Mesh inguinodynia: a new clinical syndrome after inguinal herniorrhaphy?

BACKGROUND: Chronic inguinodynia or neuralgia after conventional inguinal herniorrhaphy is rare, and diagnosing the exact cause is difficult. Treatment has ranged from local injection to remedial surgery with variable results. The increasing popularity of prosthetic mesh repairs (tension free, plug, or laparoscopic) has not eliminated these pain syndromes from occasionally occurring. Recommended management in these situations is extremely difficult. STUDY DESIGN: Since 1994, 117 inguinal reexplorations have been performed for inguinodynia and 20 of these patients had primary mesh herniorrhaphy. All 20 patients had mesh removal. Records were reviewed and patients contacted to evaluate outcomes. RESULTS: All 20 patients were evaluated (15 by telephone or direct contact, 5 by chart review). Three patients had their initial repair performed laparoscopically. Symptoms persisted for 12.2 +/- 1.7 months before remedial surgery. Four patients underwent inguinal reexploration and mesh removal; 16 had mesh removal plus ilioinguinal or iliohypogastric neurectomy. Good to excellent results were achieved in 12 out of 20 patients (60%). Average followup time was 15.9 +/- 3.1 months. Two of 3 patients who had laparoscopic herniorrhaphy had favorable outcomes (67%). Ten of the 16 patients who had mesh removal plus neurectomy reported good to excellent results (62%) compared with 2 of 4 reporting the same with mesh excision only (50%). Eleven patients had pain relief with preoperative nerve block. Of these, 9 had elective neurectomy resulting in good to excellent results in 5 (56%). CONCLUSIONS: Remedial inguinal exploration and mesh removal with or without neurectomy resulted in favorable outcomes in 60% of patients with mesh herniorrhaphy chronic inguinodynia (neuralgia). It appears that coincident neurectomy affords better results than mesh removal alone. Relief with nerve block did not predict favorable outcomes. Despite the popularity and favorable outcomes of prosthetic mesh repairs, persistent postoperative pain still occurs in a small cohort of patients. This may become more evident with the rising interest in laparoscopy. Correcting this problem once presented can be a formidable task. Remedial inguinal surgery with mesh removal and neurectomy will cure selected patients.

Tertiary hyperparathyroidism after renal transplantation: surgical strategy.

BACKGROUND: An analysis of our experience with tertiary hyperparathyroidism (III HPT) in renal transplantations between 1981 and 1996 was reviewed to examine a variety of laboratory and clinical variables in this population. METHODS: A total of 3233 kidney transplantations were performed; 48 patients underwent parathyroidectomy for III HPT. Five patients were excluded from analysis due to the development of renal dysfunction. The index 43 patients were divided into two groups. Group I consisted of 31 patients (72%) with either enlargement of all parathyroid glands (n = 26) or 3/4 gland enlargement (n = 5). These patients were assumed to have hyperplasia and underwent subtotal parathyroidectomy or total parathyroidectomy. Group II consisted of 12 patients (28%) with single (7/12; 58%) or two-gland enlargement (5/12; 42%). Group II patients underwent resection of only the enlarged glands. RESULTS: Laboratory and clinical parameters showed no difference between the groups during long-term follow-up. Most patients in groups I and II were eucalcemic after parathyroidectomy. However, postoperative hypercalcemia and hypocalcemia did occur in group I (mean postoperative calcium: group I = 9.29 +/- 0.63 mg/dL; group II = 9.42 +/- 0.58 mg/dL). CONCLUSIONS: Four gland parathyroid enlargement is a frequent finding in III HPT, although asymmetric enlargement can occur. Histologically, this represents sporadic adenomas and asymmetric hyperplasia. Intraoperative findings should dictate surgical strategy; with asymmetric enlargement only the enlarged parathyroid glands should be resected.

Physiologic evaluation and surgical management of failed ileoanal pouch.

BACKGROUND: Following proctocolectomy and ileal pouch-anal anastomosis, a small percentage of patients will have poor functional results attributable to pouchitis or anastomotic or septic complications. Additionally, functional failures can occur secondary to limited pouch capacity and compliance. We present five such patients managed with operative conversion to W-ileal pouch-anal anastomosis and examined physiologic parameters important for improving functional results. METHODS: Five female patients (mean age, 30 (range, 24-39) years) with poorly functioning J-ileal pouch-anal anastomoses were referred for evaluation with symptoms of high stool frequency and incontinence problems. Three had severe nocturnal incontinence, and the remaining two patients experienced minor nocturnal incontinence. Preoperative and postoperative evaluation included barium pouch studies, flexible sigmoidoscopy, anal manometry, evacuation volume, and pouch compliance. Pouch-to-anal pressure gradients were calculated. To improve reservoir capacity and compliance, all five patients underwent conversion to W-ileal pouch-anal anastomoses. RESULTS: Twenty-four hour and nocturnal stool frequencies decreased from 13.8+/-1.7 and 3+/-1.3 to 5.8+/-0.3 and 0.3+/-0.2 postconversion (P < 0.05). Mean pouch evacuation volume increased from 83+/-27 to 290+/-29 ml postoperatively (P < 0.05). Pouch compliance increased from 2.7+/-0.5 mmHg/ml to 7.7+/-0.6 mmHg/ml postconversion (P < 0.05). Improvement in postconversion stool frequency correlated with an increase in pouch evacuation volume (r=-0.87). All patients reported improved day and nocturnal continence, despite no significant change between preoperative and postoperative anal manometric pressures. Improved continence correlated with a significant widening of the pouch-to-anal pressure gradients, which increased from 5 to 25 mmHg at 150 ml following pouch conversion. CONCLUSIONS: Poorly functioning ileal reservoirs secondary to limited capacity and compliance can be successfully managed with conversion to W-ileal pouch-anal anastomosis. The increased pouch capacity is associated with improvement in compliance and widening of the pouch-to-anal pressure gradients, providing excellent functional results.

Thoracic versus lumbar epidural anesthesia's effect on pain control and ileus resolution after restorative proctocolectomy.

BACKGROUND: Epidural anesthesia as a perioperative adjunct has been shown to provide superior pain control and has been implicated in more rapid ileus resolution after major abdominal surgery, possibly through a sympatholytic mechanism. Studies suggest that the vertebral level of epidural administration influences these parameters. METHODS: One hundred seventy-nine patients (120 male, 59 female; average age, 36 years) underwent restorative proctocolectomy for ulcerative colitis or familial polyposis between 1989 and 1995. Patients were grouped according to type of anesthesia. Group THO (n = 53) received thoracic (T6 to T10) epidurals. Group LUM (n = 51) received lumbar (L2 to L4) epidurals, and group PCA (n = 75) received patient-controlled intravenous narcotic analgesia. Patients were compared for complications, perioperative risk factors, postoperative pain, and ileus resolution. RESULTS: Epidural narcotics, alone or combined with local anesthetics, were administered for an average of 2 (LUM) to 4 (THO) days without significant complications. Infrequent problems related to the epidural catheters included self-limited headaches or back pain (four) and site infections (two). Epidural failure, as measured by conversion to PCA for inadequate pain control, was not significantly greater for LUM (25%) than THO (23%). Average pain scores, rated daily on a visual analog scale, were significantly higher (indicating more pain) for PCA patients (4.2) during postoperative days 1 through 5 than for LUM (3.5) (p < 0.05) and for THO (2.4) (p < 0.05). Ileus resolution, as determined by stool output and return of bowel sounds, was significantly faster in THO than in LUM or PCA (p < 0.05). Resolution of ileus was not significantly different between PCA and LUM (p > 0.05). CONCLUSIONS: Thoracic epidural analgesia has distinct advantages over both lumbar epidural or traditional patient-controlled analgesia in shortening parameters measuring postoperative ileus and in reducing surgical pain. The procedure is safe and associated with low morbidity. Thoracic epidural anesthesia is also economically justifiable and may prove to impact significantly on future postoperative management by reducing length of hospitalization. Our data and those of others are most striking in these regards for patients with thoracic catheters, indicating the importance of vertebral level in epidural drug administration.

Immunohistochemical evaluations of ultrashort-segment Hirschsprung's disease. Report of three cases.

PURPOSE: Unlike classic Hirschsprung's disease, short-segment and ultrashort-segment varieties are usually found to be latent and milder. Ultrashort-segment Hirschsprung's disease may present as intractable chronic constipation in children over one year of age, adolescents, and adults. Anorectal myectomy has been shown in many instances to provide effective long-term treatment for certain patients with ultrashort-segment Hirschsprung's disease. Histologically, the affected segment in Hirschsprung's disease has been shown to have increased cholinergic nerves, lack of nitric oxide synthase-containing neuronal elements, and show moderate to severe loss of myenteric neurons. METHODS: Here, we report three cases that showed clinical and manometric evidence of ultrashort-segment Hirschsprung's disease. Two of the three patients responded well to myectomy. RESULTS: Detailed histologic and immunohistochemical evaluation of the internal anal sphincter and a comparison with three normal controls revealed absence of nitric oxide synthase-containing neurons in both cases that responded well to surgery and continued presence of these neurons in the patient who did not respond. A review of the current literature on various treatment modalities is included. CONCLUSIONS: Anorectal myectomy provides long-term relief of this chronic problem in a subgroup of patients with ultrashort-segment Hirschsprung's disease who lack nitrinergic neurons at the internal anal sphincter.

Management of paraesophageal hernia with a selective approach to antireflux surgery.

BACKGROUND: The role of an antireflux procedure in the management of paraesophageal hernia is controversial. To address this issue, we reviewed our experience with selective use of antireflux procedures in patients with pure paraesophageal hernia (type II; n = 26) and those with a partial sliding component (type III; n = 11). PATIENTS AND METHODS: Surgical repair was performed on diagnosis in all 37 patients. Competency of the lower esophageal sphincter was evaluated on the basis of reflux symptoms, and objectively, with endoscopy in 21 patients and 24-hour esophageal pH studies in 17 patients. Repair included an antireflux procedure in 11 patients, as indicated by reflux disease. RESULTS: Preoperatively, 80% of both type II and type III patients reported obstructive symptoms. Reflux symptoms were present in 27% of patients--19% of type II and 45% of type III patients. Endoscopy revealed esophagitis in 5 cases, and 24-hour pH studies indicated significant reflux in 3 of 17 patients. There were no operative deaths and 1 recurrence. Symptoms improved in 92% of patients after surgery. Medically manageable reflux was identified in 2 patients. CONCLUSIONS: Frequent obstructive symptoms and the potential for gastric volvulus indicate elective repair of paraesophageal hernia on diagnosis. Significant gastroesophageal reflux is less common, especially in type II patients, and excellent symptomatic results are obtained with selective application of an antireflux procedure.

Abnormal rectal mucosa of the anal transitional zone in ulcerative colitis.

OBJECTIVE: To determine the frequency of atypia and active ulcerative colitis (UC) in rectal mucosa within the anal transitional zone (ATZ). DESIGN: Surgeons identified ATZ tissues from restorative proctocolectomy specimens for determination by surgical pathologists of specific histopathologic features in rectal mucosa of the ATZ. SETTING: Surgical referral center for restorative proctocolectomy. PATIENTS: Ninety-four patients with symptomatic UC underwent restorative proctocolectomy between January 1991 and December 1994. INTERVENTIONS: Specific histopathologic features of active UC in the ATZ were evaluated by a single reviewer who did not know the clinicopathologic details of individual study patients. MAIN OUTCOME MEASUREMENTS: Presence and coexistence of rectal mucosal dysplasia (high or low grade), mucosa classified as indefinite for dysplasia, and acute UC (crypt abscess or cryptitis) in the ATZ. RESULTS: Of 94 ATZ tissue specimens, acute intracryptic inflammation was present in 60 rectal mucosa specimens (64%). In 29 (48%) of these 60 specimens, inflammation was neither widespread nor intense. Rectal mucosal dysplasia (low grade but not high grade) was present in 15 (16%) of 94 ATZs specimens. Inflammation elsewhere in the rectal mucosa accompanied dysplasia in 11 (73%) of 15 ATZ specimens. Rectal mucosa classified as indefinite for dysplasia was present in 24 (26%) of 94 ATZ specimens and coexisted with inflammation in 15 (63%) of these 24. Thus, rectal mucosal atypia was present in 39 (41%) of 94 ATZ specimens, and in 26 (67%) of these 39, abnormal rectal mucosa coexisted with acute inflammation. CONCLUSIONS: Rectal mucosa in the ATZ can exhibit active UC and/or atypia. Long-term monitoring is advisable if the ATZ is preserved during restorative proctocolectomy.

Management of fulminant ulcerative colitis by primary restorative proctocolectomy.

UNLABELLED: Severe acute ulcerative colitis unresponsive to medical management is characterized by multiple associated risk factors including anemia, hypoproteinemia, and high steroid requirements when urgent surgery is required. Current surgical options include use of primary ileal pouch-anal anastomosis (IPAA) vs. historic trends favoring colectomy with ileostomy. PURPOSE: To evaluate the efficacy of primary IPAA in patients with severe colitis, we reviewed our own experience in 20 patients with this condition. METHODS: Patients undergoing primary restorative proctocolectomy included 13 males and 7 females (mean age, 30.5 +/- 2.4 years). Exclusion criteria for primary reconstruction included septic patients and patients with associated medical conditions such as pulmonary or cardiovascular disease. History of ulcerative colitis averaged 3.1 +/- 1.1 years (range, 1 month to 19 years). Preoperative mean total serum protein concentration was 5.0 +/- 0.2 g/dl, and mean albumin concentration was 2.1 +/- 0.2 g/dl, reflecting disease severity. The average daily steroid requirement at the time of urgent colectomy was 58.0 +/- 4.4 mg of prednisone (or intravenous equivalent). Primary IPAA included 18 "W" reservoirs, 1 "S" reservoir, and 1 "J" reservoir. RESULTS: Major surgical complications included mild pancreatitis (10 percent), anastomotic leak (5 percent), adrenal insufficiency (15 percent), an upper gastrointestinal bleed (5 percent), and small bowel obstruction (15 percent). There were no deaths, and no patients developed pelvic sepsis or required IPAA removal. At three and twelve months, 24-hr stool frequency averaged 7.3 +/- 0.4 and 4.9 +/- 0.3, respectively. Overall day and night continence was excellent and not different from patients who underwent elective IPAA procedures for ulcerative colitis. CONCLUSIONS: Improved options such as primary IPAA may be safely used in selected patients requiring urgent surgery for severe or fulminant ulcerative colitis. Medical management should be abbreviated when disease control cannot be promptly achieved.

Absence of maladaptive neuronal plasticity after genitofemoral-ilioinguinal neurectomy.

BACKGROUND: Pain (neuralgia) and paresthesia in the inguinal region after lower abdominal surgery is rare. Historically, treatment consisted of neurolysis, local injections, and administration of various medications. The management of chronic pain syndromes is often coordinated by anesthesiologists. Neurolytic therapy is seldom recommended, on the basis of the theory of maladaptive neuronal plasticity. METHODS: Twenty-three patients underwent genitofemoral neurectomy at our institution between 1981 and 1990. Records were reviewed to determine preoperative symptoms, evaluation, and treatment. Patients were contacted and questioned about current symptoms and disability. RESULTS: All records were reviewed. Sixteen (70%) of the patients were located for long-term follow-up. Patients were symptomatic for an average of 3.3 years and underwent 3.1 operations before referral. Inguinal herniorrhaphy was the most common initial surgery (14 of 16 patients). All patients underwent multidisciplinary evaluation. Fifteen underwent L1-2 paraspinous nerve block, and 13 had total pain relief. Postoperative follow-up ranged from 36 to 144 months. Ten patients reported significant pain relief, and three patients reported slight improvement. Three of the six patients who had persistent neuralgia had significant orchialgia. None of the patients who had significant relief had preoperative testicular pain. CONCLUSIONS: Genitofemoral neurectomy provided long-term relief in 62.5% of patients with genitofemoral neuralgia. Severe testicular pain indicated a less favorable outcome. These data do not support the maladaptive neuronal plasticity theory but do support early referral of some patients for neurectomy.

Proctocolectomy and quadruple-limb W pouch reconstruction for the management of pediatric ulcerative colitis and familial polyposis.

Proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the procedure of choice for many children with ulcerative colitis and familial polyposis. The modified quadruple-limb (W) IPAA was designed to increase reservoir compliance and capacity, and to improve functional results by decreasing stool frequency. However, only limited information has been reported concerning the technical considerations and functional outcomes from W IPAA modification and utilization in the pediatric population. Additionally, pediatric IPAA physiological adaptation, expressed as IPAA volume/pressure relationships, for any type of IPAA design has not been described. In this report, the authors analyze their functional and physiological results with W IPAA in 19 children undergoing colectomy for ulcerative colitis and familial polyposis. Since 1986, 19 children (5 girls, 14 boys; mean age, 15.3 years [range, 11 to 18 years]) have undergone proctocolectomy with W IPAA for ulcerative colitis (n = 9) and familial polyposis (n = 10). IPAA pressure and volume profiles were measured in 10 patients at 2 and 12 months postileostomy takedown, and in five patients at 3 years. W IPAA compliance was calculated as the change in volume over change in pressure (delta V/delta P). There were no deaths, anastomotic leaks, or pelvic sepsis. The 24-hour stool frequency (mean +/- SEM) decreased significantly (P < or = .05) from 4.6 +/- 0.6 at 2 months to 3.3 +/- 0.1 at 12 months. No nighttime evacuation occurred after 12 months. W IPAA evacuation volume significantly increased (P < or = .05) from 238 +/- 22.9 mL at 2 months to 346 +/- 26.5 mL at 12 months and remained stable thereafter.(ABSTRACT TRUNCATED AT 250 WORDS)

Repair of anal stricture and mucosal ectropion with Y-V or pedicle flap anoplasty.

Cicatricial stenosis and mucosal ectropion of the anal canal are disabling complications of anal surgery or disease and are extremely difficult to manage. Perusal of the literature reveals minimal consensus as to the most successful way to surgically manage patients with these conditions. During a 4-year period, we managed 19 patients who had anal stenosis (n = 14) or anal ectropion (n = 5). Eighteen of these patients had prior anal rectal surgery. We employed a Y-V anoplasty or advancement diamond-shaped pedicle flap and obtained satisfactory to excellent results in all patients. Concurrent lateral internal sphincterotomy was also employed in selected patients who had a fibrotic muscular component contributing to the stenosis. Based on our cohort of patients, we believe the pedicle skin flap technique is slightly superior to the Y-V anoplasty in functional and cosmetic results.

The W ileal reservoir: long-term assessment after proctocolectomy for ulcerative colitis and familial polyposis.

BACKGROUND: This report examines the viability of the W reservoir as a reliable option for the treatment of ulcerative colitis and familial polyposis and studies W reservoir adaptation as reflected by changes in compliance and stool frequency. METHODS: Since 1984, 109 patients have undergone proctocolectomy with W reservoir reconstruction. Ileal reservoir static compliance was measured in 70 and 57 patients at 2 and 12 months after ileostomy takedown and in 25 patients at 3 years. Compliance was calculated as the change in volume over change in pressure. RESULTS: Twenty-four-hour stool frequency decreased from 7.3 +/- 0.2 at 2 months to 4.9 +/- 0.2 at 1 year for patients with ulcerative colitis and from 6.3 +/- 0.4 to 3.4 +/- 0.4 for patients with familial polyposis (p less than or equal to 0.05). Compliance increased from 12.7 +/- 0.6 ml/mm Hg to 14.3 +/- 0.6 ml/mm Hg between 2 months and 1 year. No significant increase in compliance occurred after 1 year. Ninety-six percent of patients were continent during the day at 12 months although 10% experienced occasional minor leakage at night. Average postoperative morbidity (for example, small-bowel obstruction, anastomotic complications) was 35%. No operative deaths, pelvic sepsis, or reservoir loss occurred. CONCLUSIONS: We conclude that W ileal reservoirs (1) are an excellent option for ileal reservoir reconstruction, (2) have optimal functional and compliance properties versus lower capacity designs and straight ileoanal pull-through procedures, and (3) maintain stable compliance characteristics and functional reservoir volume after the initial year of adaptation.

A comparison of the effects of hyperbaric oxygen culture on survival of murine and canine thyroid gland grafts.

Canine thyroid tissue (CTy) was subjected to hyperbaric oxygen culture (HOC) under conditions that affect immunoalteration in murine thyroid tissue (MTy). Survival of autografts and allografts implanted under the kidney capsule was determined after 21 days by 125I uptake and histology. Unlike MTy, autograft CTy subjected to normothermic HOC (95% O2, 5% CO2; 1.76 kg/cm2) for 48 h did not survive (0/8) whereas decrease of culture duration to 24 h resulted in autograft CTy survival (3/3). Under hypothermia (5 degrees C), HOC could be extended to 7 days with autograft CTy survival (3/3 after 4 days and 3/3 after 7 days). Allograft CTy after 24 h of normothermic HOC and 7 days of hypothermic HOC was rejected. Indicators of oxygen free radical injury were determined:catalase activity was comparable in MTy and CTy (means 14.82 and 6.3-10.8 mm/mg protein, respectively) but superoxide dismutase activity was low in CTy (means 0.01-0.29 and 4.75 U/mg protein, respectively). Malondialdehyde content after 48 h of normothermic HOC was higher in CTy than in MTy (means 2215 and 1275 nmol/g, respectively). The results show that CTy is injured by HOC under conditions tolerated by MTy, and that this difference is related to the greater sensitivity of CTy to oxygen free radical injury.

Current status of sphincter preservation in rectal cancer.

Surgical management of rectal carcinoma has progressed during the past decade to a wider utilization of sphincter preservation procedures. As such techniques have been modified and advanced, options for sphincter preservation have been employed to significantly preserve quality of life without adversely affecting patient survival or functional results. The documentation that recurrence of rectal carcinoma is based more upon individual tumor biology than simply wide or radical margins of resection has supported the rationale for sphincter-sparing procedures. The surgical management of rectal carcinoma has moved from traditional radical excision with colostomy to functional preservation in selected patients.

Superoxide dismutase and catalase in skin flaps during venous occlusion and reperfusion.

We studied the enzymatic concentrations of superoxide dismutase (SOD) and catalase (CAT) in rabbit abdominal island skin flaps during 8 and 10 hours of venous occlusion followed by 4 hours of reperfusion. A correlation between such enzyme activity at the end of ischemia and flap viability was tested. The results show that the accumulation of blood and blood-derived substances cause enzyme activity to increase considerably during venous occlusion. The amount of increase was similar for both 8- and 10-hour venous occlusion. "True tissue enzyme activity" (corrected for the contribution of blood and blood-derived substances) remained constant during venous occlusion, suggesting that the availability of scavenging enzyme does not correlate with ultimate flap viability. During early reperfusion, however, both SOD and CAT activity decreased, suggesting that membrane damage leads to an increase in membrane permeability and to the loss of intracellular enzymes.

Pulmonary transvascular fluid filtration response to hypoproteinemia and Hespan infusion.

Management of major blood loss utilizing protein-free fluids for volume replacement frequently results in plasma protein depletion and plasma volume expansion. These factors can increase pulmonary transvascular fluid filtration which may lead to life-threatening pulmonary edema. We studied the combined effects of plasma protein depletion and plasma volume expansion on lung lymph flow (QL) in awake sheep prepared with chronic lung lymph fistulae. Animals were first chronically protein-depleted by batch plasmapheresis and then infused for 2 hr with either lactated Ringer's (Hypo/LR; n = 7) or 6% hydroxyethyl starch (Hespan) (Hypo/HES; n = 6). Control normoproteinemic animals (Norm/LR; n = 13) only received lactated Ringer's. Hypoproteinemia alone resulted in an average 2-fold increase in QL over normoproteinemic baseline levels (P less than or equal to 0.05). Infusion of LR into hypoproteinemic animals caused a 7.9-fold increase in QL (P less than or equal to 0.05). By comparison, HES infusion under similar hypoproteinemic conditions limited the increase in QL to 3.2-fold over baseline. We attributed this reduced rise in QL to Hespan's high oncotic pressure, which dramatically widened (by 4-5 mm Hg) the pulmonary-to-lymph oncotic pressure gradient. We did not observe this with LR infusion, or in previous studies employing intravenous infusion of plasma protein. Thus, the oncotic pressure of Hespan appears to significantly limit pulmonary fluid filtration during hypoproteinemia compared to LR. We do not believe that these effects are the results of any changes in microvascular porosity.

Comparison of clinical and compliance characteristics between S and W ileal reservoirs.

Ileal reservoir reconstruction has become the preferred technique for restoration of bowel continuity in most patients after colectomy for ulcerative colitis or familial adenomatous polyposis. We analyzed and compared compliance characteristics of triple-limb S and quadruple-limb W reservoir designs and correlated changes in capacity with overall function. Fifty patients underwent colectomy and reservoir construction for ulcerative colitis or familial adenomatous polyposis; 12 received S reservoirs and 38 received W reservoirs. Reservoir compliance was assessed by means of a specially designed condom catheter that continuously recorded intrareservoir pressure and changes in perfused volume. During reservoir infusion, volumes and pressures at initial fullness, normal sensation of evacuation, and maximum tolerated volume were noted. Studies were performed at 2 and 12 months after ileostomy takedown. An increase in normal evacuation volume from 218 +/- 9 mL to 310 +/- 12 mL between 2 and 12 months (p less than or equal to 0.05) was observed in patients with W reservoirs. Similar changes were recorded in S reservoir reconstructions (201 +/- 14 mL to 291 +/- 22 mL, p less than or equal to 0.05). No significant differences were observed in the mean pressure at normal evacuation volume between the S and W groups at 2 and 12 months. The 24-hour stool frequency decreased an average of 3 per day for both reservoir designs between the 2- and 12-month study period (p less than or equal to 0.05). This frequency was most directly predicted by normal evacuation volume (r = 0.90 for W and 0.88 for S). The decrease in stool frequency correlated with increased reservoir compliance, as shown by larger tolerated volumes at similar pressures. Restorative proctocolectomies with S or modified W reservoirs are both acceptable alternatives and demonstrate similar compliance characteristics and functional results.

Tertiary hyperparathyroidism after renal transplantation: operative indications.

A retrospective analysis of our renal transplant population between 1981 and 1987 was undertaken to study the natural history of posttransplant hypercalcemia and to review indications and recommendations regarding the timing of parathyroidectomy. During this period, 1158 renal transplant procedures were performed in 1025 patients, with 819 allografts (71%) functioning currently. Posttransplant hypercalcemia greater than 10.5 mg/dl was associated with a longer duration of dialysis and developed in 227 patients, with onset of hypercalcemia occurring in 90% of these patients by 1 year. In 69% of these patients, spontaneous resolution of the hypercalcemia occurred between 6 months and 7 years after transplantation. A total of 42 patients with asymptomatic hypercalcemia are currently being followed up, with a mean serum calcium level of 11.0 +/- 0.41 mg/dl and a mean follow-up interval of 3.3 +/- 1.6 years since transplantation. Nine symptom-free patients with moderate hypercalcemia (12.0 to 12.4 mg/dl) more than 1 year after transplantation were identified. Five of these patients had spontaneous resolution of the hypercalcemia between 2 and 7 years. Fifteen patients with posttransplant hyperparathyroidism (6.6%) required parathyroidectomy--11 for symptomatic and four for asymptomatic hyperparathyroidism. One patient had symptomatic hyperparathyroidism despite the presence of normocalcemia. One symptom-free patient with significant hypercalcemia (serum calcium level, 14.7 mg/dl) underwent parathyroidectomy 3 months after transplantation. The remaining three symptom-free patients had serum calcium determinations of greater than or equal to 12.5 mg/dl more than 1 year after renal transplantation. Patients with pretransplant and posttransplant hypercalcemia required parathyroidectomy more frequently than did patients with only posttransplant hypercalcemia (18% versus 3.0%; p less than 0.001). An unusual finding was the occurrence of a single adenoma in two patients, which represents sporadic primary hyperparathyroidism in the patient undergoing renal transplantation rather than tertiary hyperparathyroidism. We recommend a conservative approach to posttransplant hypercalcemia, with surgery reserved for patients with symptomatic disease and patients with asymptomatic persistent hypercalcemia greater than or equal to 12.5 mg/dl more than 1 year after transplantation.