Repeat colonoscopy after endoscopic polypectomy.

The records of all patients undergoing endoscopic polypectomy between December 1979 and December 1982 were reviewed. One hundred seventy-two patients underwent colonoscopic polypectomy in the absence of carcinoma or inflammatory bowel disease. Of these, the polyp could not be retrieved in 4, and 19 were lost to follow-up. One hundred forty-nine patients underwent subsequent endoscopy from one to four years after the initial polypectomy. Seventy-five (50.3 percent) of the patients developed new polyps. Although 61 of the 75 patients with new polyps were identified in the first two years, new polyps were noted throughout all four years. The presence of multiple polyps on the initial examination was statistically significant in predicting new polyps. The age and sex of the patients, size of the polyps, and the presence of atypia did not identify patients at higher risk for new polyps. The data indicate that new polyps are more likely to develop in patients who had a previous polyp. It would appear that annual examinations should be performed until two successive examinations are negative. Following a second negative examination, reexamination at two- or three-year intervals, unless symptomatic, would appear to be adequate.

Minimal incision closing base wedges. Transpositional axis rotation deformity correction.

The closing base wedge osteotomy will consistently yield excellent prognostic results when performed as described. The technique should be used when an angular change at the first metatarsal base is needed in any direction.

Telescoping anastomosis of the colon: a comparative study.

The incidence of large-intestinal anastomotic leaks remains unacceptably high. For this reason, we studied the resistance to dehiscence of a telescoping type of anastomosis and compared it with the conventional one-layer, two-layer, and stapled anastomoses in a canine model. These experiments demonstrated that the telescoping anastomosis provided a more resistant suture line during the early postoperative phase and did not cause encroachment of the lumen by the diaphragm, which was consistently produced when an inverting suture line was used. Three days postoperatively the mean bursting pressures of the one-layer, two-layer, and stapled anastomoses were 31 +/- 12, 120 +/- 46, and 52 +/- 21 mm Hg, respectively. The telescoping anastomosis had a mean bursting pressure of 210 +/- 44 mm Hg, which was significantly (P less than 0.01) higher than those of all the other anastomoses tested. However, seven and 14 days after operation, there was no statistically significant difference among the bursting pressures of the various anastomoses. When the different types of anastomoses were examined histologically, it was found that there was considerably more suture-line inflammation, edema, micro-abscess formation, mucosal ulceration and pericolic inflammation of the fat in the one-layer, two-layer, and stapled anastomoses than in the telescoping anastomosis.

Bowen's disease of the anal and perianal area. A report and analysis of twelve cases.

Retrospective evaluation of twelve patients treated at the Cleveland Clinic for perianal Bowen's disease showed that these patients can be cured by wide local excision with skin grafting when necessary. No recurrence or metastasis was found during the follow-up period when the systematic technic was used. Only involved anal mucosa was removed, and normal mucosa was preserved; this aids in controlling anal continence. The margins of the resected skin must be subjected to frozen section study to be sure that total excision has been achieved. In this study a diagnosis of perianal Bowen's disease was made incidentally in six of the twelve patients during histologic examination of anorectal tissue removed for other reasons. Seven of the twelve either had had a systemic or cutaneous cancer previously or another systemic or cutaneous cancer subsequently developed, indicating the high association between Bowen's disease and other cancers. Therefore, it is important that all excised skin from anal or perianal operations be submitted for histologic examination, and if the diagnosis is Bowen's disease, the lesion must be completely removed using wide local excision. These patients should be evaluated and followed up because other malignancies may be present or evolve at a later time.

Cimetidine, carbenoxolone sodium, and antacids for the prevention of experimental stress ulcers.

Cimetidine, an H2-receptor, antagonist, and carbenoxolone sodium, a drug used to stimulate gastric mucus synthesis and increase the life span of gastric epithelial cells, were studied to determine their possible prophylactic effect on the formation of stress ulcers, gastric transmucosal potential difference and gastric pH in rats, using a restraint stress model. The number of ulcers substantially decreased in the rat groups receiving either cimetidine or carbenoxolone pretreatment for two or more days before stress. When the drugs were used in combination, there was an additive effect, since there was a significant decrease in ulcer formation even after half a day of pretreatment. When antacids were used, there was also decreased ulcer formation with half a day of pretreatment. Gastric pH was significantly increased from control levels in all the groups treated with antacid, cimetidine and carbenoxolone. Both cimetidine and carbenoxolone, either alone or in combination, prevented the decrease in potential difference that was produced in the untreated stressed rats. This study suggests that either cimetidine or carbenoxolone, and particularly their combination, may be a useful prophylactic regimen for the prevention of stress ulceration in patients subjected to severe stress.

Gangrene of the stomach: a case of acute necrotizing gastritis.

Of the several causes of gastric necrosis, the rarest is acute necrotizing gastritis which appears to be a variant of phlegmonous gastritis. In acute necrotizing gastritis all four major gastric vessels are patent, but gastric gangrene occurs secondary to an over-whelming necrobiotic infection. The case presented herein is of unusual interest because it appears to be only the third reported case of acute necrotizing gastritis with overt gangrene of the stomach. Review of the literature on suppurative gastritis emphasizes the rarity and high morbidity of acute necrotizing gastritis; the patient reported on in this study, however, survived after subtotal gastrectomy and antibiotic therapy. It is our opinion that debridement by gastrectomy must be performed in those patients with transmural, diffusely infected, nonviable gastric tissue.

Ileorectal anastomosis for inflammatory disease of the colon.

We have reported long-term results in the cases of 42 patients following total colectomy and ileorectal anastomosis for inflammatory bowel disease. In this group, 35 patients had Crohn's disease and seven had ulcerative colitis. Five of those seven patients with ulcerative colitis had carcinoma of the colon at the time of colectomy. A diverting loop ileostomy was constructed in 14 of the 35 patients who had Crohn's colitis at the time of operation, and none of these patients had any anastomotic leakage either before or after the ileostomy was closed. However, there patients with Crohn's colitis in whom anastomotic leaks developed postoperatively; all three patients died. In the group with ulcerative colitis, one patient had an anastomotic leak but there was no operative nortality. Of the 29 patients with Crohn's disease followed for one to 18 years, 12 (41 per cent) developed recurrences in the ileum and/or rectum, and seven of these patients had to have their anastomoses taken down.

The surgical management of toxic dilatation of the colon: a report of 28 cases and review of the literature.

Experience with 28 patients with toxic dilatation of the colon is reviewed. The operative mortality in this series was 32% (9/28). Eight of the 9 patients who died were found to have colonic perforations at operation; in contrast, the group of patients with no perforations had a mortality rate of only 6%. Colonic perforation and sepsis were the most significant factors contributing to mortality and morbidity in this series. A review of the literature showed an overall operative mortality rate of 19.5% for patients with toxic megacolon; the mortality rate was 41% for patients with perforations and 8.8% for patients without perforations. It appears that the keystone to successful management is the avoidance of colonic perforation and sepsis; protracted medical management of toxic megacolon seems to have been at least partly responsible for these complications. Sixteen of the 18 survivors following subtotal colectomy required removal of the rectum within 9 months because of continued symptoms and disease in the rectal stump.