"Gallstone hip" and other sequelae of retained gallstones.

The fate of gallstones spilled during laparoscopic cholecystostomy has been thought to be relatively benign. Recent experience and a review of the recent literature shows that this is not always the case. We report three cases of complications of retained stones and analyse the literature with regard to types of complications, time to presentation, and recommendations for managing spilled gallstones. Retained gallstones have been shown to cause adhesions in the rat and inflammatory reactions in dogs with no evidence of absorption. The average time to presentation of complications arising from retained gallstones is 27.3 weeks. Complications include: Intraabdominal abscess formation with or without abdominal wall sinus tract formation, persisting abdominal wall sinus tracts from port site abscess, subhepatic inflammatory masses, cholelithoptysis, microabscesses and granuloma formation, liver abscess and "dumbell" shaped abscess with one side of the "dumbell" forming a subcutaneous abscess. We recommend the judicious use of retrieval devices during the extraction phase of the laparoscopic cholecystectomy, diligent removal of any spilled stones and awareness of delayed postoperative pain and tenderness as a harbinger of symptomatic retained gallstones. Documentation of intraoperative gallstone spillage, volume, type of gallstones, and effort to retrieve is recommended.

A manometric study of anal fissure treated by subcutaneous lateral internal sphincterotomy.

A prospective, manometric trial of anal fissure treated by subcutaneous lateral internal sphincterotomy (SLIS) was designed to elucidate the pathophysiology of this condition. Anorectal manometry with a closed, precalibrated, water-filled microballoon using the station pull-through technique was performed on 13 patients with anal fissure before, and at one and 150 days after SLIS. The results were compared with 13 control subjects, matched for age and sex, who had no history of anal disease. Both resting pressure (RP) and maximum voluntary contraction pressure (MVCP) were measured at centimeter intervals of the anal canal. At all levels RP was significantly higher in the preoperative patients compared with controls (p less than 0.0001). After operation RP fell significantly at all levels with the result that there was no significant difference in RP between postoperative patients and controls, except at 4 cm from the anal verge, where there remained a significant elevation in RP in the postoperative group. There was no significant difference in the two sets of postoperative manometric results. All patients underwent rapid healing and resolution of their symptoms. MVCP did not change significantly after operation, nor did it differ from the control values. This suggests that the increase in RP is due to activity of the internal anal sphincter. This over-activity is present throughout the entire length of the internal anal sphincter and sphincterotomy of its lowest portion returns RP to normal values throughout most of the anal canal.

Rectal carcinoma; restorative resection using a sutured colo-anal anastomosis.

Over the last forty years, rectal resection with preservation of the anal sphincters has become widely accepted as satisfactory treatment for carcinoma of the upper rectum. Tumors lower in the rectum are more difficult to treat in this way because of the difficulty of performing an anastomosis low in the pelvis. Seventy-six patients have had a rectal carcinoma resected and bowel continuity restored by means of a sutured anastomosis between colon and anal canal. Ten patients developed significant pelvic sepsis. 69 of the 70 patients whose bowel function could be assessed were either completely normal or had only minor functional defects. Four of the 39 patients who had the operation three or more years ago have developed recurrent pelvic tumor. 21 of 32 patients are alive three years and 12 of 19 are alive five years after a curative operation for rectal carcinoma. The survival rate is similar to that seen following total excision of the rectum and pelvic floor for tumors in similar sites.

A neurogenic factor in faecal incontinence in the elderly.

Idiopathic faecal incontinence in middle-aged people has been found to be commonly associated with neurogenic damage to the anal sphincter musculature. Because neurogenic atrophy of skeletal muscle is a common feature of ageing, we have investigated the possibility that faecal incontinence in elderly people might be due to age-related denervation of the anal sphincter musculature. The technique of single fibre electromyography was used to measure the motor unit fibre density in the external and sphincter muscle in ten patients aged 78 to 99 years. Those patients whose continence was impaired had a markedly increased fibre density. Our findings suggest that neurogenic damage to the anal sphincter musculature may so reduce its functional reserve in elderly people that incontinence occurs when other factors, such as looseness of stool or depression of cerebral function, co-exist.

Ileal pelvic reservoir: a correlation between motor patterns and clinical behaviour.

An attempt has been made to correlate motility patterns of the pelvic ileal reservoir with patients' clinical experience. In order to evaluate the motility characteristics of the ileal reservoir, we have related its behaviour to the motility pattern observed in ileum proximal to an ileostomy. Seven patients with an ileostomy and 11 patients with a pelvic ileal reservoir have been investigated. The ileum and ileal reservoir were found to behave similarly during the fasting state and in response to distension and eating; however, a quantitative functional difference was discovered. Distension with 30 ml was enough to produce forceful contractions in the normal ileum, while a mean of 322 ml was necessary to initiate similar activity in the ileal reservoir. The ileal reservoir thus behaves as a capacitance organ with the ability to distend without contraction before a considerable volume has accumulated within it. When it does contract, it initiates a sensation of impending evacuation, but escape of ileal content is opposed by active contraction of the intact external anal sphincter.

Resection and sutured colo-anal anastomosis for rectal carcinoma.

Resection with preservation of the anal sphincters is new widely accepted as providing satisfactory treatment for carcinoma of the upper rectum. However, restorative resection is less widely performed for tumours of the lower rectum because anastomosis can be technically difficult when performed low in the pelvis. Between 1973 and 1980, 76 patients with rectal carcinoma underwent rectal resection and restoration of bowel continuity by means of a sutured anastomosis between colon and anal canal. The pathological characteristics of these tumours were similar to those of all cases of carcinoma of the rectum treated at St. Mark's Hospital between 1948 and 1972. Two patients developed pelvic sepsis following colonic necrosis and anastomotic breakdown. Eight developed pelvic sepsis without major anastomotic breakdown. No patient died as a result of pelvic sepsis. Sixty-nine of the 70 patients who were able to be assessed were either completely normal functionally or had only minor deficiencies of bowel function. Six patients have been observed to develop recurrent pelvic tumour, localized to the pelvis in 4 patients and concurrent with the development of widespread metastases in 2. Twenty-one of 32 patients are alive 3 years and 12 of 19 patients are alive 5 years after a curative operation for rectal carcinoma. These results are comparable with those seen following total excision of the rectum and pelvic floor for similarly sited tumours.

Electrophysiological study of motor nerve supply of pelvic floor.

Direct stimulation of a branch of the sacral nerves which lies above the pelvic floor and electromyographic recording of activity in the muscles of the pelvic floor showed that this nerve supplied the puborectalis muscle in 19 of the 20 nerves studied in 16 patients. Similar results were obtained when this nerve was stimulated in 2 patients undergoing anterior resection of the rectum. The pudendal nerve was also directly stimulated in 3 patients and found to supply only the ipsilateral external anal sphincter muscles. These findings suggest that the motor nerve supply of the important muscle of continence usually lies above the pelvic floor and not below it as previously believed.

Acute pancreatitis occurring in gastric aberrant pancreatic tissue.

The occurrence of acute pancreatitis in gastric aberrant pancreas is described. The patient presented initially with acute abdominal pain and a palpable epigastric mass. The symptoms were severe and recurrent, and laparotomy with antrectomy was required.