Ileoanal pouch operation: long-term outcome with or without diverting ileostomy.

HYPOTHESIS: Avoiding a diverting ileostomy does not influence the long-term overall morbidity and functional outcome of patients after ileoanal pouch operation (IAP). DESIGN: All patients undergoing IAP were prospectively entered into a database, and those undergoing operation from October 1, 1989, through January 31, 1996, were contacted by mail questionnaire. SETTING: Tertiary referral center. PATIENTS: One hundred thirty unselected sequential patients. INTERVENTIONS: The IAP was completed by a stapled method without diverting ileostomy, provided the patient agreed, and there were no other complicating factors. MAIN OUTCOME MEASURES: Need for reoperation, fecal leakage, pouch frequency, ability to defer evacuation, pouchitis, and overall quality of life. RESULTS: Of 102 patients (78.5%) who initially underwent IAP without diverting ileostomy, 10 (9.8%) developed an anastomotic leak and required a diverting ileostomy. Additional surgery was required in 12 (9.2%) of the 130 patients for bowel obstruction and in 3 (2.3%) for pouch excision. Two patients died of unrelated causes, leaving 125 functioning pouches (96.2%). Questionnaires were completed in 111 (88.8%) of the 125; 75 patients (67.6%) reported perfect continence for gas and stool, 10 patients (9.0%), regular nighttime leakage, and 24 patients (21.6%), occasional fecal leakage. Pouch evacuation frequency (+/-SD) per 24 hours was 7.8+/-2.4 (range, 4-12), and 95.5% of patients could defer pouch evacuation. Of the 111 patients, 42.3% reported pouchitis, with 7.2% receiving long-term antibiotic therapy. Of the patients, 74.8% reported total satisfaction, and 84.7% regarded themselves as being in perfect health. CONCLUSION: Long-term outcome after IAP remains favorable with or without diverting ileostomy.

Outpatient thyroid and parathyroid surgery: a prospective study of feasibility, safety, and costs.

BACKGROUND: The purpose of this study was to determine feasibility, safety, and cost savings of outpatient thyroid and parathyroid surgery. METHODS: Consecutive unselected patients undergoing thyroid and parathyroid operations by two surgeons with a special interest in endocrine surgery were studied prospectively. RESULTS: One-hundred patients underwent operation, 61 as outpatients and 39 as inpatients. Outpatients included those undergoing thyroid lobectomy (39), total thyroidectomy (10), total thyroidectomy with parathyroidectomy (1), total thyroidectomy with modified neck dissection (1), and parathyroidectomy (10). Inpatients included those undergoing thyroid lobectomy (15), total thyroidectomy (8), total thyroidectomy with neck dissection (4), removal of substernal goiter (2), and parathyroidectomy (10). The average age of inpatients was slightly higher than that of outpatients (p < 0.05). Average hospital cost for outpatients was $1991 +/- $279 (range, $1594 to $2783) and for inpatients it was $2875 +/- 615 (range, $2031 to $4216), p < 0.001. Reasons for admission included extent of surgery (6), nausea (5), oversedation (4), urinary retention (2), inadequate home help (6), long travel time (2), patient preference (9), and medical reasons (5). No outpatients subsequently required admission. CONCLUSIONS: Outpatient thyroid and parathyroid surgery can be feasible and safe and resulted in a 30% savings in hospital costs. After extensive operations patients continue to require admission for postanesthetic complications, social reasons, or presence of serious comorbid disease.

Outcome of early surgical complications following ileoanal pouch operation without diverting ileostomy.

BACKGROUND: Many surgeons use a diverting ileostomy routinely following ileoanal pouch operation because they fear that complications may lead to permanent unsatisfactory pouch function or even death. We report the outcome of early surgical complications when ileoanal pouch operation is performed without a diverting ileostomy. We performed 74 consecutive ileoanal pouch operations since ileoanal pouch operations since October 1989 using a transition-zone-sparing stapled J pouch method. RESULTS: Of the 74 patients, 68 (92%) underwent the operation without a diverting ileostomy. Five of the 68 patients (7.4%) required reoperation within 30 days of operation. Pouch excision was necessary in 2 patients (3%) for reasons not resulting from omitting the diverting ileostomy, and they now have excellent pouch function. CONCLUSION: Patients who required early reoperation and placement of a temporary diverting ileostomy did not suffer long-term consequences. The fear that early surgical complications following ileoanal pouch operation without diverting ileostomy are permanently detrimental is unjustified.

Fine-needle aspiration of normal thyroid tissue may result in the misdiagnosis of microfollicular lesions.

BACKGROUND: Inadvertent sampling of normal thyroid tissue surrounding a nodule may occur when clinically inexperienced personnel perform fine-needle aspiration (FNA) or when a nodule is small. Because the cytologic characteristics of normal thyroid tissue are not well known, we prospectively studied 42 patients undergoing thyroidectomy. METHODS: FNA was performed from the grossly normal contralateral lobe during thyroidectomy. Cytopathologists examined the slides without knowing the source of the tissue. RESULTS: FNA of grossly normal thyroid tissue was adequate for interpretation in 32 of 42 patients, and in nine of 42 cases it was interpreted as unremarkable. However, the remaining specimens were classified as microfollicular lesions (18), mixed macromicrofollicular lesions (three), Hürthle cell lesion (one), and papillary thyroid carcinoma (one). CONCLUSIONS: FNA of grossly normal thyroid tissue suggested a microfollicular lesion in 18 (56%) patients, a result that would raise the possibility of a follicular carcinoma and often lead to the recommendation for operation. When FNA is performed, normal thyroid tissue surrounding a nodule should be avoided, and the possibility of a sampling error should be considered when a microfollicular pattern is obtained in a patient with a small nodule.

Factors favoring continence, the avoidance of a diverting ileostomy and small intestinal conservation in the ileoanal pouch operation.

Ileoanal pouch operation was performed upon 38 consecutive patients with ulcerative colitis (36 patients) or familial polyposis (two patients). Mucosectomy was avoided by rectal mobilization to the dentate line and eversion and stapling of the exteriorized anorectal junction with the dentate line in view. An 8 centimeter J pouch was stapled to the anorectal junction. A diverting ileostomy was not used in 34 of the 38 patients. Physicians independent of the operation evaluated patients postoperatively. Eighty-four percent of the patients did not experience any problems with incontinence or nocturnal spotting at one month postoperatively. No incontinence or nocturnal spotting was seen in any patient by one year postoperatively, with the exception of one patient with chronic pouchitis who had occasional nocturnal spotting that continues to improve. The average number of bowel movements per 24 hours was five at 12 months postoperatively, despite the small pouch. The mean distance from the dentate line to the ileoanal anastomosis was 0.9 +/- 0.5 centimeter (range of zero to 2 centimeters).

Improving the cost-effectiveness of laparoscopic cholecystectomy.

The rapid shift from open to laparoscopic cholecystectomy has not been the result of carefully planned studies, but rather the result of pressure from patients to undergo the new procedure in order to avoid the pain from a traditional incision. In order for laparoscopic cholecystectomy to prove cost effective, there must be a low complication rate, the cost of discretionary equipment must be considered, and the role of routine cholangiography seriously questioned.

Why catheterize the bladder for laparoscopic cholecystectomy?

Bladder catheterization is widely employed for laparoscopic cholecystectomy. Fifty consecutive laparoscopic cholecystectomies were performed without bladder catheterization. Patients were asked to void shortly before induction of anesthesia to ensure that the bladder was empty. Postoperative bladder catheterization for urinary retention was required in 3 of the 50 patients. Routine bladder catheterization for laparoscopic cholecystectomy is unnecessary, and its elimination will reduce costs, urethral trauma, and nosocomial urinary tract infections.

Effect of hyperparathyroidism and hypercalcemia on lower esophageal sphincter pressure.

Heartburn is a frequent and sometimes initial complaint in hyperparathyroidism, and it is often relieved by successful parathyroid surgery. Four of five patients with primary hyperparathyroidism and heartburn obtained relief of symptoms and had an increase in lower esophageal sphincter pressure after successful operative treatment. Four of five volunteers undergoing calcium infusion exhibited a decrease in lower esophageal sphincter pressure after about 2.5 to 3 hours of infusion. Calcium infusion in a treated patient who had an increase in lower esophageal sphincter pressure postoperatively resulted in a transient return of lower esophageal sphincter pressure to preoperative levels.