Two case reports of perineal hernia after laparoscopic abdominoperineal resection with a proposed modification to the operative technique.

Perineal hernia is a rare complication following laparoscopic abdominoperineal resection (APR) for rectal cancer. We present two case reports of perineal hernia following laparoscopic APR and discuss their management. We suggest that they developed because the pelvic peritoneum was left open during laparoscopic APR and propose that closure of the pelvic peritoneum should be routine in this operation.

Post-traumatic appendicular-cutaneous fistula: a case report.

Appendicular-cutaneous fistula is an uncommon condition that usually occurs as a complication of appendicitis. We report the case of a 28-year-old woman with a chronic appendicular-cutaneous fistula following a road traffic accident in which she sustained a penetrating injury to the abdomen.

Prospective audit of 200 patients undergoing laparoscopic inguinal hernia repair with follow-up from 1 to 4 years.

The results of 215 laparoscopic transabdominal pre-peritoneal inguinal hernia repairs are reported with a follow-up of 1-4 years (median 2.5 years). The patients" age range was 17-85 (median 59 years). Three recurrences occurred in the first 75 repairs, where a 12 x 7 cm mesh was used. There has been no recurrence in the subsequent 140 repairs where a larger 15 x 10 cm mesh was used for the repair. A total of 5% of patients developed urinary retention after the operation and a further 13% developed minor complications. The procedure was remarkably pain-free, with 25% requiring no analgesia after the operation and 67% requiring no analgesia after discharge from hospital. There was a rapid return to normal activity, with 55% driving within 1 week of the operation and 85% within 2 weeks. Sixty per cent returned to work within 2 weeks of the operation and 69% within 3 weeks. Forty-two of the patients had undergone a previous open hernia repair and 93% of these preferred the laparoscopic repair as there was less post-operative pain and a quicker recovery. The results show that laparoscopic hernia repair is remarkably pain-free, allows a rapid return to normal activity and has a low recurrence rate when a 15 x 10 cm mesh is used.

Ascorbic acid absorption in Crohn's disease. Studies using L-[carboxyl-14C]ascorbic acid.

Total body pool and intestinal absorption of ascorbic acid were studied in 12 patients undergoing operation for Crohn's disease (six with fistulae and six without) and in six control patients undergoing operation for reasons other than Crohn's disease. L-[carboxyl-14C]Ascorbic acid, 0.19-0.40 megabecquerels (MBq), was given orally. After a period of equilibration, the labeled ascorbic acid was flushed out of the patient's body tissues using large doses of unlabeled ascorbic acid. Intestinal absorption of ascorbic acid, assessed from the total cumulative urinary 14C recovery, was found to be similar in patients with fistulizing Crohn's disease (73.9 +/- 8.45%), those without fistulas (72.8 +/- 11.53%), and in controls (80.3 +/- 8.11%). Total body pools of ascorbic acid, calculated using the plasma 14C decay curves, were similar in patients with Crohn's disease with fistulas (17.1 +/- 5.91 mg/kg), patients without fistulas (9.6 +/- 3.58 mg/kg), and in controls (13.3 +/- 4.28 mg/kg). The results indicate that ascorbic acid absorption is normal in patients with both fistulizing and nonfistulizing Crohn's disease. The results suggest that routine supplements of vitamin C are not necessary unless oral ascorbic acid intake is low.

The operative management of fistulous Crohn's disease.

In 100 consecutive patients with fistulous Crohn's disease who were managed surgically during a 12 year period, a 96 per cent closure rate was obtained with only a 1 per cent 30 day mortality rate. En bloc resection of the diseased intestine and fistula with primary anastomosis was the preferred treatment, but temporary exteriorization of the intestinal ends was undertaken in patients compromised by extensive sepsis or profound hypoalbuminemia. In 43 patients, there were 70 secondary intestinal defects caused by the fistula eroding into otherwise healthy intestine. The majority of these defects were successfully closed by primary suture; however, three secondary duodenal defects, treated by primary suture alone, failed to heal and fistulas recurred. As a result, two of these patients died of overwhelming sepsis. Since adopting closure or protection of duodenal defects by a jejunal serosal patch, this problem has not arisen again. One defect in the sigmoid colon treated by primary suture also had recurrence of fistula, probably because the repair lay adjacent to an abscess cavity. Temporary loop colostomy is now used to protect repairs of defects in the sigmoid colon undertaken in the presence of local sepsis.

Home parenteral nutrition: a review of 100 patient years of treatment in 76 consecutive cases.

Over the last 10 years, the Nutrition Unit at Hope Hospital has trained and looked after 76 patients on home parenteral nutrition for a total of 100 patient years. Although 40 per cent of patients have required home parenteral nutrition for 6 months or less one patient has been on treatment for 7 years. The quality of life measured on a 4 point scale was good for the majority of patients. Sepsis and superior vena caval thrombosis are the main problems encountered. Overall mortality rate was 18 per cent and the sepsis rate was 0.14 episodes per patient per year. Home parenteral nutrition is an effective and safe treatment of intestinal failure.

Does local intestinal ascorbate deficiency predispose to fistula formation in Crohn's disease.

Samples of maximally diseased and adjacent macroscopically normal intestine from 52 patients undergoing surgery for Crohn's disease were analyzed for ascorbate content; 26 of the patients had intestinal fistulas and 26 did not. Ascorbate analyses were also performed on samples of normal intestine from ten control patients. Diseased intestine from both groups of patients with Crohn's disease contained significantly more ascorbate than the adjacent macroscopically normal intestine. Their diseased intestine also contained significantly more ascorbate than normal intestine from controls. Whereas diseased intestine from patients without fistulas contained 47 percent more ascorbate than their normal intestine (P less than .001), the diseased intestine from patients with fistulas contained only 23 percent more ascorbate than their normal intestine (P less than .02). Patients with fistulas appear unable to concentrate as much ascorbate in their diseased intestine as patients without fistulas. This difference may be a factor in the pathogenesis of fistula formation in Crohn's disease because of the importance of ascorbate in collagen production.

Comparison of clinical scores and acute phase proteins in the assessment of acute Crohn's disease.

Fifty-two patients with Crohn's disease have been assessed using acute phase proteins and a scoring system. Thirty-nine underwent operation and intra-abdominal abscesses were found in seventeen. Both scores and acute phase proteins have been shown to reflect inflammation due to secondary sepsis in addition to that from active Crohn's disease. The scores were higher, and acute phase changes greater, in patients with sepsis than those without. By choosing a threshold for each variable that excludes patients without sepsis it has been found that a score greater than 181, ESR greater than 45 mm/h, CRP greater than 33 mg/l, orosomucoid greater than 1.8 g/l and albumin less than 26.7 g/l identify sepsis with a specificity greater than 95 per cent and sensitivity greater than 35 per cent. Over 70 per cent of patients with abscesses exceeded one or more of these thresholds. We believe that operative management should be strongly considered if one or more of these criteria are positive as such patients have a greater than 90 per cent chance of having an intra-abdominal abscess. This will prevent these abscesses eroding into adjacent viscera or to the surface with resulting fistula formation.