Ileal pouch anal anastomosis without ileal diversion.

OBJECTIVE: To evaluate continued experience with a one-stage stapled ileoanal pouch procedure without temporary ileostomy diversion. SUMMARY BACKGROUND DATA: Most centers perform colectomy, proctectomy, and ileal pouch anal anastomoses (IPAA) with a protective ileostomy. Following a previous report, the authors performed 126 additional stapled IPAA procedures for ulcerative colitis and familial adenomatous polyposis, of which all but 2 were without an ileostomy. Outcomes in these patients question the need for temporary ileal diversion, with its complications and need for subsequent surgical closure. METHODS: Two hundred one patients underwent a stapled IPAA since May 1989, 192 as a one-stage procedure without ileostomy, and 1 with a concurrent Whipple procedure for duodenal adenocarcinoma. Patient charts were reviewed or patients were contacted by phone to evaluate their clinical status at least 1 year after their surgery. RESULTS: Among the patients who underwent the one-stage procedure, 178 had ulcerative colitis (38 fulminant), 5 had Crohn's disease (diagnosed after IPAA), 1 had indeterminate colitis, and 8 had familial adenomatous polyposis. The mean age was 38 +/- 7 (range 7--70) years; there were 98 male patients and 94 female patients. The average amount of diseased tissue between the dentate line and the anastomosis was 0.9 +/- 0.1 cm, with 35% of the anastomoses at the dentate line. With 89% follow-up at 1 year or more (mean 5.1 +/- 2.4 years) after surgery, the average 24-hour stool frequency was 7.1 +/- 3.3, of which 0.9 +/- 1.4 were at night. Daytime stool control was 95% and night-time control was 90%. Only 2.3% needed to wear a perineal pad. Average length of hospital stay was 10 +/- 0.3 days, with 1.5 +/- 0.5 days readmission for complications. Abscesses or enteric leaks occurred in 23 patients; IPAA function was excellent in 19 of these patients (2 have permanent ileostomies). In patients taking steroids, there was no significant difference in leak rate with duration of use (29 +/- 8 with vs. 22 +/- 2 months without leak) or dose (32 +/- 13 mg with vs. 35 +/- 3 mg without leak). Two (1%) patients died (myocardial infarction, mesenteric infarction). CONCLUSIONS: The triple-stapled IPAA without temporary ileal diversion has a relatively low complication rate and a low rate of small bowel obstruction, provides excellent fecal control, permits an early return to a functional life, and can be performed in morbidly obese and older patients.

Greater risk of incisional hernia with morbidly obese than steroid-dependent patients and low recurrence with prefascial polypropylene mesh.

BACKGROUND: Incisional hernia is a serious complication of abdominal surgery. We compared incisional hernia frequency following gastric bypass (GBP) for morbid obesity versus total abdominal colectomy and ileal pouch-anal anastomosis (IPAA) for ulcerative colitis. A prefascial polypropylene mesh repair was also evaluated. PATIENTS AND METHODS: All patients had midline incisions, xiphoid to umbilicus in GBP patients and midepigastrium to pubis in IPAA patients. Fascia were closed with running No. 2 polyglycolic acid suture. Ninety-eight patients underwent prefascial polypropylene mesh repair; 80 were GBP patients, 46 had 1 previous repair, and 17 had 2 to 9 previous repairs (6 with properitoneal mesh). RESULTS: Incisional hernia occurred in 20% (198/968) of GBP patients (19% without versus 41% with a previous hernia, P < 0.001) versus 4% (7/171) of the IPAA patients (P < 0.001), of whom 102 (60%) were taking prednisone (32 +/- 2 mg/d) and 5 were quite obese (body mass index > or = 30 kg/m2). Additional risk factors for hernia in GBP patients included wound infection, diabetes, sleep apnea, and obesity hypoventilation. For the 98 patients who underwent prefascial polypropylene mesh repair, the mean follow-up was 20 +/- 2 months (range 6 to 104), and complications occurred in 35% of patients, including minor wound infection (12%), major wound infection (5%), seroma (5%), hematoma (3%), chronic pain (6%), and recurrent hernia (4%). CONCLUSIONS: Severe obesity is a greater risk factor for incisional hernia and hernia recurrence than chronic steroid use in nonobese colitis patients. A prefascial polypropylene mesh repair minimizes recurrence.

Stapled ileoanal anastomosis without a temporary ileostomy.

Stapled J-pouch ileoanal operations were performed in 75 patients (35 men, 40 women; 72 with ulcerative colitis, 3 with familial polyposis) without an ileostomy in 68 (43 taking prednisone, 12 emergent surgery, 8 completion proctectomy with ileostomy takedown). The seven primary ileostomies were due to technical difficulties in two patients and toxic colitis in four patients. No patients were lost to follow-up. Of patients followed for more than 1 month, 96% had perfect daytime control, 86% had no nocturnal accidents, and 73% had no nocturnal spotting. Mucosa between the dentate line and the anastomosis averaged 1.1 +/- 1.0 cm, with the anastomosis at, or below, the dentate line in 16 patients, of whom 14 had excellent continence. Stools in 24 hours averaged 6.9 +/- 0.3, of which 1.8 +/- 0.2 were at night. Stool frequency was unrelated to gender, anastomotic distance from the dentate line, or age; however, patients 50 years of age or older had more problems with nocturnal fecal control than those younger than 50 years of age. Anastomotic leaks (four), cuff abscess (one), pouch leaks (two), and pelvic abscesses (three) were treated with drainage in all patients and ileostomy in five. Pouchitis occurred in 31% of patients and responded to oral antibiotic therapy. Acute complications were fewer, functional pouches greater, stool control better, and overall hospitalization shorter (all p < 0.01) than those in our 63 patients with a mucosectomy and handsewn ileoanal anastomosis.

Stapled ileoanal anastomosis for ulcerative colitis and familial polyposis without a temporary diverting ileostomy.

Between March 1989 and August 1990, we performed 21 stapled J pouch ileonal procedures (20 ulcerative colitis [UC], 1 familial polyposis [FP]) without an ileostomy in 19, of whom 13 were taking prednisone and eight underwent semi-emergent surgery for uncontrollable bleeding. During the same time, an additional four patients required a standard ileonal procedure. The results of anal manometry and clinical function were compared to 25 patients who had previously undergone mucosal stripping and a sutured J pouch ileoanal anastomoses with a temporary diverting ileostomy between October 1982 and August 1990. During this same time period, an additional 19 patients underwent an anti-peristaltic reversed J pouch and 18 an S pouch, for a total of 83 ileoanal procedures. The reversed J pouch had a lower stool frequency than a standard J pouch but had an unacceptable incidence of complications and problems with pouch emptying. The S pouch had a stool frequency similar to the standard J pouch but provided greater length in patients with a short mesentery. Stapled J pouch ileoanal patients had a better (p less than 0.02) maximum and sphincter resting pressure (46 +/- 11 versus 34 +/- 12 mmHg), fewer (p less than 0.05) night-time accidents (22% versus 68%), daytime (17% versus 55%) or night-time (28 versus 61%) spotting, or use of a protective pad at night (11% versus 42%) than nonstapled J pouch ileoanal patients. Stool frequency was similar in the two groups. All but one UC patient had residual disease at the anastomosis. Anal mucosa between the dentate line and stapled anastomosis was 1.8 +/- 1.3 cm (range, 0 to 3.5 cm). Complications in the nonstapled J pouch group included 4 pouches excised (2 for complications, 2 for excessive stool frequency), 1 pelvic abscess, 2 stenosis requiring dilation under anesthesia, 1 enterocutaneous fistula after ileostomy closure, 1 ileostomy site hernia, and 2 small bowel obstructions. Of the 65 patients who underwent ileostomy closure in the entire series, 8 (12%) developed a complication requiring surgical intervention. Complications in the stapled group included 1 anastomotic leak, 1 pouch leak, and 1 pelvic abscess. Patients were managed successfully with drainage (all 3) and diverting ileostomy (1). One patient developed stenosis requiring dilation under anesthesia. The stapled J pouch ileoanal anastomosis is a simpler, safer procedure with less tension than a standard handsewn J pouch but leaves a very small cuff of residual disease. It provides significantly better stool control and may obviate the need for an ileostomy with its complications.

Clinical predictors of infection of central venous catheters used for total parenteral nutrition.

To identify predictors of infection in catheters used for total parenteral nutrition (TPN), clinical and microbiological data were prospectively collected on 169 catheter systems (88 patients). Based on semiquantitative catheter cultures, infection was associated with a positive insertion site skin culture taken close to the time of catheter removal (relative risk [RR] = 4.50), especially one yielding greater than or equal to 50 colonies of an organism other than coagulase-negative staphylococci. Infection was also associated with erythema at the insertion site greater than 4 mm in diameter (RR = 2.93). In a subset of 67 catheters for which blood cultures were obtained, infection was also associated with a positive peripheral venous blood culture (RR = 5.90) and a positive central venous blood culture obtained through the catheter (RR = 5.44). Based on a logistic regression model, periodic cultures of the insertion site should be useful in evaluating subsequent fever in stable patients with indwelling central venous catheters. Another source of fever is likely if inflammation is absent and there is either no colonization or there is colonization by less than 50 colonies of coagulase-negative staphylococci at the insertion site. Conversely, the catheter should be removed and cultured semiquantitatively if the site is colonized by an organism other than coagulase-negative staphylococci. We suggest that blood culture results add little to the risk estimate in these situations.

Ethanol modulation of plasma norepinephrine response to trauma and hemorrhage.

Does ethanol affect the adrenergic response to trauma? In 52 trauma victims, grouped according to blood ethanol concentrations, we found there was a significantly higher mean plasma norepinephrine (NE) concentration in heavy imbibers than in those with no detectable blood ethanol (790 +/- 84 pg/ml vs. 1,260 +/- 310; p = 0.02). To control confounding variables such as intensity of pain, injury severity, etc., we selected blood loss (0.9% body weight over 15 min), as an aspect of trauma to study in six normal subjects before and after ingestion of 6 oz and 10 oz of 86-proof liquor on successive days. As expected, the increase in plasma NE upon assumption of an upright position was accentuated by blood loss, (384 +/- 43 pg/ml prebleed; 694 +/- 16 post-bleed; p = 0.001). The postural or hypovolemic effect on plasma NE was enhanced by ingestion of ethanol at 6 oz prebleed (529 +/- 42 pg/ml pre-ethanol vs. 732 +/- 64 post ethanol; p = 0.02) or at 10 oz post-bleed (694 +/- 16 pg/ml vs. 1,154 +/- 166; p = 0.04). There was an approximate dose-response effect of ethanol on plasma NE under all conditions; for example, post-bleeding upright NE: 717 +/- 57, no ethanol; 1,045 +/- 221, 6 oz ethanol, and 1,257 +/- 182, 10 oz ethanol. Plasma epinephrine concentrations were not significantly affected by positional changes, blood loss, or ethanol consumption.(ABSTRACT TRUNCATED AT 250 WORDS)

Prolonged insulin resistance following insulin-induced hypoglycaemia.

Nineteen normal male volunteers underwent a 10-h glucose clamp study to examine the duration and mechanism of insulin resistance after hypoglycaemia. Dextrose delivery by the Biostator to maintain the target blood glucose level fell below baseline 2 h after induction of hypoglycaemia and remained suppressed for at least 7 h after insulin hypoglycaemia. Insulin secretion as manifested by C-peptide levels remained suppressed for 3-4 h after insulin hypoglycaemia despite return of blood glucose to baseline by 90 min. Glucose kinetic data (3-3H-glucose) performed in six of the subjects indicated that the prolonged insulin resistance was due to significantly increased hepatic glucose production and to suppressed glucose utilisation, persisting for at least 4 h after counterregulatory hormone levels had returned to normal. Post-hypoglycaemic insulin resistance as determined by dextrose delivery was markedly attenuated and the rise in hepatic glucose output totally eliminated in five hypopituitary subjects without growth hormone or cortisol responses to hypoglycaemia. We conclude that post-hypoglycaemic insulin resistance occurs in non-diabetic subjects and persists for at least 7 h following hypoglycaemia. This prolonged insulin resistance is largely related to release of growth hormone and cortisol.

Single-dose antibiotic prophylaxis for biliary surgery. Cefazolin vs moxalactam.

Cefazolin was compared with moxalactam for single-dose prophylaxis against infection in a double-blind, prospective, randomized trial of 90 patients undergoing cholecystectomy. Risk factors for infection were present in 65 (72%) of the 90 patients and were evenly distributed. Antibiotic levels in plasma, bile, and tissue measured when the cystic duct was divided were similar for both drugs. Age greater than 65 years but not recent cholecystitis or type of antibiotic was predictive of recovery of bacteria from bile cultures. Wound infections occurred in two patients receiving cefazolin and one patient receiving moxalactam for an overall infection rate of 3%. No toxic reactions to antibiotics, including bleeding disorders, were observed. In conclusion, no significant difference in prophylactic efficacy was detected in this comparison of a first-generation with a third-generation cephalosporin. Because of its lower cost and narrower antimicrobial spectrum, however, cefazolin should remain the agent of choice.

Effect of sleep loss on beta-endorphin activity, epinephrine levels, and ventilatory responsiveness.

Sleep loss impairs ventilatory responsiveness to hypercapnia and hypoxia, and also interferes with performance on spirometry. To test the hypothesis that the decline in hypercapnic drive due to sleep loss is mediated by endorphin production, we measured loaded and unloaded CO2 response after injection of placebo and naloxone in 11 normal subjects who were alternately rested and sleep-deprived. Blood for beta-endorphin and epinephrine assay was drawn before testing each day. Unloaded CO2 response was lower after sleep loss than after sleep restoration; naloxone had no effect on this difference. Likewise, there was no difference between CO2 response after naloxone administration and CO2 response in control subjects. beta-Endorphin activity did not rise after sleep loss. Loaded CO2 response was reduced compared to unloaded response and was not affected by sleep loss or by naloxone. The serum epinephrine level rose significantly with sleep loss. We conclude that naloxone is not a respiratory stimulant in normal people, and that it does not reverse the fall in CO2 response that follows sleep loss.

The effect of acute discontinuation of total parenteral nutrition.

The present study was undertaken to assess the impact of acute discontinuation (AD) of total parenteral nutrition (TPN) on serum glucose, insulin, and glucagon levels and on the generation of symptomatic hypoglycemia. Fifty studies were performed in 48 patients. In none of the 30 studies of 1 hour duration nor in the 20 studies of 8 hours duration was there a single episode of symptomatic hypoglycemia. One patient had a glucose below normal (60 mg/dl) during the first hour after AD. Glucose and insulin concentrations were elevated at the start of TPN discontinuation but returned to normal values within 60 minutes and remained there during the successive 7 hours of study. Although glucagon levels were slightly elevated at zero time, no significant decrease occurred. There was no evidence for counter-regulation based on the patterns of glucose and hormone levels. With some restrictions, acute discontinuation is a safe, rapid method of ending a prolonged TPN infusion.

Prospective study of catheter replacement and other risk factors for infection of hyperalimentation catheters.

To determine risk factors for infection of hyperalimentation catheters, we prospectively studied 169 catheter systems (88 patients) by using a semiquantitative culture technique. Infection occurred in 24 (14%) catheters (16 patients), was inversely proportional to the number of previous catheters inserted by the operator (P less than .02), and was proportional to the interval between admission and catheter insertion (P less than .0005). Catheter replacement over a guidewire was no more likely to be associated with infection than was a de novo percutaneous insertion at another site (P = .6). Using a proportional hazards model, we estimated the risk of infection per day to be 1.3 times greater for a catheter if the patient had been hospitalized 50 days instead of seven days, and 3.8 times greater if the patient had a Swan-Ganz catheter at the time of insertion.

Cushing's syndrome resulting from primary pigmented nodular adrenocortical disease.

In a 10-year-old boy with Cushing's syndrome, the dexamethasone suppression test, the metyrapone test, and both basal and corticotropin-releasing factor-stimulated corticotropin levels all indicated a primary adrenal disorder. However, a computed tomographic scan failed to detect an adrenal tumor. At surgery, the adrenal glands were not enlarged but were studded with small pigmented nodules composed of enlarged nonmalignant adrenocortical cells. This unusual abnormality, referred to as primary pigmented nodular adrenocortical disease, is associated with autonomous hypersecretion of cortisol primarily in children and young adults. Our patient was cured by total bilateral adrenalectomy and corticosteroid replacement therapy, the treatment of choice for this condition.

Selective drainage for pancreatic, biliary, and duodenal obstruction secondary to chronic fibrosing pancreatitis.

Twenty-eight patients underwent surgery for intractable pain, duodenal or extrahepatic biliary obstruction secondary to chronic pancreatitis. Eleven had pancreatic duct obstruction alone, six biliary obstruction alone, seven combined pancreatic and biliary, two combined biliary and duodenal, one combined pancreatic and duodenal, and one simultaneous pancreatic, biliary, and duodenal obstruction. Pancreatitis was secondary to alcohol in all but one case. The following operations were performed: longitudinal pancreatojejunostomy (20), choledochoduodenostomy (8), choledochojejunostomy (7), cholecystojejunostomy (1), and gastrojejunostomy (4). Of the 20 patients with pancreatic duct drainage, pain relief was complete in 11 and partial in six. Initial incomplete relief of pain, or recurrence, stimulated further diagnostic procedures, leading to improvement or correction of the problem in five patients. A significant (p less than 0.01) fall in alkaline phosphatase (935 +/- 228 to 219 +/- 61 U/L) occurred following surgery. One patient was subsequently found to have pancreatic carcinoma. Two patients were lost to follow-up and four patients died (one perioperative and three late). In conclusion, the possibility of pancreatic, biliary, and duodenal obstruction must be considered in symptomatic patients with chronic pancreatitis. Surgery must be individualized. Drainage procedures, either alone or in combination, are associated with a low morbidity and improved clinical condition and may be preferable to resection in the surgical management of these patients.

Flow cytometric determinations of ploidy and proliferation patterns of adrenal neoplasms: an adjunct to histological classification.

Flow cytometric deoxyribonucleic acid measurements were performed with propidium iodide on 7 adrenal neoplasms and 4 normal adrenal glands to determine how useful this technique would be in defining malignancy. The 4 cases classified histologically as carcinoma all had aneuploid stemlines of 2.7, 3.3, 3.4 and 3.6c respectively, whereas the 4 normal glands and an aldosteronoma had only a small percentage (less than 10 per cent) of hyperdiploid cells (greater than 2c) at the tetraploid level (4c). A pheochromocytoma and benign adenoma had significant tetraploid populations of 30 and 18 per cent, respectively, with no evidence of aneuploid cells. Flow cytometry determination of deoxyribonucleic acid ploidy values is an accurate, objective, quantitative mean to identify adrenal malignancy and should have a role in the pathological evaluation of adrenal neoplasms.

Mechanical complications from insertion of subclavian venous feeding catheters: comparison of de novo percutaneous venipuncture to change of catheter over guidewire.

Since a percutaneous catheter insertion into the subclavian vein can be tedious, time consuming, and risky, we have compared the morbidity of 137 de novo subclavian catheter insertions to that of 93 reinsertions over guidewire. Mechanical complications were significantly higher (p less than 0.03) in those with catheter insertions (8.8%) than in those with the guidewire insertions (2.2%). These included pneumothorax (4), arterial puncture (4), catheter-size bleed (3), and hemothorax (1) in the catheter insertion group and local bleeding (1) and hydrothorax (1) in the guidewire insertion group. The difference in complications between methods is probably inherent in the techniques. Operator experience was not a factor: 55% of the physicians in each group had previously done less than 26 subclavian venous catheterizations. Preliminary analysis indicates that the infection rate, as determined by semiquantitative, cultures, is the same in each group. When considering the equal potential for infection, we conclude that change over a guidewire is an acceptable alternative to contralateral de novo percutaneous subclavian venipuncture for feeding catheter insertion. In view of fewer mechanical complications and greater ease of insertion, change of subclavian feeding catheters by guidewire is probably the method of choice.

Mechanical brain injury: the sympathoadrenal response.

Catecholamine release was studied in cats as a function of injury severity in the fluid-percussion model of brain injury. Hyperglycemia was also studied as a function of catecholamine response and injury severity. Epinephrine (E) and norepinephrine (NE) increased as a function of injury. This increase was maximal at about a 3.0-atmosphere (atm) injury level and amounted to a 500-fold increase for E and 100-fold increase for NE. Both catecholamines increased maximally by 10 seconds postinjury. Glucose increased to about 350% of baseline at 500 seconds postinjury and also increased as a function of injury severity. Results suggested that the sympathoadrenal discharge was capable of a graded response which was maximal at about 3.0 atm. Associated with this increase were hypertensin, bradyarrhythmias, tachyarrhythmias, and hyperglycemia.

The lack of normal catecholamine responses in patients with pheochromocytomas.

Because of divergent reports of catecholamine secretion with the patient positioned upright in patients with pheochromocytomas, we have measured plasma norepinephrine (NE) and epinephrine (E) by radioenzymatic assay, both in normal subjects (eight) and in patients with pheochromocytomas (12) during three conditions that stimulate release of catecholamines. Standing (S), isometric hand exercise (H), and hand immersion in cold water (C) resulted in a significant rise in plasma NE concentrations in normal subjects; plasma E concentrations rose only at 6 minutes of S. Average rises (percentage +/- SEM) for NE were 68 +/- 3 (S), 22 +/- 6.5 (H), and 46 +/- 4.1 (C); for E, 33.1 +/- 12.2 (S). On the other hand, in patients with pheochromocytomas, no significant changes from basal NE (except at 2 minutes S) or E concentrations were seen during S, H, or C. Average percentage changes (+/- SEM) for NE were 18.2 +/- 7.8 (S), 11.6 +/- 3.6 (H), and -17.9 +/- 8.3 (C). There was a significantly lower percentage response of plasma NE concentrations in patients during S (P less than 0.001) and C (P less than 0.01), compared with that in normal subjects. The NE responses in two patients with metastatic pheochromocytoma after adrenalectomy were similar to those seen in patients with benign tumors in the adrenal medulla. Finally, a reciprocal relationship between plasma E and NE concentrations seen in normal subjects during S was not seen in the patients. Our findings support the conclusion that pheochromocytomas are not functionally integrated with or innervated by the sympathetic nervous system.

Hypocalciuric hyperparathyroidism with chronic renal failure.

A patient with hypertension and chronic renal disease was evaluated for hypercalcemia and hypophosphatemia. Serum parathyroid hormone and urine nephrogenous cyclic adenosine monophosphate levels were both elevated. Absolute and fractional urine excretion of calcium was low, thereby raising the suspicion of hypocalciuric hypercalcemia. Surgical removal of a parathyroid adenoma led to normalization of the serum calcium, and phosphate values associated with the complete absence of calcium from the 24-hour urine collection returned to normal.

Cervical distribution of iodine 131 following total thyroidectomy for thyroid cancer.

The use of postoperative radioiodine thyroid scanning has questioned whether total thyroidectomy is surgically possible. Similar to earlier studies, we have found functioning iodine 131 (131I)-avid thyroid tissue in our patients following total thyroidectomy for thyroid cancer. Preoperative and postoperative thyroid scans were compared in 24 patients to study the cervical location of postthyroidectomy residual thyroid tissue. Thyroid scanning detected 44 distinct sites of uptake. Thirty-eight of these foci were located either at the extremes of the upper poles of the thyroid gland (24) or along the embryonic thyroid descent tract (14). We conclude that these foci of 131I uptake represent incomplete resection of normal thyroid tissue, and that surgical attention to these areas should result more frequently in extirpation of the entire thyroid gland.

Impact of sonography on surgery for primary hyperparathyroidism.

The impact of preoperative sonographic localization of enlarged parathyroid glands was evaluated from the standpoint of operative time and complication rates. There was a reduction in the average time from 135 minutes when findings were false-negative to 111 minutes when findings were positive. The rate of complication was not changed by accurate preoperative localization. When the operative goal is to find all parathyroid glands in every patient, the value of preoperative localization of parathyroid tumors by any current method is slight. Should operative policy favor a search for only one enlarged and one normal gland, or should methods improve to the point that even normal parathyroid glands can be located reliably, noninvasive localization should prove to be useful, safe, and cost-effective, even when it is carried out before initial operation.