Benefit of emergency haemorrhoidectomy: a comparison with results after elective operations.

OBJECTIVE: To compare the outcome of emergency and elective haemorrhoidectomy. DESIGN: Retrospective study. SETTING: Teaching hospital, Belgium. SUBJECT: 104 patients who had haemorrhoidectomy for acutely ulcerated or strangulated haemorrhoids, and 545 who had elective haemorrhoidectomy. RESULTS: Early complications (26/104, 25%), reoperation (7/104, 7%) and late anal stenosis (7/104, 7%) were more common after emergency than elective haemorrhoidectomy, for which the corresponding figures were 74/545 (3.6%), 9 (1.7%) and 1/545 (0.2%). Late outcome was similar for the two groups. CONCLUSIONS: Emergency haemorrhoidectomy is indicated for the treatment of the acute complications of haemorrhoids.

Isolated colonic injury following blunt abdominal trauma.

A case of delayed diagnosis of colonic injury after blunt abdominal trauma leading to faecal peritonitis is presented. Diagnostic problems and possibilities as well as treatment of these injuries are reviewed. The key to diagnosis remains the serial clinical and ultrasound examinations.

Functional results after total gastrectomy with enteric pouch reconstruction. A review of 34 cases.

34 patients with gastric carcinoma, treated by total gastrectomy, had a reconstruction procedure, consisting of a pouch as proposed by Lygidakis or as a variant of the procedure: the beta-modification. In 31 patients a total gastrectomy was performed for histologically proven gastric adenocarcinoma. Two patients presented with a gastric lymphoma and one with a gastric leiomyosarcoma. Operative mortality was 8.8%. Two patients (5.8%) developed leakage of the oesophago-enteral anastomosis and subsequently died from sepsis, while a third patient died from a postoperative pneumonia. Early complications occurred in 4 patients and consisted of dysphagia, due to stenosis of the oesophago-enteric anastomosis. All 4 patients (12.9%) were treated with endoscopic dilatation and were cured of their dysphagia. One patient developed a late peptic ulcer at the pouch anastomosis and needed a reintervention. Nine patients died from extension of their primary disease within the first postoperative year. The 22 surviving patients are all without symptoms and regained their pre-illness weight. In conclusion, the proposed technique of pouch reconstruction has an acceptable operative mortality and morbidity comparable to or even better than in previously described methods. The long term functional results are better and more patients gain weight.

The Hartmann procedure revisited.

The results of 37 consecutive cases of Hartmann's procedure over a 5-year period (1985-1990) were reviewed. The series consisted of 27 emergency procedures (11 diverticular disease, 13 carcinoma, two trauma and one sigmoid volvulus) and ten elective procedures (nine carcinoma and one peridiverticular abscess). The indications for emergency procedures were obstruction and perforation. All patients presented with faecal peritonitis owing to colonic perforation. The mean (range) age was 79.4 (34-90) years. The postoperative mortality rate was 30 per cent overall (11 of 37), 33 per cent (four of 12) in the diverticulitis group, 23 per cent (five of 22) in the carcinoma group, and 100 per cent in the iatrogenic trauma group. Death was mainly due to sepsis (82 per cent). Postoperative complications were mainly wound infections, which occurred in 43 per cent (16 of 37) cases. In 25 per cent of the surviving patients, re-establishment of continuity was performed in three of 17 (18 per cent) of the carcinoma group and three of seven (43 per cent) of the diverticulitis group. No attempt at restoration of intestinal continuity was made in six cases due to medical risk in two, extensive carcinoma in two and local recurrence with metastatic disease in two. Three patients refused all further intervention. There were no postoperative deaths after the restoration of continuity. This series reflects the severity of the pathology in this high risk group of patients. However, the operation can be life-saving for a selected group of patients and offers good palliation for advanced colorectal tumours.

Selective rupture of the Wirsung duct: a rare form of pancreatic trauma.

A patient with a traumatic pancreatic lesion, confined to the Wirsung duct, is presented. At first laparotomy, the diagnosis was missed. Posttraumatic acute pancreatitis led to endoscopic pancreatography, disclosing the exact localization of the lesion. Left pancreatectomy led to rapid recovery. A late postoperative pancreatic fistula healed without problems.

Effect of cisapride on the post-cholecystectomy upper gastrointestinal transit time.

For the evaluation of postoperative upper gastrointestinal transit, the breath hydrogen test is a convenient method, which is simple but more reliable than the recording of clinical parameters such as bowel sounds. The test was used to study the effect of cisapride on the postoperative mouth-to-caecum transit time. Twenty patients undergoing cholecystectomy were tested pre-operatively and on the first postoperative day after having received either 10 mg of cisapride i.v. or matching placebo under double-blind conditions. The median preoperative transit time in the placebo group was 45 min, and the median postoperative transit time at least 3 h longer. The postoperative transit time after cisapride dosing was still longer than before the operation but was significantly (p = 0.02) reduced as compared with that after placebo administration.

Upper gastrointestinal bleeding due to benign tumours of the stomach.

Benign tumours of the stomach are usually asymptomatic and are discovered incidentally during radiology, endoscopy or pathological examination. In some cases, however, these tumours produce overt clinical symptoms. The authors report eight patients with significant upper gastrointestinal bleeding due to benign gastric tumours, who required surgical resection of their lesion. Histologically, the growths proved to be leiomyoma in five cases, polyps in two and lipoma in one. Surgical treatment consisted in local excision in three patients and subtotal gastrectomy in five patients. Bleeding was stopped in all cases and there was no operative mortality.

[Treatment of anal fistulas]. / De behandeling van anale fistels.

It is generally accepted that laying-open constitutes the only effective cure for anal fistulae. The sacrifice of at least some part of the anal sphincter apparatus is therefore the inevitable consequence of every operation for fistula. In the case of an intersphincteric or low-trans-sphincteric fistula, only the internal sphincter or the lower half of the external sphincter need to be incised. This may usually be performed without endangering postoperative faecal continence. High trans-sphincteric or suprasphincteric fistulae, however, involve the entire external sphincter and/or the puborectalis muscle. Straightforward trans-section of these sphincters would lead to faecal incontinence. For this reason such high fistulae should be progressively laid open in staged procedures, after encircling the sphincters for some weeks with a seton. The same procedure should also be employed for complex horseshoe-shaped fistulae. Contrary to traditional teaching, anal fistulae in Crohn's disease are no exception to these general therapeutic guidelines. Finally, exploration for an underlying fistula and, if possible, immediate fistulotomy are advocated for all patients with an acute perianal abscess.

Single-dose parenteral antibiotic prophylaxis in gastrointestinal surgery.

In the course of two consecutive, double-blind and prospective studies, the authors evaluated the prophylactic effect of a single peroperative intravenous dose of gentamicin (this study included 166 patients) or the combination gentamicin and clindamycin (this study included 127 patients), on the wound infection rate following interventions involving the incision of an abdominal hollow viscus. Antibiotic prophylaxis lowered the post-operative wound sepsis rate, especially following clinically contaminated interventions, but this reduction did not reach statistical significance. It is concluded that a single peroperative parenteral dose of antibiotics does not constitute an entirely satisfactory means of wound infection prophylaxis in digestive surgery.

The effect of Lord's procedure on anal pressure.

In this study, the authors recorded pre- and postoperative anal resting pressures in 28 patients with hemorrhoidal disease and in 32 controls. No significant difference was found between these two groups preoperatively. In the patient population anal pressure was significantly lowered following Lord's anal dilation treatment. No such pressure reduction was recorded after a standard St. Mark's hemorrhoidectomy. Finally, the authors confirm that anal pressure measurements record only the tonus of the sphincter apparatus and are not influenced by the volume of the hemorrhoidal masses themselves.

[Our experience of the Vest-Margulis test in the differential diagnosis of mechanical and paralytic ileus (author's transl)]. / Onze ervaring met de test van Vest-Margulis bij de differentiële diagnose tussen mechanische en paralitische ileus.

In order to evaluate the Vest-Margulis test in the differential diagnosis between mechanical and paralytic ileus a retrospective study was undertaken on 51 such tests performed before and after operation. Transit of gastrografin (Sodium amidotrizoate) through the caecum 4 hours after ingestion was controlled through roentgenograms. The diagnostic value of a positive test in pure paralytic ileus can be confirmed. Indeed 23 positive cases proved to have paralytic rather than mechanical ileus. On the contrary a negative test has no diagnostic value. Twenty-eight patients in which the contrast medium had not reached the caecum within 4 hours had either form of intestinal obstruction. The attention is drawn on the interesting therapeutic action of gastrografin in patients with a paralytic ileus and the simplicity of the investigation.