Effect of Morphine and incision length on bowel function after colectomy.

PURPOSE: Return of bowel function remains the rate-limiting factor in shortening postoperative hospitalization of patients with colectomies. Narcotics are most commonly used in the management of postoperative pain, even though they are known to affect gut motility. Narcotic use has been felt to be proportional to the length of the abdominal incision. The aim of this study was to determine whether return of bowel function after colectomy is directly related to narcotic use and to evaluate the effect of incision length on postoperative ileus. METHODS: A prospective evaluation of 40 patients who underwent uncomplicated, predominantly left colon and rectal resections was performed. Morphine administered by patient controlled analgesia was the sole postoperative analgesic. The amount of morphine used before the first audible bowel sounds, first passage of flatus and bowel movement, and incision length were recorded. Spearman correlation coefficients were calculated between all variables. RESULTS: The strongest correlation was between time to return of bowel sounds and amount of morphine administered (r = 0.74; P = 0.001). There were also significant correlations between morphine use and time to report of first flatus (r = 0.47; P = 0.003) and time to bowel movement (r = 0.48; P = 0.002). There was no relationship between incision length and morphine use or incision length and return of bowel function in the total group. CONCLUSIONS: Return of bowel sounds, reflecting small-intestine motility after colectomy, correlated strongly with the amount of morphine used. Similarly, total morphine use adversely affects colonic motility. Because no relationship with incision length was found, efforts to optimize the care of patients with colectomies should be directed less toward minimizing abdominal incisions and more toward diminishing use of postoperative narcotics.

Abdominal closure using nonabsorbable mesh after massive resuscitation prevents abdominal compartment syndrome and gastrointestinal fistula.

Patients who receive high-volume resuscitation after massive abdominopelvic trauma, or emergent repair of a ruptured abdominal aortic aneurysm (RAAA), are at a significant risk for postoperative abdominal compartment syndrome (ACS). Absorbable prosthetic closure of the abdominal wall has been recommended as a means of managing ACS. However, use of absorbable prosthetic has been associated with very high rates of intestinal fistula formation and ventral hernia formation. The purpose of this study was to retrospectively review our experience with the use of nonabsorbable prosthetic abdominal closures in patients with documented ACS or at high risk for ACS. All patients managed by this technique from July 1995 through July 1997 after repair of ruptured abdominal aortic aneurysm or massive abdominopelvic trauma were evaluated. A total of 18 patients were identified: 15 primary prosthetic placements (Gore-Tex patch, 12; Marlex mesh, 2; and silastic mesh, 1) and 3 delayed prosthetic placements for ACS (Gore-Tex, 1 and Marlex, 2). The mortality rate was 22 percent (4 of 18) and resulted from multisystem organ failure (2 patients), cardiac arrest 1 hour postoperatively (1 patient), and severe closed head injury (1 patient). Secondary closure and prosthetic removal was possible in 16 of 18 patients, including the 2 patients who died of multisystem organ failure within the same hospitalization. Delayed abdominal closure at a subsequent admission was performed in two cases. This same patient developed an enterocutaneous fistula 2 months after discharge. Importantly, only 1 of 18 closed in this manner developed ACS requiring reoperation. The results indicate that use of a nonabsorbable prosthetic, particularly with Gore-Tex, is efficacious in the prevention of postoperative ACS in high-risk patients, while it enhances the possibility for delayed abdominal closure and minimizes the risk of gastrointestinal fistulization associated with other techniques.

Ileoanal pouch function and release of peptide YY.

PURPOSE: This study evaluates peptide tyrosine-tyrosine (PYY), intestinal transit, fecal retention time, and anal sphincter manometry in colectomized patients with ileal pouch-anal anastomosis. METHODS: Plasma and pouch PYY, mouth-to-pouch transit time, fecal retention time, and anal canal pressures were studied in 27 patients with ileoanal pouches a mean of 50 (range, 3-84) months after loop ileostomy closure. RESULTS: Basal and peak postprandial plasma PYY were significantly reduced in patients with pouches compared with controls (P < 0.0001). Pouch PYY was decreased compared with control ileal PYY (P = 0.0003). No significant correlation was noted between intestinal transit and total integrated PYY response in patients with pouches (r=0.36; P=0.06). Fecal retention time was related to postprandial total integrated response of plasma PYY (r=0.43; P=0.02), mouth-to-pouch transit (r=0.87; P < 0.0001), and resting (r=0.44; P=0.02) and squeeze (r=0.62; P=0.0006) anal sphincter pressures. CONCLUSIONS: Colectomized ileoanal patients with pouches showed decreased plasma and pouch PYY compared with controls. Intestinal transit was not significantly related to PYY release. However, prolonged pouch fecal retention was associated with greater PYY release, mouth-to-pouch transit, and anal sphincter pressures.

Pudendal nerve function in normal and encopretic children.

BACKGROUND: Abnormal pudendal nerve function contributes to fecal retention and incontinence in adults. To determine the role of pudendal neuropathy in childhood, we prospectively evaluated pudendal nerve function in normal and encopretic children. METHODS: We studied pudendal nerve terminal motor latency in 23 encopretic children and in an equal number of similarly aged, normal children. Anal manometry and electromyography were also obtained in all children. RESULTS: Pudendal nerve latency in the encopretic children equaled 1.58 +/- 0.33 msec, which was the same as that in control children. Of the 75 pudendal nerves tested, latency was prolonged in only one encopretic child. In contrast, anal electromyography demonstrated nonrelaxation of the external anal sphincter in 75% of the encopretic children but in only 13% of the normal children (p < 0.001). Anorectal manometry demonstrated, on average, lower and sphincter pressures at rest and with squeezing in the encopretic children (p < 0.01), but only 17% had sphincter pressures more than two standard deviations below normal. CONCLUSIONS: Other than poor relaxation response of the external anal sphincter during evacuation, these data reveal a paucity of functionally important abnormalities in encopretic children. In particular, we find no evidence that abnormal pudendal nerve function is important in the etiology or pathogenesis of encopresis in children.

Colobronchial fistula: an unusual complication of Crohn's disease.

Fistulas secondary to Crohn's disease occur in about 33% of patients. A colobronchial fistula complicating Crohn's disease is very rare, having been reported only twice previously. We present an unusual fistula secondary to Crohn's colitis that originated from the splenic flexure and crossed the diaphragm to involve the bronchial tree.

Transanal ultrasound and manometry in the evaluation of fecal incontinence.

PURPOSE: This preliminary study was undertaken to clarify the role of ultrasonography of anal sphincters in the colorectal laboratory. METHODS: Twenty-eight parous female patients with fecal incontinence were evaluated with transanal ultrasonography (TAUS), anal manometry, and pudendal nerve terminal motor latency (PNTML). Ultrasound images were recorded and labeled in centimeters from the anal verge. The continuity of the internal anal sphincter (IAS) was identified as either intact or disrupted. The separation of the external anal sphincter (EAS) was measured at the 1.5-cm level and below. TAUS findings were then compared with anal manometric pressures. Clinical data were obtained by patient interview and examination during TAUS. RESULTS: Evidence of IAS disruption was associated with significantly decreased mean maximum resting pressures (P = 0.023). EAS separation was inversely proportional to mean maximum squeezing pressures (r = -0.61). In the group of patients offered sphincteroplasty, the IAS was disrupted more often (P = 0.016), mean maximum resting pressures were significantly lower (P = 0.023), mean EAS separation was significantly greater (P = 0.022), and mean PNTML was significantly faster (P = 0.004). Twenty-five percent of patients with normal clinical examinations had significant muscular injury by TAUS requiring sphincteroplasty. CONCLUSIONS: Manometric findings correlate significantly with anal sphincter defects visualized by TAUS. TAUS is useful in the evaluation and management of patients with fecal incontinence.

Effect of prostaglandin E1 and steroid on healing colonic anastomoses.

PURPOSE: The effect of prostaglandin E1 (PGE1) and corticosteroids alone and in combination were studied in the healing rat colon to determine whether PGE1 could not only improve healing but reverse the negative effect of steroids on colonic wound healing. METHODS: Colonic anastomoses were performed in 144 male Sprague-Dawley rats divided into four groups. The control group (I) received no further treatment. The steroid group (II) received cortisone acetate (5 mg/kg/day) beginning six days preoperatively and continuing until sacrifice. The PGE1 group (III) received 2 micrograms of PGE1 intra-aortically at surgery and for three days postoperatively. The combination PGE1/steroid group (IV) received both drugs in the same doses as those in Groups II and III. Animals were sacrificed on postoperative days 6, 10, and 14. Wound healing was evaluated by hydroxyproline content, bursting pressures, and histology. RESULTS: The hydroxyproline assay at day 10 revealed that steroid-treated rats have significantly lower levels than any other group. The PGE1 group (III) had the highest level of significance in comparison to the steroid group (II) (P = 0.001). The addition of PGE1 to steroid (Group IV) appeared to abolish the negative effect of the steroid as measured by hydroxyproline content on day 10 (P = 0.038). When measuring bursting pressures, the PGE1 group (III) had significantly higher pressures than any other group at day 10. However, no amelioration of the steroid effect on bursting pressures was seen. Histologic evaluation of the anastomosis did not reveal any significant differences among the four groups. CONCLUSIONS: PGE1 reverses the negative effect of the steroid on hydroxyproline levels at day 10. Furthermore, using bursting pressure as a parameter of wound healing, administration of PGE1 results in significantly improved anastomotic healing at day 10.

Cumulative incidence of metachronous colorectal cancer.

The incidence of metachronous colorectal cancer has most often been reported as a crude rate: second cancers/index cancers. The reported incidence varies between 0.5 percent and 3.6 percent. However, these calculations do not take into account factors such as length of survival and length of follow-up. The cumulative incidence more accurately reflects the risk for developing a metachronous cancer and was determined in a retrospective analysis of 5,476 patients who were diagnosed with colon or rectal cancer between 1965 and 1985. The cumulative probability was calculated by determining the number of patients developing a metachronous colon cancer vs. the number remaining at risk at that point in time. The calculated annual incidence for metachronous tumors was 0.35 percent per year. The cumulative incidence at 18 years was 6.3 percent. Analysis also demonstrated that metachronous cancers were diagnosed at earlier stages than were index cancers (P = 0.03). Subgroup analysis was performed on patients diagnosed with metachronous cancer before and after 1980. There was a difference in the incidence of metachronous cancers between these two groups (P = 0.04).

Bilateral internal carotid artery agenesis: a case study and review of the literature.

Bilateral internal carotid artery agenesis is a rare lesion, with only 18 cases previously reported. Blood supply to the anterior cerebral circulation is most commonly through enlarged basilar and posterior communicating arteries. Occasionally collateral flow is through abnormal transsellar anastomoses or anastomoses between the external carotid and intracranial systems. Associated intracranial aneurysms occur in 25% of patients, accounting for a significant incidence of intracranial hemorrhage as the initial symptom. Diagnosis is best made by cerebral arteriography with computed tomography to verify the congenital nature of the abnormality by demonstrating the absence of carotid canals. This is the second case to begin with transient ischemic attacks suggestive of carotid territory ischemia but originating from the vertebral system. Angiographic findings included absent internal carotid arteries, small common carotid arteries, and bilateral high-grade stenoses at the origins of large vertebral arteries. This is the first such case to be treated with reimplantation of the vertebral artery with resolution of symptoms.

Normal variation in anorectal manometry.

A study was performed to define the normal range of values for anorectal manometry. Normal volunteers were divided according to gender and parity. There were 20 males, 21 nulliparous females, and 18 multiparous females among the 59 subjects. Anorectal manometry using a radial eight-port catheter was performed during resting and squeezing maneuvers of the anal sphincter. Computerized data analysis and three-dimensional imaging were used to calculate sphincter length at rest and squeeze, mean maximum resting and squeeze pressures, and vector symmetry index. The sphincter length at rest and with squeezing in males was significantly greater compared with the two female groups (P < 0.007). Mean maximum squeeze pressures were also significantly elevated in the male group compared with the female groups (P = 0). Mean maximum resting pressures were significantly higher in nulliparous women than in multiparous women (P = 0.04). However, no difference in resting pressures was found between males and nulliparous females. A comparison of the symmetry of the anal canal revealed no differences among the three groups. Ranges for normal anorectal manometry are definable. Normal ranges are distinct for subgroups of patients, particularly with regard to gender and parity. Patients must be compared with their normal subgroups to correctly identify manometric abnormalities.

Rare pelvic floor hernias. Report of a case and review of the literature.

The case of a 64-year-old female who presented with difficult evacuation of stool is reported. A posterior perineal hernia was diagnosed by dynamic proctography. The patient had an unusual herniation of the upper rectum through the perineal defect. At surgery, there was no peritoneal sac, since the herniation occurred extraperitoneally. The patient was treated with repair of the pelvic floor using Marlex mesh and rectopexy. Pelvic floor hernias are rare and often difficult to diagnose. The three types, in order of decreasing frequency, are obturator, perineal, and sciatic. The etiology, diagnosis, and treatment of each is discussed.

"House" advancement pedicle flap for anal stenosis.

Long strictures of the anal canal, extending from the dentate line to the perianal skin, have challenged surgeons for many years. Numerous techniques have been devised to treat anal strictures. A technique to relieve an anal stenosis that involves the entire circumference and the length of the anal canal from the dentate line onto the perianal skin is described. It has two principal advantages: 1) it provides a broad skin flap for the entire length of the involved anal canal; and 2) it provides primary closure of the donor site. In addition, it avoids extensive mobilization of tissue, the flap maintains good blood supply with minimal tension, and there is no small tip prone to necrosis.

Estrogen replacement therapy--boon or bane? Current status of the controversy.

The three primary indications for estrogen replacement therapy in postmenopausal women are severe vasomotor symptoms (hot flashes), prevention or treatment of osteoporosis, and atrophy of the genital tract. Estrogen replacement therapy is well established as reducing the morbidity and mortality associated with osteoporosis. The increased incidence of endometrial cancer associated with estrogen use (from 1/1,000 to 4/1,000 per year) must be accepted and viewed in perspective. Many of these estrogen-related cancers are stage I lesions, with a cure rate of 95%. In addition, the risk associated with estrogen replacement therapy can be reduced by coadministration of a progestogen during the last ten days of the cycle.

Complications of abdominal aortic reconstruction. An analysis of perioperative risk factors in 557 patients.

From 1974 through 1978, 557 patients (mean age: 63 years) underwent Dacron graft replacement of the abdominal aorta at the Cleveland Clinic. Postoperative complications occurred in 110 patients (20%), with mortality rates of 5.1% for those having intact aortic aneurysms, 26% for those with ruptured aneurysms, and 2.3% for those with aortoiliac occlusive disease. Myocardial infarction was the most common cause of postoperative death, affecting 3.1% of the entire series, but all 87 patients who had previously required myocardial revascularization survived subsequent aortic procedures (p less than 0.01). As defined in this investigation, temporary renal failure (7.0%) or pulmonary insufficiency (5.9%) were encountered more frequently than were other complications, but each of these was the singular cause of death in only 0.2% of all patients. Several risk factors significantly influenced postoperative mortality, (p less than 0.01), including age over 60 years, suspected coronary artery disease, serum creatinine greater than 2.0 mg/dl, complementary renal artery revascularization, and aneurysm rupture. In addition, intraoperative blood loss had a statistically valid correlation with postoperative mortality (p less than 0.01), myocardial infarction (p less than 0.010, renal failure (p less than 0.001), and pulmonary insufficiency (p less than 0.001).