Loop ileostomy: a reliable method of diversion.

Between September 1983 and March 1989, 36 loop ileostomies were performed on 34 patients (16 male and 18 female, mean age 36 years, range 11 to 68). Thirty-two patients had ileoanal pouch procedures (30 for ulcerative colitis and two for familial polyposis). One patient had a low anterior resection and another had a coloanal procedure. By the time of this review, 31 of the loop ileostomies were closed. The average time before closure was 5 months and the average length of follow-up was 37 months. All stomas were brought out through the rectus muscle in the right side of the abdomen, without ileal rotation, mesenteric fixation, or parastomal fascial sutures. A support rod was left in place for 3 to 4 weeks postoperatively. There were no major difficulties with skin irritation or appliance management and no instance of parastomal abscess and stoma retraction. Although no complications related to the ostomy or its closure were encountered in these patients, small bowel obstruction before closure (8 patients) or after takedown (5 patients) of the loop ileostomy required operative correction in one patient in each group.

Overlapping sphincteroplasty for acquired anal incontinence.

Overlapping sphincter repair is the operation of choice for incontinence due to obstetric injuries, trauma, or previous anorectal surgery. We present our experience from 1981 to 1990 using the overlapping sphincter repair for anal incontinence resulting from childbirth in 21 patients (58%), previous anorectal surgery in 7 (19%), trauma in 1 (3%), gynecologic surgery in 1 (3%), multifactorial causes in 1 (3%); the incontinence was idiopathic in 5 (14%). All 36 patients were operated on by one surgeon and had identical care. There were no deaths. Two patients required colostomy for wound sepsis. Two additional patients (with idiopathic incontinence) elected to have a colostomy after failure of sphincter repair. Long-term follow-up was possible in 33 patients (92%). Twenty-four patients (73%) were considered to have good to excellent results. Eliminating those patients with idiopathic anal incontinence improved the results significantly. Twenty-two patients (85%) reported good to excellent results. Twenty-four patients (92%) consider their continence better now than before surgery and 25 patients (96%) would undergo the procedure again. In conclusion, overlapping sphincteroplasty has a definite role in treatment of anal incontinence due to obstetric injury, anorectal surgery, and trauma, but a more limited role in treatment of idiopathic anal incontinence.

Island flap anoplasty for the treatment of anal stricture and mucosal ectropion.

Twenty patients with benign anal strictures and five patients with mucosal ectropion were treated with island flap anoplasty. U-shaped or diamond-shaped islands of perianal skin were created, without undermining, and advanced into the anal canal to remedy the stricture or site of ectropion. Over a postoperative follow-up period that averaged 19 months, 16 patients judged their clinical results as excellent and 7 as good. There were two failures. In all patients the skin flaps survived, even in the elderly patients. Island flap anoplasty is a simple, effective alternative to other forms of anoplasty such as Y-V advancement or S-plasty.

Role of highly selective vagotomy and duodenoplasty in the treatment of postbulbar duodenal obstruction.

The indications for highly selective vagotomy have expanded in recent years, with the technique being applied to selected cases of perforation and bleeding. Its use in obstruction is controversial, but two options are available for managing the stenotic pylorus or duodenum: dilatation or duodenoplasty. The latter choice requires that the stenosis be located in the postbulbar area. Since 1981, we have managed 15 patients with postbulbar stenosis by means of highly selective vagotomy and duodenoplasty. All patients had a previous history of ulcer disease, and vomiting was a consistent symptom. All patients were referred for surgery, 10 by a gastroenterologist. There was no operative mortality or procedure-related morbidity. Two patients have been lost to follow-up. Both were classified as Visick I and had normal endoscopic results at their last visit. The remaining 13 patients have all been followed very recently. Twelve patients (92%) are currently classified as Visick I or II. One patient (Visick IV), who was essentially asymptomatic, was found to have a recurrent ulcer on endoscopy. Endoscopic (11 patients) or radiographic (1 patient) patency of the duodenoplasty has been demonstrated in 12 patients. Highly selective vagotomy and duodenoplasty should be a surgical consideration when the pathologic anatomy of the duodenum lends itself to that choice.

Lower gastrointestinal bleeding. A systematic approach to classification and management.

Early classification of lower gastrointestinal bleeding as occult, minor overt, or major overt allows a practical approach to evaluation and management. Localization of the bleeding site is the next step. In occult and minor overt bleeding, the cause can usually be determined from results of conventional diagnostic tests; however, angiography and even intraoperative endoscopy may be necessary in some particularly difficult cases. In contrast, major overt bleeding may only allow time for angiographic localization before surgery. Using this approach, the primary care physician can successfully manage most patients with lower gastrointestinal bleeding.

Gastroesophageal reflux is not increased by highly selective vagotomy.

In an attempt to determine whether or not highly selective vagotomy leads to increased gastroesophageal reflux, 20 patients were studied after vagotomy (ten underwent highly selective vagotomy and ten, truncal vagotomy and drainage) and ten patients with duodenal ulcer disease were studied preoperatively by history, esophageal manometry, basal pH studies, standard acid reflux tests, acid perfusion tests (Bernstein tests), acid clearance tests and endoscopy with biopsy. Nine of ten patients had either no or minimal reflux symptoms after highly selective vagotomy were contrasted with five of ten preoperative patients who underwent truncal vagotomy and four of ten patients with duodenal ulcer disease. No significant differences in the three patient groups studied were found by esophageal manometry, pH tests, acid perfusion tests, acid clearance tests or endoscopic and histologic examinations. Our results add support to the view that gastroesophageal reflux is not increased after vagotomy (including highly selective vagotomy).

Highly selective vagotomy with dilatation or duodenoplasty. A surgical alternative for obstructing duodenal ulcer.

Highly selective vagotomy (HSV) is an accepted choice for the treatment of uncomplicated duodenal ulcer. Its use in patients with gastric outlet obstruction, however, remains quite controversial. Since 1980, 69 patients have undergone HSV at the Medical College of Georgia Hospitals. Of these, 20 (29%) underwent either dilatation (14) or duodenoplasty (6) for accompanying outlet obstruction. The obstruction was graded as severe in 17 (85%) and moderate in three (15%). Follow-up evaluation has included Visick grading and endoscopy. There have been two deaths (38 and 54 months following surgery). Both patients were Visick I. Of the 18 patients available for review to date, 12 (67%) are Visick I and four (22%) are Visick II. There have been two failures (11%), discovered only by endoscopic follow-up in asymptomatic patients. No patients have required reoperation. HSV with dilatation or duodenoplasty is a reasonable surgical alternative for the treatment of obstructing duodenal ulcer disease.

Oral neomycin sulfate and erythromycin base before colon surgery: a comparison of serum and tissue concentrations.

It is accepted that the use of oral neomycin sulfate and erythromycin base before colon surgery results in decreased numbers of intestinal bacteria. Intraluminal levels of these agents are reported to be very high, but systemic availability is still debated. The systemic levels were studied in 8 patients undergoing colon surgery. Each patient received neomycin sulfate and erythromycin base, 1 g each, 19, 18 and 9 hours preoperatively. Twelve samples from serum, one from wound muscle and one from the intestinal wall were obtained from each patient in the 26 hours after the initial dose. Considerable variation was observed among levels. The following means were calculated: peak serum levels were 3.4 and 0.59 micrograms/ml, muscle levels were 1.68 and 0.23 micrograms/g and intestinal wall levels were 6.4 and 12.9 micrograms/g for erythromycin and neomycin respectively. Observed times to peak levels were 19 and 12 hours after the initial dose for erythromycin and neomycin respectively. The detectable systemic concentrations that result when these agents are given orally for bowel preparation before colon surgery may contribute to the drugs' efficacy.

Prophylactic parenteral cephalosporins in surgery. Are the newer agents better?

Parenteral prophylactic cephalosporins used in surgery were compared in 17 published studies. Examination of these studies reveals little justification for preference of one cephalosporin over another. For gastrointestinal, obstetrical-gynecologic, or cardiac operations, newer cephalosporins did not result in substantial decreases in adverse postoperative clinical events (eg, wound infections, intra-abdominal and pelvic infections, and endocarditis) when compared with older cephalosporins. There is no evidence that second- or third-generation cephalosporins result in postoperative infection rates lower than with first-generation cephalosporins.

Chronic constipation. Important aspects of workup and management.

Constipation is at best an annoying problem and at worst an incapacitating one. Two common causes are a faulty diet and inactivity. Drs Nivatvongs and Hooks propose a trial of dietary fiber for patients in whom an organic cause for constipation cannot be found. Such a trial may prove to be not only diagnostic but also therapeutic. They also discuss the proper use of laxatives, enemas, and surgical procedures.

Highly selective vagotomy. A closer look at the technique.

It is becoming apparent that the results (and especially recurrence rates) with highly selective vagotomy (HSV) vary considerably. Furthermore, the techniques utilized vary considerably as well. Interestingly, most series with higher recurrence rates have shown these trends relatively early on. The author presents a more detailed look at a technique of HSV associated with one of the lowest recurrence rates over a long follow-up period.

The stomach after surgery. An endoscopic perspective.

Twenty-five per cent of the authors' total upper endoscopy experience since 1974 has been in patients who have had upper gastrointestinal tract surgery. The observations from 617 examinations in 400 of these patients is reviewed. Pain or nausea and vomiting was a common presenting symptom. Multiple complaints were frequent. Gastritis was the most common endoscopic finding present in 127 patients (32%). Biopsy yielded an 89% histologic confirmation of the endoscopic perception. Coexisting mucosal pathology was common, with 39% of the patients having two or more abnormalities. X-ray in 190 patients had only a 30% accuracy rate and a frequent occurrence of false negatives (46%). Bezoars and intraluminal sutures were seen commonly and endoscopy provided a therapeutic choice for enzyme injection of the bezoar and removal of the sutures. Endoscopy provided a method of evaluation of our highly selective vagotomy technique; 96% of our patients with ulceration at the time of surgery were healed by endoscopy and 93% had active antral-pyloric function.

Intestinal vascular ectasias: a new look at an old disease.

Seventeen patients had rectal bleeding and intestinal vascular ectasia. Actual bleeding from the ectasia was seen in five patients. The average age of the 17 patients was 60.2 years, but 41% were under the age of 60. Melena was common initially. Both colonoscopy and angiography had a high degree of diagnostic accuracy, but angiography failed to demonstrate some lesions seen by colonoscopy. We consider these examinations complementary. Intraoperative endoscopy with transillumination was of value of determining the distribution of those lesions that had not been completely demonstrated by colonoscopy and angiography. We have used intraoperative endoscopy to guide the eventual amount of bowel resection, and intraoperative marking with this technic has resulted in a more specific pathologic examination. There has been no operative mortality. Six patients have re-bled from sources other than vascular ectasia.

Intraoperative gastrointestinal endoscopy.

A four year experience with the adaptation of the flexible fiberoptic endoscope to the intraoperative environment is presented in 30 patients. The technique of intraoperative endoscopy was utilized in a wide variety of difficult gastrointestinal surgical problems to include the location of the site and cause of bleeding of obscure etiology; resolution of intraoperative dilemmas without the necessity of opening abdominal viscera; resection of lesions during operations conducted for other pathological processes; and enhancement of diagnosis at laparotomy. There were no complications from the use of intraoperative endoscopy and the technique was beneficial in 28 of the 30 patients (93.3%). Limiting factors in the full utilization of the endoscope at celiotomy were dense adhesions with a shortened mesentery and massive hemorrhage with blood obscuring the intestinal lumen.

Intraoperative gastrointestinal endoscopy in the management of occult gastrointestinal bleeding.

Intraoperative gastrointestinal endoscopy has become an increasingly valuable diagnostic and therapeutic adjunct in the management of a variety of complicated problems in surgical patients. At the Medical College of Georgia, intraoperative gastrointestinal endoscopic technics have been successfully used to locate the site and cause of occult gastrointestinal bleeding; to diagnose, biopsy, and, when appropriate, resect lesions during operations conducted for other pathologic processes; to gain endoscopic access for resection of lesions otherwise inaccessible (endoscopically) by virtue of intestinal distortion caused by adhesions; to guide the operating surgeon to an area of resectable disease through dense adhesions secondary to multiple previous laparotomies; and to enhance diagnosis at laparotomy. The value of intraoperative gastrointestinal endoscopy in lesions resulting in occult gastrointestinal hemorrhage and the value of combined radiographic and intraoperative endoscopic technics in diagnosing and managing occult GI bleeding are discussed.