Management of colovesical fistulae caused by diverticulitis: 12 years of experience in one medical centre.

BACKGROUND: Diverticulitis can be complicated by a colovesical fistula (CVF). This phenomenon is relatively uncommon in surgical practice. The aim of this study was to evaluate diagnostic and surgical management of CVF at our medical centre. MATERIAL AND METHODS: In this retrospective study, details of 31 patients undergoing surgery for CVF between January 1998 and March 2010 were recorded. These patient records were analysed for presenting symptoms, diagnostic investigations and surgical procedures. RESULTS: The most common presenting symptoms were pneumaturia, urinary tract infections, abdominal pain, and fecaluria. CT identified CVF in 28 patients (92.2%), cystoscopy in 4 patients (23.5%), and barium enema in 3 patients (13.6%). Surgical management was resection of the diseased colon segment with primary anastomosis in 29 of 31 patients. The bladder fistulae were oversewn and an omental plasty was placed between bowel anastomosis and bladder. There was only one postoperative leak and one case of mortality (3.2%). CONCLUSIONS: CT is the most sensitive test in identifying CVF. Resection of the diseased colon segment and primary anastomosis seems to be an effective and safe surgical method for treating CVF. This surgical treatment has an acceptable risk for anastomotic leak and mortality.

Low morbidity and mortality after stenting for malignant bowel obstruction.

BACKGROUND: The difference in mortality between emergency and elective surgery for malignant colonic obstruction is more than 5% in healthy patients below the age of 65 and increases with age to around 20%. Emergency surgery can be avoided by endoscopic placement of a self-expandable metal stent (SEMS). AIM: To evaluate the effectiveness and safety of SEMS as 'bridge to surgery'. METHOD: Between January 2001 and July 2008, SEMS were placed for acute malignant colonic obstruction in 45 patients (median age 72 years, range 35-91). RESULTS: The procedure was technically successful in 43 patients (94%) with resolution of obstructive symptoms within 48 h in 87% of the patients. No perforations occurred during the procedure or while awaiting surgery. Two (4%) patients required a second endoscopic procedure. All patients underwent a single-stage surgical procedure. Postoperative mortality was 2.2% (n = 1). Histology showed advanced colorectal cancer (T3-4N1-2M0-1) in 75% of the patients. CONCLUSION: SEMS placement is a safe and effective procedure as bridge to surgery in patients presenting with colonic obstruction due to colorectal malignancy. This procedure carries a risk of serious complications well below that of the reported difference in mortality between emergency an elective surgery.

Results of 244 consecutive patients with hemorrhoids treated with Doppler-guided hemorrhoidal artery ligation.

AIM: This study was designed to determine the effect of treating hemorrhoids with the Doppler-guided hemorrhoidal artery ligation (DG-HAL) procedure. METHODS: From June 2005 to March 2008, 244 consecutive hemorrhoidal patients underwent hemorroidal artery ligation performed with the DG-HAL system from AMI. All patients were evaluated postoperatively with a proctologic examination and interview. Further follow-up was performed by telephone with a standardized questionnaire. When indicated, patients revisited the clinic for further examination and treatment. RESULTS: 244 patients were treated with DG-HAL. The mean follow-up time was 18.4 months (range 1.4-37.2). Sixty-seven percent of the patients had an improvement of symptoms after one treatment. Fifty-three patients (22%) underwent a second procedure because of persisting symptoms. Thirteen patients (25%) underwent a second DG-HAL and 40 (75%) underwent rubber band ligation. In total, 69% of the patients had a good response using the DG-HAL technique. Multivariate logistic regression analysis revealed prolapse to be an independent risk factor for persistent symptoms (OR = 2.38, 95% CI 1.10-5.15). Patients with grades 3 and 4 hemorrhoids had a higher risk of developing recurrent disease (OR = 4.94, 95% CI 0.67-36.42). CONCLUSION: DG-HAL seems to be an effective procedure for treating low-grade hemorrhoids. A resection procedure should be the treatment for patients with recurrent disease.

Treatment of grade 2 and 3 hemorrhoids with Doppler-guided hemorrhoidal artery ligation.

AIM: We evaluated the results of the Doppler-guided hemorrhoidal arterial ligation (DG-HAL) method in the management of symptomatic grade 2 and 3 hemorrhoids. PATIENTS AND METHODS: Between June 2005 and March 2006, 110 consecutive patients with symptomatic grade 2 and 3 hemorrhoids according to the DG-HAL method were treated. All procedures were performed in daycare under spinal anesthesia. The primary objective was the reduction in hemorrhoidal gradation as determined by proctoscopy; the secondary was patient satisfaction. This was measured by interviewing patients over the telephone. RESULTS: The average age was 47.6 years. 42 patients had grade 2 hemorrhoids, 68 grade 3. An average of 7.3 ligations were placed. Proctoscopy showed that, after 6 weeks, 97 (88%) patients had a significant improvement in their hemorrhoidal gradation. After an average follow-up of 37 weeks, 93 of the 110 (84.5%) patients were satisfied with the postoperative result. Mortality was 0% and morbidity 3%. CONCLUSION: DG-HAL is a safe and effective treatment in the management of symptomatic grade 2 and 3 hemorrhoids.

Rectal carcinoma treated with short-term preoperative radiotherapy followed by abdominoperineal resection. Significantly more presacral abscesses with absence of local recurrence.

BACKGROUND: Treatment of choice for rectal carcinoma is short-term preoperative radiotherapy (5 x 5 Gy) followed by a total mesorectal excision (TME) of the rectum. This treatment has led to a reduction in local recurrence 2 years after surgery from 8.2 to 2.4%. Side effects of this treatment seem to be marginal and of no consequence. After introduction of short-term preoperative radiotherapy we noticed a rise in the postoperative presacral abscess formation which is difficult to treat and results in readmissions and prolonged hospital stay. Research was needed to investigate whether short-term preoperative radiotherapy can be held accountable for the presumed rise in presacral abscess formation in the treatment of rectal carcinoma. METHODS: A retrospective study was performed over the period January 2000-October 2004. Two groups were formed. Group 1 existed of 30 patients who underwent a TME of the rectum without short-term preoperative radiotherapy. Group two existed of 35 patients who underwent a TME of the rectum with short-term preoperative radiotherapy. RESULTS: Statistical analysis showed a significant increase in presacral abscess formation (13 vs. 40%) after introduction of short-term preoperative radiotherapy. Radiotherapy proved to be an important risk factor. Reduction in incidence of local recurrence was not evident. CONCLUSION: We found a significant increase in presacral abscess formation strongly suggestive due to the introduction of short-term preoperative radiotherapy in the treatment of rectal carcinoma. We noticed no reduction in incidence of local recurrence. We advocate that additional research is needed in order to formulate extra patient selection criteria for the use of preoperative radiotherapy in the treatment of rectal cancer.

Platelet gel and fibrin sealant reduce allogeneic blood transfusions in total knee arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) is often associated with a considerable amount of post-operative blood loss, necessitating the transfusion of allogeneic blood, which can add to the complications. Optimization of strategies to reduce the need for blood transfusion is desired. This study was designed to evaluate the efficacy of autologous platelet gel and fibrin sealant in unilateral TKA. METHODS: Consecutive patients were operated on and assigned to the study and control groups. Study group patients (n = 85) were operated on according to our standard TKA protocol, with the application of autologous platelet gel and fibrin sealant on the wound tissues at the end of surgery. Eighty patients were operated on according to the same protocol, but without the use of platelet gel and fibrin sealant, and served as the control group. All blood transfusions, occurrence of wound leakage, wound healing disturbances and incidences of post-operative infections were recorded. RESULTS: Patients in the treatment group had a significantly higher post-operative haemoglobin level (11.3 vs. 8.9 g/dl, respectively) and a decreased need for allogeneic blood products (0.17 vs. 0.52 units, respectively) than those in the control group (P < 0.001). The incidences of wound leakage and wound healing disturbance were significantly less (P < 0.001) in patients managed with platelet gel and fibrin sealant. Four patients in the control group, who received blood products, developed wound infection. The hospital stay was decreased by 1.4 +/- 1.5 days for patients in the treatment group (P < 0.001). CONCLUSION: Peri-operatively applied platelet gel and fibrin sealant may reduce the incidence of allogeneic blood transfusions and complications associated with TKA.

[A patient with sclerosing autoimmune pancreaticocholangitis as the cause of recurrent cholangitis following a pylorus-sparing pancreaticoduodenectomy]. / Een patient met scleroserende auto-immune pancreaticocholangitis als oorzaak van recidiverende cholangitis na pylorussparende pancreaticoduodenectomie.

A pylorus-sparing pancreaticoduodenectomy was performed in a 67-year-old man because of indications for a carcinoma of the distal common bile duct. Histology of the postoperative specimen, however, revealed a sclerosing inflammation of the distal common bile duct and the surrounding pancreatic parenchyma. Initial postoperative recovery was followed by recurrent cholangitis. Stenosis of the choledocho-jejunostomy could not be demonstrated. Instead, repeated endoscopic retrograde cholangiopancreaticography revealed extensive sclerosis of the intrahepatic bile ducts, which suggested a sclerosing cholangitis associated with an autoimmune pancreatitis: sclerosing autoimmune pancreaticocholangitis. This disorder was recently described; it is characterised by a disorder in the pancreas that is indistinguishable from malignancy by imaging techniques and that is followed by a sclerosing inflammation of the bile ducts. The disease responds well to steroids. The patient described demonstrated a complete clinical and biochemical recovery after initiation ofprednisone therapy.

[The use of a self-expanding stent as palliation or before elective surgery in patients with obstructive colorectal carcinoma]. / Zelfexpanderende stent bij obstruerend colorectaal carcinoom als palliatie of als overbrugging naar electieve chirurgie.

OBJECTIVE: To evaluate the use of colorectal stents. DESIGN: Retrospective. METHOD: Data were collected on all patients treated at the Deventer Hospital, the Netherlands, between 1 April 1996 and 31 December 2003 in whom the placement of a self-expanding colorectal stent was attempted. Each patient's physician was contacted to inquire about the patient's status, including quality of life with the stent in situ. RESULTS: Stent placement was attempted in 57 patients as palliation (n = 45) or before elective surgery (n = 12). Of the 57 patients, 29 were men and 28 were women, and the mean age was 71 years (range: 46-94). All patients had colorectal carcinoma, except 1 patient with stenosis following ischaemic colitis. Passage of air and faeces occurred immediately after stent expansion in 55 of the 57 patients (96%). Perforation during stent placement occurred in 2 patients, who subsequently underwent colostomy. 4 additional patients required a colostomy due to stent migration within a few hours or days after placement (n = 3) or obstruction by tumor growth after 65 days (n = 1). Patients in the palliative group had an acceptable quality of life. Those who received a stent before elective surgery were able to undergo resection, did not require colostomy, and had no postoperative complications. One patient did not undergo surgery because of extensive metastases. CONCLUSION: A colorectal stent can be used in the palliative treatment of terminal patients with colorectal carcinoma before colostomy is considered. Experiences with stents before elective surgery were also positive.

[Diagnostic image (199). A woman with palmar pustulae]. / Diagnose in beeld (199). Een vrouw met palmaire pustulae.

A 83-year-old woman developed several small abscesses in the palm of her left hand, caused by a scattering, infected false aneurysm of the radial artery where a catheter had been inserted.

Magnetic resonance cholangiopancreaticography as a diagnostic tool for common bile duct stones: a comparison with ERCP and clinical follow-up.

BACKGROUND/AIMS: The diagnostic potential of magnetic resonance cholangiopancreaticography (MRCP) has improved as a result of evolving technique. MRCP has the advantage of negligible morbidity and mortality in contrast to endoscopic retrograde cholangiopancreatography (ERCP). This study was performed to evaluate MRCP as a replacement for diagnostic ERCP for the suspicion of common bile duct (CBD) stones. METHODS: From 1998 to 2001, MRCP was performed in 202 patients with a suspicion of CBD stones based on medical history (MH), cholestatic liver function tests (CL), both MH and CL or other reasons. ERCP was performed in all patients where MRCP indicated the presence of CBD stones and in those patients with a persistent strong clinical suspicion for CBD stones despite a negative MRCP. RESULTS: In 25 patients, MRCP suggested CBD stones which were proven with ERCP in 24 patients. Despite a negative MRCP, 27 patients had a subsequent ERCP. None of these patients appeared to have CBD stones. In this group, MRCP resulted in 100% sensitivity and 96% specificity in detecting CBD stones. Follow-up of all patients revealed 5 more patients with persistent clinical suspicion or cholestatic liver function values. Assuming CBD stones in these patients, MRCP had a sensitivity of 83 % and a specificity of 99% for this diagnosis. CONCLUSION: In the case of CBD stone suspicion, MRCP should be the diagnostic procedure of choice.

[Unusual form of ileus, except in elderly patients?]. / Een ongebruikelijke vorm van dunnedarmileus, tenzij bij oudere patiënten?

Two women aged 88 and 92, recently admitted to hospital, were diagnosed with gallstone ileus. Over a longer period of time they had suffered intermittently from abdominal pain related to a migrating and impacting stone. This disease is mostly diagnosed correctly during exploratory laparotomy for persistent intestinal obstruction. CT scanning, however, is a new and helpful way to early diagnosis. Both women had successful surgery. Gallstone ileus is a disease of the elderly; its early diagnosis is important. CT can be very helpful in this respect.

Richter's femoral hernia: a clinical pitfall.

A.G. Richter described in 1777 a hernia in which the antimesenteric part of the small intestine was incarcerated. We demonstrate in the article the diagnostic pitfalls of the Richter's femoral hernia. The physical signs consist of vague abdominal complaints, swelling in the groin but usually no symptoms of intestinal obstruction. The Richter's femoral hernia can be complicated by a stenosis in the initially incarcerated distal ileum.

[Alleviation of inoperable malignant colon stenosis using endoscopic placement of an endoprosthesis]. / Opheffen van een inoperabele maligne colonstenose door endoscopische plaatsing van een endoprothese.

Treatment modalities for patients with an obstruction due to an irresectable malignant stenosis of the colon are: a palliative colostomy proximal of the obstruction, radiotherapy, laser therapy, cryosurgery, and photodynamic therapy. In 4 patients, 3 men and 1 woman of 70, 66, 74, and 38 years respectively with obstruction ileus caused by an irresectable distal colonic carcinoma, a self-expanding wallstent was successfully placed endoscopically in the stenosis of the latter three as a palliative measure, resulting in the unimpeded passage of faeces and intestinal gas.

Metastatic malignant melanoma to the gastrointestinal tract.

Two cases of gastrointestinal metastasis of malignant melanoma are reported. We describe diagnosis and treatment of these metastases.

Randomised controlled trial comparing transfusion of leucocyte-depleted or buffy-coat-depleted blood in surgery for colorectal cancer.

In retrospective studies, perioperative blood transfusions were associated with poor prognosis after surgery for cancer and were a major independent risk factor for postoperative bacterial infection. Leucocyte-depleted, in contrast to buffy-coat-depleted, blood has no immunosuppressive effects in transplantation and so might lack detrimental effects on cancer prognosis and postoperative infections. We studied this hypothesis in a controlled trial by randomly allocating patients to receive either leucocyte-depleted red cells or packed cells without buffy coat when blood was needed. Between 1987 and 1990, 871 eligible patients with colorectal cancer, including 697 patients operated upon with curative intent, were randomised in the 16 participating hospitals. Neither the eligible group nor the curative group showed significant differences between the two trial transfusions in survival, disease-free survival, cancer recurrence rates, or overall infection rates after an average follow-up of 36 months. Patients who had a curative resection and who received blood of any sort had a lower 3-year survival than non-transfused patients (69% vs 81%, p = 0.001) and a higher infection rate (39% vs 24%, p < 0.001). Colorectal cancer recurrence rates, however, were not influenced by blood transfusion (30% vs 26%, p = 0.22). These combined observations confirm the association between blood transfusion and poor patient survival but indicate that the relation is not due to promotion of cancer.

The Hartmann procedure, five years' experience.

During a 5-year period (1985-1990) a Hartmann procedure was performed in 66 patients. Retrospective analysis was done to analyse circumstances influencing mortality, restoration of bowel continuity, prognostic value of per-operative peritonitis and results of open wound treatment. Thirteen patients (19.6%) died post-operatively. Colorectal continuity was subsequently restored in 27 patients of 44 potential candidates (61%). Peroperative purulent or faecal peritonitis and acute diverticulitis was found to significantly influence (p < 0.05) the mortality rate. Resection below the sigmoid level gave a significant lower frequency of reanastomosis. Open wound treatment in selected patients proved to be effective: only two (3.0%) cases of wound infection were seen in 66 patients.

Intermittent gallstone ileus following endoscopic biliary sphincterotomy. A case report.

A 72-year-old woman presented with periods of colicky abdominal pain following endoscopic sphincterotomy and lithotripsy for choledocholithiasis. A diagnosis of intermittent gallstone ileus was made, while it appeared that a large gallstone, that was not removed from the common bile duct, obstructed the small bowel. The intermittent course was elicited by pendulation of a gallstone between two stenoses, which originated from chronic radiation enteritis.

A nonelemental versus an elemental diet for early postoperative enteral feeding by needle catheter jejunostomy.

In a prospective randomised study the use of an elemental versus a nonelemental diet for early postoperative enteral feeding by needle catheter jejunostomy was investigated. After extensive gastrointestinal surgery, 25 patients received an elemental and 24 patients a nonelemental diet. The incidence of diarrhoea, the effects of the feeding and the costs were evaluated. The occurrence of diarrhoea was observed more frequently in the elemental diet group (14 25 ) compared to the nonelemental diet group (7 24 ), although this difference was statistically not significant (p > 0.05). No difference was found between the two groups in postoperative restoration of total protein and serum albumin levels and the extent of the postoperative weight loss. The costs showed a clear difference: the nonelemental diet was three times cheaper than the elemental diet. For early postoperative enteral feeding by needle catheter jejunostomy we therefore recommend the use of a nonelemental diet.

Therapy of esophageal carcinoma. Results from the Joint Group on Esophageal Carcinoma in Rotterdam.

During the period 1978-1981 172 patients were referred to the Rotterdam Joint Group on Esophageal Carcinoma. Ninety-one patients were considered for combined therapy, comprising radiation therapy and surgery, and 10 patients refused surgery. The figures given in this material are actuarial survival values corrected for intercurrent death (the actuarial overall survival in parentheses). The 4-year survival in 69 patients who completed this treatment was 39 per cent (26%) (significantly better for women compared with men; significantly better for tumors less than 2 vertebrae compared with tumors greater than or equal to 2 vertebrae). The resectability rate was 85 per cent and the operation mortality rate 20 per cent. Thirty-eight patients had curative radiation therapy with a 4-year corrected survival of 5 per cent (3%). For palliative treatment, radiation therapy and endoscopic introduction of a Celestin tube were mostly used. The results of curative as well as of palliative treatment of esophageal carcinoma have shown improvement during the past decade compared with an earlier period.

The role of early surgery in the treatment of acute hemorrhagic necrotizing pancreatitis (AHNP).

A retrospective study of the effect of surgical treatment and the value of different biochemical criteria in the early identification of AHNP in 33 patients with this condition, as proven by laparotomy, is presented. Biochemical criteria were not specific for AHNP and could only infrequently be used for assessment of the severity of acute pancreatitis. Surgical treatment consisted of pancreatic resection in 22 patients and drainage in 11 patients. Twenty-six of the 33 patients died regardless of the type of surgery. Mortality was due to multiple organ failure, either shortly after operation (eight patients) or after a protracted septic clinical course (18 patients). In total AHNP early subtotal pancreatectomy is probably not the treatment of choice since it did not improve the outcome.