitis had a change in diagnosis to Crohn's disease (P = 0.006; Fisher's exact test). CONCLUSION: Pouch-related complications, eventual pouch failure, and discovery of underlying Crohn's disease occurred in a significant number of patients with a diagnosis of indeterminate colitis. Until more accurate diagnostic differentiation is available, caution is advised in recommending the ileoanal pouch procedure to patients with indeterminate colitis.

Laparoscopic resection for diverticular disease.

PURPOSE: The role of laparoscopic surgery in treatment of patients with diverticulitis is unclear. A retrospective comparison of laparoscopic with conventional surgery for patients with chronic diverticulitis was performed to assess morbidity, recovery from surgery, and cost. METHODS: Records of patients undergoing elective resection for uncomplicated diverticulitis from 1992 to 1994 at a single institution were reviewed. Laparoscopic resection involved complete intracorporeal dissection, bowel division, and anastomosis with extracorporeal placement of an anvil. RESULTS: Sigmoid and left colon resections were performed laparoscopically in 25 patients and by open technique in 17 patients by two independent operating teams. No significant differences existed in age, gender, weight, comorbidities, or operations performed. In the laparoscopic group, three operations were converted to open laparotomy (12 percent) because of unclear anatomy. Major complications occurred in two patients who underwent laparoscopic resection, both requiring laparotomy, and in one patient in the conventional surgery group who underwent computed tomographic-guided drainage of an abscess. Patients who underwent laparoscopic resection tolerated a regular diet sooner than patients who underwent conventional surgery (3.2 +/- 0.9 vs. 5.7 +/- 1.1 days; P < 0.001) and were discharged from the hospital earlier (4.2 +/- 1.1 vs. 6.8 +/- 1.1 days; P < 0.001). Overall costs were higher in the laparoscopic group than the open surgery group ($10,230 +/- 49.1 vs. $7,068 +/- 37.1; P < 0.001) because of a significantly longer total operating room time (397 +/- 9.1 vs. 115 +/- 5.1 min; P < 0.001). Follow-up studies with a mean of one year revealed two port site infections in the laparoscopic group and one wound infection in the open group. Of patients undergoing conventional resection, one patient experienced a postoperative bowel obstruction that was managed nonoperatively, and, in one patient, an incarcerated incisional hernia developed that required urgent laparotomy. CONCLUSIONS: Laparoscopic resection in patients with chronic diverticulitis is safe, with faster recovery and shorter hospital stay compared with conventional open surgery. Higher cost of operating room usage time makes the laparoscopic technique difficult to justify economically. Simplification of operating room use and better case selection may improve cost-effectiveness of the laparoscopic approach.

Ileocolic resection for acute presentation of Crohn's disease of the ileum.

PURPOSE: Traditional therapy for patients with terminal ileitis found at laparotomy for appendicitis has been to perform appendectomy when the cecum is normal and to leave the diseased ileum in place. METHODS: To determine the role of ileocolic resection in the setting of acute ileitis, records of 1,421 patients with Crohn's disease seen from 1986 to 1994 were retrospectively reviewed. RESULTS: Crohn's disease was found at laparotomy for presumed appendicitis in 36 patients (2.5 percent). Ten patients underwent ileocolic resection, 23 had appendectomy, and 3 had exploratory laparotomy alone. One patient whose appendix was removed also had ileocecal bypass. Of the 36 patients, 20 were women and 16 were men. Mean age at operation was 24 (range, 11-61) years, and mean follow-up time was 14 (range, 0.1-49) years. After initial ileocolic resection, five patients (50 percent) required no further resection, with a mean follow-up time of 12.4 (range, 4-19) years. None required more than three ileocolic resections, with a mean follow-up time of 18.1 (range, 4-49) years. Of 26 patients treated traditionally, 24 (92 percent) required ileocolic resection for intractability or complications of Crohn's disease. Thirty-eight percent required resection within one year and 65 percent within three years (intractability, 8; obstruction, 3; fistula, 4; and perforation, 2). Of 24 patients who subsequently underwent resection, only 6 (25 percent) required further small-bowel resection for Crohn's disease, with a mean follow-up time of 13 (range, 0.1-34) years. CONCLUSION: The majority of patients found to have Crohn's disease at laparotomy for appendicitis required early ileocolic resection. Therefore, the traditional dictum of nonoperative therapy for these patients may not be in their best long-term interest and merits re-evaluation.

Endoscopic management of malignant colorectal polyps.

Malignant polyps are adenomatous polyps that contain cancerous cells that have penetrated the muscularis mucosae. Pedunculated malignant polyps that have not yet developed to level 4 invasion and have no other adverse histopathologic criteria have a high likelihood of cure by endoscopic excision alone. However, if level 4 invasion has been reached or if any additional adverse characteristic, such as poor differentiation, lymphatic or venous invasion, or close or involved margins, is present, the risk of inadequate treatment from endoscopic excision alone becomes appreciable. Under such circumstances, a definitive resection is favored unless the increased risk of recurrence is offset by age-related limited life expectancy or substantial comorbidities. Sessile malignant polyps are more likely to demonstrate level 4 invasion. In addition, these lesions are often less satisfactorily treated by endoscopic excision. In most circumstances, unless patient factors contraindicate intervention, resection should be performed.