Predictive value of a pathophysiological score in the surgical treatment of perforated diverticular disease.

Resection is the preferred method of perforated diverticular disease treatment compared to conservative treatment. However, the immediate or deferred timing of bowel continuity restoration for advanced degrees of peritoneal contamination is debatable. This is a retrospective study designed to identify operative mortality predictors and guidelines for safe primary anastomosis. A pathophysiological score (acute physiology and chronic health evaluation, APACHE II) was applied to 135 consecutive patients who had undergone surgery for acute inflammatory complication of diverticular disease. A multivariate analysis was used to identify prognostic factors such as age, chronic diseases, neoplastic cancer, Acute Physiology Score (APS), Hinchey's classification and APACHE II scores. Seventy patients underwent primary resection and anastomosis, 35 underwent Hartmann's procedure and 15 conservative treatment. There was a significant correlation between operative mortality and increasing disease severity based on Hinchey's classification, APS and APACHE II scores. The multivariate analysis proved APACHE II scores to be the only prognostic factor of operative mortality. Both single and multivariate analysis of variance failed to identify a factor significantly associated with surgical and/or medical postoperative complications. APACHE II scores were the best predictor for operative mortality in patients with diverticular disease complications, but none of the classification criteria used was effective in predicting postoperative complication. Patients with phlegmonous sigmoiditis can be safely treated with primary resection and anastomosis. Conservative treatment should not be considered an effective method for diverticular disease. A prospective trial comparing resection with and without colostomy should be done for local and diffuse purulent peritonitis treatment. Hartmann's procedure is seen to be the only indicator for faecal peritonitis.

Patterns of distribution of endoscopic and histological changes in the ileal reservoir after restorative proctocolectomy for ulcerative colitis. A long-term follow-up study.

OBJECTIVE: This study was undertaken to assess the long-term macroscopic appearance of the ileal reservoir after restorative proctocolectomy for ulcerative colitis, to determine whether there is any correlation between macroscopic and histological changes and whether the distribution of these is homogeneous, focal or patchy. BACKGROUND: No study has examined the macroscopic appearance of the ileal reservoir over a long period and it is still unknown to what degree histological changes are diffuse or patchy. Moreover, the relationship between macroscopic and histological changes is poorly understood. METHOD: Fifty-nine patients were examined by one clinician (PSC) 5.3-14.5 years (median 8.2 years) postoperatively. A rigid sigmoidoscopy of the reservoir was performed. Four zones in the posterior midline at 5-cm intervals from the ileoanal anastomosis were inspected. At each level a macroscopic score of severity of inflammation was given and a biopsy taken. The degree of acute and chronic inflammation was assessed using a histopathological scoring system. RESULTS: All reservoirs showed macroscopic abnormalities, which were more marked distally in 14 (24%). There was no case in which severity of inflammation was greater in proximal than in distal zones. Endoscopy overall correlated with both acute and chronic histological changes. On histological examination the patients could be divided into three groups as follows: (1) all four biopsies were normal (group 1, n = 8, 14%), (2) the score of acute and chronic inflammation decreased from distal to proximal zones (group 2, n = 25, 42%) and (3) all four biopsies were abnormal with the same score (group 3, n = 26, 44%). The latter group significantly correlated with a present or past history of pouchitis. CONCLUSION: The study has shown that when there is a gradation of inflammation within the ileal reservoir this is more severe in distal than in proximal zones.

Modification of visceral sensitivity and pain in irritable bowel syndrome by 5-HT3 antagonism (ondansetron).

Intrinsic neurons containing serotonin (5-HT) are involved in the regulation of gastrointestinal motor function and are also thought to be important in the modulation of visceral sensory function. We have evaluated the effect of a specific 5-HT3 antagonist (ondansetron, O) on visceral sensation and rectal compliance in a randomized, double-blind, cross-over, placebo (P) controlled study of O 16 mg 3 times/day, in healthy volunteers and patients with irritable bowel syndrome (IBS). Symptoms were also evaluated in the latter group. A 2-week run-in period was followed by two 2-week treatment arms of P and O, separated by a 2-week wash-out period. Twelve healthy subjects and 9 patients with IBS were recruited. Assessment was by daily symptom and bowel function diary, and physiological tests of anal manometry, rectal sensory testing to distension and electrical stimulation, and rectal compliance. Ten healthy subjects completed the entire study, and 6 IBS patients completed the diary card evaluation, including 5 who also completed the physiological evaluation. O caused significantly (p < 0.01) firmer stools when considering both subject groups together. In the healthy subjects no physiological parameters were altered by O. In IBS patients the rectal sensory threshold to electrical stimulation tended to increase with O (20 vs. 28 mA, P vs. O, median, p = 0.06) while the urge (80 vs. 60 ml, p = 0.05) and maximum tolerated volumes (130 vs. 90, p = 0.03) to distension tended to decrease with O. Patients with IBS experienced significantly fewer daily episodes of pain while on O (2 vs. 1, p = 0.03). Serotonin-3 antagonism (O) causes firmer bowel actions in all subjects, and may affect gut sensitivity and pain in patients with IBS.

Choice of prophylactic surgery for the large bowel component of familial adenomatous polyposis.

The surgical options for treating the large bowel component of familial adenomatous polyposis are total proctocolectomy, colectomy with ileorectal anastomosis, and restorative proctocolectomy, with or without mucosectomy. Although the first of these eradicates all mucosa at risk, it carries several disadvantages, not least of which is a permanent ileostomy. There is little to choose functionally between the other two operations. The choice should be based on the perceived risk of cancer developing in any residual rectum; the factors influencing this risk are discussed.

Follow-up in colorectal cancer patients: a cost-benefit analysis.

BACKGROUND: No conclusive evidence exists concerning the effectiveness of follow-up programs after curative surgery for colorectal cancer, and presently cost-benefit analyses have not indicated that follow-up strategies increase survival or quality of life. METHODS: Five hundred five patients who survived curative surgery for stage I-III colorectal adenocarcinoma were closely followed for at least 4 years. RESULTS: One hundred forty-one (28%) patients had recurrence. Of these, 32 underwent one or more surgical procedures for cure, whereas 109 could only benefit from palliation. Eighteen were cured. The mean survival of all recurrent cases was 44.4 months. Of those operated on with curative intent, the mean survival was 69.3 months compared with 37.1 months in those operated on with palliative intent. Of those 18 patients who were cured by reoperative surgery, the average survival was 81.4 months. The overall follow-up cost was $1,914,900 (U.S.) for the 505 patients; $13,580 (U.S.) for each recurrence, $59,841 (U.S.) for each case treated for cure, and $136,779 (U.S.) for those effectively cured. CONCLUSIONS: Careful postoperative monitoring is expensive yet effective when one considers that one-quarter of the detected recurrences were suitable for potentially curative second surgery; however, only 3.6% of the original group were effectively cured. Follow-up programs should be tailored according to the stage and site of the primary to reduce costs.

Longterm appraisal of the histological appearances of the ileal reservoir mucosa after restorative proctocolectomy for ulcerative colitis.

Between November 1976 and December 1985, 110 patients had restorative proctocolectomy for ulcerative colitis. The histological appearances in the reservoir mucosa were followed up in 60 of 109 survivors over 19-173 months (median 97). The median number of biopsy specimens taken per patient was six with a range of 3-13. These were examined by one pathologist (ICT) unaware of the clinical details using a scoring system previously described to assess the degree of chronic and acute inflammation. There was a significant correlation between the degree of severity of chronic and acute changes (r = 0.6192, p < 0.000001). There was no correlation between the severity of inflammation and the following variables: preoperative duration of disease, presence of cancer or dysplasia in the original operative specimen, extra-alimentary manifestations or the type of reservoir. A significant correlation between severe inflammation and male sex was found (p < 0.035). The 60 patients could be divided into three groups based on the severity and fluctuation of histological inflammation. In group A (n = 27, 45%) chronic changes were minor and acute inflammation was never seen. In group B (n = 25, 42%) chronic changes were more severe and there were transient episodes of acute inflammation. In group C (n = 8, 13%) severe chronic and severe acute inflammation were constantly present. Differentiation of the three groups had clearly occurred within six months from closure of the ileostomy. Patients in group C could be identified on histological criteria within weeks of closure of the ileostomy and were those exclusively at risk of developing chronic pouchitis. Chronic pouchitis never occurred in patients of groups A and B. No case of dysplasia was seen. Histological assessment of the reservoir mucosa with in a few months after closure of the ileostomy seems to define patients who will and who will not subsequently develop pouchitis.

The first 10 years' experience of restorative proctocolectomy for ulcerative colitis.

Between 1976 and 1985, 110 patients had restorative proctocolectomy or proctectomy for ulcerative colitis and 103 were followed up until death or February 1992. There was one postoperative and one late death related to surgery. The cumulative probability of pouch failure was 12% at five years: half of the failures occurred within one year. The commonest reasons were perianal/pelvic sepsis and probable Crohn's disease. The cumulative probability of readmission, excluding that for ileostomy closure, was 68% at five years. There were 152 operations carried out during readmissions. These included 44 laparotomies. Function was assessed in 80 patients at a mean of 99.3 months after ileostomy closure. For 66 patients with spontaneous evacuation, average minimum diurnal frequency was 3.8, maximum 4.9, with 35 evacuating at night. One patient experienced major continence problems, 30 had minor leaks, and 49 were completely continent. Postoperatively, five patients gave birth to nine babies, four had renal stones, two myasthenia gravis, and two severe anaemia: seven had pre or postoperative thyroid dysfunction.

Postanal repair for faecal incontinence persisting after rectopexy.

Eleven patients (nine women) with persistent faecal incontinence after rectopexy for rectal prolapse were treated by postanal repair. Follow-up data, including clinical and anorectal physiology, at 5-8 years (median 76 (range 64-95) months) were available for nine patients. At long-term follow-up, seven of the nine patients had improved continence (two were continent to solid and liquid stools, and five to solid stool). One patient required a colostomy. Median (range) physiological findings before and after postanal repair in the nine patients were: anal canal length 2.3 (1.5-3.0) versus 3.5 (2.0-5.5) cm (P < 0.05); resting anal pressure 20 (0-49) versus 35 (10-55) cmH2O (P < 0.05); perineal descent 2 (1-3) versus 0 (3 to -0.2) cm; and mean pudendal nerve terminal motor latency 2.35 (2.0-3.1) versus 2.85 (2.3-3.4) ms.

Long-term results of postanal repair for neurogenic faecal incontinence.

Between 1984 and 1986, 54 patients underwent postanal repair for neurogenic faecal incontinence. Forty-two (41 women) were available for follow-up 5-8 (median 6.2) years after operation. Of these, 34 women attended for clinical and anorectal physiological assessment. Anal endosonography was also performed in 30 patients. In the 34 patients examined, continence categories (Browning and Parks' classification) of C (n = 12) and D (n = 22) before surgery became A (n = 2), B (n = 12), C (n = 16) and D (n = 1) at 6 months and A (n = 4), B (n = 5), C (n = 21) and D (n = 4) at 5-8 years. Nine patients therefore had continence for solids and liquids, five of whom were incontinent to flatus, in the long term. Assessment of outcome by patients revealed long-term improvement in 28 and no change in six. Two of the 34 patients assessed were housebound because of incontinence. Of the total of 54 patients, only one required a stoma. The length of the anal canal increased significantly from a preoperative median (range) of 2.0 (1.5-4.0) cm to 3.8 (1.8-5.5) cm 5-8 years after surgery. Perineal descent at rest decreased markedly. Progression of neuromuscular damage was demonstrated by prolongation of the pudendal nerve terminal motor latency from a median (range) 2.38 (1.80-3.35) ms to 2.80 (2.20-4.25) ms and increasing median (range) fibre density in the external sphincter, from 1.86 (1.76-2.40) to 3.63 (2.03-6.20). The pudendal nerve terminal latency was the only preoperative physiological variable that correlated significantly with long-term outcome (A and B 2.20 ms versus C and D 2.65 ms, P < 0.05). At long-term assessment, maximal anal squeeze pressure was the only physiological variable that correlated significantly with clinical outcome. Anal endosonography revealed a clinically undetected sphincter defect in 19 of 30 patients examined but the presence of a defect did not relate to clinical outcome.

Large bowel perforations in war surgery: one-stage treatment in a field hospital.

Over a period of 14 months between 1990 and 1992, 73 Afghan war wounded with penetrating colon injuries were admitted and treated by a single surgical team in a field hospital of the International Committee of the Red Cross (ICRC). There were 67 males and 6 females, with a mean age of 23 years (range 6 to 80 years). Fifty six (77%) patients had multiple associated injuries; admission was delayed longer than 12 hours in 39 (44%); hypotension or deep shock was present at admission in 34 (47%) and 12 (16%) respectively. At laparotomy faecal contamination was limited to one quadrant in 58 (79.5%) cases and major in 15 (20.5%). Fifty-two (71.2%) patients underwent resection and primary anastomosis and 21 (28.8%) primary repair. Exteriorisation or diverting colostomy were never used. Four (5.5%) patients died and 11 (15%) had postoperative complications. Overall failure rate was 2.7%, including one faecal fistula conservatively treated and one colostomy raised as a precaution in a patient undergoing relaparotomy for intra-abdominal abscess. No primary repair leaked Deaths were significantly related to delay in admission and age, but not to surgical treatment. One stage primary treatment of large bowel injuries from penetrating abdominal wounds has low mortality, failure and colostomy rates suggesting its wider use regardless of risk factors.

Percutaneous ultrasonic lithotripsy of intrahepatic gallstones under endoscopic control.

Percutaneous ultrasonic lithotripsy in association with endoscopic control and balloon catheter dilatation of stenosed cholangiojejunostomy was successfully used in the treatment of a 53-year-old man with intrahepatic gallstones and severe cholestasis. Previously, he had undergone several biliary surgery operations, but all interventions were complicated by stenosis. The good results obtained in this case lead us to consider percutaneous ultrasonic lithotripsy a possible alternative to surgical treatment of complicated gallstones.