Management of uncomplicated acute diverticulitis: results of a survey.

PURPOSE: A survey was conducted to document current medical treatment of patients with uncomplicated acute diverticulitis. METHODS: A survey was mailed to 667 fellows of The American Society of Colon and Rectal Surgeons certified by the American Board of Colon and Rectal Surgery. Queries were based on a clinical scenario of a patient with uncomplicated diverticulitis. RESULTS: Three hundred seventy-three surveys (56 percent) were returned completed. The majority (66 percent) chose an abdominal computed tomographic scan as the initial diagnostic test. One-half used a single intravenous antibiotic with second-generation cephalosporins (27 percent) and ampicillin/sulbactam (16 percent) being the most common. Oral antibiotics given at discharge were ciprofloxacin (18 percent), amoxicillin/clavulanate (14 percent), metronidazole (7 percent), and doxycycline (6 percent). Combinations chosen were ciprofloxacin/metronidazole (28 percent) and metronidazole/trimethoprim sulfamethoxazole (6 percent), whereas 21 percent chose a variety of other antibiotics. The majority (74 percent) prescribed oral antibiotics for 7 to 10 days. Dietary recommendations at discharge were low residue (68 percent), regular (21 percent), and high residue (10 percent). Half of those surveyed believed avoidance of seeds and nuts were of no value. Follow-up examinations chosen included sigmoidoscopy and barium enema (29 percent), colonoscopy (25 percent), sigmoidoscopy (17 percent), barium enema (13 percent), and other (16 percent). Sixty-five percent of colon and rectal surgeons claim to handle more than half of their patients with uncomplicated diverticulitis on an outpatient basis. CONCLUSION: Variations in the management of uncomplicated sigmoid diverticulitis are noted among colon and rectal surgeons, especially in terms of antibiotic choice, discharge instructions, and follow-up outpatient studies. The survey results are compared with the conclusions reached in The American Society of Colon and Rectal Surgeons practice parameters. Documentation of practice pattern variation may serve as an educational tool for physicians to improve their quality and cost of medical care. Consideration should be given to better publicize already existing American Society of Colon and Rectal Surgeons practice parameters for this common entity.

Presacral cysts: transrectal excision in select patients.

Fourteen patients presenting with presacral cystic lesions were managed over a 20-year period. Retrospective review identified 12 females and 2 males. Fifty-seven per cent were symptomatic at diagnosis. Forty-three per cent presented with pain; half of these patients had infected cysts. All lesions were palpable on digital rectal exam. Computed tomography identified the cyst in all seven patients in which it was performed. The transrectal approach was used for cyst excision in ten patients. One patient had transrectal drainage and wall biopsy only. Three patients underwent posterior parasacral excision. Pathologic review demonstrated four dermoid cysts, four epidermoid cysts, four cyst hamartomas, and two benign teratomas. One cyst hamartoma had a focus of invasive adenocarcinoma. Two complications occurred. There were no deaths. Follow-up averaged 39 months, at which time there were no recurrences. Developmental cysts are the most common presacral tumors. Excision is recommended, and the transrectal approach may be used in select patients with low morbidity and minimal recurrence.

Reappraisal of partial lateral internal sphincterotomy.

PURPOSE: The aim of this study was to delineate the results, mortality, and morbidity of partial lateral internal sphincterotomy for the treatment of chronic anal fissure. METHOD: A retrospective review of 500 patients undergoing partial lateral internal sphincterotomy for chronic anal fissure between 1980 and 1990 was performed. Patients were identified by a review of an office surgical ledger and included all patients whose diagnosis was anal fissure and for whom a partial lateral internal sphincterotomy was performed as treatment. RESULTS: Over an average follow-up of 5.6 years, only 1 percent of patients failed to health their fissures after performance of this operation. Minor complications included pain, pruritus, wound abscess, discharge, delayed healing, bleeding, fecal impaction, minor incontinence, and urgency and were present in 16 percent of patients, postoperatively. Two percent of patients who initially healed their fissures suffered a recurrence. Complication rates in open vs. closed sphincterotomy were 15 percent vs. 8 percent (P < 0.01). Disorders of fecal continence occurred in 8 percent of patients over the long term. CONCLUSION: Extended follow-up after partial lateral internal sphincterotomy demonstrates a higher complication rate than was seen in patients being followed for shorter periods. However, the complication of impaired fecal continence only occurred in 8 percent of our patients, compared with 15 percent reported in the current literature, although using the same evaluative criteria. Patient satisfaction with the results of surgery was 98 percent. Careful patient selection, absence of preoperative continence problems, and meticulous surgical techniques are necessary to achieve this type of result.

Computerized tomographic scan-guided drainage of intra-abdominal abscesses. Preoperative and postoperative modalities in colon and rectal surgery.

PURPOSE: Computerized tomographic (CT) scan-guided percutaneous drainage of intra-abdominal abscesses has changed the colon and rectal surgeon's approach to preoperative and postoperative intra-abdominal infections. This study is an effort to prove the efficacy of CT scan-guided percutaneous drainage. METHODS: A retrospective study was performed on 133 patients who underwent CT scan drainage of intra-abdominal abscesses over a 6.3-year period. RESULTS: 67 patients had underlying lower gastrointestinal disease. Twenty-three of these patients (34 percent) had spontaneous abscesses and underwent drainage as a preoperative or final modality, whereas 44 patients (66 percent) were drained postoperatively. In 78 percent of patients, surgery was successfully avoided or delayed. Ten patients had acute diverticulitis associated with a large pelvic abscess. Eight patients underwent successful CT scan-guided percutaneous drainage, yielding an 80 percent success rate. Morbidity from the CT scan-guided percutaneous drainage procedure in spontaneous and postoperative groups was 0 percent and 9 percent, respectively. Mortality was 9 percent and 11 percent, respectively, and associated with an elevated Acute Physiology and Chronic Health Evaluation II (APACHE II) score. CONCLUSION: CT scan-guided percutaneous drainage of intra-abdominal abscesses is an important adjunct to colon and rectal surgery because roughly 80 percent of spontaneous and postoperative abscesses were successfully managed.

Simple method for polyp retrieval during colonoscopy.

Retrieval of small polyps can often be frustrating for the skilled endoscopist. We introduce a technique of polyp retrieval that is simple and effective in yielding intact specimens for accurate pathologic examination.

Delorme's procedure for complete rectal prolapse in severely debilitated patients. An analysis of 41 cases.

PURPOSE: This study was designed to assess the results of a minimally invasive surgical procedure for the correction of complete rectal prolapse in a poor surgical risk group. METHODS: Over a ten-year period, 40 patients underwent 41 Delorme operations when advanced age and/or poor overall health mitigated against an abdominal approach. Mean age was 82 (range, 30-100) years. Eighty-eight percent were females. Surgery was performed in the prone jackknife position utilizing intravenous sedation and local anesthesia. RESULTS: Follow-up ranges from 1 year to 2 years (mean, 47 months). There have been 9 recurrences in 8 patients (22 percent). Mean time to recurrence was 13 months (range, 1 month to 6 years). One death occurred in an 81-year-old patient within 24 hours of surgery from cardiopulmonary arrest. Minor complications occurred in 25 percent of patients. CONCLUSION: Satisfactory prolapse repair was safely performed in 78 percent of this high-risk group. Pitfalls in performing this procedure relate primarily to associated perineal and colonic conditions. Most prominent among these conditions are weak or absent and sphincter tone, perineal descent, and previous sphincter injury. Extensive diverticular disease may prohibit effective and complete proximal mucosectomy. An inadequate mucosectomy sets the stage for early recurrence of prolapse.

Is preoperative computerized tomography useful in assessing patients with colorectal carcinoma?

PURPOSE: Controversy exists over the appropriate preoperative evaluation of colorectal cancer patients. Most surgeons agree that basic laboratory studies are indicated. Computerized tomography of the abdomen and pelvis has been used in our practice to augment the preoperative evaluation of these patients. METHODS: One hundred fifty-eight consecutive patients with primary colorectal carcinoma underwent computerized tomography (CT) of the abdomen as part of their preoperative evaluation. Their medical records were retrospectively reviewed. RESULTS: In 88 patients, 120 findings present on CT were otherwise unknown. Of these, 35 percent were clinically significant in that they allowed the surgeon to alter the proposed operative procedure or added additional technical information for consideration preoperatively. Findings include liver metastasis (26), atrophic kidney (3), and abdominal wall or contiguous organ invasion (11). In addition, two other solid organ carcinomas were detected. In the remaining 70 patients, CT contributed no additional pertinent information about the patient prior to this initial operative procedure. CONCLUSIONS: CT aids in the preoperative evaluation of individuals with colorectal carcinoma. It provides important clinical information that is useful to the surgeon planning the procedure. Additionally, CT permits the patient and his family to be aware of their overall status and to subsequent treatment options. Computerized tomography eliminates the need for preoperative intravenous pyelogram, improves the preoperative staging for metastatic disease, and provides a baseline for comparison during the postoperative follow-up period should recurrence be suspected or adjuvant therapy be planned.

Computed tomography in the initial management of acute left-sided diverticulitis.

Computed tomography (CT) was used in place of contrast enemas as the initial imaging study to evaluate patients with the clinical diagnosis of acute sigmoid diverticulitis. This report attempts to clarify the role of CT in the management of acute sigmoid diverticulitis by reviewing its usefulness in the diagnosis and treatment of 59 patients. CT established that three patients (5 percent) were hospitalized with an incorrect clinical diagnosis. Thirty-seven patients (62.7 percent) were identified as having uncomplicated acute diverticulitis. These patients were all treated successfully with nonsurgical therapies and were discharged in an average of 6.8 days. In the remaining 19 patients (32.2 percent), CT revealed complicated acute diverticulitis by identifying abscess, fistula, peritonitis, or obstruction. Eleven of these 19 patients required urgent surgery or CT-guided percutaneous drainage of an abscess. The four patients whose abscesses were drained percutaneously responded favorably and underwent an elective single-stage resection. The average hospital stay for patients with complicated diverticulitis was 13.6 days. Computed tomography is a useful aid in the initial management of patients with acute diverticulitis. It is a noninvasive test that recognizes and stratifies patients according to the severity of their disease. It has the further advantage of providing information about extracolonic pathology and anatomic variation useful for surgical planning. Additionally, early CT-guided needle drainage allowed downstaging of complicated diverticulitis, avoided emergent surgery, and permitted single-stage elective surgical resection.

Electrocoagulation for adenocarcinoma of the low rectum.

Cancers of the distal rectum (less than 7.5 cm from the anal verge) that are freely mobile, moderately well or well differentiated, less than 4 cm in size, limited to the bowel wall, and without evidence of metastasis should be considered candidates for treatment with electrocoagulation for cure. Tumor cell ploidy and evaluation with intrarectal ultrasound may in the future add additional useful information with regard to patient selection. Electrocoagulation and laser ablation of tumors may also be useful modalities for palliation of patients with metastatic disease or who are not candidates for curative surgery.

Anterior perineal sinus.

Each year we treat several patients with an anterior perineal sinus tract. They do not conform to commonly encountered perineal problems such as pilonidal disease, epidermal cysts, hidradenitis, fistulous abscess, or inflammatory bowel disease. In an effort to improve understanding of the problem and its clinical significance, we reviewed our practice records for the period from 1968 through 1988. Fifty-six patients underwent surgery for an anterior perineal sinus tract. In 31 patients, the clinical and pathologic condition defied classical diagnostic categorization. We have termed these lesions "anterior perineal sinuses." Their clinical characteristics, treatment, and pathologic assessment from the body of this report. Male predominance (87 percent) and midlife presentation (average age, 44 years) characterized this group. Local symptoms were present from several weeks to several years prior to treatment. Local anesthesia (74 percent) and limited surgery (100 percent) resulted in complete healing in all patients (average, 7 weeks). A 15 percent recurrence rate was noted. The pathologic evaluation demonstrated acute and chronic dermal and subcutaneous inflammation. The etiology of this process remains uncertain. Its predominance along the median raphe suggests a congenital midline inclusion disorder.

Seton management of complex anorectal fistulas in patients with Crohn's disease.

Anorectal fistulas associated with Crohn's disease are difficult to manage, particularly when the rectum is diseased. Significant morbidity has been associated with both medical and surgical therapy. Although conventional therapy is acceptable in the management of simple fistulas in Crohn's disease, these approaches often exacerbate rather than ameliorate problems in patients with complex fistulas. The authors report ten cases of complex fistulas in patients with Crohn's disease managed with their technique of long-term, indwelling setons. These setons are placed through the fistula tract and tied loosely to maintain the patency of the fistula without cutting through the sphincters. At the time of insertion, although abscesses are incised and drained, no attempt is made to divide the superficial tissues or sphincter overlying the fistulous tract. The patients ranged in age from 23 to 81 years and had a history of Crohn's disease for 1 to 20 years. All cases resulted in excellent palliation. No patient required a proximal colostomy. These patient have been followed for four months to seven years. Despite severe proctitis in six of these patients at the initial operation, no patient has required a proctectomy. The authors believe this technique achieves adequate palliation and should be employed as the procedure of choice in patients with complex anal fistulas associated with Crohn's disease.

New method for low transection of the rectum.

A method for low transection of the rectum within a narrow pelvis is described using the new GIA 90 autosuture instrument.

Complications of colostomies.

One hundred twenty-six patients underwent 130 end colostomies, 44 for benign and 86 for malignant disease, and were followed for an average of 35 months. The left or sigmoid colon was used in 99 and the transverse colon in 31. Stomas were made electively in 98 patients and urgently in 32. Seventy-six stomas were brought out through the incision and 54 from separate sites. There were 69 complications in 55 patients (44 percent) including 11 strictures, 9 wound infections, 14 hernias, 9 small-bowel obstructions, 4 prolapses, 2 abscesses, 1 peristomal fistula, 17 skin erosions, and 2 poor stoma locations. Fifteen complications required reoperation. Five of these procedures included stoma revision. Total numbers of complications were not related to the stoma site, the disease process, the urgency of the procedure, or the segment of colon used. Wound infections, however, were increased in urgently made stomas. The incidence of hernia was equivalent in stomas brought out through the incision or at a separate site. Forty-one patients (30 percent) had 43 colostomies closed an average of 3.5 months after creation. Thirteen patients had 14 complications--5 wound infections, 6 hernias, 2 small-bowel obstructions, and 1 rectovaginal fistula. One patient died. Four patients required reoperation. There were no anastomotic leaks. Complications were equivalent in Hartmann closures and transverse colostomy closures. Complications were similar in stomas created for cancer and those created for diverticular disease.

Value of subcutaneous and intraperitoneal antibiotics in reducing infection in clean contaminated operations of the colon.

A prospective study of 443 patients undergoing clean contaminated operations of the colon was undertaken to determine the efficacy of subcutaneous and intraperitoneal antibiotics in reducing infection. All of the patients received a mechanical intestinal preparation as well as preoperative antibiotics taken orally and preoperative and postoperative antibiotics administered intravenously. The over-all wound infection rate was 2 per cent. The routine additional use of subcutaneous or intraperitoneal antibiotics had no proved efficacy in this study.

Electrocoagulation of selected carcinoma of the rectum.

Abdominoperineal resection for the treatment of carcinoma of the rectum has been the benchmark for all other forms of therapy since Miles described the procedure in 1908. During the past 25 years, 81 patients have had carcinoma of the rectum treated curatively by electrocoagulation and have been observed for five years or more. Treatment was selectively applied to those patients whose tumors were less than 7.5 centimeters from the anal verge with less than 50 per cent of the rectum involved. All of the tumors were freely movable. The over-all five year survival rate was 47 per cent. Thirty-one of the 81 patients underwent conversion to abdominoperineal resection because of recurrence. The survival rate for those treated by electrocoagulation alone was 58 per cent and for those converted to abdominoperineal resection, 29 per cent. The survival rate was 65 per cent for those with lesions less than 4 centimeters in diameter versus 30 per cent for those with lesions more than 4 centimeters. The morbidity rate was 21.0 per cent and the mortality rate was 2.7 per cent. There were an additional 33 patients treated for palliation with only one five year survivor. Electrocoagulation for the treatment of carcinoma of the distal part of the rectum is a reasonable alterative to abdominoperineal resection when selectively applied.

Is preoperative colonoscopy necessary in carcinoma of the colon and rectum?

The incidence of synchronous polyps of the colon has been shown to be 25 to 40 per cent and the incidence of synchronous carcinomas to be two to eight per cent. Because of this, many surgical groups now advocate routine preoperative colonoscopy on all patients with colon carcinoma. The possibility of spreading and implanting tumor cells with the colonoscope has prompted the authors to purposely avoid preoperative colonoscopy and then clear the colon of any missed lesions with an early postoperative colonoscopy. This study is a retrospective review of 104 patients who have undergone a partial colectomy for colon and rectal carcinoma followed by a postoperative colonoscopy between June 1982 and June 1986. The purpose is to determine the adequacy of intraoperative palpation to detect synchronous neoplasms, and to further define the role of perioperative colonoscopy. The results of 34 per cent synchronous polyps and 5.8 per cent synchronous carcinomas parallels previous studies. The six patients with synchronous carcinomas were discovered by intraoperative palpation and the operation was modified in four of the six patients. Postoperative colonoscopy revealed polyps in 20 per cent of the patients, but all of these were amenable to snare polypectomy or electrocoagulation. No carcinomas were overlooked by palpation. It is our conclusion that intraoperative palpation is adequate for detection of synchronous carcinomas and therefore the risk and expense of preoperative colonoscopy can be avoided. Early postoperative colonoscopy, however, is imperative to clear the colon of small polyps which have the potential to progress to carcinoma.

The role of nasointestinal intubation in elective colonic surgery.

One hundred thirty-eight consecutive patients undergoing elective colonic resections were treated prospectively and randomly with either a long intestinal (Cantor) tube preoperatively, a nasogastric tube placed intraoperatively, or no gastrointestinal tube at all. Patients were evaluated for length of hospital stay, duration of postoperative ileus, adequacy of intraoperative intestinal decompression, gastric dilatation, and operative complications. No significant difference could be seen in the tubed or no-tube group.

Tube cecostomy with cecal extraperitonealization in the management of obstructing left sided carcinoma of the large intestine.

The technique of tube cecostomy has enabled us to manage safely and expeditiously patients with obstruction of the large intestine secondary to left sided carcinoma. Extraperitonealization of the cecum and insertion of a large bore catheter are each critical to the success of this modality.

Electrogalvanic stimulation in the treatment of levator syndrome.

The records of 102 patients with levator syndrome were reviewed. All had failed trials of conservative management prior to treatments with electrogalvanic stimulation. The symptoms of 12 patients were subsequently found not to be due to levator syndrome. Of 90 patients with correct diagnoses, 77 percent were relieved or improved after courses of electrogalvanic stimulation, a valuable adjunct to the management of this frustrating condition.