Development and evolution of pelvic exenteration: historical notes.

Fifty years after the development of pelvic exenteration, the operation remains a gold standard in the surgical management of advanced pelvic malignancy. The operation has evolved through several predictable phases including technical improvements, lowered morbidity and mortality, and improved patient selection. Despite progress in supportive peri-operative care, pelvic exenteration is a major undertaking that should be performed in centers with proven interest and expertise in the field. We trace the early developments of the operation, the period of maturation, and the current place of this procedure in the armamentarium of the oncologic surgeon.

Pelvic exenteration for carcinoma of the colon and rectum.

Carcinoma of the colon and rectum is one of the most common causes of cancer deaths in the United States. The mortality of patients treated by surgery alone is 55% within 5 years of surgery. Despite efforts to decrease local recurrence and their concomitant problems of pain and disability, a significant number of patients will still have pelvic recurrences that carry a significant morbidity. In selected cases, pelvic exenteration may cure or provide palliation of the symptoms of colorectal carcinoma. Pre-operative evaluation is performed to detect signs of unresectability. During surgery, exploration is performed for evidence of metastases to the liver, omentum, and peritoneum, followed by an assessment of the local extent of the tumor. The margins of resection must be clear even if resection of contiguous organs or bony structures is necessary. The urinary tract is resected with an ileal loop, sigmoid or transverse colon conduits, or continent urinary diversion. Depending upon the involvement of neighboring structures, exenterative pelvic surgery can be modified for organ preservation.

Markers of severe appendicitis.

Appendicitis is a common surgical disease that often presents with vague, inconclusive symptoms. Despite the development of technologically advanced diagnostic modalities, perforation has usually occurred before the surgeon sees the patient. Morbidity, length of stay, and hospital costs associated with appendiceal perforation have not changed markedly in the past 50 years. To evaluate prognostic markers for severe appendicitis, we reviewed 18 years' worth of records of patients with appendicitis who were admitted to St. Elizabeth's Medical Center of Boston and found that the combination of history and physical examination has withstood the test of time. We found that advancing age, duration of symptoms for 36 or more hours, white blood cell count, shift left in white blood cell count, and fever were significantly related to severe appendicitis. An abnormal plain film was a marker if fever coexisted.

Extraperitoneal rectal perforation due to retroflexion fiberoptic proctoscopy.

The increasing use of retroflexion proctoscopy to evaluate the distal rectum is not without complications. We report a series of three patients who experienced extraperitoneal rectal perforation secondary to retroflexion proctoscopy and discuss our success with conservative management. By evaluating each clinical situation individually and following certain principles, successful outcome can be achieved without surgical intervention. Success depends on several factors: 1) the injury must be below the peritoneal reflection; 2) the patient must have undergone a complete bowel preparation before endoscopy; 3) postinjury, the patient must continue to show no evidence of peritonitis or hemodynamic instability; and 4) the patient must be given nothing by mouth, started on intravenous antibiotics and possibly parenteral nutrition, and closely monitored with serial abdominal examinations. The presence of comorbid conditions does not necessarily diminish the chance that conservative therapy will succeed.

Retroperitoneal and abdominal wall emphysema after transanal excision of a rectal carcinoma.

The use of transanal excision to remove rectal carcinomas is a relatively new application of this surgical procedure, which may require full thickness excision. Retroperitoneal and abdominal wall emphysema are potential complications of surgical procedures that breach the wall of the colon and rectum. Computed tomographic scans provide the clearest diagnostic picture of developing emphysema, and prompt diagnosis through accurate interpretation of the scans is essential to minimize morbidity and mortality. When the diagnosis is made early and no active infection accompanies the emphysema, the preferred approach to initial treatment is nonsurgical. This article presents a case in which local transanal excision was performed on a 70-year-old male to remove a superficial adenocarcinoma from the lower rectal wall. He developed postoperative retroperitoneal and abdominal wall emphysema. Conservative treatment is discussed.

Complete intraoperative small-bowel endoscopy in the evaluation of occult gastrointestinal bleeding using the sonde enteroscope.

OBJECTIVE: To review our experience with intraoperative small-bowel Sonde enteroscopy in evaluating occult bleeding in the small intestine. DESIGN: Retrospective study with 100% follow-up. SETTING: University-affiliated, tertiary-care teaching hospital. PATIENTS: Sixteen consecutive patients referred with occult gastrointestinal bleeding in whom esophagogastro-duodenoscopy , push enteroscopy, and colonoscopy had failed to identify the source of bleeding. Fourteen of the 16 patients had required one or more transfusions. MAIN OUTCOME MEASURE: Completeness of visualization, diagnostic accuracy, and complications of the procedure and follow-up for recurrent bleeding. RESULTS: In all 16 patients, intraoperative Sonde enteroscopy allowed visualization of the entire small bowel. In 14 of the 16, it revealed the cause of bleeding, which was ileal angiodysplasia in three patients, ileal ulcers in six patients, neoplasia in two patients, and ileal ulcers caused by Crohn's disease, small-intestinal enteropathy and varices caused by portal hypertension, and radiation stricture in one patient each. Two patients had normal small bowel mucosa. The patients with mucosal disease underwent small-bowel resection or oversewing of bleeding sites. Two surgical complications occurred: prolonged postoperative ileus (one patient) and small-bowel obstruction that resolved without surgery (one patient). Two of the patients with angiodysplasia had recurrent bleeding postoperatively. CONCLUSIONS: Intraoperative Sonde enteroscopy is safe and effective in localizing small-intestinal bleeding sites, providing complete visualization of the small-bowel mucosa without enterotomy while avoiding the trauma that can be caused by push endoscopy. It is the diagnostic assessment of choice in selected patients with occult gastrointestinal bleeding of presumed small-bowel origin.

Patient-controlled analgesia and prolonged ileus after uncomplicated colectomy.

BACKGROUND: Because the duration of postoperative ileus after uncomplicated colon surgery has increased at our institution in the past 4 years, thereby prolonging length of hospital stay for some patients, we assessed several clinical factors to determine which were responsible for the increase. PATIENTS AND METHODS: We retrospectively studied a cohort of 358 patients who underwent uncomplicated colon resection to investigate risk factors for prolonged postoperative ileus. Postoperatively, all patients received an analgesic agent, delivered either intramuscularly (IM) or by patient-controlled analgesia (PCA) pump, until their postoperative ileus resolved, as indicated by the passage of flatus and tolerance of a clear liquid diet. RESULTS: There was no significant relationship between the length of postoperative ileus patient age or gender, the operating time, or the type or amount of analgesic agent used postoperatively. A significantly larger proportion of the patients who received PCA than those given an IM agent had ileus at 7, 6, and 5 days after surgery (P < 0.0001 for all comparisons after controlling for confounding factors), however. Overall, the use of PCA was associated with a delay in return of normal bowel function of 0.9 days. Patients who underwent a right colectomy had a significantly shorter ileus than those who had other procedures. CONCLUSIONS: Our findings indicate that the use of PCA after uncomplicated colectomy increases the risk of prolonged postoperative ileus. We suggest that the routine use of PCA after colon surgery be reevaluated.

Avulsion fracture of the anterior superior iliac spine presenting as acute-onset meralgia paresthetica.

Avulsion fracture of the anterior superior iliac spine is rare. Most cases occur in adolescents involved in competitive sports or vigorous exercise in which the sartorius and tensor fascia lata muscles are contracted strongly and suddenly against a hyperextended trunk. Patients who sustain this injury usually experience acute pain in the anterior pelvic region. We describe a patient with avulsion of the anterior superior iliac spine who presented with meralgia paresthetica. The symptoms resolved with conservative treatment.

Patient-controlled analgesia and postoperative urinary retention after hysterectomy for benign disease.

BACKGROUND: Because postoperative urinary retention can result in considerable morbidity and the rate of retention after hysterectomy has recently increased at our institutions, we conducted a study to determine risk factors for the disorder. STUDY DESIGN: A cohort of 366 consecutive patients who had undergone uncomplicated abdominal or vaginal hysterectomy for benign disease and who met strict inclusion criteria were studied retrospectively by means of a review of their medical records. Student's t test and multivariate logistic regression analysis were used to assess the effects of operative time, amount of fluid given perioperatively, type and amount of analgesic agent administered postoperatively, age of the patient, performance of a vaginal versus an abdominal hysterectomy, and the postoperative use of patient-controlled analgesia on the rate of postoperative urinary retention in these patients. RESULTS: After adjustment for confounding factors, only the use of patient-controlled analgesia (p = 0.0001) and vaginal hysterectomy (p = 0.0003) were significantly related to postoperative urinary retention. Patients who used patient-controlled analgesia were 5.7 times (95 percent confidence interval, 2.6 to 12.4) more likely to have urinary retention than those given an intramuscular agent. CONCLUSIONS: Urinary retention after hysterectomy might be avoided by administering analgesic agents intramuscularly or inserting a suprapubic cystostomy catheter postoperatively, especially in patients who have undergone a vaginal procedure.

Healing of transsphincteric perianal fistulas in Crohn's disease using a new technique.

OBJECTIVES: Transsphincteric perianal fistulas in Crohn's disease are often refractory to medical therapy and difficult to treat surgically. Our objective was to determine whether a new method of anal fistulotomy was effective in healing these fistulas. METHODS: In this new method, the internal opening of the fistula tract was displaced distally to the region of the anal mucosa in 26 patients with Crohn's disease. RESULTS: Healing was achieved within 5 weeks of surgery in 45/49 (92%) of the fistulas and was not influenced by perioperative medication, site of preexisting Crohn's disease, or condition of the rectum. There has been no alteration of preoperative continence. CONCLUSIONS: We conclude that this method is highly effective in treating transsphincteric perianal fistulas in Crohn's disease.

Clinical presentation of chronic anal fissures.

Chronic anal fissures have a varied and often confusing clinical presentation. To clarify this picture, we retrospectively studied 172 patients to determine associations between patient characteristics and manifestations of these lesions. We found that anterior fissures and sentinel piles were significantly more common in women; pruritus and rectal drainage occurred significantly more often in men; and patients with a longer duration of symptoms and those with pruritus and drainage were more likely to have a fistula. Younger patients were more likely to report rectal bleeding. Patients with chronic anal pruritus or an anal abscess should be carefully evaluated for an anal fistula, since anorectal problems may recur if a fistula remains untreated.

Patient-controlled analgesia and postoperative urinary retention after open appendectomy.

We retrospectively studied 279 patients who had undergone uncomplicated open appendectomy for acute appendicitis to determine risk factors for postoperative urinary retention. The gender of the patients, the operating time and the amount of fluid given perioperatively had no influence on the occurrence of retention. The amount of analgesic agent administered postoperatively and the age of the patient were significantly associated with urinary retention (p = 0.01 and p < 0.0001, respectively, after adjustment for potential confounding factors). The use of meperidine hydrochloride as compared with morphine and of patient-controlled analgesia as compared with intramuscular delivery were initially found to be significantly related to retention (p = 0.014 and p < 0.0001, respectively). After the effects of the age of the patient, the drug type and the amount of fluid and analgesic agent administered were controlled for, patient-controlled analgesia remained significantly associated with retention (p < 0.0001), whereas the type of drug given was no longer significant after controlling for potential confounding factors. Because we found that urinary retention was 13 times more likely to occur in the patients who had patient-controlled analgesia, we recommend that the use of this form of analgesia delivery be avoided after open appendectomy.

Hidden colonic adenomas in a patient with a family history of polyposis.

We describe an asymptomatic patient with a strong family history of polyposis who was found to have flat and depressed adenomas that were not visible on colonoscopy. The diagnosis required assessment of multiple, randomly obtained biopsy specimens. Partial deflation of the colon during colonoscopy may allow hidden lesions to be seen. Biopsies should be performed in all patients with a family history of polyposis who are examined colonoscopically, even if they are asymptomatic and no lesions are visible through the colonoscope.

Metastatic breast carcinoma presenting as persistent diarrhea.

Patients with breast carcinoma metastatic to the colon generally present with multiple symptoms, usually pain, vomiting, nausea, and ascites. We describe a patient who presented only with persistent diarrhea, underwent surgery for colon cancer, and, on pathological evaluation of the surgical specimen, was found to have metastatic breast cancer affecting the colon. Metastatic breast cancer should therefore be suspected in patients with a history of breast cancer and diarrhea of unknown cause that is not accompanied by other symptoms. Evaluating such patients by colonoscopy and biopsy would provide important information relevant to choosing between colon surgery and systemic therapy.

Endometriosis causing colon obstruction in two postmenopausal women.

Colonic endometriosis is an uncommon lesion usually found in premenopausal women. We describe two postmenopausal women with colonic endometriosis that resulted in colonic obstruction. One of the women was receiving estrogen-replacement therapy. Colonic endometriosis in postmenopausal women may become more common as the population ages and the use of long-term estrogen-replacement therapy becomes increasingly widespread.