Femoral neuropathy: an infrequently reported postoperative complication. Report of four cases.

Postoperative femoral neuropathy is an uncommon complication of abdominal surgery. We present four cases occurring after colectomy at our institution and discuss the diagnosis and treatment.

Presacral cysts: transrectal excision in select patients.

Fourteen patients presenting with presacral cystic lesions were managed over a 20-year period. Retrospective review identified 12 females and 2 males. Fifty-seven per cent were symptomatic at diagnosis. Forty-three per cent presented with pain; half of these patients had infected cysts. All lesions were palpable on digital rectal exam. Computed tomography identified the cyst in all seven patients in which it was performed. The transrectal approach was used for cyst excision in ten patients. One patient had transrectal drainage and wall biopsy only. Three patients underwent posterior parasacral excision. Pathologic review demonstrated four dermoid cysts, four epidermoid cysts, four cyst hamartomas, and two benign teratomas. One cyst hamartoma had a focus of invasive adenocarcinoma. Two complications occurred. There were no deaths. Follow-up averaged 39 months, at which time there were no recurrences. Developmental cysts are the most common presacral tumors. Excision is recommended, and the transrectal approach may be used in select patients with low morbidity and minimal recurrence.

Local treatment of rectal cancer.

While abdominoperineal resection with permanent colostomy is still required for most distal [corrected] rectal cancers, sphincter-saving local treatment by means of local excision, electrocoagulation or endocavitary contact radiation can be used for some highly selected distal tumors. Local treatment avoids a permanent colostomy and is associated with much lower morbidity and mortality rates than abdominoperineal resection. Strict criteria for patient selection are essential to successful local treatment. Optimal candidates include patients exhibiting the following features of rectal cancer: a distal rectal cancer less than 8 cm from the anal verge; a tumor with a diameter of 3 cm or less; a tumor that is well to moderately well differentiated histologically, and a tumor that is limited to the bowel wall. Preoperative studies such as transrectal ultrasonography enhance the accuracy of preoperative staging. In properly selected patients, the results of local treatment are equivalent to those of abdominoperineal resection of comparable tumors. Close follow-up is essential, and tumor recurrence can be treated for cure by abdominoperineal resection.

Island flap anoplasty for anal canal stenosis and mucosal ectropion.

Anoplasty is a technique used to treat patients with mucosal ectropion and anal canal stenosis. The island flap design has been demonstrated to have distinct advantages over the older forms of anoplasty. Few reports have addressed the long-term results of this procedure. A review of all patients undergoing island flap anoplasty between 1987 and 1992 was performed. Twenty-eight patients were identified. Indications for anoplasty included anal stenosis in 20 patients and mucosal ectropion in eight patients. Complications included five minor wound separations and one urinary tract infection with subsequent clostridium difficile enterocolitis. In-office follow-up averaged 7 months, at which time all patients were completely healed and significantly improved. Follow-up by phone was performed in 23 patients, extending their follow-up to 36 months. Based on the phone questionnaire, 91 per cent of the patients judged their symptoms as improved, and 9 per cent of patients judged their symptoms as unchanged. No patient judged their condition has worsened. Compared with the earlier forms of anoplasty, the island flap anoplasty is associated with a more simple design, less morbidity, and excellent long-term outcome. The island flap anoplasty should be the preferred design in cases of mucosal ectropion and anal stenosis.

Delayed presentation of an inflammatory polyp following colonic ischemia.

Inflammatory polyps are usually associated with inflammatory bowel disease. The majority of these lesions are asymptomatic, however, they may be a source of obstruction or hemorrhage. These polyps represent re-epithelialization of the damaged colonic mucosa. Although inflammatory polyps have been associated with the acute phase of ischemic colitis, there has been only one report of delayed presentation of a symptomatic inflammatory polyp following ischemic injury to the colon. We present the second such report and a review of the literature.

A prospective study on intermittent pneumatic compression in the prevention of deep vein thrombosis in patients undergoing total hip or total knee replacement.

Three hundred and forty-six consecutive patients undergoing total hip or total knee replacement were prospectively studied to evaluate the effectiveness of intermittent pneumatic compression of the legs for the prevention of postoperative deep vein thrombosis. All patients were serially studied using impedance plethysmography and duplex ultrasound with color flow preoperatively and on the fourth and seventh postoperative day. The incidence of postoperative deep vein thrombosis in this series was 4 percent. Each patient with a postoperative duplex ultrasound had positive impedance plethysmography. Of the 14 patients who had postoperative deep vein thrombosis, seven had positive test results on postoperative day four and seven had positive tests on postoperative day seven. No patients were symptomatic. The results suggest that the high incidence of postoperative deep vein thrombosis after extensive orthopedic operation is significantly lowered by the use of intermittent pneumatic compression. Intermittent pneumatic compression, therefore, may be the preferred approach in prophylaxis of postoperative deep vein thrombosis.

Pneumoperitoneum following percutaneous endoscopic gastrostomy. Does the timing of panendoscopy matter?

Percutaneous endoscopic gastrostomy (PEG) has had a significant impact on enteral alimentation in patients unable to maintain adequate oral caloric intake. PEG avoids the morbidity and mortality associated with the traditional feeding gastrostomies placed by celiotomy. Several authors have documented benign, self-limiting pneumoperitoneum following PEG placement. No study has addressed whether the timing of panendoscopy in relation to gastric puncture has an effect on the incidence of post-PEG pneumoperitoneum. The authors prospectively studied 30 patients undergoing PEG. Panendoscopy was either performed before or after gastric puncture, and each patient then had abdominal radiographs to determine the presence of pneumoperitoneum. Four of 16 patients (25%) having panendoscopy prior to gastric puncture had radiographic evidence of pneumoperitoneum compared to three of 14 patients (23%) having panendoscopy following gastric puncture. The authors conclude that the timing of panendoscopy in relation to gastric puncture does not significantly effect the incidence of post-PEG pneumoperitoneum.