Ileal pouch fistulas after restorative proctocolectomy: management and outcomes.

BACKGROUND: Fistula between an ileal pouch and the vagina, anus, or perineum is an uncommon complication of ileal pouch-anal anastomosis and is a cause of considerable morbidity. Its optimal management has not been determined because of its low incidence. The aim of this study was to review the outcomes of patients who presented with symptomatic ileal pouch-associated fistulas after restorative proctocolectomy (RPC) and to present a diagnostic and treatment algorithm. METHODS: Retrospective review of patients treated for symptomatic ileal pouch-associated fistulas after RPC from 1989 to 2011. RESULTS: Twenty-five patients (14 men, mean age 40 years) were presented with symptomatic ileal pouch-associated fistulas. Median time to pouch fistula following RPC was 6.9 years (range 1 month-20 years). Fistulas were classified as pouch-anal (n = 12, 48 %), pouch-vaginal (n = 7, 28 %), complex (n = 4, 16 %), and pouch-perineal (n = 2, 8 %). Etiology included Crohn's disease (n = 15, 60 %), cryptoglandular (n = 6, 24 %), and anastomotic failure (n = 4, 16 %). Each patient underwent an average of 2.8 local procedures or repairs. Overall healing rate was 64 % at a median follow-up of 29 (range 2-108) months. None of the complex fistulas were healed. Postoperative pelvic sepsis, fecal diversion, anti-tumor necrosis factor therapy, and fistula etiology did not significantly impact fistula healing. Three patients required pouch excision with end ileostomy. CONCLUSIONS: Operative treatment of pouch fistulas after RPC resulted in complete healing in 64 % of patients following a stepwise diagnostic and therapeutic approach.

Results of combined medical and surgical treatment of recto-vaginal fistula in Crohn's disease.

AIM: Surgical repair of recto-vaginal fistula (RVF) in Crohn's disease (CD) has been associated with high rates of failure. The aim of this study was to compare the outcome in patients with CD who underwent RVF surgery with or without infliximab infusion. METHOD: A retrospective review was carried out of 51 consecutive patients with CD treated for a symptomatic RVF between March 1998 and December 2004. RESULTS: Fifty-one patients (mean age 39 years) underwent 65 procedures, including seton drainage (n = 35), advancement flap (n = 8), fibrin glue injection (n = 8), transperineal repair (n = 6), collagen plug placement (n = 4) and bulbocavernosus flap (n = 4). All patients were on medical treatment at the time of surgery and 26 patients had received preoperative infliximab treatment (minimum of three infusions, 5 mg/kg). Ten patients underwent preoperative diversion. At a mean follow up of 38.6 months, 27 fistulas (53%) had healed and 24 (47%) had recurred. Fistula healing occurred in 60% of patients treated with preoperative diversion, whereas 51% of nondiverted repairs were successful. Neither active proctitis nor infliximab therapy significantly affected fistula healing. Fourteen (27%) patients eventually required proctectomy. CONCLUSION: RVF in CD is difficult to treat. Failure rates are significant despite repeated surgical interventions and concomitant medical treatment.

Blastomyces dermatitidis of the perianal skin: report of a case.

Isolated fungal infections of the perianal skin are rare and their diagnosis is frequently overlooked. We report a case of a 78-year-old male patient who presented with a friable, violaceous, papulopustular lesion, with heaped-up edges along the anal verge. Biopsy revealed unicellular yeast consistent with blastomycosis. The patient was treated with itraconazole with resolution of this lesion. An extensive MEDLINE literature review from 1958 to the present indicates that this is an uncommon manifestation of cutaneous blastomycosis. A summary of the medical literature is presented with a review of the characteristics, diagnosis, and management of blastomycosis.

Assessment: transcranial Doppler ultrasonography: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology.

OBJECTIVE: To review the use of transcranial Doppler ultrasonography (TCD) and transcranial color-coded sonography (TCCS) for diagnosis. METHODS: The authors searched the literature for evidence of 1) if TCD provides useful information in specific clinical settings; 2) if using this information improves clinical decision making, as reflected by improved patient outcomes; and 3) if TCD is preferable to other diagnostic tests in these clinical situations. RESULTS: TCD is of established value in the screening of children aged 2 to 16 years with sickle cell disease for stroke risk (Type A, Class I) and the detection and monitoring of angiographic vasospasm after spontaneous subarachnoid hemorrhage (Type A, Class I to II). TCD and TCCS provide important information and may have value for detection of intracranial steno-occlusive disease (Type B, Class II to III), vasomotor reactivity testing (Type B, Class II to III), detection of cerebral circulatory arrest/brain death (Type A, Class II), monitoring carotid endarterectomy (Type B, Class II to III), monitoring cerebral thrombolysis (Type B, Class II to III), and monitoring coronary artery bypass graft operations (Type B to C, Class II to III). Contrast-enhanced TCD/TCCS can also provide useful information in right-to-left cardiac/extracardiac shunts (Type A, Class II), intracranial occlusive disease (Type B, Class II to IV), and hemorrhagic cerebrovascular disease (Type B, Class II to IV), although other techniques may be preferable in these settings.

Transanal excision for T1 and T2 rectal cancer--efficacy of local resection vs. adjuvant therapy. Extended abstract.

The principal goal in the management of any patient with rectal cancer is to provide the optimum chance for cure while maintaining their quality of life. Treatment options over the past century have reflected our ability to provide safe surgical care and, more recently, a greater understanding of tumor biology. Prior to the introduction of the abdominoperineal resection (APR) that was reported in the Lancet in 1908 by Sir Ernest Miles, perineal excision was the accepted approach for nearly all rectal cancer. Unfortunately, inconsistent surgical outcomes and high local recurrence even in Miles personal experience promoted alternative treatment. The acceptance of APR and subsequently low anterior resection reduced recurrence and improved long-term survival but often with the cost of decreased quality of life. A recent review by McCall et al. report disease specific recurrence at 8.5 percent, 16.3 percent and 28.6 percent for cancer stages I, II and III respectively with an overall reported recurrence rates following APR ranging from 10 to 29 percent. Reported five-year survival rates range 78 to 100 percent for stage I, 45 to 73 percent for stage II and 22 to 66 percent for stage III. The wide variations in recurrence and survival rates likely reflect differences in tumor size, proximity to the anal canal, depth of penetration in the rectal wall and unfavorable histologic characteristics. An additional confounding variable in the management of rectal cancer has been the use of adjuvant therapy do in part to the timing and dose/fractionation differences utilized. Given the variation in outcomes with APR and ongoing concerns regarding morbidity and quality of life issues associated with radical resection, many centers have revisited local therapy as a means of managing select patients with distal rectal cancers. These therapies include transanal and transcoccygeal excision as well as endocavitary radiation and even fulguration. It is the belief of many surgeons that our ability to more accurately stage patients preoperatively and add adjuvant therapy when indicated will improve our success with local excision.

Association of intraoperative transcranial doppler monitoring variables with stroke from carotid endarterectomy.

BACKGROUND AND PURPOSE: The outcomes of carotid endarterectomy (CEA) are, in addition to patient baseline characteristics, highly dependent on the safety of the surgical procedure. During the successive stages of the operation, transcranial Doppler (TCD) monitoring of the middle cerebral artery (MCA) was used to assess the association of cerebral microembolism and hemodynamic changes with stroke and stroke-related death. METHODS: By use of data pooled from 2 hospitals in the United States and the Netherlands, including 1058 patients who underwent CEA, the association of various TCD emboli and velocity variables with operative stroke and stroke-related death was evaluated by univariable and multivariable logistic regression analyses in combination with receiver operating characteristic (ROC) curve analyses. The impact of basic patient characteristics, such as age, sex, preoperative cerebral symptoms, and ipsilateral and contralateral internal carotid artery stenosis, on the prediction of operative stroke was also evaluated. RESULTS: We observed 31 patients with ischemic and 8 patients with hemorrhagic operative strokes. Four of these patients died. Emboli during dissection (odds ratio [OR] 1.5, 95% CI 0.8 to 2.9) and wound closure (OR 2.3, 95% CI 1.2 to 4.4) as well as > or =90% decrease of MCA peak systolic velocity at cross-clamping (OR 3.3, 95% CI 1.3 to 8.5) and > or =100% increase of the pulsatility index of the Doppler signal at clamp release (OR 7.1, 95% CI 1.4 to 35.7) were independently associated with stroke. The ROC area of this model was 0.69. Of the patient characteristics, only preoperative cerebral ischemia (OR 1.9, 95% CI 1.0 to 3.7) and > or =70% ipsilateral internal carotid artery stenosis (OR 0.5, 95% CI 0.2 to 0.9) were associated with stroke. Adding these patient characteristics to the model, the area under the ROC curve increased to 0.73. CONCLUSIONS: In CEA, TCD-detected microemboli during dissection and wound closure, > or =90% MCA velocity decrease at cross-clamping, and > or =100% pulsatility index increase at clamp release are associated with operative stroke. In combination with the presence of preoperative cerebral symptoms and > or =70% ipsilateral internal carotid artery stenosis, these 4 TCD monitoring variables reasonably discriminate between patients with and without operative stroke. This supports the use of TCD as a potential intraoperative monitoring modality to alter the surgical technique by enhancing a decrease of the risk of stroke during or immediately after the operation.

Transcranial Doppler ultrasonography: year 2000 update.

In this update, the main clinical applications of transcranial Doppler ultrasonography are reassessed. A specific format for technology assessment, personal experience, and an extensive review of the literature form the basis of the evaluation. The document is approved by the American Society of Neuroimaging and the Neurosonology Research Group of the World Federation of Neurology.

Time-scale detection of microemboli in flowing blood with Doppler ultrasound.

Small formed elements and gas bubbles in flowing blood, called microemboli, can be detected using Doppler ultrasound. In this application, a pulsed constant-frequency ultrasound signal insonates a volume of blood in the middle cerebral artery, and microemboli moving through its sample volume produce a Doppler-shifted transient reflection. Current detection methods include searching for these transients in a short-time Fourier transform (STFT) of the reflected signal. However, since the embolus transit time through the Doppler sample volume is inversely proportional to the embolus velocity (Doppler-shift frequency), a matched-filter detector should in principle use a wavelet transform, rather than a short-time Fourier transform, for optimal results. Closer examination of the Doppler shift signals usually shows a chirping behavior apparently due to acceleration or deceleration of the emboli during their transit through the Doppler sample volume. These variations imply that a linear wavelet detector is not optimal. We apply linear and quadratic time-frequency and time-scale detectors to a set of noise-corrupted embolus data. Our results show improvements of about 1 dB using the time-scale detectors versus an STFT-based detector signifying that embolus detection is best approached as a time-scale problem. A time-scale-chirp detector is also applied and is found to have the overall best performance by about 0.5-0.7 dB while coming fairly close (about 0.75 dB) to a theoretical upper bound.

A clinical comparison of Dacron patch closure of small-caliber carotids compared with primary closure of large-caliber carotids after endarterectomy.

The objective was to study results of carotid endarterectomies performed between 1975 and 1991, comparing primary closure to Dacron patch closure. This was a retrospective study. Data from patient follow-up by physical examination, chart review, and Duplex study were used. Scan data were obtained in 92 of the primary cases, at a mean of 5 years postoperatively, and in 63 of the patch cases, at a mean of 4.1 years postoperatively. During this period, 269 endarterectomies were closed primarily and 101 were closed with a knitted Dacron patch. Twenty patients in the primary group and nine patients with patch closure were lost to follow-up, which extended for up to 12.5 years, with a mean of 4.7 +/- 3.6 years. No acute closures, infections or aneurysms developed in either group. Perioperative stroke incidence was 4.1 per cent for primary closure and 3.0 per cent for the patch group (P > 0.05). Late stenosis occurred in 17.3 per cent of the primary group and 11.1 per cent of the patch closure group (P > 0.05). Five-year survival was 76.2 per cent in the primary group, compared with 79.2 per cent for patch closure. Late stroke incidence was 2.8 per cent in the primary group and 3.3 per cent in the patch closure group. Results of smaller (< or = 3.5 mm) carotid arteries closed with knitted Dacron patches are equivalent to those of larger carotid arteries closed primarily.

Should patients with combined colonic inertia and nonrelaxing pelvic floor undergo subtotal colectomy?

PURPOSE: Treatment of severe constipation caused by combined colonic inertia and nonrelaxing pelvic floor is controversial. This study is designed to evaluate the outcome of preoperative biofeedback and subtotal colectomy for patients with combined colonic inertia and nonrelaxing pelvic floor. METHODS: One hundred six patients who underwent subtotal colectomy for intractable constipation from 1982 through 1995 answered a detailed questionnaire regarding postoperative bowel function, symptoms of abdominal pain and bloating, and degree of satisfaction after the operation. Sixteen of these patients had a combination of colonic inertia and nonrelaxing pelvic floor diagnosed by transit marker study, electromyography, and defecography. These patients completed preoperative biofeedback training. RESULTS: Electromyographic relaxation of pelvic floor musculature was demonstrated after the biofeedback treatment in all patients, but symptoms of difficult evacuation persisted. Postoperatively, seven patients (43 percent) had complete resolution of symptoms of constipation or difficult evacuation. Six patients still complained of incomplete evacuation that was severe in two and unresponsive to postoperative biofeedback. Three patients (18 percent) complained of diarrhea (>5 bowel movements per day) and incontinence of liquid stools (at least one episode a week). Nine patients (56 percent) were satisfied despite persistent symptoms. CONCLUSIONS: Subtotal colectomy can improve some symptoms in patients with slow transit constipation and nonrelaxing pelvic floor. However, incomplete evacuation persists in a significant number of patients and almost one-half of patients are dissatisfied with their surgery.

The evolving role of transcranial doppler in stroke prevention and treatment.

Without focusing on established indications for transcranial Doppler (TCD) such as monitoring vasospasm after subarachnoid hemorrhage and detecting intracranial stenosis (sickle cell disease, stroke, etc.), we describe the role of TCD in carotid endarterectomy (CEA) and angioplasty, acute ischemic stroke, as well as competence and the practice of TCD. In addition to duplex ultrasound and angiography TCD can be used to select patients for CEA because it detects hemodynamically significant extracranial stenosis and tandem intracranial stenoses, and identifies asymptomatic patients at potentially high risk of stroke because of exhausted vasomotor reactivity or brain microembolization. TCD identifies in real time brain hypoperfusion, embolism, and hyperperfusion and thus may be helpful in reducing cerebrovascular complications of CEA/angioplasty. In acute ischemic stroke, TCD can reliably identify the patency of middle cerebral and basilar arteries, high resistance flow patterns due to increased intracranial pressure, and progression to cerebral circulatory arrest. TCD also can monitor spontaneous or induced arterial recanalization. Limitations include operator and interpreter dependency, absent temporal "windows" leading to unsuccessful insonation in 10% to 15% of patients older than 60 years, as well as difficulties with probe positioning and fixation for monitoring. However, the use of ultrasound contrast agents and improved probe fixation devices help avoid these factors. The key to the successful practice of TCD is training of technical personnel and education of the interpreting and referring physicians as to when to use TCD and what to expect from it. The advantages of TCD should be given particular consideration: portability, repeatability, long-term monitoring, emboli detection, and inexpensiveness. TCD machines and transducers need to be tuned to the target disorders; that is, larger sample volume, higher power, and so forth, and TCD technology should be implemented in phases I to II as well as in phase III trials of preventive interventions and stroke therapies.

Influence of oxygen ventilation on Doppler microemboli signals in patients with artificial heart valves.

BACKGROUND AND PURPOSE: The purpose of this study was to evaluate the influence of inhalation of 100% oxygen on microembolic signal (MES) counts in patients with artificial cardiac valves. METHODS: A total of 134 outpatients were examined. Transcranial Doppler baseline monitoring (45-minute duration) was performed in all patients under resting conditions. The first 30 patients subsequently underwent transcranial Doppler monitoring for at least 20 minutes under noninvasive positive pressure ventilation with 100% oxygen and for an additional 30 minutes under resting conditions. The same protocol was applied to all following patients with a baseline MES count > or = 10, while the examination was discontinued in the remaining patients. RESULTS: Baseline MES counts < 10, which remained unchanged during oxygen inhalation and the subsequent resting period, were observed in 26 of 30 initial patients. A total of 46 patients with MES counts > or = 10 were identified. Oxygen application was feasible in 43 patients. An exponential MES decrease was noted in 42 patients during oxygen inhalation (statistically significant in 38 patients), followed by a subsequent increase in 38 of 43 patients (statistically significant in 25 patients) under resting conditions. CONCLUSIONS: The exponential reduction of MES counts observed in this study corresponds to blood denitrogenation, thus strongly arguing for nitrogen bubbles as underlying embolic material in prosthetic valve carriers.

Computed tomography-guided percutaneous abscess drainage in intestinal disease: factors associated with outcome.

PURPOSE: This study was designed to assess the efficacy of computed tomography-guided percutaneous abscess drainage in intestinal disease. METHODS: Retrospective chart review of patients who underwent percutaneous abscess drainage for complications of intestinal disease with or without surgery between 1990 and 1994. RESULTS: Eighty-two patients with 111 abscesses were identified. Causes of abscess included anastomotic leaks (35 percent), postoperative complications without leak (30 percent), and diverticular disease (23 percent). Complete success (no surgery necessary) was achieved in 53 of 82 patients (65 percent). Nine patients (11 percent) who underwent interval surgery were classified as having partial successes. Twenty-six of 26 (100 percent) well-defined unilocular collections containing pus were successfully drained. Complex abscesses (loculated, poorly defined, multiple, associated with fistula, draining feces) were successfully drained in 35 of 55 patients (63 percent). Success rates varied inversely with the number of complicating factors present. Apache II scores of 15 or higher were associated with decreased success rates. CONCLUSION: Percutaneous abscess drainage is a highly successful technique for treatment of patients with intra-abdominal infection related to intestinal disease. Although several factors are associated with decreased success rates and multiple complicating factors combine to reduce success rates, no identifiable factor or combination of factors preclude the possibility of a successful outcome.

Transcranial Doppler monitoring and causes of stroke from carotid endarterectomy.

BACKGROUND AND PURPOSE: The value of carotid endarterectomy (CEA) depends on the safety of the operation. Transcranial Doppler ultrasound (TCD) was used to evaluate the possibilities of hypoperfusion, hyperperfusion, and embolization as causes of stroke and to evaluate the significance of Doppler microembolic signals (DMES). METHODS: Five hundred CEAs were monitored with TCD of the ipsilateral middle cerebral artery during various phases of CEA to determine hemodynamic changes and incidence of DMES. Complications were graded according to their severity, and their probable cause was determined from TCD criteria and review of hospital charts. RESULTS: We observed 24 cerebrovascular complications (4.8%), including 9 with transient ischemic attacks and 15 (3%) with permanent deficits. Among all cerebrovascular complications, embolism was judged to be responsible in 13 (54%; P < .02 compared with hypoperfusion), hyperperfusion in 7 (29%; P < .14 compared with hypoperfusion), and hypoperfusion in 4 (17%; P < .08 compared with embolism plus hyperperfusion). The surgeons responded to TCD information by several strategies depending on the TCD information. The incidence of permanent deficits diminished from 7% in the first 100 operations to 2% in the last 400 (P < or = .01). Shunting was more strongly associated with cerebrovascular complications than nonshunting, but this difference was not significant (P = .24). Intraoperative prevalence of DMES was strongly associated with cerebrovascular complications (P = .02). CONCLUSIONS: Embolism is the principal cause of cerebrovascular complications from CEA; hyperperfusion and hypoperfusion are also important causes. TCD provides information that allows prompt identification and treatment of these three major causes of stroke from this operation. The perioperative stroke rate can be reduced by appropriate measures, taken by the surgeons, based on findings of TCD monitoring.

Transcranial Doppler intraoperative monitoring during carotid endarterectomy: experience with regional or general anesthesia, with and without shunting.

To determine whether continuous transcranial Doppler (TCD) can significantly alter therapeutic conduct during carotid endarterectomy, a retrospective study of 117 carotid endarterectomies was done. There was no perioperative mortality; one perioperative stroke was recorded in a patient who was symptomatic preoperatively. Continuous TCD of the ipsilateral middle cerebral artery (MCA) was attempted in 99 cases, and successful in 90; nine patients (9.1%) had inadequate temporal windows for MCA access. MCA velocities and emboli were recorded before and during carotid cross-clamping, and on clamp release. There were no significant velocity differences between the patients with regional and general anesthesia, and patients with and without carotid shunts, but there was a statistically significant difference in the total number of emboli (air and particulate transients) noted for the shunted and nonshunted patients after clamp release: 12.7 versus 23.6, respectively (p = 0.05). There was no significant difference when particulate and air microemboli were compared. During surgery TCD identified residual flow of less than 40% in the MCA in 17 patients (18.8%). TCD also identified hyperperfusion in two patients, shunt abnormalities in three patients, and influenced postop treatment in four patients, one of whom was returned to surgery. TCD is an important tool for identifying patients who would benefit from a shunt, preventing hyperperfusion, identifying postop emboli, and detecting technical errors.

Prevalence of plaques and stenoses detectable by echo-Doppler examination in the femoral arteries of an elderly population.

Using echo-Doppler evaluation, we assessed the prevalence of possible atherosclerotic lesions in the common femoral arteries (n = 478) and superficial femoral arteries (n = 478) in 239 subjects (age range 65-94 years) living in retirement houses in Seattle. Ankle pressure was measured with a pneumatic cuff and a continuous wave Doppler. There were 68 individuals with an ankle arm index less than 0.97 and 39 of these with a index below 0.90. An echo-Doppler examination was performed with an Advanced Technologies Laboratories Mark 600 Duplex Scanner. We found 167 (34.9%) common femoral arteries affected by non-stenosing plaque while 19 arteries (4%) had stenosis or occlusion. In addition, 178 (37.2%) superficial femoral arteries showed non-stenosing plaques. The subjects with common femoral disease were 27 (11.3%), those with evidence of superficial femoral artery disease were 48 (20.1%), and those affected by disease in both sites were 84 (35.1%). There were 80 people (33.5%) with no ultrasound evidence of femoral artery disease. We found that the presence and severity of disease increased progressively in the decades 65-74, 75-84 and 85-94. We also demonstrated a positive association between major cardiovascular risk factors and ultrasound evidence of peripheral disease. The prevalence of femoral artery disease in an apparently healthy population was relatively high, although stenoses in most instances were not severe.(ABSTRACT TRUNCATED AT 250 WORDS)

Strictureplasty for obstructive Crohn's disease: the Mayo experience.

BACKGROUND: Strictureplasty for obstructive Crohn's disease of the small bowel continues to gain favor throughout the world. Although the potential advantages of preserving intestinal length are obvious, the optimal clinical setting for performing strictureplasty remains to be determined. PATIENTS: Of 244 patients who underwent abdominal exploration for complications of Crohn's disease between Jan. 1, 1985, and Jan. 1, 1991, at the Mayo Clinic, 35 had a total of 71 strictureplasties. Concomitant resection of bowel with active disease was performed in 67% of the procedures. RESULTS: In this series, no perioperative deaths occurred, and no anastomotic leaks, enteric fistulas, or intra-abdominal abscesses were noted during a 3-year follow-up. The overall perioperative complication rate was 14%. Postoperatively, 33 of the 35 patients were able to resume enteral nutrition and discontinue medical treatments. The symptomatic recurrence rate at 3 years was 20%; six patients have required reoperation. CONCLUSION: These findings support the use of strictureplasty for isolated, quiescent, stenotic bowel lesions associated with Crohn's disease.