The fate of retained gallstones following laparoscopic cholecystectomy in a prairie dog model.

BACKGROUND AND OBJECTIVES: Reported complications of retained gallstones following laparoscopic cholecystectomy (LC) are increasing. This study was undertaken to evaluate the effects of retained gallstones following LC in a prairie dog model. METHODS: Twenty-seven prairie dogs with diet-induced gallstones were divided into three groups of nine. Group I (control) had LC with removal of stones. Group II had LC followed by return of native stones intra-abdominally. Group III had LC followed by return of infected stones (stones dipped in Escherichia coli) intra-abdominally. Animals were euthanized at two months and the character and extent of intra-abdominal adhesions were scored. RESULTS: Adhesions were present in 56% of animals in Group I, 89% in Group II, and 100% in Group III. The character and extent of adhesions in groups II & III were significantly greater than the control group (p < 0.03). Group III exhibited the highest degree of adhesions when compared to control (p < 0.007). Histopathology revealed evidence of micro-abscess formation, foreign body giant cell reaction, and fat necrosis adjacent to retained stones. CONCLUSION: Retained intra-abdominal gallstones, especially if infected, are associated with increased adhesions and inflammatory response in this LC model. Further investigation into the long-term consequences of this entity is warranted.

Dysplasia in chronic ulcerative colitis: implications for colonoscopic surveillance.

Mucosal dysplasia has been used as a marker for patients with chronic ulcerative colitis considered to be most at risk of developing cancer, and its identification is the basis for colonoscopic surveillance programs. To evaluate the reliability of this premise, colectomy specimens from two groups of patients who had undergone surgery for chronic ulcerative colitis (50 with cancer and 50 without) were retrieved. The groups were matched by age, sex, duration of disease, disease extent, and symptoms at the time of surgery. Using a standard technique of multiple random biopsies, we utilized the standard colonoscopic biopsy forceps to obtain four biopsies from mucosa that was not macroscopically suspicious for dysplasia or cancer in eight defined regions in each of the 100 colon specimens. This technique mimicked exactly the methods used in our clinical surveillance program. All 3,200 biopsies were evaluated blindly by one pathologist for presence and grade of dysplasia. Twenty-six percent of colons with an established cancer harbored no dysplasia in any biopsy from any region in the colon. While an overall association between the presence of cancer and high-grade dysplasia was detected (relative risk = 9.00; 95 percent CI of 2.73-29.67), the sensitivity and specificity of random colonic biopsies to detect concomitant carcinoma were 0.74 and 0.74, respectively. These findings prompt concern that reliance on random biopsies, obtained during colonoscopic surveillance, may be misplaced.

Transcatheter embolization of small bowel anastomosis: a case report and review of the literature.

A 45-year-old woman underwent exploratory laparotomy for recurrent intra-abdominal abscesses subsequent to a sigmoid resection for diverticulitis. Her postoperative course was complicated by massive hemorrhage from a small bowel anastomosis, which was successfully managed with transcatheter embolization. To our knowledge, this report documents only the second recorded successful embolization of a bleeding small bowel anastomosis. In certain high-risk patients, transcatheter embolization may be considered a useful adjunct in the management of gastrointestinal hemorrhage including anastomotic bleeding.

Ileal pouch-anal anastomosis: comparison of results in familial adenomatous polyposis and chronic ulcerative colitis.

The aim of this study was to compare the immediate postoperative results and the long-term outcome of ileal pouch-anal anastomosis in 94 patients with familial adenomatous polyposis to those in 758 patients with ulcerative colitis. Two colitis patients died after operation (0.3%), but no polyposis patients died. Overall operative complications appeared in 26% and 29% of polyposis and colitis patients, respectively (NS). Reoperation for intestinal obstruction did not differ between the two groups, but sepsis requiring reoperation was more common in colitis patients (6%) than in polyposis patients (0%, p less than 0.04). At follow-up (mean, 3 years), polyposis patients had fewer daytime stools (4.5 stools per day), less nighttime fecal spotting (26%), and less pouchitis (7%) than colitis patients (5.8 stools per day; spotting, 40%; pouchitis, 22%; p less than 0.002). The conclusion was that polyposis patients tolerated the operation better and had less long-term disability than did colitis patients. The data suggest that postoperative sepsis, daytime stooling frequency, nocturnal incontinence, and pouchitis may be, at least in part, disease related and not surgeon or operation related.

Piles of defeat. Napoleon at Waterloo.

Major events of history have frequently turned on seemingly trivial matters. One such situation involves Napoleon Bonaparte at Waterloo. Napoleon was not feeling well on the day of the battle of Waterloo, despite fighting well at Ligny, a few days before the last, dramatic June 18 battle. There is considerable indication that Napoleon was bothered by very painful thrombosed hemorrhoids. Did this affect his generalship that day? What is the evidence that Napoleon was afflicted with thrombosed hemorrhoids? What contribution could this factor have made to the French defeat at Waterloo?

The ileal pouch-anal anastomosis: surgical technique and current clinical results.

During the six-year period between January 1981 and January 1987, 582 ileal pouch-anal anastomoses were constructed at the Mayo Clinic-affiliated hospitals for either ulcerative colitis (509 patients) or polyposis coli (71 patients). Two patients had Crohn's disease. Two patients died postoperatively. Pelvic sepsis, intestinal obstruction, and pouchitis were seen in 4%, 13%, and 14%, respectively. At one year postoperatively, the mean number of stools was 5.6 during the day and 1.5 during the night. Younger patients and those with polyposis had fewer stools. Incontinence was observed in 2% patients during the day and 3% during the night. Ileal pouch-anal anastomosis is safe, provides satisfactory continence, and improves the quality of life of patients who require proctocolectomy.

Surgical alternatives in the treatment of polyposis coli.

The history of familial polyposis coli and its various surgical treatment alternatives are presented. Each form of treatment has advantages and disadvantages. The menu of alternatives allows the surgeon the freedom to choose the best option for each patient.