Intradermal botulinum toxin a for peristomal hyperhidrosis: a case study.

BACKGROUND: Peristomal hyperhidrosis can interfere with pouch adherence, resulting in pouch leakage and peristomal skin damage. CASE: A patient with autonomic dysregulation resulting in excessive sweating (hyperhidrosis) experienced difficulty with adherence of her ileostomy appliance. Two hundred units of botulinum toxin A (BTX-A) were injected in the dermis of the surrounding skin in order to improve adherence of her pouching system and alleviate moisture of her peristomal skin. RESULTS: Following BTX-A injection, the typical wear time of her pouching system improved from less than 24 hours to 120 hours. Peristomal moisture-associated skin damage resolved almost completely. These effects lasted 3 months. A repeat intradermal BTX-A injection had a similar positive effect. CONCLUSION: Peristomal hyperhidrosis can be controlled with BTX-A intradermal injections, improving patient pouch adherence and alleviating moisture-associated skin damage.

Dysplasia in ulcerative colitis as a predictor of unsuspected synchronous colorectal cancer.

BACKGROUND: Endoscopic surveillance of patients with ulcerative colitis aims to prevent cancer-related morbidity through the detection and treatment of dysplasia. The literature to date varies widely with regard to the importance of dysplasia as a marker for colorectal cancer at the time of colectomy. OBJECTIVE: The aim of this study was to accurately characterize the extent to which the preoperative detection of dysplasia is associated with undetected cancer in patients with ulcerative colitis. DESIGN/PATIENTS/SETTING: A retrospective chart review was conducted of patients undergoing surgery for colitis within the Mayo Clinic Health System between August 1993 and July 2012. MAIN OUTCOME MEASURES: Patient demographics and pre- and postoperative dysplasia were tabulated. The relationship between pre- and postoperative dysplasia/cancer in surgical pathology specimens was assessed. RESULTS: A total of 2130 patients underwent abdominal colectomy or proctocolectomy; 329 patients were identified (15%) as having at least 1 focus of dysplasia preoperatively. Of these 329 patients, the majority were male (69%) with a mean age of 49.7 years. Unsuspected cancer was found in 6 surgical specimens. Indeterminate dysplasia was not associated with cancer (0/50). Preoperative low-grade dysplasia was associated with a 2% (3/141) risk of undetected cancer when present in random surveillance biopsies and a 3% (2/79) risk if detected in endoscopically visible lesions. Similarly, 3% (1/33) of patients identified preoperatively with random surveillance biopsy high-grade dysplasia harbored undetected cancer. Unsuspected dysplasia was found in 62/1801 (3%) cases without preoperative dysplasia. LIMITATIONS: This study is limited by its retrospective nature and by its lack of evaluation of the natural history of dysplastic lesions that progress to cancer. CONCLUSIONS: The presence of dysplasia was associated with a low risk of unsuspected cancer at the time of colectomy. These findings will help inform the decision-making process for patients with ulcerative colitis who are considering intensive surveillance vs surgical intervention after a diagnosis of dysplasia.

Use of diagnostic laparoscopy in a patient with gastric pneumatosis and portal venous gas.

Gastric pneumatosis is a radiographic finding that represents a spectrum of conditions ranging from benign disease to abdominal sepsis and death. Along with portal venous gas, it is generally considered an ominous sign prompting emergent operative intervention. We report a rare case showing that diagnostic laparoscopy can be used to confirm or refute full thickness ischemic necrosis and that conservative management can be considered in some patients, recognizing the possibility of a benign process.

Integration of radiation oncology with surgery as combined-modality treatment.

Integration of surgery and radiation (external beam, EBRT; intraoperative, IORT) has become more routine for patients with locally advanced primary cancers and those with local-regional relapse. This article discusses patient selection and treatment from a more general perspective, followed by a discussion of patient selection and treatment factors in select disease sites (pancreas cancer, colorectal cancer, retroperitoneal soft-tissue sarcomas). Outcomes with combined modality treatment (surgery, EBRT alone or with concurrent chemotherapy, IORT) are discussed. The ultimate in contemporary integration of radiation and surgery is found in patients who are candidates for surgery plus both EBRT and IORT.

Eosinophilic enteritis confined to an ileostomy site.

Eosinophilic enteritis is a rather rare condition that can manifest anywhere from esophagus to rectum. Its description in the literature is sparse, but associations have been made with collagen vascular disease, malignancy, food allergy, parasitic or viral infections, inflammatory bowel disease, and drug sensitivity. We present the case of a 41-year-old male diagnosed with ulcerative colitis who underwent proctocolectomy with ileal pouch anal anastomosis and loop ileostomy formation utilizing Seprafilm®, who later developed eosinophilic enteritis of the loop ileostomy site. This is the first report of eosinophilic enteritis and its possible link to the use of bioabsorbable adhesion barriers.

The Association of Ménétrier Disease with Ulcerative Colitis: A Case Report with Implications on the Pathogenesis of Ménétrier Disease.

Ménétrier disease (MD) is a rare hypertrophic condition of the gastric mucosa. The unusual association of MD with ulcerative colitis (UC) has been reported in the literature in eight cases. Transforming growth factor-alpha (TGF-alpha) is overexpressed in UC and appears to play a role in colonic healing and repair. Overproduction of TGF-alpha in murine stomach has been shown to induce gastric hypertrophy similar to MD. It can be hypothesized that increased expression of TGF-alpha may occur in the gastric mucosa in patients with UC and may lead to MD. We report the ninth case of MD associated with UC. The role of TGF-alpha and treatment with cetuximab are discussed.

Effect of perioperative immunosuppressive medication on early outcome in Crohn's disease patients.

BACKGROUND: The aim of the present study was to examine the early outcome in patients undergoing intestinal resection for Crohn's disease (CD) while they are receiving perioperative immunosuppressive medication. METHODS: We reviewed patients with CD undergoing intestinal surgery from 1999 to 2007. Demographics and relevant perioperative information, including medication, were extracted from patient charts. Statistical analysis was performed using Fisher's exact test. RESULTS: During the course of the study period 112 with Crohn's disease underwent intestinal resection, and 69 of them were receiving perioperative medication (47, corticosteroids; 39, immunomodulators; and 17, anti-tumor necrosis factor-alpha antibodies). There were no deaths. Median blood loss was 137 ml. Twenty-two of the patients using perioperative medication (32%) experienced complications, 10 of which were major. The major complications occurred in 3 of the 43 patients (7%) who were not receiving perioperative medications, in 5 of 38 patients (13%) who were receiving one drug, 4 of 28 patients (14%) receiving two drugs, and 1 of 3 patients (33%) receiving three drugs. Thus the occurrence of major complications was not significantly greater in patients receiving perioperative medication. Risk factors for a major complication were intraoperative blood loss >400 ml (P < 0.003) and emergency surgery (P < 0.005). CONCLUSIONS: The occurrence of complications in Crohn's disease patients undergoing intestinal resection was not associated with the use of immunosuppressive medication. However, emergency surgery and blood loss were risk factors, and reflect the difficulty of surgery in this group of patients.

Intussusception in the adult: an unsuspected case of Peutz-Jeghers syndrome with review of the literature.

Peutz-Jeghers syndrome is an uncommon genetic defect in the signal pathways of growth. The incidence has most recently been estimated to be in the range of 1 per 120,000 live births [1]. It is characterized by hamartomas throughout the gastrointestinal tract, mucocutaneous melanotic spots and increased predisposition to malignancy. The infrequent presentation of this syndrome in most practice combined with some less well-known diagnostic features may contribute to a misdiagnosis. Further, understanding of the genetic defect leading to the phenotypic syndrome and the future implications of this defect continue to evolve. Therefore we present a review in the setting of a case of misdiagnosed Peutz-Jeghers syndrome to portray illuminating features of the syndrome and review the literature.

Stratification of rectal cancer stage for selection of postoperative chemoradiotherapy: current status.

Disease relapse (local, distant) and survival rates (overall [OS], disease-free [DFS]) are dependent on disease stage at time of diagnosis. In rectal cancer pooled analyses of phase III North American trials, OS and DFS were dependent on TN stage (N substage within T stage), NT stage (T substage within N stage), and treatment method. Three risk groups of patients were defined: (1) intermediate T1-2N1, T3N0; (2) moderately high T1-2N2, T3N1, T4N0; and (3) high T3N2, T4N1, T4N2. Patients with a single high-risk factor (T1-2N1, T3N0) were shown to have better OS, DFS, and disease control than patients with both high-risk factors. Although adjuvant chemoradiotherapy (CRT) is indicated for patients with moderately high-risk and high-risk stage of disease, many of these patients are currently treated preoperatively if stage of disease can be defined. If surgery precedes adjuvant treatment, however, postoperative CRT is certainly indicated for these risk groups. For patients with intermediate-risk stage of disease (T1-2N1, T3N0), use of trimodality treatment (surgery plus radiotherapy and chemotherapy) in all patients may be excessive. The challenge is in determining which patients can be spared adjuvant CRT and whether it is worth the exercise.

Parastomal hernia: short-term outcome after laparoscopic and conventional repairs.

The purpose of this study was to evaluate the short-term outcomes after laparoscopic and conventional parastomal hernia repairs. A retrospective review of parastomal hernia repairs was performed. Conventional repairs included primary suture repair, stoma relocation, and mesh repair. Laparoscopic repairs included the Sugarbaker and keyhole techniques. Forty-nine patients underwent repair of symptomatic parastomal hernias: 19 ileostomies, 13 colostomies, and 17 urostomies. Thirty patients underwent 39 conventional repairs. Nineteen patients underwent laparoscopic surgical repairs. Operative times were longer for laparoscopic repair (208 +/- 58 vs 162 +/- 114 minutes, P = .06). The mean length of stay was 6 days for both groups (P = .74). The mean follow-up was shorter in the laparoscopic group (20 vs 65 months, P < or = .001). There were no significant differences in the incidence of surgical site infections (11% laparoscopic vs 5% conventional, P = .60) or complication rates (63% laparoscopic vs 36% conventional, P = .67). Laparoscopic parastomal hernia repair is a feasible operation with similar short-term outcomes to conventional repairs.

Ischiorectal abscess after sacrospinous ligament suspension.

An ischiorectal abscess in a 66-year-old patient was determined to be an uncommon complication of sacrospinous fixation. The abscess was diagnosed 9 months after the patient had a sacrospinous ligament suspension. She was treated successfully with perianal incision, drainage, and intravenous antibiotics.

CT colonography with intravenous contrast material: varied appearances of colorectal carcinoma.

Computed tomographic (CT) colonography is a noninvasive, rapidly evolving technique that has been shown in some studies to be comparable with conventional colonoscopy for the screening of colorectal cancer. Because colorectal cancer has a widely varying appearance at both endoscopy and CT colonography, familiarity with the gamut of morphologic appearances can help improve interpretation of the results. The addition of intravenous contrast material to CT colonography can aid differentiation of true colonic masses from pseudolesions such as residual stool and improves the depiction of enhancing masses that might otherwise be obscured by residual colonic fluid. In contrast to staging of most other tumors, staging of colorectal carcinoma depends more on the depth of tumor invasion than on the size of the primary mass. The diverse appearances of colorectal cancers at two- and three-dimensional CT colonography include sessile, annular, ulcerated, necrotic, mucinous, invasive, and noninvasive lesions. Imaging pitfalls that can simulate or obscure neoplasms are retained fecal material or fluid, incomplete distention, and advanced diverticulosis.

Wide local excision and split-thickness skin graft for circumferential Paget's disease of the anus.

BACKGROUND: Our aim was to evaluate the results of wide local excision followed by split-thickness skin graft for circumferential perianal Paget's disease. METHODS: Between 1995 and 1999, 5 patients with perianal Paget's disease underwent wide local excision of the disease. The circumferential involvement was documented by preoperative mapping. Standard orthograde bowel cleansing and oral antibiotics were given the day prior to surgery. The wound was allowed to granulate and confirmation of negative margins was obtained on permanent sections taken from the excised specimens. On postoperative day 4, split-thickness skin grafts harvested from the lateral thigh were applied (surface using area ranging from 100 cm(2) to 240 cm(2)). The grafts were secured in place with a 3-0 Vicryl suture and covered with a pressure dressing. After 4 days of bedrest, the dressing was taken down under anesthesia (day 8). RESULTS: Graft survival was 100% in 3 patients, 80% in 1 patient, and 70% in another. Postoperatively, clinical follow-up was conducted at 3-month intervals. In 2 patients, anal stenosis developed after the operation and resolved by gentle self-dilation. At a mean follow-up of 42 months (range 21 to 78), adequate cosmetic and functional results were obtained. Recurrence of Paget's disease has occurred in 1 patient (at 21 months) and an invasive anal gland carcinoma was found in 1 patient (at 48 months). CONCLUSIONS: Wide local excision and circumferential split-thickness skin grafting achieves adequate cosmetic and functional results without the need for diverting colostomy. However, there is a considerable recurrence rate after surgery, which warrants very close follow-up to rule out recurrent disease or underlying adenocarcinoma.

Reoperation on the abdomen encased in adhesions.

PURPOSE: To determine outcome after lysis of intestinal adhesions, relief of obstruction, closure of fistulas and drainage of abscesses in patients with an abdominal cavity obliterated by chronic postoperative adhesions. METHODS: Among 40 patients with an abdomen encased in dense adhesions after a mean of 5 previous operations, 31 patients also had intestinal obstruction, 25 enteric fistulas and 20 abdominal abscesses. Reoperation was done and outcome assessed from the medical records and by a mailed questionnaire. RESULTS: Only 1 postoperative death occurred, but 24 early complications appeared. At hospital discharge, obstruction, fistula and abscess were completely resolved in all but 3 patients (P <0.001). Only 2 of 16 patients on parenteral nutrition before operation (TPN) still required it (P = 0.004). At late follow-up (mean, 4.6 years) the patients' quality of life (mean score +/- SD, 8.6 +/- 2.1) was similar to that of a healthy control population (9.2 +/- 1.2, P = 0.17). CONCLUSIONS: Reoperation on the abdomen encased in adhesions restores most patients to good health and an excellent long-term quality of life.