[Dilatation enteroplasty for obstructive Crohn disease. Experience of the University of Montreal]. / L'entéroplastie d'élargissement pour maladie de Crohn obstructive. Expérience de l'Université de Montréal.

Multiple small bowel resections for obstructive symptoms caused by Crohn's disease can lead to a short bowel and malabsorption. Preservation of intestinal length is possible by the use of strictureplasty. Between August 1983 and March 1993, ninety strictureplasties were performed in 25 patients. They were 13 males and 12 females with a mean age of 37 years. Fourteen (56%) previously had small bowel resection for Crohn's disease. A mean number of 4.3 strictureplasties per patient were performed. Concomitant resection of bowel with active disease was performed in 18 patients (72%). In this series, no perioperative death occurred and one patient developed an enterocutaneous fistula. The overall complication rate was 8%. Postoperatively, 18 patients (72%) were completely relieved of symptoms, 6 were improved (24%) and one became worst (4%). After a 27 month follow-up period, the symptoms recurred in 13 patients (52%); three had no treatment, 7 had medical treatment and 3 required reoperation (12%). Our results support the safety and the use of strictureplasty for stenotic bowel lesions associated with Crohn's disease.

Toxic megacolon. An analysis of 70 cases.

The clinical features and outcome of 70 patients treated for toxic megacolon between 1970 and 1984 in five university-affiliated hospitals were determined. There were 35 women and 35 men with a mean age of 39 +/- 0.2 years. Toxic megacolon occurred at the initial episode of colitis in 43 patients (61 percent). Only five patients had a specific colitis: salmonellosis, two; ischemic, two; and pseudomembranous, one. Of the 65 remaining patients with nonspecific colitis, six had to be operated on without delay because of peritonitis. In the remaining 59 patients, toxic megacolon was cured with intensive medical management in nine (15 percent), improved temporarily in 14 (24 percent), and remained unchanged in 36 (61 percent). The postoperative mortality rate was 11 percent for all patients (6/56), 4 percent for patients without perforation (2/50) compared with 27 percent for patients with perforation (4/15). None of the patients who underwent surgery within five days of medical treatment died. When toxic megacolon was complicated by hemorrhage (nine patients) or peritonitis (eight patients), the mortality rate increased to 33 percent and 27 percent, respectively. A one-stage proctocolectomy was performed in 19 patients (32 percent). Of 32 patients in whom the rectum was retained, successful restoration of continuity was possible in only seven (22 percent) within 12 months after surgery. In well-selected patients, a plea is made for rectal preservation to offer an alternative to permanent ileostomy.

[Seat belt syndrome: a new abdominal pathology]. / Le syndrome de la ceinture de sécurité: une pathologie abdominale nouvelle.

Between January 1976 and December 1980, 43 patients involved in automobile accidents while wearing passive restraints were treated at l'Hôpital du Sacré-Coeur in Montreal. Thirty-seven showed signs of abdominal trauma and were operated upon. There was a strikingly high incidence of gastrointestinal injury. Thirty-two of the 37 had injury to the bowel or its mesentery. This spectrum of injury is most likely related to the rapid deceleration caused by the restraint with the three-point harness.

Changing trends with abdominal injury in seatbelt wearers.

Seatbelts were incorporated as standard equipment for automobiles constructed in North America in 1964. The first seatbelt law was made mandatory in Canada as of 1 January 1971. Between January 1976 and January 1980 38 patients involved in automobile accidents while wearing passive restraints were treated at l'Hôpital du Sacré-Coeur: 32 of these 38 patients had signs and symptoms of abdominal injury. These patients wearing passive restraints had an unusually high incidence of gastrointestinal injury in comparison to previously reported patients not wearing restraints. Twenty-seven of the 32 patients had injury to the bowel or the bowel mesentery. This different spectrum of injuries is most likely related to the altered physics of rapid deceleration caused by restraint with the lap belt and shoulder harness.

Importance of the serum amylase level in patients with blunt abdominal trauma.

Possible intra-abdominal injuries were sought in 101 patients admitted with blunt abdominal trauma. The serum amylase level was measured in the first 12 hours after the accident. Twenty-five patients had hyperamylasemia; 18 underwent laparotomy and 7 were treated conservatively. At laparotomy all 18 patients exhibited at least one serious intra-abdominal lesion, and there was a total of 28 lesions in the who group (including only four pancreatic injuries). The mean value of the serum amylase for those who had laparotomy was 1190 IU, while it was only 363 IU for those not operated upon. The authors conclude that hyperamylasemia in blunt abdominal trauma is not specific to pancreatic injury, but may suggest the presence of a serious intra-abdominal lesion.

Resection and primary anastomosis for diverticulitis with perforation and peritonitis.

Primary resection is the treatment of choice for diverticulitis of the colon with perforation and generalized peritonitis. Although there has been controversy concerning the management of the bowel ends after resection, for the last 20 years immediate anastomosis has been gaining increasing support. Between 1970 and 1981, at the Hôpital du Sacré-Coeur in Montreal, 15 patients having diverticulitis with perforation and diffuse spreading peritonitis who fulfilled specific criteria were treated by primary resection of the perforated segment of bowel and immediate anastomosis. The criteria for operation were : (a) the bowel must not be distended; (b) the bowel should be empty of feces; (c) edema of bowel wall at the resection site must be minimal; (d) the distal segment of colon should be above the peritoneal reflection; (e) there should be no fecal contamination; (f) the patient's general condition should be reasonably good. If these criteria were met, the procedure was safe and gave satisfactory results. In the authors' series, postoperative hospital stay was reduced considerably (it averaged 11 days). There was one anastomotic pulmonary edema.

Benign solid teratoma of the ovary with rupture into the rectum.

The authors present an unusual case of benign, solid, complex teratoma of the ovary with rupture into the rectum. A young woman, investigated for bowel problems, was found to have a prolapsing tumour in the upper rectum. A diagnosis of benign solid teratoma of the ovary was made by histologic examination of the surgical specimen; the tumour had perforated the rectal wall and protruded into the bowel lumen, a most unusual complication for this type of tumour. Pararectal teratomas can arise from either the ovaries or the soft tissues of the sacrococcygeal region. The latter do, on rare occasions, perforate the rectum. The possible mechanisms of rectal perforation by these teratomas are briefly discussed.

Primary adenoid cystic carcinoma of the esophagus.

Primary adenoid cystic carcinoma or cylindroma of the esophagus is rare, only 22 cases having been reported previously. The histogenesis of this tumour is disputed, but it is believed to arise from the submucosal glands. A 75-year-old man with a cylindroma of the esophagus underwent radical excision of the tumour and has been clinically disease-free and asymptomatic since his operation in February 1979. Despite the poor results of surgery in the small number of patients reported in the literature, this unusual type of adenocarcinoma of the esophagus should be treated like epidermoid carcinoma--by radical excision.

Teflon felt for closure of the pelvic floor after abdominoperineal excision of the rectum.

Teflon felt has been used in ten patients without complications or delay in healing, as a satisfactory means of closing a large gap in the peritoneal floor after abdominoperineal excision of the rectum. The technique is described.