Incontinence rates after cutting seton treatment for anal fistula.

OBJECTIVE: To determine the incidence of anal incontinence after the use of cutting seton treatment for anal fistula. METHOD: Literature searches were performed on PubMed, MEDLINE and Google Scholar using the words 'cutting seton(s)', 'seton(s)' and 'anal fistula'. An analysis of the data in the collected references was performed. RESULTS: The average rate of incontinence following cutting seton use was 12%. The rate of incontinence increased as the location of the internal opening of the fistula moved more proximally. In the studies that described the types of incontinence, liquid stool was the most common followed closely by flatus incontinence. Incontinence associated with the treatment of fistulas defined as nonspecific cryptoglandular in nature was 18%. CONCLUSION: The high incontinence rates that result from the use of cutting setons suggest that this commonly used therapy can damage the continence musculature. Other techniques that do not involve cutting the sphincter, when available, should be preferred, especially for higher fistulas.

Decreased cerebrospinal fluid absorption during abdominal insufflation.

BACKGROUND: Intracranial pressure (ICP) is known to rise during induced CO(2) pneumoperitoneum. This rise correlates with an increase in inferior vena caval pressure; therefore, it is probably associated with increased pressure in the lumbar venous plexus. Branches of this plexus communicate with arachnoid villi in the lumbar cistern and the dural sleeves of spinal nerve roots-areas where cerebrospinal fluid (CSF) absorption to normally takes place. The increased venous pressure in this area may impede CSF absorption. Because CSF is produced at a constant rate, decreased absorption will increase ICP. We hypothesized that increased ICP occurring during abdominal insufflation is due, at least in part, to decreased absorption of CSF. The purpose of this study is to show that CSF absorption is inhibited during abdominal insufflation. METHODS: After appropriate approval was obtained, 16 domestic swine were anesthetized and injected into the CSF with 100 microcuries (microCu) of I(131) radioactive iodinated human serum albumin (RISA) in 2 ml of normal saline. Eight subjects underwent CO(2) abdominal insufflation to 15 mmHg and were maintained for 4 h. A control group did not undergo insufflation. Blood levels of RISA were measured over a 4-h period to determine the rate of CSF absorption. RESULTS: Blood levels of RISA increased at a slower rate in the subjects undergoing abdominal insufflation than in the control group. The mean change over 2 h in the insufflated group was 15% compared to 34% in the control group (p = 0.02). This difference indicates decreased absorption of CSF in the insufflated group. CONCLUSIONS: These results demonstrate decreased absorption of CSF during abdominal insufflation and support the hypothesis that the increase in ICP pressure occurring during abdominal insufflation is caused, at least in part, by decreased absorption of CSF in the region of the lumbar cistern and the dural sleeves of spinal nerve roots.

Intraabdominal adhesion formation after preperitoneal dissection in the murine model.

BACKGROUND: The laparoscopic approach to hernia repair has been advocated by many as a potentially superior method of herniorraphy. Several techniques have been described, each with its own proposed advantages. These techniques involve different anatomic approaches, the most recent of which is the totally extraperitoneal approach (TEPA). One presumed advantage of the extraperitoneal approach is the avoidance of adhesion formation because the peritoneum is not entered and mesh is not placed in direct contact with intra-abdominal structures. We hypothesize, however, that when the peritoneum is dissected from the abdominal wall, it is partially devascularized, leading to scar formation and potential adhesion formation. This would suggest that the TEPA method of herniorraphy may not completely avoid the risks of intra-abdominal adhesion formation. METHODS: After appropriate approval was obtained, 88 male Sprague-Dawley rats were divided into two equal groups. One group underwent laparotomy followed by careful blunt dissection of the peritoneum from the left abdominal wall. The control group underwent laparotomy without manipulation of the peritoneum. All animals were re-explored 14 days later, and the abdominal cavity was examined for adhesions. The type and location of any adhesion was recorded. RESULTS: Adhesion formation occurred in 10 of 44 (23%) subjects in the peritoneal dissection group, compared with 3 of 44 (7%) in the nondissection group (p < 0.05). CONCLUSIONS: Dissection of the peritoneum from the overlying abdominal wall in the murine model leads to intra-abdominal adhesion formation. This suggests that peritoneal dissection in the TEPA method of herniorraphy may lead to intra-abdominal adhesion formation.

Endoscopic axillary exploration and sentinel lymphadenectomy.

BACKGROUND: Minimally invasive approaches have changed the practice of surgery in several specialties. The purpose of this study was to develop a reproducible endoscopic technique for the evaluation of the axilla in breast cancer patients. METHODS: A total of 23 patients with biopsy-proven breast carcinoma were enrolled. Patients were positioned in the supine position with the ipsilateral arm abducted at 90 degrees. A 1-cm skin incision was made at the superior aspect of the axilla. Dissection was carried bluntly to the lateral border of the pectoralis major. A balloon distention device was inserted into the tract and distended under endoscopic vision to create a working space. Insufflation was initiated up to a pressure of 8 mmHg. A 30 degrees laparoscope was introduced for visualization of axillary contents. One or two additional 5-mm cannulas were placed as needed under direct visualization. Manipulation of axillary contents was performed, and in 19 patients a sentinel node identification technique was applied. RESULTS: In all patients, using insufflation and minimal instrument dissection, the axillary vein, long thoracic, and thoracodorsal nerves were found in their usual anatomical locations. Utilizing blunt and sharp dissection, the axilla was thoroughly inspected, and individual lymph nodes were easily identified and extracted. In 11 of 19 patients, a sentinel node or blue dye was identified using isosulfan blue. There was a procedure concordance of 84%, and there were no complications. CONCLUSIONS: We describe a novel endoscopic technique for the evaluation of the axilla in breast cancer patients. This technique allows (a) creation of a minimally invasive working space within the axilla, (b) recognition of key axillary anatomic landmarks, and (c) instrument manipulation within the axilla to identify and extract lymph nodes, and apply the sentinel node technique. This is the first report of a minimally invasive approach to axillary exploration to employ sentinel lymph node mapping.

Gastric adenocarcinoma associated with isolated granulomatous gastritis.

BACKGROUND: Granulomatous gastritis is a rarely observed pathological diagnosis. This condition often mimics gastric adenocarcinoma clinically, resulting in gastric resection. However, granulomatous gastritis has long been viewed as a benign process not observed in association with adenocarcinoma of the stomach. This article describes a patient with granulomatous gastritis occurring in close proximity to an area of superficially invading gastric adenocarcinoma. METHODS: Acid-fast stains, fungal stains, standard cultures, tuberculosis cultures, and a VDRL serum test were all obtained. Both upper endoscopy and colonoscopy were performed. Chest radiographs were taken and pulmonary consultation was obtained. RESULTS: The gastric samples obtained from resection showed no evidence of foreign body reaction. The acid-fast stains, fungal stains, cultures, and VDRL were all negative. Endoscopic exams did not show granulomatous inflammation in any other part of the gastrointestinal tract. No pulmonary disease was evident on radiographic or pulmonary exam. CONCLUSION: Isolated granulomatous gastritis is a diagnosis of exclusion. The findings in this patient do not support a diagnosis of Crohn's disease, tuberculosis, sarcoidosis, syphilis, histoplasmosis, berylliosis, or foreign-body reaction. This is a unique case suggesting an association between isolated granulomatous gastritis and metaplastic mucosal changes.

A method of objectively evaluating improvements in laparoscopic skills.

BACKGROUND: In this paper, we explored a quick and inexpensive method to evaluate the improvement in laparoscopic skills gained by residents after attending a formal training course in laparoscopy. METHODS: Surgical residents attending an endoscopic workshop were randomly selected to perform tasks in a training simulator. Each was evaluated qualitatively and quantitatively before and after the workshop. A control group of six residents who did not attend the workshop were selected to perform the same tasks twice in succession. RESULTS: The total mean time improvement for all tasks in the study group was 34.3% and in the control group 7.3% (p = 0.0001). When the data was separated for each task, statistically significant improvement was demonstrated in five of the six tasks. CONCLUSIONS: Residents who attend a formal workshop in endoscopy can gain significant improvement in skills. The methods described in this study can be used to quantitatively measure this improvement throughout a resident's training.

Utility of insufflation filters in laparoscopic surgery.

OBJECTIVES: To determine whether filters, regularly used as part of the insufflator tubing during laparoscopic surgery, trap microbial and particulate matter from CO2 tanks, thus preventing passage from one patient to another. METHODS: A total of 67 used filters were collected from 17 CO2 tanks and six insufflation machines at three local hospitals, and sterile unused filters were used as controls. The used filters were distributed equally and sequentially into three groups: Group I-viewed under a dissecting microscope for particulate matter; group II-examined by mass spectrometry for contamination with oils and other impurities; group III-incubated on sheep blood agar plates and evaluated for growth of microorganisms. RESULTS: Negative. Used filters were indistinguishable by all parameters from controls. CONCLUSIONS: This limited study suggests filters now used in laparoscopic surgery fail to trap microbes or particulate matter. The question remains whether tank waste is absent or these filters fail to trap waste matter.

Splenosis of the mesoappendix: case report and review of the literature.

The development of splenosis is a known consequence of splenic rupture. A case is presented of acute appendicitis in a patient with a past history of abdominal trauma who required laparotomy for unknown reasons. During appendicectomy a mass was found in the mesoappendix which proved to be evidence of splenosis.

Common bile duct T-tubes. A caveat and recommendations for management.

Operations on the common bile duct can result in severe long-term consequences. To prevent some of these complications, it is common practice to drain the biliary tree with a T-tube. The T-tube is usually removed 2 weeks after it was placed. There have been numerous reports of bile leak following T-tube removal in the literature. These leaks can result in bile ascites, biloma, or bile peritonitis. Control of bile leaks can be accomplished in a number of ways, including endoscopically or radiologically placed stents or drains and radiologic techniques to drain the fluid collections. We describe a novel technique that can be utilized at the time of T-tube removal that will allow immediate control of the bile leak and prevent the complications of bile accumulation within the peritoneal cavity. We have performed fluoroscopic removal of T-tubes on two patients and found no complications with the technique. We have successfully visualized the T-tube tract in both patients. The T-tube tract can be visualized at the time of T-tube removal in an effort to prevent the complications of tract disruption and subsequent bile leak.

The investigation of symptomatic inguinal hernia: a complication of barium enema.

The controversy surrounding the value of performing screening barium enema in patients with inguinal hernia persists. It was Myers & Zollinger who, in 1942, reviewed 200 consecutive cases of inguinal hernia and noted that 18%; of patients complained of gastrointestinal symptoms. Of these, two cases of adenocarcinoma were discovered on further evaluation. Subsequently, many authors have reported a low diagnostic yield of barium enema in patients with inguinal hernia unless specific colonic symptoms were present. We present a case in which this investigation was indicated, but led to irreducibility.

Incidental detection of cystic neoplasms of the pancreas.

Cystic neoplasms of the pancreas are rare, accounting for less than 1% of all pancreatic tumors Since the advent of computerized tomography (CT), an increasing number of these lesions are being discovered incidentally. Compagno and Oertel were the first to thoroughly describe and differentiate the benign serous cystadenoma from the potentially or overtly malignant mucinous cystadenoma/cystadenocarcinoma spectrum. At present, our ability to definitively differentiate between these two classes of cystic neoplasms is limited. Because of this, controversy exists as to their appropriate surgical management. A case report is presented and followed by a review of the literature on incidentally detected cystic neoplasms of the pancreas.

Determination of the learning curve of the AESOP robot.

BACKGROUND: As the variety of procedures performed with laparoscopic technology increases, the skill levels and equipment demands also increase. Laparoscopic appendectomy, hernia repair, colon resection, and Nissen fundoplication all require someone whose only responsibility is to control the laparoscope and therefore the operative field. This is usually the most inexperienced person on the operating team. The Automated Endoscope System for Optimal Positioning (AESOP) robot provides a means to eliminate the need for the camera person, returns control of the camera and operative field to the operating surgeon, and enhances human performance. The purpose of this study was to evaluate the acquisition of skills to control the laparoscope in a satisfactory fashion. METHODS: We selected medical students as our study group because they have no prior experience in laparoscopic procedures. They performed a readily reproducible task in a pelvic trainer with hand control and with the AESOP robot. Their initial times are compared, as is the improvement in their times after 10 min of practice with the AESOP robot. RESULTS: These data show that in this study group use of the AESOP robot was not as fast as hand control but the skill to use it was learned as quickly. Additional features of the robut such as a steady view and the ability to acquire images and return to them reliably are other advantages. CONCLUSION: The AESOP robotic arm provides a stable support for the laparoscope during laparoscopic procedures which can be manipulated by the surgeon. We found that the time required to learn control of the laparoscope manually and with the AESOP robot is equal.

Laparoscopic versus open Nissen fundoplication: outcome of surgery in monozygotic twins.

Differences in outcome and cost of laparoscopic and open surgery are continuously being evaluated. Two-year-old monozygotic twin boys with a previous history of prematurity, severe gastroesophageal reflux disease, and intractable reactive airway disease were each scheduled to undergo a laparoscopic Nissen fundoplication (LNF) on the same day. Current medications for both patients included albuterol, cromolyn sodium, dexamethasone, ranitidine, and metoclopramide. In the first case, the laparoscopic procedure was converted to an open Nissen fundoplication (ONF) to gain expeditious control of bleeding from a short gastric vessel close to the spleen. The second patient underwent LNF without complication. Operative time for each patient was 3.5 h. The postoperative length of stay for each patient was 6 days (ONF) and 4 days (LNF). The total hospital charges were $21,931 (ONF) and $19,108 (LNF). The first patient (ONF) was readmitted later on the day of discharge (postoperative day 6) for vomiting and was discharged after 24 h with no further treatment. The subsequent course of each patient was similar. At a 6-week follow-up visit, both patients were tolerating a regular diet with weight gain and dramatic improvement in pulmonary symptoms.

Management of colorectal foreign bodies.

Colorectal foreign bodies (CFBs) present a serious dilemma regarding extraction and management. In an 11-year period ending March 1994, 48 patients presented to the University of California, San Diego Medical Center and Hammersmith Hospital London with CFBs. Identified patients charts were reviewed in a retrospective manner and the medical literature was reviewed. A wide variety of CFBs were identified and all were extracted transanally. Circumstances surrounding CFB insertion was most commonly sexual stimulation (78%), but included sexual assault (10%). Extraction in the emergency department was successful in 31 (63%) patients. Operating room extraction was performed in 18 (37%) patients; in 12 cases the CFBs were simply extracted under anaesthesia, five patients required primary repair and diverting colostomy for rectal perforation and one required primary repair of an external anal sphincter laceration. Post-extraction observation following simple extraction ranged from immediate discharge to 72 h (mean 13.1 h) and there were no reported complications. A thorough history is essential in order to identify those cases that have resulted from assaults. With adequate sedation, most CFBs can be extracted transanally either in the emergency department or operative suite under direct vision. Sigmoidoscopy is required following extraction to evaluate mucosal injury or perforation. After effortless extraction of a smooth object, with no evidence of mucosal injury, the patient can be discharged after a short period of observation. Rectal perforation can be treated with primary repair and diverting colostomy with low morbidity. This is a relatively common surgical dilemma that requires a thorough history, physical examination, radiographs inventiveness to treat. Additionally, the physician should demonstrate a caring attitude and not subject the patient who is suffering pain and embarrassment to ridicule.

New applications of laparoscopy in gastrointestinal surgery.

Although laparoscopy has been available since the turn of the century, the technique did not become widely accepted for gastrointestinal surgery until it was used in cholecystectomy. Since then, various gastrointestinal operations have been performed using laparoscopic guidance. Laparoscopic operations must conform to principles for open general surgery, especially in cases of oncologic resection. Procedures for treatment of conditions such as hiatal hernia, gastroesophageal reflux, intractable peptic ulcer disease, bypass for malignant pancreatic obstruction and repair of rectal prolapse have received immediate acceptance. Other procedures, such as Whipple's operation and colectomy for cancer, have met with a more guarded response.