Suprapubic prostatectomy for benign prostatic hyperplasia in rural Asia: 200 consecutive cases.

OBJECTIVES: To assess the safety and efficacy of a suprapubic prostatectomy technique performed in a rural hospital in Asia. METHODS: A retrospective study of 200 consecutive suprapubic transvesical prostatectomies with a removable bladder neck partition suture for benign prostatic hyperplasia from 1995 to 1998 in a rural mission hospital in northern Pakistan was performed. RESULTS: Despite preoperative comorbidities in 28% of patients, the postoperative morbidity (14%) and mortality (1%) was low. The partition suture is credited with a very low transfusion rate (1%) and a lower intensity of nursing care in the postoperative period. Patient satisfaction was high with regard to both relief of symptoms and cost. CONCLUSIONS: This study demonstrated that suprapubic prostatectomy with a routine bladder neck partition suture for benign prostatic hyperplasia can be carried out with a high degree of safety and efficacy in a rural setting with limited facilities in a developing country.

Surgical treatment for ductal adenocarcinoma of the pancreas.

A ten year community hospital experience of 124 patients with ductal adenocarcinoma of the pancreas proved at biopsy is reported. All patients underwent a celiotomy, and 94 per cent were observed until death. All of the patients were stratified by stage (I, 9 per cent; II, 30 per cent; III, 18 per cent, and IV, 43 per cent). Nine of the patients with Stage I disease underwent resection with a high postoperative mortality rate of 44 per cent and only one five year survivor. Fifty-nine patients with Stages II and III disease underwent biliary bypass with a low postoperative mortality rate of 2 per cent. Bypass of the common bile duct (N = 24) provided more permanent palliation against recurrent jaundice or cholangitis (p less than 0.05), but did not improve the survival time when compared with bypass of the gallbladder (N = 20). This was not true for those with Stage IV disease in whom recurrent jaundice did not develop in those with either bypass of the gallbladder or common duct. Adding prophylactic gastroenterostomy (GE) to biliary bypass (N = 25) conferred no survival benefit, but did protect against subsequent duodenal obstruction (p less than 0.05). Thirty-seven per cent of the 38 patients in whom a GE was not performed had duodenal obstruction develop. Adjuvant radiation and chemotherapy in 22 patients with unresectable Stages II and III disease resulted in a significant prolongation of survival time compared with 15 untreated patients in the control group (p less than 0.05). Fifty-one patients with Stage IV disease underwent biliary bypass or biopsy of the tumor resulting in a 14 per cent postoperative mortality rate and a median survival time of four months. Nine per cent of the 44 survivors with Stage IV disease lived at least one year. The implications of these findings to clinical practice are discussed.

Charcoal bezoar. Small-bowel obstruction secondary to amitriptyline overdose therapy.

Nasogastric administration of activated charcoal is effective in decreasing the half-life of amitriptyline. A case is reported in which this therapy for amitriptyline overdose led to charcoal bezoar formation and small-bowel obstruction. Amitriptyline's atropinic side effects on the gut make this a possible complication in such patients.

Surgical treatment for inflammatory bowel disease in the older patient.

Twenty-six patients who were 60 years of age or older underwent a surgical procedure for inflammatory bowel disease (IBD). Twenty patients had involvement of the colon (14 had ulcerative colitis and six, Crohn's disease). The indications for operation were intractable colitis (eight patients), perforation (three patients), stricture (three patients), toxic megacolon (three patients), anorectal disease (two patients) and carcinoma (one patient). Operations performed were abdominal colectomy (ten patients), segmental colectomy (seven patients), local anorectal procedures (two patients) and total coloprotectomy (one patient). Five patients had a preoperative diagnosis of diverticulitis and two of carcinoma. Among 17 patients who were observed, nine had symptomatic recurrences. In six patients with Crohn's disease of the small intestine, operation was performed for intractability in two patients, perforation in two patients and obstruction, two patients. All underwent resection and primary anastomosis. Four of five patients had recurrences. IBD in the older patient may be confused with other diseases. Recurrence is frequent with limited colonic resection.