Cost of open versus laparoscopically assisted right hemicolectomy for cancer.

The aim of this study was to estimate and compare the costs of open right hemicolectomy (ORHC) versus laparoscopically assisted right hemicolectomy (LARHC) performed for cancer. A retrospective cost analysis of 61 consecutive patients operated on between January 1992 and August 1994 for right-sided colonic cancer by either LARHC (n = 28) or ORHC (n = 33) was performed. The analysis focused on the cost (in Australian dollars) incurred from the date of operation to the date of discharge. LARHC was significantly more expensive than ORHC (total cost LARHC $9064, ORHC $7881; p < 0.001). LARHC was associated with a significantly longer operating room utilization time (LARHC 261 minutes, ORHC 203 minutes; p < 0.001) and a greater cost of disposables (LARHC $854, ORHC $189; p < 0.001). This study demonstrates no cost benefit for LARHC compared to ORHC when performed for cancer.

Radiology of the continent ileostomy reservoir: I. Method of examination and normal findings.

The aim of the present study is to describe the radiologic methods used to study continent ileostomy reservoirs and to depict the normal radiologic features and variations identified by these procedures. During an 8-year period, 408 double-contrast studies were performed in 261 patients. The present study comprises 170 examinations in 99 patients with normal findings. A high-density barium contrast medium and air were used. Modes variation in the size and shape of the reservoirs was observed. The mucosal pattern of the reservoirs resembled that of the ileum but the folds were slightly wider. The continence-providing valves were 3-5 cm long and had a diameter of 2.5-4.0 cm. The diameter of the afferent ileal segments was usually slightly larger than that of more proximal ileal segments, with an upper limit of approximately 4 cm. The efferent ileal segments generally had a straight course without widening or out-pouches. Retrograde barium double-contrast examination is a satisfactory method for the evaluation of continent ileostomy reservoirs. Here we define the range of normal variations of such reservoirs as seen on retrograde double-contrast radiologic examinations.

Radiology of the continent ileostomy reservoir: II. Findings in patients with late complications.

During an 8-year period, 238 barium double-contrast studies performed in 162 patients with continent ileostomy reservoirs who had signs and symptoms of late complications (malfunction of the valve, nonspecific inflammation of the mucosa, stenoses, hernias, and fistulas) showed radiologic abnormalities. The aim of the present study is to depict the radiologic findings in patients with late complications of continent ileostomy reservoirs. With radiologic examination, the correct diagnosis of valve malfunction was made in 96% of patients with surgically proven valve defects. We were able to differentiate between various types of valve dysfunction and complications related to the fixation of the reservoir to the abdominal wall. Inflammatory mucosal changes and fistulas of the reservoir and the afferent ileal segment were depicted with a high degree of accuracy. Barium double-contrast radiologic examination proved to be very valuable in the work-up of patients with dysfunction of continent ileostomy reservoirs. The method was of particular value in assessing the cause of valve dysfunction and in the appraisal of the afferent ileal segment.

Comparison between radiologic and endoscopic evaluation of the continent ileostomy reservoir.

The present study was performed to compare the results of radiologic examination and endoscopy in 156 patients with continent ileostomy reservoirs. Data from clinical follow-up and findings at revisional surgery were used for confirmation of diagnosis. One hundred and one patients had the clinical diagnosis nonspecific inflammation, 48 had symptoms of valve dysfunction, and 7 were studied because of suspected valve-shunting fistulas. For moderate and severe inflammation the findings on radiographs and at endoscopy were in accordance, whereas slight inflammation was more frequently reported by radiology than endoscopy. Radiology overdiagnosed slight inflammation. One disadvantage of endoscopy in patients with inflammation was that the afferent ileal segment could be reached in only 56%. By radiology 41 of 44 defective valves were identified (93%), whereas endoscopy disclosed only 24 defective valves (55%). The combined efforts of radiologic examination and endoscopy only managed to diagnose three of the seven patients with valve-shunting fistulas (two by radiologic and one by endoscopic examination). In conclusion, the retrograde double-contrast examination is a valuable complement in the assessment of patients with continent ileostomies and appears to be superior to endoscopy in the diagnosis of valve dysfunction and in depicting the afferent ileal segment.

Sodium and potassium excretion before and after conversion from conventional to reservoir ileostomy.

Sodium and potassium in the ileostomy output and urine were determined in 28 patients with ulcerative colitis on a free diet and in eight patients on a defined constant diet, before and after conversion from a conventional ileostomy (CI) to a continent reservoir ileostomy (RI). Feces and urine were collected both in the hospital and at home. Patients with CI on free diet had a median intestinal loss of 62 mmol sodium and those with RI 74 mmol/24 h collected in the hospital (p < 0.05). The figures for at home was 79 and 81 mmol/24 respectively, and were larger than in the hospital (p < 0.01). Sodium loss in the urine (U-Na) and the intake of sodium did not change significantly after conversion. Patients with a low U-Na before conversion also had a low U-Na after, in a few almost nil, implying a need for increased intake of sodium. Patients with a CI and low urinary output of sodium should be carefully studied with respect to their sodium balance before accepting them for conversion to RI. The ileostomy output of potassium increased after conversion (4.3 vs. 6.8 mmol/24 h; p < 0.01) in the hospital (5.3 vs 7.1 mmol/24 h; p < 0.01) at home. Patients on a defined constant diet before and after conversion did not show any significant differences in absorption of sodium, potassium, magnesium or calcium after conversion, but did show a reduced dry weight of the ileostomy output, indicating an increased degradation of intestinal contents in RI patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Structure of mucosa in continent ileal reservoirs 15 to 19 years after construction.

Mucosa biopsy specimens were obtained from 12 patients with continent ileostomy reservoirs constructed 15 to 19 years previously. Biopsies from normal ileal mucosa, taken from six other patients with no apparent bowel disease, served as controls. The specimens were processed for light and electron microscopy. The reservoir mucosae showed an increased amount of inflammatory cells, but there were no signs of dysplasia. In the goblet cells, sialomucins dominated over sulfomucins; in this respect no difference was found between reservoirs and controls. Morphometric studies showed an increase of mucus-storing goblet cells in the reservoir mucosae, both with regard to relative number and to volume density. The mitotic index was higher than normal in the reservoirs, but the relative number of the Paneth cells and the height of the villus epithelial cells were similar in the reservoirs and the controls. In the reservoirs, the surface amplification factors due to villi and to microvilli (near the villus tips) were reduced by some 29% and 20%, respectively, indicating villus hypotrophy. It is concluded that only minor morphologic changes appear in the ileal reservoir mucosa 15 to 19 years after construction. Morphometry provides a sensitive tool to demonstrate such changes in intestinal morphology.

Long-term follow-up of patients with continent ileostomies.

Thirty-six patients were evaluated after having continent ileostomies for 16 to 20 years. Follow-up included clinical examination, response to a questionnaire, blood tests, and radiologic studies of the gallbladder. In addition, reservoir biopsies from 15 patients were examined. The patients were in excellent general health, all but one having gained weight postoperatively. There was no increased risk for gallstone formation or for urinary tract stone development. Although 11 of the 36 patients had reservoirs that were not provided with a valve, 92 percent of all patients were continent. Working capacity was normal in most patients and no harmful effects of the reservoir were revealed by morphologic or biochemical studies. In conclusion, no deleterious long-term effects were found as a result of the continent ileostomy.

Renal function and upper urinary tract configuration following urinary diversion to a continent ileal reservoir (Kock pouch): a prospective 5 to 11-year followup after reservoir construction.

We followed 17 patients who underwent urinary diversion via a continent ileal reservoir (Kock pouch) with yearly examinations for 5 to 11 years postoperatively. The examinations involved control of renal function and configuration of the upper urinary tract. In 5 patients the upper urinary tract had become dilated during followup and in 2 of these renal scarring also had developed. All 5 patients had endured temporary outflow obstruction or reflux (stricture, overdistension of the reservoir or a defective antireflux valve). Of the patients 1 had a marked decrease in renal function before the outflow obstruction was corrected by an operation. Routine blood chemistry study was normal and hyperchloremic acidosis was not noted in any patient. After peroral loading of 6 patients with ammonium chloride significant excretion of titratable acid was found in the urine. Substitution with vitamin B12 was given to 6 patients due to subnormal values in 2 and borderline values in 4.

Voiding pattern, urinary volume, composition and bacterial contamination in patients with urinary diversion via a continent ileal reservoir.

A series of 41 patients with a continent ileal reservoir for urinary diversion (Kock pouch) was studied with regard to voiding pattern (voiding frequency), voided volume, urinary composition, bacterial contamination and mucus secretion. The mean voiding frequency in 21 patients was 5/24 h and the time required for the procedure, including the time to cover the stoma with a bandage, was 3 to 5 min; 2 patients voided once or twice at night, while 19 patients never did so. The mean volume voided during the day were significantly smaller than the volume voided in the morning. The total 24-h urinary volume exceeded that of normal individuals but the 24-h secretion of electrolytes was within normal limits. Bacterial contamination was found in most samples of urine. Evacuation was not impeded by the rich mucus content of the urine and mucus production did not diminish with time.

Pregnancy and delivery in patients with a continent ileostomy.

Patients undergoing surgical treatment for inflammatory disease of the intestine are often in their reproductive years. Therefore, it is highly relevant to study the influence of surgical treatment on later pregnancy and delivery. Reported herein are 28 patients with continent ileostomies who have carried 37 pregnancies to term. An increased urge to empty the ileostomy reservoir, especially in the late period of pregnancy, was noted by the majority of patients. About one-third of the patients reported some difficulties with intubation of the reservoir in late pregnancy but in only a few patients did these disturbances result in a revisional operation after delivery. Pregnancy was normal in most instances and only four premature childbirths occurred. All pregnancies resulted in live birth. Vaginal delivery was successful in the majority of the patients, cesarean section being chosen for obstetric reasons in nine instances. From this study, it is concluded that, in patients with a continent ileostomy, normal pregnancy and delivery can be expected. However, in a few instances, the ileostomy function may be disturbed, necessitating later revisional operations.

Absorption of L-phenylalanine in human ileal reservoirs exposed to urine.

The mucosa of ileal reservoirs exposed to urine undergoes successive structural changes, indicating a loss of absorptive capacity. In patients with urinary diversion via a continent ileal reservoir, the active absorption of L-phenylalanine from the reservoir was studied at different postoperative time intervals. A test solution containing L-phenylalanine was instilled into the reservoir and samples were taken at intervals during a period of one hour for determination of phenylalanine. In one group of patients, urine from the kidneys by-passed the reservoir via a catheter inserted into the afferent segment. Within three months after construction of the ileal reservoir, the uptake was significantly slower than that in ileostomy reservoirs and the absorption decreased even more with longer observation times. Mixing of urine with the reservoir contents did not influence the uptake of L-phenylalanine to any significant degree. The reduced absorption of L-phenylalanine indicates that the uptake of other substances from this type of ileal reservoirs might be decreased also.

Clinicopathologic studies on mesothelioma of the pleura. Differentiated approach to treatment.

A surgical series of 23 patients with pleural mesothelioma is reviewed. Three who had benign localized mesothelioma of fibrous type are alive and well at least 10 years postoperatively. In two others, radically extirpated localized mesothelioma was histologically classified as benign, but later proved to be malignant, causing death from recurrent disease 27 and 79 months postoperatively. Four patients with diffuse malignant mesothelioma underwent pleurectomy or open biopsy and survived for 2-9 months. Radical en-bloc pleuropneumonectomy was performed on 14 patients with diffuse malignant mesothelioma. One patient died postoperatively and the others succumbed to the disease after 3-51 (mean 20) months. The survival time was greater than or equal to 1 year in 62% of the patients and greater than 3 years in 23%. Patient age, histologic tumour type and extent of disease seemed to be important prognostic factors. Despite the generally poor prognosis, the results of radical surgery in this study appear to warrant an aggressive approach to treatment of benign or localized malignant pleural mesothelioma, and possibly also to stage I diffuse malignant mesothelioma of epithelial type.

Gastroduodenal and ileal polyps in patients treated surgically for familial polyposis coli with proctocolectomy and continent ileostomy.

Eighteen patients, who previously had been treated surgically for familial polyposis coli with proctocolectomy and a continent ileostomy were re-investigated with endoscopy and X-ray for gastric, duodenal and ileal polyps. Gastric and/or duodenal polyps were found in 6 patients and ileal polyps in 2. Altogether upper GI-polyps were found in 7 patients (39%). Most polyps were true adenomas. In one patient with large gastric adenomas, the severe dysplasia called for a gastric resection. It is obvious that familial polyposis may affect the whole gastro-intestinal tract, therefore necessitating regular surveillance of the upper GI-canal as well as the colon and rectum in patients with this hereditary affliction.

Drainage of the upper urinary tract as recorded with renography in patients with a continent urostomy (Kock pouch). An experimental study with various degrees of reservoir filling.

The drainage from the upper urinary tract was studied by the use of renography in thirteen patients with well functioning continent ileal reservoirs for urinary diversion (Kock-pouch). Renography was performed with empty reservoir and with submaximal or maximal filling of the reservoir. The reservoir pressure was continuously recorded when renography was performed with a full reservoir. When the reservoir was empty renography showed normal drainage in all patients. When the reservoir was full the renography was normal in eight patients, these having a mean reservoir volume of 715 ml but showed a delay in five patients, these having a mean reservoir volume of 930 ml. When the renography was repeated in the latter group of patients with submaximal filling (mean reservoir volume 544 ml) there was no delay of the drainage phases on the renograms. In these five patients the considerable "over-filling" of the reservoir had resulted in volumes greatly exceeding the previously recorded maximal reservoir capacity and also in pressures exceeding considerably those usually recorded in ileal reservoirs. These results show that the pressure in the bladder substitute is of great significance for the drainage from the upper urinary tract and that the low pressure ileal reservoir under ordinary circumstances does not obstruct the flow from the upper urinary tract.

Volume capacity and pressure characteristics of the continent ileal reservoir used for urinary diversion.

The volume capacity and the pressure characteristics of the continent ileal reservoir for urinary diversion were studied at specific intervals postoperatively in 26 patients. The reservoir volume increased during the first year postoperatively from approximately 100 ml. at operation to a mean of 735 ml. and then remained stable during an observation period of up to 7 years. The basal pressure increased during filling from 0 to about 10 cm. water. During physiological conditions, that is when the reservoir was filled by diuresis, the basal pressure was equal to those pressures measured during saline infusion at corresponding reservoir volumes. Calculation of the magnitude of motor activity by 2 different methods showed a significant decrease in activity at 12 months compared to at 2 months after construction of the reservoir. Data from the continent urostomy reservoir were compared to corresponding data from the continent ileostomy and cecal reservoirs for fecal diversion, these being obtained in previous studies in our laboratory. The ileal reservoirs used for fecal or urinary diversion were practically identical with regard to volume capacity, basal pressure and motor activity. However, the cecal reservoir had a significantly lower volume capacity and higher basal pressure at corresponding reservoir volumes, while the motor activity was approximately 10 times greater than in the ileal reservoir. The results indicate that with regard to volume capacity and pressure characteristics the ileal reservoir is superior to the cecal reservoir as a receptacle for urine.

Morphologic changes in ileal reservoir mucosa after long-term exposure to urine. A study in patients with continent urostomy (Kock pouch).

In patients with supravesical urinary diversion, continent ileal reservoirs utilized for urinary collection were examined by endoscopy at intervals of 1 month to 9 years after surgical construction, and biopsy specimens were obtained for light microscopy and morphometry. The gross appearance of the mucosa showed alterations in the shape of the shorter and broader finger-like villi during the first postoperative month to the subsequent very low ridges and convolutions or, in some instances, flat mucosa devoid of individual villi. Starting between 1 and 3 years after the surgical construction, endoscopically smooth areas were encountered in caudal areas of the reservoir, and the areas were mixed with islands of villous mucosa. Microscopically and morphometrically, the specimens from villous areas confirmed reduction in villous height and increase in crypt depth, whereas no changes were seen in the epithelial mitotic frequency. The number of mucus-storing goblet cells increased already within 1 month after construction. Specimens obtained from smooth areas showed alterations in the intestinal structure, with reduction of crypts, decreased height of epithelial cells, and occasional epithelial denudation. No signs of fibrosis, foreign-body reaction, or dysplasia were encountered. The constant exposure to urine leads to adaptive changes of the reservoir mucosa, resulting in a true atrophy of villi, crypts, and individual epithelial cells.