Does sodium hyaluronate- and carboxymethylcellulose-based bioresorbable membrane (Seprafilm) decrease operative time for loop ileostomy closure?

BACKGROUND: Adhesions can result in serious clinical complications and make ileostomy closure, which is relatively simple procedure into a complicated and prolonged one. The use of sodium hyaluronate and carboxymethyl cellulose membrane (Seprafilm) was proven to significantly reduce the postoperative adhesions at the site of application. The aim of this study was to assess the incidence and severity of adhesions around a loop ileostomy and to analyze the length of time and morbidity for mobilization at the time of ileostomy closure with and without the use of Seprafilm. METHODS: Twenty-nine surgeons from 15 institutions participated in this multicenter prospective randomized study. 191 patients with loop ileostomy construction were randomly assigned to either receive Seprafilm under the midline incision and around the stoma (Group I), only under the midline incision (Group II), or not to receive Seprafilm (Group III). At ileostomy closure, adhesions were quantified and graded; operative morbidity was also measured. RESULTS: All 3 groups were comparable relative to gender, mean age and number of patients with prior operations (26, 25 and 19, respectively). Group II patients were significantly more likely to have pre-existing adhesions than Group III patients (30.6% vs. 14.1%, p = 0.025). At stoma mobilization, significantly more patients in Group III than in Group I had adhesions around the stoma (95.2% vs. 82.3%, p = 0.021). Mean operative times were 27, 25, and 28 minutes, respectively (p = 0.38), with significant differences among sites. There was no significant difference in the number of patients needing myotomy or enterotomy (29, 27 and 24 patients, respectively), nor in the number of postoperative complications (7, 9 and 7 patients, respectively). CONCLUSIONS: When consistently applied, Seprafilm significantly decreased adhesion formation around the stoma but not operative times without any increase in the need for myotomy or enterotomy. These findings were not seen in the overall study population possibly due to the large number of surgeons using a variety of application techniques.

Intraoperative lower extremity compartment pressures in lithotomy-positioned patients.

PURPOSE: Measurement of anterior leg compartment pressures in eight patients (16 limbs) who were positioned in the lithotomy position for prolonged periods of time while undergoing colorectal intra-abdominal surgery. METHODS: Anterior leg compartment pressures were measured in eight patients (16 limbs) by using a slit catheter, whereas subjects were positioned in the lithotomy position for prolonged periods of time while undergoing colorectal intra-abdominal surgery. RESULTS: Compartment pressures had minor elevations after initial lithotomy positioning, and gradually increased over time. Levels elevated to 30 mmHg at an average of five (range, 3.5 to 6) hours. The maximum recorded leg compartment pressure was 70 mmHg. The addition of Trendelenburg positioning was noted to consistently increase compartment pressures. All pressures returned to less than 10 mmHg shortly after removing the limb from the stirrups and placing the limb supine. No patients developed clinical evidence of compartment syndrome. CONCLUSIONS: Leg anterior compartment pressures rise when limbs are placed in the lithotomy position for prolonged periods of time. The rise in pressure is increased with the addition of Trendelenburg positioning. Anterior compartment pressures reached a threshold of 30 mmHg at an average of five hours. The results of this study suggest that lithotomy positioning of the lower extremities has the potential to initiate leg compartment syndrome when the period of positioning approaches five hours. Removing the limbs from the stirrups and placing them in the supine position allows the pressure in the compartments to return to normal.

Characteristics of rectal carcinomas that predict the presence of lymph node metastases: implications for patient selection for local therapy.

BACKGROUND AND OBJECTIVES: It has been estimated that approximately 5% of middle and low rectal adenocarcinomas are amenable to local therapy. However, these treatment modalities are limited by their failure to identify and treat regional nodal metastases. METHODS: This study was undertaken to evaluate the role of tumor size, depth of penetration into the rectal wall, degree of histologic differentiation, DNA ploidy status, and their combination on the presence or absence of metastases in perirectal lymph nodes. Logistic regression was used to quantitatively predict the probability of positive lymph nodes. RESULTS: Tumor size did not correlate with the presence of nodal involvement; however, worsening degree of differentiation, increasing depth of wall penetration and aneuploidy did statistically correlate with the presence of nodal metastases. For any combination of tumor traits, aneuploidy markedly increased the probability of positive lymph nodes over that observed with diploid tumors. CONCLUSIONS: The combination of degree of differentiation, depth of penetration, and ploidy status may be used to identify patients whose tumors may be adequately treated with local measures. For any combination of tumor traits, aneuploidy markedly increased the probability of positive lymph nodes over that observed with diploid tumors.

Modulatory effects of the colonic milieu on neutrophil oxidative burst: a possible pathogenic mechanism of ulcerative colitis.

An important hallmark of ulcerative colitis (UC) is mucosal neutrophil (PMN) infiltration associated with mucosal damage. This suggests that colonic chemoattractants such as bacterial products (e.g., N-formyl-methionyl-leucyl-phenylalanine (fMLP), lipopolysaccharide (LPS)) reach systemic circulation and attract PMNs to the colon. PMNs are then activated in the colonic mucosa and release their toxic oxidative metabolites. However, bacterial products are also present in the systemic circulation of healthy subjects. Thus we hypothesized that PMNs develop tolerance to colonic factors in the normal state and that this tolerance is absent in UC. We evaluated the PMN respiratory burst in response to stimulation with fMLP, LPS, or phorbol 12-myristate 13-acetate (PMA) by measuring the production of reactive oxygen species (ROS) with both luminol-enhanced chemiluminescence and a cytochrome C reduction assay. PMNs were obtained from control subjects, inactive UC patients, patients with UC who had undergone colectomies, and non-UC patients with colectomies. All three stimuli induced a significant rise in ROS. PMNs from non-UC colectomy subjects produced significantly higher ROS than PMNs from control subjects with intact colons in response to both fMLP and LPS. In contrast, PMNs from UC colectomy patients produced levels of ROS similar to those produced by PMNs from UC patients with intact colons in response to fMLP and LPS. Colectomy had no effect on PMA-induced ROS production in controls. The observed difference in fMLP-induced ROS production in control subjects with intact colons was not due to fMLP receptor down-regulation because a competition assay performed with the fMLP blocker BMLP showed a similar receptor apparent affinity in all four groups. We conclude the following: (1) the normal colonic milieu modulates the PMN respiratory burst, resulting in hyporesponsiveness of PMNs to "physiologic" but not "pharmacologic" stimulation. This effect is not due to receptor down-regulation. (2) UC colonic milieu does not appear to modulate PMN respiratory burst. This loss of PMN "tolerance" to colonic factors may have a pathogenic role in the sustained inflammation and tissue damage in UC.

The effects of different corticosteroids on the healing colon anastomosis and cecum in a rat model.

Corticosteroids are known to adversely affect wound healing in experimental skin models; however, their effect on healing colonic anastomoses is still disputed. Different steroids have not been compared to each other in the same study. We studied the effect of equipotent doses of dexamethasone, hydrocortisone, and methylprednisolone on healing colon anastomoses in a rat model. High-dose steroid therapy was started 2 days prior to the operation and continued until the bursting pressures were measured at 5 and 7 days after the surgery. Anastomotic bursting pressure was not decreased for any of the steroid treatments when compared to the control, but the frequency of anastomotic rupture in the dexamethasone group at day 5 was significantly higher than either of the other steroid groups or the control group (P < 0.01). Bursting pressures of the intact cecum were lower in all the steroid-treated groups compared with the control group. We concluded that dexamethasone slows the rate of wound healing, but short-term high-dose steroid therapy does not decrease the strength of the anastomoses as measured by bursting pressure.

Factors influencing bowel function following total abdominal colectomy.

PURPOSE: The purpose of this study was to determine which factors influenced bowel function following total abdominal colectomy. METHODS: Thirty-two patients who had undergone total abdominal colectomy were studied with regard to factors that are classically thought to influence bowel function, namely, residual stump length, transit time, and rectal stump manometry. In a limited subset of patients, anal manometry was done also. RESULTS: Transit time was the best predictor of bowel function following total abdominal colectomy. This was followed by stump length. If transit time was short, then stump length became important in predicting the occurrence of diarrhea following total abdominal colectomy. CONCLUSIONS: Two factors have an important influence on bowel function following total abdominal colectomy: transit time and rectal stump length. Rectal stump length is an anatomic factor that can be controlled by the surgeon. In total abdominal colectomy, rectal stump length of at least 20 cm is necessary if the patient is to have satisfactory postoperative bowel function. This may not always be possible. In these patients, modification of diet to influence transit time and methods to increase rectal compliance will be necessary.

Technetium-labelled red blood cell scintigraphy: is it useful in acute lower gastrointestinal bleeding?

Radionuclide scintigraphy is commonly utilized as a screening examination before performing more invasive procedures in the work-up of patients with lower gastrointestinal (GI) bleeding. We reviewed our institutional experience with technetium-labelled red blood cell scintigraphy (TRCS) in detecting and localising acute lower GI bleeding. The study group included 72 patients who had 80 red cells scans over a five year period. Thirty-eight scans were positive (47.5%), and 42 were negative (52.5%). Sites of lower GI bleeding were confirmed by endoscopy, arteriography, surgery and/or pathology in 22 of the 38 positive scans. There were four false-negative scans (9.5%). The overall sensitivity and specificity of TRCS in detecting lower GI bleeding was 84.6% (22/26) and 70.4% (38/54), respectively. The accuracy of localization of bleeding sites in the patients with confirmed positive scans was 72.7% (16/22). Thirty mesenteric arteriograms were performed on patients in this series. Eleven arteriograms were performed after negative TRCS; one was positive. Technetium-labelled red blood cell scintigraphy appears to be a useful screening examination for patients with lower GI bleeding who are hemodynamically stable. This may avoid the potential morbidity of arteriography in patients who are not actively bleeding.

Necrotizing infections of the perineum.

During a 6-year period, 10 patients were treated for severe necrotizing infections of the perineum (Fournier's gangrene) at the Edward Hines Veterans Administration Hospital (Hines, Ill). All were male, and their average age was 60 years. When known, duration of symptoms was 2 to 5 days. Prodromal signs such as edema, erythema, and pain frequently developed into rapidly spreading, full-thickness cutaneous gangrene in less than 24 hours. All patients had significant concomitant disease; 60% were diabetic. All patients had expedient and aggressive initial debridement, usually within 24 hours of presentation to the surgical service. Each patient had a "second-look" debridement within 1 or 2 days. Debridement was done an average of 2.6 times per patient. The cause of the infection was noted in seven patients--five with perirectal abscess and two with urethral trauma. Suprapubic catheters were placed in both patients with urethral trauma. Diverting colostomy was done on two patients who had perirectal abscess as a nidus; eight patients were treated without colostomy. Polymicrobial bacteriologic flora were found in all patients, with a predominance of Escherichia coli, Bacteroides sp, and staphylococci. Broad spectrum antibiotics and early nutritional supplementation were given. Hospital stay averaged 4 weeks (range, 3 to 12 weeks). One patient died (mortality of 10%). Successful management of these patients requires expedient diagnosis, aggressive nutritional supplementation, and early and repeated debridement as clinically indicated. We have not found diverting colostomy to be a necessary part of the management of these patients even when the nidus is perirectal.

Preliminary results of a prospective randomized study of Cooper's ligament versus Shouldice herniorrhaphy technique.

Surgeons have developed many methods for the repair of direct inguinal hernias. The Cooper's ligament (McVay) repair and the Shouldice repair are widely used techniques. To determine the recurrence rates with differing techniques performed in a surgery residency program, we conducted a prospective randomized study for elective adult direct inguinal herniorrhaphies. Three hundred and eight elective direct inguinal herniorrhaphies in 269 adult patients were performed by residents in general surgery supervised by staff surgeons. Patients had yearly follow-up physical examinations (compliance rate of 87 percent) during an average follow-up period of 36.4 months. The recurrence rate was 8.8 percent for the McVay repair and 6.6 percent for the Shouldice repair (not significant). Bilateral inguinal hernias (repaired six weeks apart) had a recurrence rate of 12.8 percent, while the recurrence rate for unilateral repairs was 5.6 percent (p = <0.05). We found no significant difference in recurrence rates between the McVay and Shouldice herniorrhaphy techniques. However, there was an increase in hernia recurrence with either technique when bilateral direct inguinal herniorrhaphies were performed.

Perianal Bowen's disease associated with Crohn's colitis. Report of a case.

A 24-year-old woman with a two-year history of inflammatory bowel disease, with no anal or perineal involvement, underwent a proctocolectomy and ileostomy. Pathologic evaluation of the specimen revealed Crohn's colitis and unsuspected perianal Bowen's disease. The patient is free of Crohn's and Bowen's disease 6.5 years later. The association of perianal Bowen's disease with Crohn's colitis is discussed.

Soft tissue infections in the compromised host.

Soft tissue infections were seen in 25 patients with underlying malignancy and immunosuppressive disease. The primary disease included leukemia, lupus, aplastic anemia, lymphoma, carcinoma and myeloma. Infectious sites included the perianal area, gluteal, chest wall, extremity and the vulva. Eighty per cent of the infectious episodes occurred in patients who were granulocytopenic. Initial presentation was of local tenderness and redness. Fluctuation and discoloration were present in nine patients who were also hypotensive. Local drainage in five patients resulted in the death of two (20%). Overall, the mortality was 3/25 (12%). Wide debridement and drainage and appropriate antibiotic therapy resulted in the death of 1/20 (5%) patients. Hypotension, discoloration and fluctuation were found to be late signs in these patients. Soft tissue infections in the compromised host present subtly and progress to death if treatment is delayed. Temperature elevation and localized tenderness and erythema are indications for broad spectrum antibiotics and extensive intraoperative drainage and debridement.

Use of the ultrasonic aspirator to strip the mesentery in construction of the continent ileostomy.

Debulking the mesenteric fat with the ultrasonic surgical aspirator facilitates intussusception of the ileum in the construction of a continent ileostomy.

Bowel cleansing with polyethylene glycol electrolyte lavage solution.

We reviewed our experience with an oral gut lavage solution (GoLYTELY), used as a rapid bowel cleansing preparation, and the prospective clinical trials reported in the literature to compare the overall experience with this type of preparation for colonoscopy and colon surgery. Five studies (546 patients) compared GoLYTELY to standard preparations for colonoscopy, while three trials (177 patients) have studied surgical patients. After evaluating patient tolerance, quality of colonic cleansing, and changes in microflora and colonic gas, GoLYTELY was found to be safe, rapid, and effective. It is well tolerated by patients and may become the preferred method of bowel cleansing.

Calcified hematoma of the greater omentum in an F-15 fighter pilot.

A high performance aircraft test pilot who presented with acalculous cholecystitis was found to have a calcified omental hematoma adjacent to the gallbladder. Omental hematomas have not previously been linked to flight in high performance aircraft. Current prevailing hypotheses regarding etiologies of omental hematomas include rapid blood flow shifts and venous fragility. Forces encountered in high performance aircraft may increase the chance of omental hemorrhage.

Routine operative cholangiography.

The records of 300 consecutive patients who underwent cholecystectomy at a large military teaching hospital from January 1981 through August 1982 were reviewed; 270 patients (90 per cent) had intraoperative cholangiograms. Four clinical indications were helpful in predicting the likelihood of a positive intraoperative cholangiogram: 1, jaundice; 2, pancreatitis; 3, dilated common bile duct, and 4, palpable stones. The 63 patients with at least one of these indications had a 35 per cent incidence of true positive cholangiograms, while the 207 patients without such indications had a 0.5 per cent incidence of true positive studies (p less than 0.01). The incidence of false-positive studies was 0.7 per cent in our series and 3.1 per cent in our review of the literature of 2,580 cholangiograms. We conclude that cholangiography in the absence of clinical indications has a low yield. If cholangiography had been used selectively during the time period of 20 months of our retrospective study, more than 25,000 dollars could have been saved without missing significant pathologic findings in the common bile duct. We conclude that the thoughtful surgeon should perform cholangiography on a selective rather than routine basis.

Comparison of cleansing methods in preparation for colonic surgery.

Golytely, an oral gut lavage solution, was compared with a standard bowel cleansing preparation in patients undergoing elective colonic surgery. Sixty patients were randomly assigned to either a one-day preparation with Golytely and bisacodyl or a standard method using a three-day clear liquid diet, cathartics, and enemas. Colon cleansing was better with Golytely (100 percent optimal cleansing vs. 64 percent, P less than 0.05). Patients receiving Golytely had less weight loss and found this preparation more tolerable. Quantitative stool cultures before and after preparation and intraoperatively were not significantly different between the two preparations. In this surgical bowel preparation study, Golytely and Bisacodyl were found to be safe, rapid, and effective. The preparation was well tolerated by patients and has become our preferred method of colonic cleansing.

Cerebral air embolism resulting from invasive medical procedures. Treatment with hyperbaric oxygen.

The introduction of air into the venous or arterial circulation can cause cerebral air embolism, leading to severe neurological deficit or death. Air injected into the arterial circulation may have direct access to the cerebral circulation. A patent foramen ovale provides a right-to-left shunt for venous air to embolize to the cerebral arteries. The ability of the pulmonary vasculature to filter air may be exceeded by bolus injections of large amounts of air. Sixteen patients underwent hyperbaric oxygen therapy for cerebral air embolism. Neurological symptoms included focal motor deficit, changes in sensorium, and visual and sensory deficits. Eight patients (50%) had complete relief of symptoms as a result of hyperbaric treatment, five (31%) had partial relief, and three patients (19%) had no benefit, two of whom died. The treatment of cerebral air embolism with hyperbaric oxygen is based upon mechanical compression of air bubbles to a much smaller size and the delivery of high doses of oxygen to ischemic brain tissue.

Surgical management of the failed Nissen fundoplication.

A significant percentage of surgery performed for complications of gastroesophageal reflux at a major medical center has been performed for problems related to prior surgery. Our patients who required remedial surgery fell into three categories. Those with recurrent reflux generally fared well. Patients with dysphagia, gastric stasis, or both presented difficult problems. The key to success for these patients lies in choosing the operation best suited to the anatomic and physiologic situation as defined by preoperative contrast studies, pH monitoring, endoscopy, and selective gastric emptying studies.