Sentinel Contributions of US Department of Veterans Affairs Surgeons in Shaping the Face of Health Care.

The vast accomplishments of the US Department of Veterans Affairs (VA) during the past century have contributed to the advancement of medicine and benefited patients worldwide. This article highlights some of those accomplishments and the advantages in the VA system that promulgated those successes. Through its affiliation with medical schools, its formation of a structured research and development program, its Cooperative Studies Program, and its National Surgical Quality Improvement Program, the VA has led the world in the progress of health care. The exigencies of war led not only to the organization of VA health care but also to groundbreaking, landmark developments in colon surgery; surgical treatments for vascular disease, including vascular grafts, carotid surgery, and arteriovenous dialysis fistulas; cardiac surgery, including implantable cardiac pacemaker and coronary artery bypass surgery; and the surgical management of many conditions, such as hernias. The birth of successful liver transplantation was also seen within the VA, and countless other achievements have benefited patients around the globe. These successes have created an environment where residents and medical students are able to obtain superb education and postgraduate training and where faculty are able to develop their clinical and academic careers.

Appendectomy for appendicitis in patients with a prior ventriculoperitoneal shunt.

BACKGROUND: Approximately 18,000 cerebrospinal fluid shunts, the majority of which are ventriculoperitoneal, are placed each year in the United States. These patients may develop appendicitis and require surgery. Whether the risk of postoperative complications is increased in these patients is unknown. We sought to determine the clinical course of patients with ventriculoperitoneal (VP) shunts who undergo appendectomy for appendicitis. METHODS: A nationwide search of Department of Veterans Affairs databases was conducted to identify patients with a VP shunt who subsequently developed appendicitis and underwent appendectomy. Patient medical records were analyzed to determine if the presence of a VP shunt affected the surgical approach or the postoperative course of patients who underwent appendectomy. RESULTS: Ten patients had ICD-9-CM codes for both appendectomy and a VP shunt. Five met the inclusion criteria for the study and had sufficient data for analysis. Medical records indicated that all of the patients had perforated or gangrenous appendicitis with peritonitis. One patient's VP shunt was converted to a ventriculoatrial shunt. Another patient's shunt was removed when culture of his peritoneal fluid grew Gram-positive cocci. There were no instances of postoperative infection, shunt malfunction, or other complication. CONCLUSION: This is the only English language study, to our knowledge, of the clinical course of adults with VP shunts in place at the time of appendectomy for appendicitis. Such patients generally have no complications related to shunt malfunction or infection. In a minority of patients, shunt revision may be required.

Outcome after colectomy for Clostridium difficile colitis.

PURPOSE: Clostridium difficile colitis is a relatively common entity, yet large series of patients with fulminant C. difficile colitis are infrequently reported. This study was designed to identify risk factors, clinical characteristics, and outcome of patients who required colectomy for fulminant C. difficile colitis. METHODS: A population-based study on all patients in 159 hospitals of the Department of Veterans Affairs from 1997 to 2001 was performed. Data were compiled from several national computerized Department of Veterans Affairs data sets. Supplementary information including demographic information, discharge summaries, operative reports, and pathology reports were obtained from local medical records. Patient variables were entered into a computerized database and analyzed using the Pearson chi-squared and Fisher's exact tests. Statistical significance was designated as P < 0.05. RESULTS: Sixty-seven patients (mean age, 69 (range, 40-86) years; 99 percent males) were identified. All 67 patients had C. difficile verified in the colectomy specimens. Thirty-six of 67 patients (54 percent) developed C. difficile colitis during a hospitalization for an unrelated illness, and 30 of 36 patients (87 percent) after a surgical procedure. Thirty-one of 67 (46 percent) developed C. difficile colitis at home. There was no history of diarrhea in 25 of 67 patients (37 percent). Thirty of 67 patients (45 percent) presented in shock (blood pressure, <90 mmHg). Forty-three of 67 patients (64 percent) presented with an acute surgical abdomen. Mean white blood cell count was 27.2; mean percent bands was 12. Twelve of 67 patients (18 percent) had a negative C difficile colitis stool assay. Abdominal computed tomography correctly diagnosed 45 of 46 patients (98 percent) who were imaged. Twenty-six of 67 patients (39 percent) underwent colonoscopy; all 26 were found to have severe inflammation or pseudomembranes. Fifty-three of 67 patients (80 percent) underwent total colectomy; 14 of 67 underwent segmental colonic resection. Perforation and infarction were found in 59 of 67 patients (58 percent) at surgery. Overall mortality was 48 percent (32/67). Mean hospitalization was 36 (range, 2-297) days. CONCLUSIONS: Patients with fulminant C. difficile colitis often present with an unexplained abdominal illness with a marked leukocytosis that rapidly progresses to shock and peritonitis. Although frequently developed during a hospitalization and often after a surgical procedure, it may develop outside of a hospital setting. Diarrhea may be absent and stool cytology may be negative for C. difficile toxin. Perforation and infarction are frequently found at surgery. In those patients who survive, a prolonged hospitalization is common. Mortality from fulminant C. difficile colitis remains high despite surgical intervention.

Fulminant Clostridium difficile colitis in a patient with spinal cord injury: case report.

BACKGROUND: In certain patients with Clostridium difficile colitis (CDC), a life-threatening systemic toxicity may develop despite appropriate and timely medical therapy. DESIGN: Literature search and case report. FINDINGS: A 39-year-old man with T10 paraplegia presented with a distended, quiet abdomen following recent treatment with antibiotics for pneumonia. Diarrhea was not present. Complete blood counts demonstrated a marked leukocytosis. A CT scan of the abdomen demonstrated a state of diffuse pancolonic inflammation with peritoneal fluid. The patient was taken to the operating room and underwent total abdominal colectomy with oversewing of the rectal stump and end ileostomy for treatment of the fulminant CDC. CONCLUSION: Patients with spinal cord injury (SCI) often receive antibiotics for infections of the aerodigestive tree and urinary tract and for problems with skin integrity. A heightened awareness of the development of fulminant CDC remains essential in the care of patients with SCI. Any unexplained abdominal illness after recent antibiotic administration should alert the physician to CDC and its potential as a fulminant, potentially fatal illness.

Spectrum of disease and outcome of complicated diverticular disease.

BACKGROUND: Diverticular disease is a common entity. The presentation, investigations performed, and management are variable. Our objectives were to assess the presentation, extent of disease, and treatment of a cohort of patients with colonic diverticulitis. METHODS: All patients with a diagnosis of diverticulitis over a 9-year period were reviewed. Patients were assessed as to age, sex, presenting symptoms, diagnostic studies, extent of disease, treatment, and outcome. RESULTS: Over a 9-year period (1992 to 2001), 192 patients were admitted with a diagnosis of colonic diverticulitis. The mean age was 61 years (range 28 to 90); 113 of 192 (59%) were female. The mean duration of symptoms prior to presentation was 14 days (range 1 to 270 days). One hundred eighteen of 192 (61%) had a previous documented attack of diverticulitis. Of the investigations performed 128 of 192 (66.7%) had a computed tomography (CT) scan of the abdomen and pelvis, 37 of 192 (20%) underwent a contrast enema, 61 of 192 (32%) underwent colonoscopy and 2 of 192 (1%) underwent a small bowel series. The abnormal findings on the CT scan were as follows: diverticular abscess (16%), diverticulitis (37%), diverticulosis without inflammation (15%), free air (10%) and fistula (1%). The locations of the diverticular abscesses were: pelvic (36%), pericolic sigmoid (36%), and "other," which included interloop (28%). Preoperative abscess drainage occurred in 10 of 192 (5%), which were either percutaneous, 6 of 192 (3%), or transrectal, 4 of 192 (2%). Nine of 192 (6%) presented with a fistula, colovesical fistulae (3%), colocutaneous (1%), enterocolic (1%), or colovaginal (1%). Overall, 73 of 192 (38%) underwent surgery. All patients undergoing surgery had a resection of their colon. The operative findings were localized abscess in 16 of 73 (22%), purulent/feculent peritonitis in 12 of 73 (17%), and phlegmon in 10 of 73 (14%). Sixty-seven of 73 (92%) had a primary resection with anastomosis; 38 of 67 (56%) had a protecting stoma. Five of 73 (7%) patients were found to have an unsuspected carcinoma. Overall, 29 of 192 (15%) developed a complication related to diverticulitis. Morbidity was 15.1%, of which 34% was infection related. Four of 192 patients (2%) died. CONCLUSIONS: In our experience, most patients presented with abdominal pain predominantly in the left lower quadrant. The symptoms were present on average of 14 days, most were female (59%), and most patients had a previous attack of diverticulitis. The commonest investigation performed was a CT scan (66.7%); however, other investigations were performed, for example, barium enemas. The practice of resection and primary anastomosis for acute diverticulitis has an acceptable morbidity and mortality. For high-risk anastomoses, a covering loop ileostomy and not a Hartmann's procedure is preferred. Surgery remains safe for the majority of patients and is associated with resolution of symptoms. We believe that because of the high number of patients in our series who had a previous attack of diverticulitis, therapy should be focused on preventing recurrent and virulent attacks by earlier operative intervention.

Patterns of disease and surgical treatment among United States veterans more than 50 years of age with ulcerative colitis.

BACKGROUND: Ulcerative colitis (UC) is a clinical entity that predominantly affects young adults yet large series of middle age or elderly patients with UC are infrequently reported. The aim of this study is to identify patterns of disease, indications for operation, surgical treatment, and outcome of patients more than 50 years of age who required surgery for UC in Department of Veterans Affairs (DVA) Medical Centers. METHODS: A population-based study on all patients in 159 hospitals of the DVA from 1997 to 2001 was carried out. Data were compiled from several national computerized VA data sets. Supplementary information including demographic information, discharge summaries, operative reports and pathology reports were obtained from local medical records. Patient variables were entered into a computerized database and analyzed using the Pearson chi-square and Fisher's exact tests. Statistical significance is designated as P < 0.05. RESULTS: One hundred fifty-eight patients were evaluable. The mean age was 59 years (range 51-81); 99% were male. The mean duration of UC was 23 years (range 2 to 50). One hundred of the 158 patients had proctocolitis; 58 had either left-sided colitis or proctosigmoiditis. The mean dose of prednisone prior to surgery was 20 mg; the mean duration of steroid use was 8 years. The indications for elective surgery were intractability (59%), mass or stricture (27%), and dysplasia (14%). Twenty of the 158 patients (12%) were operated on emergently for either toxic colitis, perforation, or hemorrhage. One hundred three of the 158 underwent proctocolectomy and permanent ileostomy, 55 underwent a restorative proctocolectomy, and underwent a segmental colectomy. Twenty of the 158 patients were found to have dysplasia in their colectomy specimens; an additional 10 (7%) were found to have invasive cancer. Surgical morbidity was 22%. Overall mortality was 4% (7 of 158); all but 1 death occurred after emergent surgery. Mean hospitalization was 36 days (range 2 to 297). CONCLUSIONS: Restorative proctocolectomy was performed in 36% of veterans more than 50 years of age requiring surgery for UC. The majority required surgery for intractable symptoms. Dysplasia and invasive cancer was found in 18% of patients. Mortality after surgery for acute surgical emergencies remains high.

Ischemic colitis: spectrum of disease and outcome.

BACKGROUND: The aim of this study was to identify risk factors, clinical characteristics, and outcome of patients with colon ischemia. METHODS: A 10-year (1992-2002) retrospective study was undertaken. Patients were identified from computerized hospital discharge information. Patient variables were entered into a computerized database and analyzed. RESULTS: One hundred twenty-nine patients were identified. The mean age was 66 years (range, 29-98 years); 47% were male. Forty-three patients (33%) had chronic renal failure; 73 patients (57%) were receiving vasoactive drugs, and 72 patients (56%) had atherosclerosis. Fifty-four of 129 patients (42%) had ischemic colitis in-hospital. Fifty-six of 129 patients (43%) had melena; 49 of 56 patients (88%) survived. Forty-three of 129 patients (33%) had an acute abdomen; 22 of 43 patients (51%) died. Seventy of 129 patients (54%) were treated nonoperatively initially; the condition of 17 of 70 patients (24%) required surgery. Of 76 patients who were treated operatively, 31 patients (41%) died. Eleven patients at operation had ischemia without colon infarction or perforation; 5 of these patients (45%) died. The overall mortality rate was 29% (37/129 patients). CONCLUSION: Ischemic colitis is associated with chronic renal failure and atherosclerosis. Patients commonly have an acute abdomen. The absence of colonic infarction does not ensure a favorable outcome. Patients who are felt to be candidates for nonoperative therapy have significant mortality rates. Mortality rates remain high, despite treatment.

Colon and rectal cancer in the elderly. High incidence of asymptomatic disease, less surgical emergencies, and a favorable short-term outcome.

BACKGROUND: This is a retrospective study aimed to report short-term outcome among patients age > or =70 years surgically treated for colorectal cancer. METHODS: All patients with the discharge diagnosis of colon and rectal cancer at St. Louis University Hospital from 1992 to 2002 were reviewed. Patients were assessed as to demographics, presenting symptoms, therapy, surgical morbidity and mortality. RESULTS: One hundred eighty-one patients age > or =70 years with colorectal cancer were identified. The mean age was 78 years; 107/181 (59%) were females. Rectal bleeding and change in bowel habits were the most common presenting symptoms. Fifty-four out of 181 (30%) were asymptomatic at diagnosis. The diagnosis was made by colonoscopy in 75% of the patients. One hundred forty-three out of 181 (79%) had colon cancer; 38/181 (21%) had rectal cancer. Fourteen out of 181 (8%) did not undergo surgery. Twenty-two out of 181 (12%) were operated on as a surgical emergency. ASA classification was I-II in 52%, III in 34%, and IV-V in 14%. Nineteen out of 38 (50%) with rectal cancer underwent a sphincter-preserving procedure. Overall, there was a 29% major morbidity from surgery. Thirty-day mortality was 11% (21 deaths). Only the development of a postoperative complication predicted mortality. CONCLUSIONS: Elderly patients tolerate surgery well for colon and rectal cancer in the short-term. Many patients are asymptomatic at diagnosis. Surgical emergencies are few and patients have a favorable stage of disease. This data supports aggressive detection of colorectal cancer in asymptomatic elderly patients who may harbor occult colorectal cancer.

Colovaginal fistulas. Etiology and management.

OBJECTIVE: To review the diagnosis and treatment of colovaginal fistulas from various causes. DATA SOURCES: Papers on colovaginal fistulas were identified using Ovid and PubMed. The search terms used were as follows: colovaginal fistulas, rectovaginal fistulas, diverticular disease and fistulas. METHODS OF STUDY: Articles were selected based on their relevance to colovaginal fistulas and were then further subdivided into epidemiology, etiology, presentation, diagnosis and management. RESULTS: English-language papers were selected based on their relevance to all aspects of colovaginal fistulas. CONCLUSION: Optimizing nutrition is paramount prior to surgery. Medical management rarely corrects the problem. Diverticular colovaginal fistulas arise in patients who have previously undergone a hysterectomy. Radiation-related fistulas often involve the distal sigmoid colon and rectum, and recurrent cancer must be ruled out. Often symptoms are associated with radiation cystitis and terminal ileitis. When indicated, restoration of intestinal continuity is preferred. Malignant fistulas carry a poor prognosis, and when surgical removal is not practical, they are treated palliatively with fecal diversion or an endoluminal stent. Those arising from inflammatory bowel disease most frequently arise due to Crohn's disease, and extirpation of diseased bowel and associated abscess will successfully treat the condition. Fistulas arising from ulcerative colitis can be malignant. There remains a small role for colostomy as a nondefinitive procedure to alleviate symptoms. Colovaginal fistulas require a multidisciplinary approach and focused diagnostics, successful treatment can dramatically improve the patient's quality of life.

Duodenal reflux produces hyperproliferative epithelial esophagitis--a possible precursor to esophageal adenocarcinoma in the rat.

Esophageal reflux of duodenal contents converts a rat nitrosamine esophageal cancer model from squamous cell carcinoma to adenocarcinoma. Further, there was a tendency for male rats to have a higher incidence of cancer than female rats. However, chemical castration with the gonadotropin-releasing hormone analog leuprolide did not protect male or female animals from developing cancer. We have identified an early (6-week) hyperproliferative epithelial cell reaction to duodenal reflux. We carried out experiments to assess the specificity of duodenal reflux in producing the hyperproliferative epithelial precursor lesion. Animals underwent specific surgical procedures to produce esophageal reflux of pure duodenal contents, mixed gastroduodenal, or bland intestinal contents. A hyperproliferative mucosal esophagitis developed in the group with duodenal reflux but not in the other groups. Mucosal thickness in the duodenal reflux group reached seven times that of normal mucosa at 6 weeks. These results suggest that esophageal reflux of duodenal contents plays an important role in the pathogenicity of proliferative esophagitis and the potential development of esophageal adenocarcinoma.

Acute surgical emergencies in inflammatory bowel disease.

BACKGROUND: Acute surgical emergencies in patients with inflammatory bowel disease may carry a substantial morbidity, but fortunately today, a low mortality. The aim of this review is to delineate the treatment of acute surgical emergencies that occur in patients with ulcerative colitis and Crohn's disease. METHODS: Suitable English language reports were identified using PubMed search. RESULTS: Inflammatory bowel disease can present in numerous ways as an acute surgical emergency. These include toxic colitis, hemorrhage, perforation, intra-abdominal masses or abscesses with sepsis, and intestinal obstruction. Toxic colitis and perforation are best managed with intestinal resection and fecal diversion. Hemorrhage in ulcerative colitis initially requires colectomy with rectal preservation and ileostomy. In Crohn's disease hemorrhage is often focal and localization and segmental resection are performed. Intra-abdominal abscesses should initially be attempted by computed tomography-guided percutaneous drainage followed subsequently by definitive resection. Perianal disease requires abscess drainage with minimal tissue trauma. Intestinal obstruction should be initially managed nonoperatively, with surgery reserved for complete obstruction or intractability. CONCLUSIONS: Acute surgical emergencies in patients with inflammatory bowel disease are rare and can have a high morbidity. With a multidisciplinary approach, morbidity can be reduced and patients can have a rapid return and improved quality of life.