Strictureplasty of the small bowel in patients with Crohn's disease. An effective surgical option.

Fibrotic strictures of the small bowel are known to cause chronic bowel obstruction in patients with Crohn's disease. Strictureplasty without resection permits relief of bowel obstruction and preservation of bowel length. The records of 13 patients who underwent 52 strictureplasties for Crohn's disease at the Lahey Clinic Medical Center, Burlington, Mass, from 1982 through 1989 were reviewed to determine the results of this surgical intervention. Nine patients were treated with strictureplasty only, while the remaining 4 patients underwent concomitant small-bowel resection for stenosed areas not amendable to strictureplasty. One early complication occurred in a patient in whom a pelvic abscess developed. In a median follow-up period of 2 years (range, 0.5 to 7 years), 9 patients were rehospitalized because of obstruction from Crohn's enteritis. Four patients required further surgery, 3 patients underwent strictureplasty at a newly stenosed area of small bowel, and 1 patient required resection of the initial strictureplasty. Strictureplasty is an effective surgical option for patients with Crohn's disease who have symptomatic small-bowel strictures.

A technique of direct percutaneous jejunostomy tube placement.

A technique for replacement of a feeding jejunostomy tube using endoscopic direct visualization is described herein. It can be used in patients who have had a previously placed open jejunostomy tube removed after recovery from resection of the gastrointestinal tract. This is accomplished quite easily using local anesthesia with intravenous sedation using an upper endoscope, guide wire, peel-away sheath and a standard Silastic catheter.

Pitfalls in ambulatory treatment of inguinal hernias in adults.

Careful patient selection and preparation for ambulatory inguinal herniorrhaphy combined with monitored local anesthesia result in a safe procedure with excellent patient acceptance. Factors contributing to early and late complications are presented, and the common methods of their treatment are reviewed.

Comparison of the incidence of Listeria on equipment versus environmental sites within dairy processing plants.

This study was undertaken to compare the incidence of Listeria contamination of processing equipment with that of the general dairy processing environment. A total of 378 sponge samples obtained from 21 dairy plants were analyzed for Listeria using three different enrichment media. Use of extended microbiological analysis allowed us to identify 26 Listeria positive sites which would have not been identified had a single test format been employed. Eighty (80) of 378 sites (21.2%) were identified as Listeria positive. Listeria innocua was isolated from 59 of the 80 (73.8%) positive samples, L. monocytogenes was identified in 35 (43.8%) of the positive samples, and L. seeligeri was isolated from 5 (6.3%) of the Listeria positive samples. Positive equipment samples were obtained from 6 of the 21 (28.6%) plants and 19 of the 21 (90.5%) plants had positive environmental sites. Seventeen of the 215 (7.9%) samples from equipment were positive for Listeria species. Eleven of these sites, including 3 holding tanks, 2 table tops, 3 conveyor/chain systems, a pasta filata wheel, a pint milk filler and a brine pre-filter machine, were positive for L. monocytogenes. Nineteen of the 21 (90.5%) plants had positive environmental sites. Sixty-three of the 163 (41.1%) samples from environmental sites were Listeria positive and 24 were positive for L. monocytogenes. Two-tailed student t-test analysis of the mean frequencies indicated that the level of contamination was significantly higher (p < 0.001) in 'environmental' (49.7%) as opposed to 'equipment' samples (7.0%). Our study indicates that environmental contamination with Listeria does not necessarily translate into contamination of equipment within the same plant, and that greater emphasis needs to be placed on the cleaning and sanitizing of the plant environment.

Combined secondary enrichment of primary enrichment broths increases Listeria detection.

The efficacy of combining dual primary enrichment cultures into a single secondary broth was evaluated for detecting Listeria in naturally contaminated meats and environmental samples obtained from dairy processing plants. A total of 336 samples were tested using University of Vermont modified Listeria enrichment broth (UVM) and Listeria repair broth containing selective agents (LRBS) as primary enrichment media. Eighty samples (23.8%) yielded Listeria by at least one method. Neither primary enrichment broth was significantly better (P>0.05) than the other in identifying Listeria-positive samples. UVM media, when used as a primary enrichment broth, identified 66 Listeria-positive samples, while the use of LRBS as a primary enrichment broth identified 65 Listeria-positive samples. Listeria detection improved significantly (P<0.01) when two primary enrichment media were used for sample analysis. It is not clear whether this improvement was due to simply replicating the primary enrichment or to the particular pair of primary enrichment media used. The use of a dual secondary enrichment procedure was better (P<0.05) than the use of either individual primary enrichment medium alone. The overall rate of recovery increased from 81.3 to 82.5% for single secondary enrichment to 93.8% using a dual secondary enrichment technique. Analysis of results obtained when combining two independent isolation methods versus combining two primary enrichment media into one single secondary enrichment broth indicated that there was no significant difference (P>0.05) in either procedure. Inoculum size (0.1 ml versus 0.2 ml) did not have an effect on the overall rate of recovery. The procedure developed increased the sensitivity of testing while decreasing the potential workload associated with an increase in enrichment procedures.

Treatment of enterocutaneous and colocutaneous fistulas with early surgery or somatostatin analog.

Standard therapy of enterocutaneous (ECF) and colocutaneous (CCF) fistulas consists of "conservative" management, with surgery reserved for failures of maximal medical treatment. We conducted a five-year retrospective review of 28 patients with low-output ECF and CCF to determine the outcome of early surgical and nonsurgical treatment of these conditions. Twelve men and 16 women with a mean age of 60 years presented with 22 ECF and 6 CCF. Six patients had early operative intervention in an attempt to close their fistulas, while the remaining 22 patients were treated without surgery. In addition, four of the nonsurgical group received parenteral somatostatin analog (SA). None of the surgical patients was septic preoperatively (mean WBC = 9.7), the mean preoperative hospital stay was 11 days, and no patients required a proximal diverting stoma. All of the surgical group resumed normal gastrointestinal function within two weeks, and seven of the nine (78 percent) demonstrated no recurrence of the fistula at a mean follow-up of 8.3 months. Of the 22 medically treated patients, three of the four who received SA healed their fistulas within two weeks. Only two of the other 13 medically treated patients (15 percent) healed their fistulas. Early surgery or the use of SA should be considered in the treatment of patients with low-output intestinal fistulas.

Colonoscopy for intermittent rectal bleeding: impact on patient management.

Rectal bleeding is a frequent presenting symptom of a number of benign anorectal disorders. However, it may also be a warning sign of more significant gastrointestinal pathology. For this reason, full colonic evaluation has been recommended in patients with intermittent bright red rectal bleeding. The purpose of this study is to evaluate the utility of colonoscopy in this setting. Data were prospectively collected on 125 colonoscopies performed on the surgical service at the Cleveland Wade Park Veterans Administration Medical Center during a two year period. During this period 33 patients underwent colonoscopy for the evaluation of intermittent bright red rectal bleeding. Fourteen patients had abnormal rectal exams, including hemorrhoids in 9, mass lesions in 3, prolapse in 1, and fistula in ano in 1. Colonoscopy was normal in only 7 (21%) of the 33 patients examined. Findings in the remaining 26 included 31 polyps in 14 patients, cancer in 3, AVM in 1, diverticula in 9, hemorrhoids in 4, and other benign lesions in 5. Positive findings on rectal examination had no relationship to findings at endoscopy, with abnormal findings in 52% of patients with normal rectal exams and in 27% of patients with abnormal rectal exams (P = 0.187, NS). Findings at colonoscopy resulted in a change in management in 16 (48%) of patients examined. In patients with intermittent rectal bleeding, the entire colon should be evaluated regardless of findings on rectal examination, as a significant number of patients will have concomitant findings. Colonoscopy is an excellent method for colonic evaluation in this setting.(ABSTRACT TRUNCATED AT 250 WORDS)

Breast cancer in a male-to-female transsexual. A case report.

The clinicopathological findings in a patient who developed breast carcinoma ten years after male-to-female sexual reassignment are reported. Only two other cases of transsexual men with breast carcinoma have been reported previously. All three patients received oral estrogens for prolonged periods to maintain secondary female characteristics. The controversies relating to hormonal influences in the etiology of breast cancer in men are discussed herein.

Failure of cyclosporine to prevent small bowel allograft rejection in pigs.

The effect of cyclosporine (CyS) on survival and function of 250 cm intraabdominal heterotopic small bowel allografts was studied in outbred pigs. Experimental animals received oral CyS alone (25 mg/kg/day), or oral CyS, donor bowel radiation, and recipient splenectomy; controls were untreated. Excluding technical failures, no significant differences in graft survival were observed, although one relatively long-term survivor occurred in each treated group. Rejection was not related to cyclosporine levels. These data show that CyS as a single agent as well as when used with supplemental therapy does not uniformly prevent rejection of small bowel allografts in pigs, although an occasional long-term survivor will occur. The failure to achieve consistently successful engraftment may reflect the large quantity of lymphoid tissue in small bowel. Further experimentation is required before human transplantation is again attempted.

Expression of Streptococcus sanguis antigens in Escherichia coli: cloning of a structural gene for adhesion fimbriae.

Chromosomal DNA from Streptococcus sanguis FW213 was partially digested with EcoRI and ligated into the positive-selection cloning vector pOP203(A2+). The ligation mixture was used to transform Escherichia coli K-12, and 4,500 transformants were examined. The tetracycline-resistant colonies had inserts averaging 3.2 kilobases. The entire colony bank was screened by colony immunoassay with polyclonal rabbit serum raised against S. sanguis FW213 whole cells. Thirty recombinant colonies produced stable positive reactions of various intensities, indicating that S. sanguis antigens could be expressed in E. coli. Restriction endonuclease digestion of these clones suggested that 26 of the clones were unique. Only two clones, VT616 and VT618, gave positive reactions with fimbria-specific antisera. That the gene coding for the antigen was located on the plasmid was confirmed by demonstrating that the presence of the plasmid was linked to antigen production. Western immunoblot analyses of sodium dodecyl sulfate-polyacrylamide gel electrophoresis gels showed that both clones produced a fimbrial peptide of Mr 30,000. The two recombinant plasmids were shown by Southern analysis and restriction mapping to contain the same 6-kilobase EcoRI fragment inserted in opposite orientations. Southern hybridization confirmed that this fragment is present in S. sanguis genomic DNA. The Mr 30,000 protein gene was expressed in both orientations, suggesting that the fimbrial promoter is located on the 6-kilobase fragment. These results show that at least one streptococcal fimbrial gene can be cloned and expressed in E. coli.

Perirectal abscess in Crohn's disease. Drainage and outcome.

The role of surgical intervention in the treatment of patients with anorectal Crohn's disease is controversial. To clarify the success of aggressive drainage and the subsequent clinical course of patients with Crohn's disease and perirectal abscesses, the authors reviewed the records of 38 patients who presented with this condition during an eight-year period. Twenty-two male and 16 female patients (median age, 32 years; range, 17 to 61 years) with clinically or pathologically confirmed Crohn's disease of the bowel underwent operation for perirectal abscesses. Thirty-two percent of patients had no previous history of anorectal Crohn's disease. Thirty simple abscesses and 8 complex horseshoe abscesses were treated. At operation, 53 percent of patients underwent incision and drainage whereas 26 percent received loop indwelling drains and 21 percent had mushroom catheters placed. After resolution of the index abscess, recurrent abscesses occurred in 45 percent of the patients who underwent catheter drainage and 56 percent of the patients who underwent incision and drainage. More importantly, 44 percent of the incision and drainage group and only 31 percent of the catheter drainage group required subsequent proctectomy to control perineal sepsis. The healing time of the perineal wound was longer than six months in 83 percent of patients requiring rectal excision. We concluded that long-term catheter drainage may offer substantial benefit in the overall outcome of the treatment of patients with Crohn's disease and perirectal abscess.