Postoperative and long-term results of ileal pouch-anal anastomosis for ulcerative colitis and familial polyposis coli.

The immediate postoperative and long-term functional results of 51 ulcerative colitis patients and 21 familial polyposis patients who underwent ileal J-pouch-anal anastomosis were compared in this study. The incidence of postoperative complications requiring reoperation was not statistically different in both groups. The mean daily stool frequency was significantly higher in colitis patients. Pouchitis occurred in 44% of colitis patients but not in polyposis patients (P < 0.005). Symptoms of pouchitis included bloody diarrhea, urgency, abdominal pain, weight loss, fever, and arthritis. Six colitis patients required pouch excision because of intractable pouchitis. The overall pouch excision rate was 22% in ulcerative colitis patients and 5% in familial polyposis patients. Patient satisfaction was good in 46% of ulcerative colitis patients and 76% of polyposis patients (P < 0.05). Our data demonstrate that the long-term outcome of ileal pouch-anal anastomosis is more favorable in polyposis patients than in colitis patients. Pouchitis is a major long-term complication occurring exclusively in colitis patients.

Enterostomy as an adjunct to treatment of intra-abdominal sepsis.

In 60 patients a small bowel enterostomy was constructed as part of the treatment of various intra-abdominal infectious and obstructive conditions. Eleven patients (18 per cent) died in the immediate postoperative period from continuing sepsis. In one patient closure of the stoma was not considered because of disseminated malignancy. In the remaining 48 patients continuity of the gut was subsequently restored. In 22 patients (46 per cent) complications occurred, 12 (25 per cent) of which were intra-abdominal septic complications. The occurrence of intra-abdominal complications was found to be linked to premature (i.e. within 3 months) closure of the stoma. Reasons for premature closure were stomal difficulties and prerenal azotaemia. Stomal closure was attended by a 10 per cent mortality rate.

Mammographic and histopathologic correlation of nonpalpable lesions of the breast and the reliability of frozen section diagnosis.

During a period of ten years, 118 (32.9 per cent) instances of carcinoma were found in 359 specimens taken at biopsy for nonpalpable mammographic lesions. In recent years, the positive predictive value has increased from 68 per cent due to the development of magnification mammography and the use of a mammographic grid. Correlating mammographic and histopathologic data, the rate of malignant disease was 12.7 per cent for instances of a circumscribed or nodular mass, 32.4 per cent for clustered microcalcifications as the only suspect finding, 28.6 per cent when a mass with microcalcifications was present and 66.7 per cent when a stellate-shaped mass was found. Of 188 instances of carcinoma, 40 were noninvasive: 32 instances of ductal carcinoma (27.1 per cent) and eight of lobular carcinoma in situ (6.8 per cent). The possibility of frozen section diagnosis was studied retrospectively by comparison with the paraffin section reports. A correct diagnosis, whether benign or malignant, was achieved in 68 per cent. No frozen section examination was done in 17.3 per cent and the diagnosis was deferred to results of paraffin section in 12.2 per cent. False-negative results were encountered in seven patients (1.9 per cent) and false-positive results in two (0.6 per cent). Both of these patients had florid sclerosing adenosis. Although frozen section diagnosis is feasible in nonpalpable lesions of the breast, it is recommended that this method not be used in instances of pure microcalcifications and tiny solid masses of 5 millimeters or less.

[Misdiagnosed rupture of the diaphragm following blunt thoracic-abdominal trauma]. / Verkannte Zwerchfellrupturen nach stumpfem Brust-Bauch-Trauma.

The histories of 67 patients with a diaphragmatic rupture due to blunt trauma were reviewed in four hospitals. In 45 patients the diagnosis was made within 24 hours after the accident, in the other 22 patients the rupture was diagnosed in a later stage. In the first group there were much abdominal injuries and during emergency laparotomy for some other reasons in 29% of these cases the diaphragmatic rupture was found accidentally. Not recognizing a rupture in the acute phase and therefore delaying operation was caused by the fact that the initial chest X-ray was not thoroughly checked for signs of a diaphragmatic rupture. The reasons for operation in the "delayed" group were mainly typical abnormalities for diaphragmatic rupture of the chest X-rays and other investigations proving the diagnosis. Only in one patient the delay in diagnosis has led to a very serious complication: because of incarceration with gangrene of a part of the small bowel it was necessary to remove this part. The other 21 patients in the group where the diagnosis was initially missed did not suffer from any serious complication.

Localization and excision of nonpalpable breast lesions. A surgical evaluation of three methods.

Three methods of excising nonpalpable breast lesions have been evaluated: (1) "blind" method, using mammographic coordinates; (2) preoperative localization with the Frank needle; and (3) Frank needle localization aided by a multiperforated compression plate. Successful removal at first attempt occurred in about 80% with any method. The size of the biopsy specimens did not differ significantly among the three groups and is most probably a function of the breast volume. The failure rate was seven (2.1%) of 332 biopsies. Since three of the six repeated biopsies yielded specimens with malignancy, the persistence of a radiographically suspicious lesion on follow-up mammogram of the operated-on breast is an urgent indication for reoperation.

Ectopic gastric mucosa in the lower esophagus, presenting as a sessile polyp.

A patient with dysphagia caused by a sessile polyp in the lower esophagus is reported. Histologic examination showed ectopic gastric mucosa. Of the benign tumors of the esophagus, only leiomyoma is seen regularly. The remaining tumors are so rare that the consequences of this diagnosis are unclear. When symptoms make treatment necessary, local excision is preferred.

Perianal fistulas in patients with Crohn's disease.

A series of 55 patients with perianal fistulas and Crohn's disease is reported herein. Thirteen patients (24%) did not need specific treatment of the fistula. Primary proctectomy was necessary in five patients. Defunctioning enterostomy was used in nine patients, followed by healing of the fistula in four patients. Local surgery of the fistula was performed in 28 patients, with an overall success rate of 79%. Healing of the fistula was not influenced by activity of the disease, type of fistula, or condition of the rectum. Local surgery did not cause incontinence in this series.

The significance of microcalcifications without palpable mass in the diagnosis of breast cancer.

Microcalcifications constitute an important part of nonpalpable breast lesions and may be the first sign of a breast carcinoma. Between 1975 and 1984, 150 consecutive patients with clusters of at least five microcalcifications without palpable findings as the only indication for biopsy were treated. One hundred seventy-three groups of microcalcifications were excised and 51 malignancies were detected (29.5%). Most of the malignant lesions were noninfiltrating (56%). Axillary or distant metastases occurred in 11% of the fully evaluable cases. This warrants the expectation that these patients have a very favorable prognosis. Breast biopsy for nonpalpable-clustered microcalcifications is a feasible and valuable procedure. Close cooperation is required between the surgeon, radiologist, and pathologist.

Multicentricity in nonpalpable breast carcinoma and its implications for treatment.

During a 9 year period, 300 consecutive women underwent breast biopsies solely because of nonpalpable, mammographically suspicous findings. One hundred clinically occult breast carcinomas were found, 65 of which were invasive and 35 noninvasive. Eighty-three mastectomy specimens were evaluable for evidence of multifocal carcinoma in another quadrant of the breast or at a distance of 5 cm and residual cancer outside the excisional biopsy cavity. Multicentricity was present in 47 percent and residual tumor in 60 percent of the whole group. When only clinically occult invasive carcinomas were considered, other foci of invasive carcinoma were demonstrated in 26 percent of the patients and residual invasive cancer in 35 percent. The rate of bilaterality was 14 percent, occurring synchronously in 11 percent of the patients. Any therapeutic procedure for nonpalpable breast carcinoma, whether invasive or noninvasive ductal carcinoma, should be directed to the whole breast. Mammography of the contralateral side should be an integral part of the preoperative work-up of patients with palpable lesions ipsilaterally.

Rectal prolapse; a review of Dutch surgical practice.

Many different technics have been described for the treatment of rectal prolapse. Transabdominal fixation of the rectum is the procedure currently most favoured, as in The Netherlands, where the majority of patients with rectal prolapse are treated in this way. A questionaire sent to all teaching hospitals showed that in only seven out of 27 hospitals postanal repair is carried out in cases of postoperative fecal incontinence.

Anastomotic insufficiency in small bowel surgery--incidence and treatment.

In the period 1977-1981 234 small bowel anastomoses were constructed in 143 patients. Eight anastomoses showed leakage (3.4%) and from nine anastomoses a fistula developed (3.8%): a total rate of disturbed healing of small bowel anastomoses (7.3%). In the presence of intra-abdominal infection this rate was 14.8%, in the absence of infection 0.8%. The results of treatment with oversewing and with resection and immediate anastomosis were disappointing. Better results were obtained by dismantling of the anastomosis, establishment of a split-enterostomy and reestablishment of continuity in a second stage. Mortality was 3/17 (18%). The literature is reviewed.

Solubility of tissue hydroxyproline in experimental intestinal anastomoses.

Salt and acid solubility of collagen are thought to reflect its degree of crosslinking. In order to examine postoperative changes in crosslinking of intestinal collagen, which are of importance to the stability of the intestinal wall, we have investigated the solubility of hydroxyproline in rabbit ileum and colon, both in unwounded intestine and after construction of an anastomosis. Solubility in salt and dilute acid was increased by a sonication procedure. This way, 9% of total hydroxyproline in the unwounded colonic wall was salt soluble and 65% acid soluble. A similar distribution was observed in ileum. Three days after operation the salt-soluble fraction was significantly elevated in samples from the anastomotic area. In colon, this increase also persisted 7 days postoperatively. Comparison of anastomotic samples collected 3 and 7 days after surgery shows a significant decrease in the acid-soluble and a significant increase in the solid fraction. This phenomenon occurs both in ileum and colon. These results indicate that during the first days after operation the integrity of the intestinal wall is weakened not only by a loss of collagen, but also by a changed solubility of the remaining collagen.

Histological features of wound repair: a comparison between experimental ileal and colonic anastomoses.

Various histological parameters of wound repair have been studied in intestinal anastomoses in the rabbit in order to compare the healing processes in ileum and colon. The sequentional appearance of granulocytes, macrophages and fibroblasts has been studied from 3 h to 7 days after operation. Also, degree of necrosis, formation of capillaries and mucosal repair were analysed semi-quantitatively. Significant differences were observed between ileal and colonic anastomoses with respect to occurrence of granulocytes, necrosis and mucosal repair, particularly 7 days after operation. At that time, granulocytes and necrosis were virtually absent from ileal anastomoses, while mucosal integrity was restored in the majority of cases examined. In contrast, granulocytes and necrosis were still abundantly present in colonic anastomoses and mucosal repair was poor. These results support biochemical evidence that wounds in the ileum heal more rapidly than wounds in the colon. Possibly, the sustained presence of granulocytes, which are a potential source of collagenase activity, is important in this respect. Investigation of the same features of intestinal wound healing in rabbits with peritonitis induced by infection showed similar results and no differences were found between infected and non-infected animals.