Use of the long tube in the management of patients with small-intestinal obstruction due to adhesions.

A retrospective analysis was performed of all patients admitted to our hospital over a six-year period with a diagnosis of small-intestinal obstruction due to adhesions, to assess the efficacy of treatment with long-tube decompression. Of 127 episodes of obstruction, two thirds responded to nonoperative treatment. Factors that were associated with a greater likelihood of success with long-tube decompression included incomplete obstruction, recurrent obstruction, and passage of the tube beyond the pylorus. Clinical findings were relatively reliable as diagnostic indicators of strangulation. The overall mortality was 1.5%, with no deaths due to a delay in operative intervention. A trial of long-tube decompression is recommended in patients presenting with a diagnosis of small-intestinal obstruction due to adhesions in the absence of clinical evidence of strangulation.

Desmoid tumor-ureteral fistula in Gardner's syndrome.

Gardner's syndrome (GS) is complicated by abdominal desmoid tumors in approximately 8% of cases. We describe two cases of ureteral obstruction and fistulization due to rapidly enlarging desmoid tumors. Initial management consisted of placement of ureteral stents to provide urine drainage from the kidney as well as from the collection in the cavities within the desmoid tumors.

Nonoperative conversion of tube gastrostomy to feeding jejunostomy.

Although esophageal reflux of gastrostomy feeds is an uncommon problem, severe pulmonary complications can arise. If implementation in an upright position and use of continuous infusion does not prevent reflux, an alternative method of providing adequate nutrition must be used. This nonoperative technique of converting a tube gastrostomy to a feeding jejunostomy is simple to perform, atraumatic and extremely useful.

Proctectomy for inflammatory bowel disease.

Between July 1973 and October 1984, we performed proctectomy either as part of a primary proctocolectomy or as a secondary staged procedure in 388 patients with ulcerative colitis and in 39 patients with Crohn's disease. The proctectomies were performed using a two-team synchronous approach. An intersphincteric or perimuscular technique was employed. All perineal wounds were closed and drained by suction drainage and the pelvic peritoneum was closed in all cases. Two patients died in the early postoperative period, one from a pulmonary embolus and one from sepsis. Three patients had to be reexplored for postoperative hemorrhage, in all cases from a branch of the superior hemorrhoidal artery. Postoperative perineal hematoma developed in two patients and perineal abscess developed in four patients which necessitated opening of the perineal skin wound. Nonhealing of the perineal wound occurred in 3 of 388 patients with ulcerative colitis and in 5 of 39 patients with Crohn's disease. No perineal dehiscence or hernias were seen. Postoperatively, one man was permanently impotent and two had prolonged but temporary impotence. Three patients had retrograde ejaculation at last follow-up.

A continent colostomy: The magnetic stoma cap.

An apparatus to create continence in an end left-sided colostomy in dogs is assessed. The device consists of a samarium-cobalt magnetic ring encased in methyl methacrylate and a magnetic cap. The ring is implanted in the abdominal wall and the colon delivered through it and matured to the skin. The stoma is later obturated by the magnetic cap to provide continence. Ten dogs exposed to "uncoated" samarium-cobalt magnets for periods of up to eight months showed no elevation of cobalt levels in the serum or tissues and no histopathologic changes on postmortem examination. In twelve dogs, magnetic rings were used to create continent colostomies. Eleven of twelve dogs followed for periods up to eight months were continent and tolerated the appliance well. One ring was extruded after a peristomal skin dehiscence occurred. Two skin strictures appeared and were readily controlled by digital dilatation. Sinus, fistula, or infection were not seen. Clinical application of this device is discussed.

Mucosal proctectomy without reservoir.

Mucosal proctectomy with endorectal pull-through allows the removal of all colonic mucosa with preservation of continence. This operation was performed in 19 patients with familial polyposis coli and ulcerative colitis. A temporary loop ileostomy was used to defunctionalize the anastomosis. Intestinal continuity was restored in 17 of the 19 patients. Mean duration of follow-up was 29 months. All patients are continent, and the mean number of bowel movements per 24 hours is 6. Follow-up barium studies revealed a gradual dilatation of the terminal ileum within the rectal cuff which accounts for the decrease in the number of bowel movements. This operation eliminates the risk of carcinoma without compromising sphincter function.

Surgical treatment, skin test reactivity, and lymphocytes in inflammatory bowel disease.

Sixty-three patients with inflammatory bowel disease were studied before and after bowel resection. Peripheral lymphocytes, T- and B-cell counts, and skin test reactivity to five recall antigens were determined before operation and 6 to 18 months postoperatively. Twenty-eight patients (44 percent) were unable to react to any skin test initially. Anergic patients had significantly lower lymphocyte and T- and B-cell counts. There was no difference in age, severity or duration of disease, or amount of weight loss between anergic patients and those who responded. Also, there was no difference between patients with ulcerative colitis and those with Crohn's disease. After surgery, 25 previously anergic patients became able to react to skin tests. They also showed a significant increase in T and B cells which did not occur in the previously reactive group. However, the overall peripheral lymphocyte and T- and B-cell counts remained well below those of the normal control subjects. Patients with inflammatory bowel disease that requires surgical treatment have significant immunologic abnormalities. Removal of the diseased bowel, weight gain, and cessation of steroid medication improves skin test reactivity but does not correct the depressed peripheral lymphocyte and especially T-cell counts.

Distribution of colorectal cancer in patients with and without ulcerative colitis.

A comparison of the anatomic distribution of colorectal cancer in patients with and without CUC is difficult because of the unequal number of patients in each group and the changing epidemiologic parameters of colorectal cancer in general. In the present study, the distribution of colorectal tumors in patients with and without CUC was compared over two different time periods at a single hospital. In the early time period (1960 to 1975), there was a significantly higher percentage of proximal tumors in the group with cancer and CUC compared to the group with cancer alone. In the most recent time period (1975 to 1981), there was no difference in distribution of colorectal cancer regardless of whether the patient had CUC or not. We believe that the increased percentage of proximal tumors in patients with colorectal cancers and no CUC that has occurred in recent years has led to the present findings of a similar distribution of tumors in patients with and without CUC.

Twelve-year experience with expanded polytetrafluoroethylene in the repair of abdominal wall defects.

BACKGROUND: A prosthetic device must be used to repair ventral hernias in patients with insufficient tissue for a tension-free primary closure. Several prosthetic materials have been employed for this purpose, with varying results. We here review a long experience with the use of expanded polytetrafluoroethylene (ePTFE) patches in the open repair of large abdominal wall defects. METHODS: Demographic, operative, follow-up, and histologic data were recorded and analyzed for all patients in a surgical practice who were treated for large abdominal wall defects with open repair using ePTFE patches between November 1983 and March 1996. RESULTS: Ventral hernia repairs using an ePTFE patch were performed in 98 patients. In 48 (49%), the patient had already undergone at least one previous ventral hernia repair. Of the 98 operations, 78 were full-thickness repairs, 11 were Rives-Stoppa procedures, and 9 were onlay operations. Complications included 5 seromas, 3 fistulas related to removal of a previously implanted prosthesis, and 9 infections. In addition, 10 patients developed recurrent hernias not related to explantation of the patch because of infection or fistula. In 3 patients, infections were treated successfully without removal of the patch. There were no complications related to adhesions, erosion of the patch into the viscera, or bowel obstruction. Histologic studies of longterm ePTFE implants showed excellent fibrous tissue ingrowth and minimal foreign body response. CONCLUSIONS: Our long-term clinical experience indicates that prosthetic patches of ePTFE are safe and effective when used in the repair of large abdominal wall defects that cannot be closed primarily. Operative complications were within acceptable limits, as was the reherniation rate.

Mucosal proctectomy and ileoanal anastomosis.

The classical surgical therapy of ulcerative colitis and familial polyposis has been total proctocolectomy and ileostomy. In order to avoid a cutaneous stoma and to achieve continence without disruption of gastrointestinal continuity, responding to a demand particularly among younger patients, a mucosal proctectomy in association with an ileoanal anastomosis has been devised. The addition of an ileal reservoir proximal to the anastomosis results in fewer bowel movements and a greater degree of continence. In our series of 70 cases, we have analyzed the normal roentgen anatomy of the ileoanal anastomosis and the proximal ileal reservoir and present our findings on plain film and contrast examinations. To assess patients postoperatively, the radiologist should be aware of the basic surgery involved and the normal roentgen anatomy resulting from this procedure.

Continent ileostomy in the pediatric patient.

Continent ileostomies have been performed in 10 juvenile patients. The operative technique and postoperative management are described. Nine patients wear only small dressings to cover the stoma. One patient is partially incontinent and frequently wears an appliance. Criteria for patient selection and contraindications are discussed.

Surgical repair of rectovaginal fistulas in patients with Crohn's disease: transvaginal approach.

The surgical management of rectovaginal fistulas complicating Crohn's disease has been associated with unacceptably high failure rates. We sought to modify the available surgical techniques to provide a solution to this challenging problem. Between December 1983 and January 1990, 14 patients with Crohn's disease underwent repair of a rectovaginal fistula. A modified transvaginal approach was employed by the authors. A diverting loop ileostomy was performed on all patients, either as the initial step in the staged management of intractable perianal disease or concurrent with the repair of the rectovaginal fistula. The fistula was completely eradicated in 13 of the 14 women and did not recur during the mean follow-up period of 55.0 months (range, 3-77 months). Intestinal continuity was reestablished in these 13 patients within 6 months after the initial fistula repair. One patient with a very low-lying fistula constituted our only failure. We have found the transvaginal method preferable to the transanal approach because of the relative ease in raising the vaginal flap as compared with a flap of fibrotic and inflamed anorectal mucosa. On the basis of this study, we conclude that a modified transvaginal approach is an effective method for repair of rectovaginal fistulas secondary to Crohn's disease.

Alterations in serum immunoglobulins after resection for ulcerative and granulomatous disease of the intestine.

Following resections for ulcerative colitis and granulomatous enteritis there is a significant rise in serum IgM levels. The rise seen in IgM following resection does not occur after bypass surgery. No consistent changes were noted in the concentrations of IgA or IgG. There was no observed difference noted between patients with ulcerative colitis and granulomatous enteritis in the IgM response following resection. The results resemble those which occur after the surgical removal of an allograft which is in process of being rejected.

The reservoir ileostomy: early experience with 54 patients.

Reservoir and ileostomies were performed in 54 patients between 1972 and 1975. Primary colonic pathology included chronic ulcerative colitis in 47 patients, Crohn's colitis in one, familial polyposes in 5 and Gardner's Syndrome in one. Followup is complete and varies from 6 months to three years. All but three patients are completely continent to feces; only one of these three requires the occasional use of a stomal appliance. There were no mortalities. Complications included suture line dehiscences, small intestinal obstruction or prolonged paralytic ileus, and hemorrhage from the reservoir. All complications were successfully treated and removal of the ileal reservoir was not required in any patient. These complications and steps which may be taken to avoid them are discussed. In addition, indications and contraindications for surgery are enumerated. It is well documented that both the colonic polyposes and long standing chronic ulcerative colitis are premalignant diseases. The availability of a continent, reservoir ileostomy as an alternative to the standard, incontinent, stoma has significantly reduced patient resistance to colectomy, and permitted earlier surgery.