Bowel dysfunction in spina bifida--an American experience with the ACE procedure.

Fecal incontinence remains a detriment to improved quality of life in many patients with spina bifida. Previous methods of conservative management frequently prove to be inadequate, causing many patients to withdraw from the social mainstream. Recent descriptions of procedures to provide access to the proximal colon for antegrade colonic enemas (ACE procedure) have provided a new approach to managing fecal incontinence. We report here our experience with these procedures in 43 patients with spina bifida. The background, techniques and outcomes of these procedures are discussed and a plea is made to consider this approach in all patients who are hampered in their social or vocational progress because of neurogenic anorectal dysfunction.

Laparoscopic appendicostomy for management of fecal incontinence.

Fecal incontinence from any cause is a socially unacceptable condition and a major detriment to educational and psychosocial development in young people with certain disabilities. Recently several procedures have been described that allow antegrade colonic enemas in the treatment of this problem. We report here an additional method of establishing this proximal colon access, namely laparoscopic appendicostomy. Although not applicable to all patients, this procedure has been successful in a select group with excellent results, and we recommend its consideration when open surgery is not otherwise required.

The Malone antegrade colonic enema enhances the quality of life in children undergoing urological incontinence procedures.

PURPOSE: Functional alterations of the gastrointestinal and genitourinary tracts, and physical limitations in children with spina bifida, imperforate anus and spinal cord injury challenge the ability to have independent fecal and urinary continence. Urologists have successfully helped these patients achieve urinary continence. We report our experience with the antegrade colonic enema procedure, which allows select individuals to achieve continence of stool, enhancing quality of life. MATERIALS AND METHODS: Since December 1992, 18 antegrade colonic enema procedures were performed in 12 female and 6 male patients 5 to 31 years old of whom 14 had spina bifida, 2 had imperforate anus and 2 had spinal cord injury. Simultaneous urological continence procedures were performed in 8 patients, including appendicovesicostomy in 4, augmentation cystoplasty in 2 and augmentation cystoplasty plus an ileal Mitrofanoff procedure in 2. Four patients previously underwent urological reconstruction. RESULTS: In 24 months of followup (average 6.6) all patients with a functioning stoma remained continent of stool and 17 were continent of urine. Complications related to the antegrade colonic enema procedure occurred in 4 children (22%) of whom 3 required further surgery. Three patients (17%) had minor stomal stenosis. CONCLUSIONS: The antegrade colonic enema procedure is easily performed and it should be considered for any child with significant physical limitations and/or refractory fecal incontinence before urological continence promoting procedures are done.

A case of biliptysis.

A 76-year-old white woman with ovarian adenocarcinoma developed massive biliptysis following an unexpected respiratory arrest. The possibility of active right upper quadrant disease had not been entertained until she developed this complication of a biliobronchial fistula. Because this sign had not previously been observed by any of us, it led to a comprehensive review of the topic of biliobronchial fistula.

The impact of mammography on breast biopsy.

To determine the efficacy of mammography in the detection of early breast carcinoma at an urban teaching hospital, the results of all breast biopsies performed between 1983 and 1987 that were preceded by mammographic examination were retrospectively reviewed. There were 503 women in this population. Malignancy was detected in 79 cases (15.7%); 21 were in situ and 58 were invasive. Among all nonpalpable malignancies, 53.0 per cent were in situ, while only 2.4 per cent of all palpable malignancies were in situ. An abnormality was found in 374 mammograms (74%), and 73 (19.5%) were malignant. The abnormality most likely to represent a malignancy (44% yield) was spiculated density, followed by clustered microcalcifications (25%), mass (22%), and asymmetric density (14%). Six malignancies were detected by biopsy for clinical indications, despite a negative mammogram (4.7% false- negative rate). The interpretation of mammograms by radiologists carried a 2.4 per cent false-negative rate. The mammographic features of mass, clustered microcalcifications, spiculations or asymmetric density should generally mandate breast biopsy, although the clinical examination should remain an important basis for management decisions. An aggressive approach toward screening mammography and breast biopsy based on mammographic criteria may enhance survival among women with breast carcinoma.

Superiority of end-diastolic volume and ejection fraction measurements over wedge pressures in evaluating cardiac function during aortic reconstruction.

Marked changes occur in cardiac function during aortic reconstruction. Numerous factors (primarily compliance changes) limit the currently used pressure-based pulmonary artery catheters' ability to reflect these changes accurately. A new pulmonary artery catheter was used in 26 patients undergoing aortic reconstruction (7 patients with abdominal aortic aneurysms and 19 with occlusive disease) that directly measures right ventricular (RV) volumes and ejection fractions. The extent of coronary artery disease (CAD) was evaluated before surgery, and the patients were divided into three classes. The greatest changes in cardiac function were noted immediately after aortic cross-clamping. Cardiac output significantly decreased in patients with mild or moderate CAD (p less than 0.01 and p less than 0.001) but not in patients with no CAD (p less than 0.5). This correlated well with RV end-diastolic volume (RV-EDV) and stroke volume (RV-SV) measurements in the groups with mild (p less than 0.05) and moderate CAD (p less than 0.01) but not in the group with no CAD (p greater than 0.5). Wedge pressure showed poor correlation, with no significant change noted in any group (p greater than 0.5). Measurements taken later in the procedure documented a significant trend toward baseline in mild and moderate groups. At the opening of the second limb of the graft, the compensated values (CO, RV-EDV, and RV-SV) did not change significantly in the groups with mild and no CAD (p greater than 0.2) but approached significance in the group with moderate CAD (p less than 0.08).(ABSTRACT TRUNCATED AT 250 WORDS)

Nonoperative observation of clinically occult arterial injuries: a prospective evaluation.

Forty-seven patients with 50 clinically occult injuries of major arteries were studied prospectively to determine the natural history of these lesions and the safety of nonoperative management. Penetrating trauma was the predominant mechanism and lower extremity arteries were most commonly involved. The morphology of these arterial injuries included 22 cases of intimal flaps, 21 cases of segmental arterial narrowing, 6 pseudoaneurysms, and 1 acute arteriovenous fistula. There was one death as a result of unrelated causes and another three injuries operated on immediately after arteriographic diagnosis. The remaining 46 injuries were followed up nonoperatively by serial arteriography (39) or clinical examination (7) during a mean interval of 3.1 months (range, 3 days to 27 months). Complete resolution was documented for 29 injuries (63%), whereas 3 improved, 9 remained unchanged, and 5 worsened during the period of follow-up. All worsened cases involved small or occult pseudoaneurysms that subsequently enlarged and then underwent immediate surgical repair without subsequent morbidity. Because 89% of the followed injuries never required surgery, nonoperative observation appears to be a safe and effective management option for clinically occult arterial injuries.

Breast biopsy. Changing patterns during a five-year period.

The current emphasis on early detection of breast carcinoma prompted an analysis of all breast biopsies performed at an urban teaching hospital between January 1, 1983, and December 31, 1987. There were 1,342 biopsies during this interval in 933 patients with an overall mean age of 45.3 years. Malignancy was diagnosed in 197 patients (14.7%) with a mean age of 57.5 years, while the remaining patients with a benign diagnosis had a mean age of 43.2 years. There were 178 nonpalpable lesions (13.3%) and 22 malignancies were detected in this group (12.4%). Most (91%) of the nonpalpable malignancies were "early" (in situ and stage I), while 71 per cent of the palpable malignancies were "advanced" (stages II and III). Although the yearly number of biopsies remained constant, upward trends were demonstrated in the number of nonpalpable lesions biopsied, the proportion of malignancies detected among all biopsies, and in the yield of proliferative benign forms of breast disease, specifically those with atypia. These trends correlated with a sixfold increase in the yearly number of mammograms performed over the same time interval. These results suggest that a commitment to an expanded use of mammography and to an aggressive approach to breast biopsy can increase the detection of both early forms of breast carcinoma and those benign breast lesions that are known pathologic risk determinants for breast carcinoma. Such a commitment may influence the future survival of this population.

New perspectives on the management of penetrating trauma in proximity to major limb arteries.

Current management of penetrating injuries in the proximity of major extremity arteries with no evidence of vascular trauma remains controversial. A total of 318 such injuries in 254 patients were evaluated prospectively to clarify the appropriate timing and role of arteriography, as well as the natural history of these injuries. The arteries at risk were: axillary, 47; brachial, 57; superficial femoral, 176; and popliteal, 38. No deaths occurred, and no morbidity resulted from arteriographic delay of 6 to 24 hours after injury. Of the 48 arteriographic abnormalities detected, 16 involved noncritical branch vessels. There were 32 injuries to major arteries (10.0%), including localized narrowing (n = 13), intimal flap (n = 12), false aneurysm (n = 6), and arteriovenous fistula (n = 1). Shotgun wounds led to a greater arterial injury rate (3/17; 17.6%) than did gunshot wounds (24/247; 9.7%) or stab wounds (5/54; 9.3%). At the surgeon's discretion, three injuries underwent immediate exploration (one negative), whereas the remaining 29 vessel injuries were followed up nonoperatively by repeat arteriography (n = 22) or clinical examination (n = 7), for a mean interval of 2.8 months. Fifteen abnormalities resolved, 10 improved or remained unchanged, and 4 worsened. The four lesions (13.7%) that worsened (two shotgun and two axillary artery injuries) were identified within 3 months of injury and repaired surgically with no morbidity. In conclusion, only 6 operations were required out of 3218 potential injuries (1.8%), suggesting that routine arteriography is not a cost-effective means of evaluating these injuries.(ABSTRACT TRUNCATED AT 250 WORDS)

A reassessment of the role of arteriography in penetrating proximity extremity trauma: a prospective study.

Penetrating proximity extremity trauma (PPET) was prospectively studied to clarify the role of routine arteriographic evaluation (AG). Over a 24-month period, 135 patients were identified with 152 injuries from PPET. All patients underwent AG and were randomized to either immediate or delayed timing. There were 27 arteriographic abnormalities from these 152 wounds, of which 16 (10.5%) were in major arteries. One acute arteriovenous fistula underwent immediate surgery. The remaining 15 major vessel injuries were nonoperatively observed, including seven cases of segmental arterial narrowing, six intimal flaps, and two small pseudoaneurysms (one of which enlarged and underwent surgical repair after 10 weeks of followup). Nine of the remaining 14 lesions resolved; two improved and three remained clinically unchanged over a mean followup interval of 2.7 months. Shotgun trauma was the mechanism which carried the greatest risk of significant vascular injury. Although "soft" clinical signs were significantly more predictive of vascular injury following PPET than proximity alone (p less than 0.0005), 50% of all injuries to major arteries did not manifest soft signs. No extremity morbidity resulted from delayed AG or from vascular injury management. We conclude from our study population: 1) the natural history of clinically occult arterial injuries was predominantly benign; 2) AG could be safely delayed up to 24 hours; 3) "soft" signs were not clinically useful predictors of vascular injury; and 4) with the exception of shotgun wounds, AG did not appear to be a cost effective screening modality, since detection of a single vascular injury requiring surgery cost $66,420.00.

Analysis of multiple organ system failure in trauma and nontrauma patients.

Multiple organ failure (MOF), a syndrome of recent evolution, has resulted from advancements in both surgical and trauma care. A prospective study of organ failure (OF) was conducted for 203 consecutive admissions to the surgical intensive care unit (SICU) between September 1986 and June 1987. Diagnosis, operations, age, OF, outcome, and culture data were recorded for each patient. OF definitions consistent with the literature were used to identify pulmonary, renal, hepatic, cardiovascular (CVS), gastrointestinal (GI), hematologic-coagulation, and central nervous system (CNS) failure. Eighty-two patients developed OF (40.4% incidence). The distribution of OF was 65 per cent trauma (T) and 35 per cent nontrauma (NT). Combined mortality for OF was 46 per cent (T = 34% and NT = 69%). The mortality of organ failure increased with the number of failed systems in the total population as well as in both T and NT groups. For the total population, the mortality by number of systems failed was no system, 1.3 per cent; one system, 13 per cent; two systems, 34.5 per cent; three systems, 75 per cent; four or more systems, 92.9 per cent. The incidence and mortality for each system is listed. Sepsis occurred in 62.1 per cent of NT patients (88.9% mortality) and in 30.2 per cent of T patients (31.3% mortality). Mortality was weakly associated with age in groups matched for severity of OF.