Limited utility of preoperative studies in preparation for colostomy closure.

Numerous diagnostic and therapeutic practices are used in an attempt to reduce the morbidity of colostomy closures. Our principal aim was to evaluate the role of preoperative studies, specifically barium enemas and endoscopic examinations, performed before colostomy closures. Additionally, we wished to identify other practices involved in the perioperative management of patients undergoing colostomy closure that influenced morbidity. The records of 100 consecutive patients who underwent elective colostomy closure at University of Louisville Hospital between January 1989 and July 1995 were reviewed. Wound infection was the most common complication (12%). Various bowel preparations were equivalent in efficacy and did not influence the complication rate. Intermittent wound irrigation with antibiotics for 3 days postoperatively, via subcutaneous drains, was associated with a low incidence of incision infection. Preoperative barium enema or sigmoidoscopy were often performed but rarely useful. Performing these examinations merely increased hospital cost without a corresponding decline in morbidity.

Increased incidence of second primary malignancy in patients with carcinoid tumors: case report and literature review.

There is an increased incidence of second noncarcinoid neoplasms in patients with carcinoid tumors. This article reports a case of a synchronous malignant ileal carcinoid tumor in a patient with an adenocarcinoma of the sigmoid colon. This report illustrates the increased association of carcinoid tumors with other gastrointestinal malignancies.

Profuse bleeding in epiphrenic diverticula: an unusual finding.

Profuse bleeding is an unusual and previously unreported finding in epiphrenic diverticula. The present case describes a man with a history of significant alcohol and tobacco abuse who presented to an emergency room expectorating blood and was then admitted. Further evaluation revealed a large bleeding ulcer crater in the distal esophagus. Findings consistent with candida esophagitis were noted on biopsy. Radiographic examination revealed two large, wide-mouthed diverticula. While hypertensive lower esophageal pressure was noted on manometric evaluation, surgery was not performed on the patient, and he subsequently curtailed his alcohol and tobacco intake. A follow-up examination at 90 days' postdischarge revealed no further bleeding episodes with continued decreased alcohol and tobacco intake.

The impact of health insurance on an African-American population with colorectal cancer.

This study evaluates the impact of health insurance as a substitute for social class on tumor location, presentation, stage, grade, and age-adjusted survival in an African-American population. Patients were stratified by insurance into two groups: group 1 (private insurance and Medicare parts A & B) and group 2 (Medicaid, Medical Charity, self-pay, uninsured, or unemployed). A total of 212 patients were evaluated. Of these, 210 patients were insured or had Medical Charity, and two were uninsured. The type of health insurance did not significantly affect age-adjusted survival. However, age and stage at presentation were positive predictors of age-adjusted survival. Higher socioeconomic status was associated with group 1 health insurance.

Consequences of delayed ileostomy closure after ileal pouch-anal anastomosis.

Temporary diverting loop ileostomy is a generally accepted component of the ileal pouch-anal anastomosis (IPAA) procedure. Ileostomy closure is usually performed within two to three months but may be delayed because of disruption of the ileonanal anastomosis, suspected leak from the ileal reservoir, concomitant medical problems, or patient convenience. Of 362 patients undergoing IPAA at The Cleveland Clinic Foundation for inflammatory bowel disease, 10 have had their ileostomy closures delayed for more than six months. Clinical and manometric parameters are examined in these patients and compared with those who had earlier closure. There appears to be no significant difference in the functional outcome of IPAA in these patients in terms of number of bowel movements and degree of continence. Reservoir compliance and maximum tolerated volumes are similar. We conclude that delaying ileostomy closure for more than six months after IPAA has no deleterious effect on pouch function.

Impact of anal manipulation and pouch design on ileal pouch function.

The frequency of defecation, leakage, maximum resting pressure, and maximum squeeze pressure of the anal canal, maximum tolerated volume, and pouch compliance were evaluated in 116 consecutive patients following total proctocolectomy (TPC) with ileal pouch anal anastomosis (IPAA) and after temporary ileostomy closure. Sixty-nine patients had a double ileal loop pouch ("J") and 47 a triple ("S") design. Seventy patients had mucosal proctectomy and hand-sewn IPAA (mucosectomy) and 46 a stapled IPAA without mucosal proctectomy (stapled). Fifty percent of the S and 30% of the J pouch patients did not have nocturnal defecations. The avoidance of anal manipulation in the stapled group resulted in higher anal canal resting pressures and a lower incidence of leakage. The maximum tolerated volume and compliance was greater in the S pouch group than in the J group. Although the median frequency of defecation was equal in both pouch groups, fewer S pouch patients had nocturnal defecations. Anal canal resting tone may be the primary factor affecting continence following TPC and IPAA, but a compliant pouch may prevent leakage if sphincter function is compromised.

Consequences of ileal pouch-anal anastomosis for Crohn's colitis.

Patients with Crohn's colitis are generally not considered candidates for the ileal pouch-anal anastomosis (IPAA) procedure. We reviewed 362 consecutive patients undergoing IPAA and analyzed the outcome of this procedure on 25 patients with a preoperative diagnosis of mucosal ulcerative colitis who were subsequently proven to have Crohn's disease. The mean follow-up was 38.1 months. Sixteen patients have a functioning pouch, seven have required pouch excision, one is diverted, and one has died. Only one of nine patients in whom there was a preoperative clinical feature suggestive of Crohn's disease has a functioning pouch, with complications uniformly occurring within months of ileostomy closure. In contrast, 15 of 16 patients without preoperative features of Crohn's disease have maintained their pouch, generally with good results. These data suggest that patients in whom there is clinical and pathologic evidence of Crohn's disease do very poorly without meaningful symptom-free intervals. However, patients without any clinical features of Crohn's disease, despite a histopathologic diagnosis of Crohn's colitis, have had a good outcome with IPAA thus far.

Functional comparison between double and triple ileal loop pouches.

Ileal pouch function in 35 patients operated upon by the same surgeon were compared. Seventeen of the patients had a double loop (J) ileal pouch-anal anastomosis (IPAA) and 18 a triple loop (S) pouch. The patients were examined a mean of 27.9 months and 5.1 months, respectively, after ileostomy closure. Ten of the S-pouch patients were evaluated more than 6 months (S greater than 6 months), mean 9.1 after ileostomy closure. There were no differences in the mean maximum resting pressures or maximum squeeze pressures between the groups. The incidence of daytime and nocturnal leakage was lower in the S-pouch group, 22 and 29 percent, than in the J group 29, and 53 percent. Though the mean maximum tolerated volume (MTV) of the S-pouch group was greater than the J group, the difference was not statistically significant. The difference in the mean compliance between the J- and S-pouch groups and the J and S greater than 6 months group was statistically significant (P less than 0.01) and (P less than 0.008). All the patients could evacuate spontaneously. The difference in the 24-hour frequency of defecation between the S greater than 6 months and J group was significant (P less than 0.05), but not between the S and J groups. The median frequency of nocturnal defecation between the S greater than 6 months and J pouch groups was significant (P less than 0.005), but not between the S and J groups. The triple loop S-pouches were more compliant than the J-pouches and had a better functional result as shown by a lower incidence of nocturnal leakage, and a lower frequency of defecation during the day and night.

Internal anal sphincter function after total abdominal colectomy and stapled ileal pouch-anal anastomosis without mucosal proctectomy.

A comparison, based on results from anal manometry and continence, was made between eight patients after circular stapled ileal J-pouch-anal anastomosis without mucosectomy (Js) and seven patients after endoanal mucosal proctectomy and hand-sewn ileal pouch-anal anastomosis (Jm). The mean and range from ileostomy closure were 3.5 months (1.5 to 12) and 21.7 months (13 to 32), respectively. The mean maximum resting pressure (MRP) ( +/- SEM and range) was 81.3 mm Hg ( +/- 6.0 and 61 to 112.5) and 50.0 mm Hg ( +/- 6.2 and 17 to 62.5), respectively, for the Js and Jm groups (P less than .003). None of the Js patients experienced leakage or wore a pad, while in the Jm group 14 percent experienced minor leakage during the day and 28 percent at night. Seventy-one percent of the Jm group wore a pad at some point. Anal sphincter resting pressures and continence were better in the Js group. The improvement in MRP resulted from avoidance of injury to the internal and sphincter during dilatation and mucosectomy and the maintenance of a normal anal canal that allowed for proper closure.

Pelvic endometriosis presenting as a Supralevator abscess.

A 32-year-old woman presented with sepsis nine days after a transrectal incision and drainage of a recurrent supralevator abscess. The findings included a large mass arising from the pelvis containing multiple, leaking, and infected endometrial cysts. After a supracervical hysterectomy, bilateral salpingo-oophorectomy, sigmoid loop colostomy, appendectomy, and extensive irrigation and debridement, her condition improved with no recurrence at two-year follow-up. This case illustrates the varied presentations of endometriosis, the importance of identifying the source of a perirectal or perianal abscess, and that when a supralevator abscess develops from an intraabdominal process, the process must be addressed to prevent recurrence, fistulization, or other complications.

Intraoperative radiotherapy for patients with carcinoma of the pancreas. The Howard University Hospital experience, 1978-1986.

During the period from 1978 to 1986, 106 patients were diagnosed with carcinoma of the pancreas; 30 of these patients were excluded from this study. Of the remaining 76 patients, 40 did not receive intraoperative radiotherapy (IORT) and were used as the nonrandomized control group for the 36 patients who did receive IORT after histologic confirmation of carcinoma of the pancreas. The records of 35 patients were available for review. The group receiving IORT ranged in ages from 43 to 89 years (20 males and 15 females). Seventeen patients had distant metastatic disease. The primary was located in the head of the pancreas in 32 and the body in three. No patient in this group had a curative resection. All patients were treated by a combination of biliary and gastric bypass prior to or concurrent with IORT. IORT was begun only after obtaining a histologic diagnosis and prior to the completion of any anastomosis. Necrotizing pancreatitis occurred in the treated group. There was no statistically significant difference in the survival of the nonrandomized control and treated groups.