Should we perform elective inguinal hernia repair in the elderly?

PURPOSE: Many surgeons are reluctant to offer elective inguinal and femoral hernia repair (IHR) to the elderly due to concerns of increased risk. The authors sought to evaluate the outcomes of elderly patients undergoing IHR compared to the general population. METHODS: We performed a retrospective review of the 2011 NSQIP database evaluating 19,683 patients undergoing IHR. Patients were divided by age into three categories: <65, 65-79 and >80. Logistic regression analysis was used to assess impact of comorbid conditions and type of surgery on outcomes. Patients were analyzed for mortality and complications based on their age and the types of surgery (elective, urgent, emergent, laparoscopic versus open) and comorbid conditions. RESULTS: There were 17,375 male patients (88 %). 92.7 % were elective. 70 % were performed using an open technique. Age distribution was 63.4 % < 65, 26.6 % 65-79, 10 % >80. Mortality was similar across age groups in elective repair. Mortality was increased in emergency repair in all age groups (p < 0.001). Mortality was increased in emergency surgery compared to elective surgery in patients >80 (OR = 57, p < 0.001). Mortality was similar between laparoscopic and open in <65 (OR = 0.96, p = 0.97) and unable to be assessed in other age groups. Dyspnea and COPD predicted higher mortality and complications with emergency surgery in the elderly (age 65-79 OR 15.3 and 14.9, respectively, age >80 OR 56.5 and 14.9, respectively). CONCLUSIONS: Elective inguinal hernia repair carries a similar mortality in the elderly compared to the general population. Emergent IHR carries a very high risk of death in the elderly. The authors recommend considering elective IHR regardless of age.

Independent predictors of morbidity and mortality in blunt colon trauma.

We sought to determine the impact of (1) grade of the colon injury, (2) the formation of an ostomy, and (3) associated injuries on outcomes such as morbidity and mortality after blunt colon injuries. We retrospectively reviewed 16,814 cases of blunt abdominal trauma. Patients with colonic injuries were selected and charts reviewed for demographic, clinical, and outcomes data. Injuries were grouped by the Colon Injury Scale (grades I-V). Independent risk factors of morbidity included spine and lung injuries, as well as increased age. A higher grade of colon injury trended toward a significant association with intra-abdominal complications. Independent risk factors of mortality included liver, heart, and lung injuries, as well as intracerebral blood and female gender. The grade of colon injury, the formation of an ostomy, and management of the colon trauma did not independently predict increased intra-abdominal complications, morbidity, or mortality. These results indicate that patients afflicted with blunt colon trauma experience a high rate of morbidity and mortality from associated injuries and or increased age. Treatment regimens directed at these factors will be most helpful in reducing the high morbidity and mortality after blunt colon trauma. Factors such as ostomy formation and management strategy are not associated with increased morbidity or mortality after blunt colon trauma.

Experience with endoluminal colonic wall stents for the management of large bowel obstruction for benign and malignant disease.

HYPOTHESIS: To assess the applicability and efficacy of endoluminal colonic wall stents (ECWSs) in the management of large bowel obstruction (LBO). DESIGN: Inception cohort study. SETTING: University-based tertiary medical center. PATIENTS: Eleven consecutive patients with LBO in the absence of peritonitis. INTERVENTION: Placement of ECWS under endoscopic and fluoroscopic guidance. MAIN OUTCOME MEASURES: The success rate in ECWS placement, the efficacy in decompressing the obstruction, and the patency rate of the ECWS. RESULTS: Successful placement of ECWSs was obtainable in 10 of 11 patients. Once placed, all 10 patients achieved immediate decompression of their LBO. Eight patients had malignant obstructions associated with distant spread of disease; 3 patients had diverticular disease. Among those with malignant obstruction, 6 patients had successful and lasting palliation without colostomy, 1 patient underwent 1-stage resection 1 month later with no evidence of obstruction, and 1 patient could not be stented so diversion was done. None of the patients with diverticular disease required diversion: 2 had complete bowel preparation followed by resection with primary anastomosis, whereas the third declined surgery. Four of the 10 patients required overlapping ECWSs to bridge the stricture. One patient required a second ECWS secondary to recurrence of obstruction after stent migration and has continued palliation of his stage 4 rectal cancer for the last 11 months. No other complications were encountered. CONCLUSIONS: Urgent surgery with colostomy for LBO was avoided in 10 of 11 patients because of successful placement of ECWSs. We believe that endoscopic colonic stenting is safe, effective, and lasting, and should be considered as initial nonoperative management in all patients seen with LBO in the absence of peritonitis.

What is the normal aganglionic segment of anorectum in adults?

INTRODUCTION: Ultrashort-segment Hirschsprung's disease as a cause of obstructed defecation is controversial because of a lack of knowledge regarding the normal aganglionic zone of the distal rectum. The intent of this study was to define the normal aganglionic zone of the distal rectum through histologic review of cadaveric dissections. METHODS: Cadavers were obtained from the anatomic pathology laboratory at the University of Massachusetts Medical School. Strip myectomy with overlying mucosa was performed from distal to the dentate line to at least 3 cm into the anal canal and rectum after the pelvis was hemisected. Specimens were fixed in 10 percent buffered formalin. Specimens were sectioned serially every 3 mm and embedded in paraffin. Four-micron slices were then stained with hematoxylin and eosin. Each section was examined by a gastrointestinal pathologist. The presence or absence of nerves and ganglion cells was recorded. RESULTS: Thiry cadavers were obtained for analysis. Mean age at time of death was 79 (range, 65-97) years. There were 13 men. The mean distance of aganglionic bowel from the dentate line was 6.6 (range, 0-21) mm in Meissner's plexus and 5.1 (range, 0-15) mm in Auerbach's plexus. CONCLUSION: The normal distance of aganglionic bowel wall is 2 cm or less from the dentate line. The absence of ganglion cells proximal to this normal aganglionic zone in the patient with clinical findings of lifelong obstructed defecation defines ultrashort-segment Hirschsprung's disease.

Duodenal perforation caused by nasogastric intubation.

We present a case of duodenal perforation following nasogastric intubation. This complication has not been previously reported in adults.

Acute cholecystitis resulting from hemobilia after tru-cut biopsy: a case report and brief review of the literature.

Acute cholecystitis following hemobilia is very rare, with only five cases reported in the literature. A case report of a 22-year-old woman who underwent a liver biopsy for staging of Hodgkin's lymphoma and developed cholecystitis due to hemobilia is presented. The incidence of hemobilia has increased with the advent of more invasive hepatobiliary procedures, but the mortality has been decreasing due to better recognition and therapy. Acute cholecystitis associated with hemobilia is very rare, but will be seen with increasing frequency; and a high index of suspicion needs to be maintained to ensure timely diagnosis and treatment.

Fertility and sexual and gynecologic function after ileal pouch-anal anastomosis.

PURPOSE: This study was designed to determine the incidence of infertility, gynecologic problems, and sexual dysfunction after ileal pouch-anal anastomosis (IPAA). METHODS: A questionnaire was sent to 206 females who underwent pouch surgery at a single institution from 1980 through 1991. Response rate was 53 percent (110/206). The computerized registry of the 206 females undergoing IPAA at this institution was reviewed to add additional data. RESULTS: Mean age at pouch construction was 32 (range, 14-61) years. Mean time from pouch surgery to survey was 49 (range, 1-132) months. Fifty-seven females had 119 children before pouch surgery, and 23 children were born to 19 females after IPAA (5 vaginal deliveries, 18 Cesarean sections). Eighteen females experienced infertility after IPAA. Thirty patients had persistent dyspareunia. Pelvic cysts developed in 15 patients; 11 patients required surgery. CONCLUSIONS: Although childbirth appears safe, gynecologic problems, such as dyspareunia and formation of pelvic cysts, may be underestimated after IPAA. The effects of IPAA on fertility are still unknown.

Pseudomembranous colitis.

Pseudomembranous colitis is an inflammatory disease of the colon and rectum characterized by the development of elevated mucosal plaques. It usually is associated with antibiotic therapy and is caused by elaboration of toxin from the anaerobic bacterium, Clostridium difficile. The hallmark of treatment is orally administered vancomycin or metronidazole. The mortality rate is high in patients whose condition is not diagnosed and appropriately treated. Emergency surgery occasionally is needed for complications, including colonic perforation and toxic colitis.

Necrotizing enterocolitis in a neonatal piglet model.

The aim of this study was to develop an animal model for necrotizing enterocolitis (NEC). Twenty-five neonatal Hanford minipigs had carotid artery and external jugular vein catheters and rectal Clinical Tonomitors placed under anesthesia. Experimental animals were subjected to a hypoxic insult (50% reduction in baseline PaO2 for 30 minutes) and hypothermic stress (core temperature reduced to 35 degrees C for 30 minutes). Regular oral diet was resumed and the survivors were euthanized 3 to 4 days later. All animals underwent necropsy with gross and histopathological evaluation of the entire bowel. Of 22 experimental animals, 14 survived (64%) and 8 (36%) died of pulmonary hemorrhage. Of the 14 survivors, 8 (57%) had gross and microscopic evidence of NEC. Six of the total 25 animals (24%) sustained rectal perforations from the tonometer. Of 3 control animals, one died of pulmonary hemorrhage and the two survivors had normal intestine. This model successfully produced gross and histological evidence of NEC. The tonometer shows promise as a predictor of NEC provided technical modifications can reduce the complication rate.