Influence of erythropoietin on transfusion requirements in patients receiving preoperative chemoradiotherapy for rectal cancer.

PURPOSE: Perioperative homologous blood transfusion has been suggested to have an adverse effect on survival in patients undergoing resection of colorectal cancers. Preoperative therapy is being increasingly used for rectal cancer patients and has an adverse effect on erythropoietic capacity. The objectives of this study were to evaluate the feasibility and safety of administration of recombinant human erythropoietin to patients receiving preoperative therapy for rectal cancer and to assess the impact of such treatment on blood transfusion requirements. METHODS: The study was an open-label, Phase I and II, nonrandomized, two-center trial. All patients received 50.4 Gy of irradiation with 5-fluorouracil infusions. Ten patients diagnosed with rectal cancer received 250 U/kg of recombinant human erythropoietin subcutaneously three times per week during preoperative radiation and chemotherapy. Oral iron was given to patients receiving erythropoietin. Ten contemporaneously treated patients who received both radiation and chemotherapy were used as controls. RESULTS: Of the 20 patients 13 were males; mean age was 64 years. Surgical procedures that patients underwent were abdominoperineal resection (14 patients), low anterior resection (4 patients), coloanal anastomosis (1 patient), or none (1 patient). There were no significant differences between groups in age, gender, stage or hemoglobin levels before therapy. No adverse reactions to erythropoietin were encountered. Hemoglobin levels were significantly higher in the treatment group during Weeks 1, 3, and 5 (P < 0.02 for each). Transfusion requirements were significantly decreased in patients who received erythropoietin (0.4 vs. 3.7 units; P < 0.0003). CONCLUSIONS: The data showed that use of erythropoietin during preoperative therapy can prevent the decline in hemoglobin that commonly occurs during therapy. Further, this was not associated with adverse events and significantly decreased the need for perioperative blood transfusions. This suggests that the use of erythropoietin in support of a preoperative chemoradiotherapy regimen for patients with rectal cancer is safe and should be considered. Whether such transfusion avoidance will translate into a survival benefit in this setting will require a large, prospective, clinical trial.

Management of recurrent rectal prolapse.

PURPOSE: Many operations have been described for the management of rectal prolapse. Despite an overall recurrence rate of greater than 15 percent, few reviews address how to deal with this problem. This report summarizes our experience with recurrent rectal prolapse and includes suggestions for reoperative management of failed repairs from both abdominal and perineal approaches. PATIENTS AND METHODS: Fourteen patients (3 male) ranging in age from 22 to 92 (mean, 68) years underwent operative correction of recurrent rectal prolapse. Average time from initial operation to recurrence was 14 (range, 6-60) months. Initial operations (before recurrence) were as follows: perineal proctectomy and levatorplasty (10), anal encirclement (2), Delorme's procedure (1), and anterior resection (1). Operative procedures performed for recurrence were as follows: perineal proctectomy and levatorplasty (7), sacral rectopexy (abdominal approach; 3), anterior resection with rectopexy (2), Delorme's procedure (1), and anal encirclement (1). Average length of follow-up was 50 (range, 9-115) months. RESULTS: No further episodes of complete rectal prolapse were observed during this period. Preoperatively, three patients were noted to be incontinent to the extent that necessitated the use of perineal pads. The reoperative procedures failed to restore fecal continence in any of these three individuals. One patient died in the postoperative period after anal encirclement from an unrelated cause. CONCLUSION: Surgical management of recurrent rectal prolapse can be expected to alleviate the prolapse, but not necessarily fecal incontinence. Perineal proctectomies can be safely repeated. Resectional procedures may result in an ischemic segment between two anastomoses, unless the surgeon can resect a previous anastomosis in the repeat procedure. Nonresectional procedures such as the Delorme's procedure should be strongly considered in the management of recurrent rectal prolapse if a resectional procedure was performed initially and failed.

Purtscher's retinopathy: a case of visual impairment associated with multiple trauma.

This case study describes a patient with multiple trauma associated with acute visual impairment. Funduscopic examination revealed scattered and confluent cotton wool exudates bilaterally. This retinopathy was first described by Othmar Purtscher, an Austrian ophthalmologist, in 1910, which he later referred to as "angiopathia retinae traumatica."

Penicillinase-producing Neisseria gonorrhoeae in a subset of nonemergent patients: I. A trend in the Washington, DC area.

A significant increase in penicillinase-producing isolates of Neisseria gonorrhoeae has been detected and documented in the District of Columbia. Currently, the prevalence of beta-lactamase isolates is approaching 50%, with the greatest number of cases being detected in the 18- to 23-year-old age group, in both males and females. Indicators suggest that this trend, which was first noted in 1987, will become more pronounced in the future. Ceftriaxone is now the first-line drug of choice in treating suspected gonococcal infections.

Isoniazid toxicity presenting as seizures and metabolic acidosis.

The presenting signs and symptoms of isoniazid toxicity are discussed, with a review of the complications and management of this metabolic encephalopathy with B6 pyridoxine. This study supports previous studies in finding that ingestion of more than 80 mg/kg body weight produces severe central nervous system symptoms that are rapidly reversed with intravenous administration of pyridoxine.

Septic complications of hemorrhoidal banding.

Rubber band ligation is an efficacious and cost-effective alternative to conventional hemorrhoidectomy for symptomatic internal hemorrhoids. Even though the well-recognized complications of bleeding and thrombosis occur infrequently, far more serious septic complications have only recently been described, as evidenced in five of our patients: four cases were serious enough to necessitate surgical intervention, and one patient died. Pain followed by urinary dysfunction with or without toxic symptoms should alert the physician to the probability of localized perianal or systemic sepsis. Acute awareness of these rare but potentially life-threatening complications and immediate aggressive treatment is mandatory if death is to be prevented. Rubber band ligation of internal hemorrhoids need not be abandoned; however, the indications should be clear, the technique mastered, and a close patient follow-up maintained.

York Mason procedure for repair of postoperative rectoprostatic urethral fistula.

Rectoprostatic fistula is a rare complication after transurethral resection of the prostate or prostatectomy for benign and malignant neoplasms of the prostate. Repair of these fistulas is difficult, especially when previous treatment includes radiation therapy to the prostate. Various operative approaches have been described to close these inaccessible fistulas. Because of their location near the outlet of the pelvis, access to or exposure of these fistulas is quite limited. These fistulas can be easily exposed and repaired through the posterior wall of the rectum (transsphincteric approach). Three patients with rectoprostatic urethral fistulas were repaired successfully by using this method.

Colorectal linitis plastica.

Primary linitis plastica of the colon is an uncommon tumor, with only 22 cases having been previously reported. Experience with two men and one woman between 17 and 55 years of age, portraying a spectrum of clinical presentations ranging from rectal bleeding to large-bowel obstruction, is reviewed. Clinical and radiologic characteristics and histologic features helpful in making the diagnosis are detailed. Though the prognosis is grim, resective surgery, including oophorectomy in women, should be undertaken. Adjuvant therapy has been disappointing.

Hepatic abscesses in diverticulitis.

Liver abscess is an uncommon but potentially lethal complication of diverticulitis. Either may be present in an occult form. We present two cases to illustrate the diagnostic and therapeutic problems created by these occult presentations. A high index of suspicion and an aggressive diagnostic approach are necessary to ensure early diagnosis and proper treatment. Barium enema should be done in patients with liver abscesses when there is no obvious source for the abscess. Intraoperative evaluation of the liver, including needle aspiration of any suggestive areas, should be done in all patients operated upon for complicated diverticulitis. Patients with diverticulitis and abnormal results of liver function tests should have liver scan or abdominal sonography.

Perineal endometrioma in episiotomy incisions: clinical features and management.

Four patients, 23--34 years old, who developed endometriomas at the site of an episiotomy 19 months to 11-years postpartum are reported. Pain, Swelling and pruritus varying in intensity with the menstrual cycle were present in all. Complete excision is curative. Symptoms of incompletely excised endometriomas may be controlled by local hormonal injections or systemic hormonal manipulation. The anatomy of the endometrium and its physiologic behavior are reviewed. A concept of WHY endometriomas develop is presented which is compatible with the theories of HOW they occur.

Jejunoaortic fistula from ingested seamstress needle.

A 27-year-old man was evaluated for sudden onset of massive hematemesis and hematochezia. A bleeding site was not seen on esophagogastroduodenoscopy. There was little blood in the stomach, which suggested that the bleeding site was below the ligament of Treitz. Angiography demonstrated the presence of an intra-aortic metallic foreign body that resembled a sewing needle. At operation, a chronic jejunoaortic fistula that contained the sewing needle was found and repaired. The patient had no recollection of having swallowed the needle, and it is presumed that he ingested it in infancy. He had an uneventful recovery.

Principles of management of colorectal foreign bodies.

We present a five-year experience with removal of 31 colorectal foreign bodies, with no morbidity or mortality. The following principles were used: (1) biplane abdominal roentgenograms to elucidate the location, type, and number of foreign bodies; (2) removal under appropriate anesthesia; (3) transanal extraction of the foreign bodies whenever possible; (4) laparotomy only as a last resort, after failure of all transanal manipulations; (5) proctosigmoidoscopy following removal of foreign bodies; and (6) inpatient observation to rule out bleeding or perforation with delayed symptoms. A classification based on the level of the foreign bodies in the rectum or colon is proposed that is helpful in the initial approach to the problem and the ultimate therapeutic plan.

The preoperative diagnosis of hepatic metastases in cases of colorectal carcinoma.

Preoperative LDH, CPK, alkaline phosphatase and liver scan results were compared with the presence or absence of hepatic metastases at operation in 124 laparotomies in 123 patients with colorectal carcinomas during a three-year period. The overall accurcy rates for the four tests ranged from 74 to 84 per cent. The false-negative rates were acceptably low (9-13 per cent) for all but the CPK determination. The false-positive rates were unacceptably high for all four tests (38 to 60 per cent). A 'metastatic score' for reducing the high false-positive rate is described. In view of the high false-positive rates of preoperative screening tests, laparotomy is presently the most accurate method of diagnosing hepatic metastases.

Fiberoptic colonoscopy: the fate of colonoscopic polypectomy sites.

Nine cases of colonoscopic polypectomy followed by colonic resection are reviewed. A properly performed colonoscopic polypectomy produces a mucosal defect resembling a superficial ulceration. Granulation tissue rapidly covers the area, and this, in turn, is eventually covered by normal colonic mucosal epithelium. Mural inflammation is mild and limited to the submucosa, and no demonstrable change occurs in the muscular layers.