Canadian attitudes toward use of primary repair in management of colon trauma. A survey of 317 members of the Canadian Association of General Surgeons.

PURPOSE: The majority of recent American articles on management of colon trauma promote liberal use of primary repair. The extent to which Canadian surgeons have embraced such recommendations is unknown. METHOD: To determine the current attitude of Canadian surgeons toward the use of primary repair, we surveyed the members of The Canadian Association of General Surgeons regarding their management of three fictitious cases of penetrating and blunt colon trauma. RESULTS: Three hundred seventeen members of the Canadian Association of General Surgeons responded. Ninety-two percent managed a fictitious case of early, uncontaminated stab wounds by primary repair. Delay in treatment or fecal contamination was associated with a significantly reduced number of respondents choosing primary repair (P < 0.001). Surgeons were less likely to choose primary repair for management of a case of blunt colon injury (35 percent; P <0.001), and only 25 percent considered primary repair an option for a case of low velocity bullet wounds; 2 percent chose it for high velocity bullet wounds. Overall, the most common response to colon trauma scenarios was colostomy. However, 96 percent of respondents selected primary repair as the treatment of choice for at least one clinical situation depicted in the questionnaire. The likelihood of choosing primary repair was independent of surgeons' experiences or the level of the surgeons' trauma center. CONCLUSIONS: Although there are still settings in which many Canadian surgeons consider colostomy the appropriate treatment for colon injuries, primary repair has definitely established a foothold in all levels of Canadian general surgery practice.

Successful treatment of horseshoe fistula requires deroofing of deep postanal space.

A total of 24 patients underwent treatment for horseshoe fistula-in-ano. In 3 patients the disease was bilateral; in 21 unilateral. Treatment consisted of deroofing the postanal space with division of overlying external sphincter muscle by seton. In 22 cases (92%), lateral wings were deroofed. At 23 months (range: 5 to 45 months), 23 cases (96%) have healed. Five (21%) have required reoperation: one remains unhealed. Mean healing time was 3.5 months (1 to 13). Five patients wear a protective pad, but 14 (64%) consider their continence normal. A total of 13 patients consider their result excellent, 9 good, 1 fair, and 1 a failure. Good to excellent results of treatment of horseshoe fistula and complete healing may be achieved in 92% of cases by a method that includes deroofing the deep postanal space and lateral wings.

Parameters of anorectal and colonic motility in health and in severe constipation.

Anorectal function and colonic transit was assessed in 17 severely constipated patients and 15 age-matched controls. The constipated patients were divided into those who had "immobile perineum" (perineal descent < or = 1.0 cm during attempted defecation) and those who had a normal descent (> 1.0 cm) of the perineum. When constipation was accompanied by an immobile perineum, patients had impaired balloon expulsion, impaired and delayed artificial stool expulsion, decreased straightening of the anorectal angle, decreased descent of the pelvic floor with defecation, and prolonged rectosigmoid colon transit compared with the patients with constipation who had a mobile perineum and with normal controls. The mobile-perineum group differed from controls only in colon transit times, having prolonged total colon transit. Anal sphincter resting pressures, immediate artificial stool expulsion, resting anorectal angles, and electromyography of the external anal sphincter and puborectalis did not differentiate the constipated patients from the controls. We concluded that descent of the perineum of < 1 cm was associated with impaired expulsion, an adynamic anorectal angle, and slowed distal colon transit. This simple sign of pelvic floor function distinguished constipated patients with disordered expulsion from constipated patients with normal pelvic floor function. These patients may respond poorly to surgery and conventional management and would therefore be candidates instead for pelvic floor retraining. Accurate characterization and appreciation of pelvic floor dysfunction in patients with severe chronic constipation may improve the selection for and results of surgical and nonsurgical intervention.

Creation of a pedicle valve unit (PVU) for establishment of enteric continence. Experimental observations.

The aim of this study was to develop a natural tissue valve that could be anastomosed into any area of the gastrointestinal (GI) tract to act as a fecal "brake" and so establish enteric continence at that site. A 4-cm-long valve created from an intussuscepted small bowel pedicle was anastomosed into the cecum and brought out through the abdominal wall as a stoma in 11 rabbits. The animals were re-explored five weeks later for assessment of valve viability and continence and microscopic appearance. In all cases, the valve was fully continent in vivo. All valves were viable, and there was no anastomotic leakage. Pressure testing of the valve at reoperation revealed that 7 of 10 valves tested withstood pressures of 30 mmHg before and after catheterization and 6 of 10 were fully continent to cecal "blanching" pressure (50 mmHg). Valve failure was due to deintussusception in three cases. In four cases, valves were continent over 50 mmHg and showed no tendency to incontinence to bursting pressure of the cecum. We conclude that a continent pedicle valve unit (PVU) for placement in a variety of locations in the GI tract is feasible. The PVU has implications in the management of short-gut syndrome, incontinent ileostomy, continent cecostomy, and as a continent valve placed in the perineum for restoration of perineal defecation following proctectomy.

Role of oxygen free radicals in the etiology of pouchitis.

Transient mucosal ischemia may cause oxygen-derived free radical production by xanthine oxidase, precipitating pouchitis after ileal pouch-anal anastomosis. Our aim, therefore, was to determine the effect of allopurinol, a xanthine oxidase inhibitor, in patients with acute and chronic pouchitis. Acute pouchitis was characterized clinically by sporadic episodes of increased frequency and decreased viscosity of stools, hematochezia, fever, malaise, and pelvic pain, which resolved promptly with treatment. Chronic pouchitis patients required continuous treatment to remain asymptomatic and invariably developed the signs and symptoms of pouchitis within one week following cessation of therapy. Eight patients with acute pouchitis were treated with allopurinol (300 mg p.o. b.i.d.) during the episode. Fourteen patients with chronic pouchitis had their standard antibiotic therapy discontinued while still asymptomatic; they were then given allopurinol (300 mg p.o. b.i.d.) for 28 days. Acute pouchitis resolved promptly in four of eight patients. Seven of the 14 patients with chronic pouchitis responded completely with no recurrence of symptoms during treatment. Allopurinol either terminated an episode of acute pouchitis or prevented pouchitis from recurring in 50 percent of patients. These data support a role for mucosal ischemia and oxygen free radical production in the etiology of pouchitis.

Failure of right-sided coloanal anastomosis for treatment of left-sided ulcerative colitis. Report of a case.

A patient with ulcerative colitis limited to the rectum and distal colon underwent a left hemicolectomy, a mucosal proctectomy, and a coloanal sleeve anastomosis using the normal proximal colon. She experienced macroscopic recurrence of her disease within 2 months of the operation and eventually required excision of the remaining colon and an end ileostomy. Our experience and that of others would indicate that a right-sided coloanal operation is unsuitable for the treatment of left-sided ulcerative colitis.

Limited value of technetium 99m-labeled red cell scintigraphy in localization of lower gastrointestinal bleeding.

The aim of this study was to assess the accuracy of technetium 99m-labeled red cell scintigraphy in localizing the site of lower gastrointestinal bleeding. The outcome of 203 patients undergoing technetium 99m-labeled red cell scintigraphy was reviewed, and the scan result was compared with the true site of bleeding. The true site of bleeding was determined by other methods including angiography and surgical pathology. Fifty-two scans (26%) were positive and indicated a specific site of bleeding. A definitive bleeding site was identified in 22 patients by other means and correlated with the technetium scan in only 9 cases. The nuclear scan was incorrect in the remaining 13 cases, implying a localization error of 25% (13 of 52). A subgroup of 19 patients with a positive scan underwent a surgical procedure directed by the nuclear scan. Eight of these 12 patients had incorrect surgical procedures based upon findings of more definitive tests, indicating a surgical error of 42% (8 of 19). We conclude that the technetium 99m-labeled red cell scan's ability to accurately localize the site of lower gastrointestinal bleeding is limited. Furthermore, performing a surgical procedure that relies exclusively on localization by red cell scintigraphy will produce an undesirable result in at least 42% of patients.

Outcome of "indeterminant" colitis following ileal pouch-anal anastomosis.

To establish whether patients with indeterminant colitis (patients with ulcerative colitis whose surgical specimens also show features of Crohn's colitis) have an adverse outcome after ileal pouch-anal anastomosis (IPAA), the authors reviewed the pathologic reports and postoperative status of 514 consecutive patients who underwent IPAA for chronic ulcerative colitis (CUC). Twenty-five patients (5 percent) had features of indeterminant colitis (IC), including unusual distribution of inflammation, deep linear ulcers, neural proliferation, transmural inflammation, fissures, creeping fat, and retention of goblet-cell population. The clinical and functional outcome of these 25 IC patients was compared with that of the remaining 489 CUC patients. The mean follow-up was 38 +/- 18 months. No significant differences in complication rates, pouch function, incidence of "pouchitis," or requirement for pouch excision were detected in the two groups at follow-up. Although the authors are continuing to perform IPAA on patients with IC, a better definition of the IC patient and a more objective, prospective analysis of outcome of IC following IPAA is required before confident and specific treatment policies can be recommended.

Function and quality of life results after ileal pouch surgery for chronic ulcerative colitis and familial polyposis.

The aim of this study was to assess gastrointestinal function and quality of life, including occupational, social, and sexual function, in 75 patients who underwent pelvic pouch construction between November 1984 and May 1988 at our institution. Complications occurred in 45 percent of patients after pouch construction and in 17 percent after ileostomy closure. One patient died from sepsis caused by an anastomotic leak after ileostomy closure. The most common complication was a pouch-anal anastomotic stricture (22 percent), and the complication with the greatest potential morbidity was pouch-anal dehiscence (8 percent), which was highly predictive of pouch failure. Functional results were assessed by questionnaire during the 3-month period after ileostomy closure in all 58 patients who successfully attained intestinal continuity. A second assessment was performed at 15 +/- 11 months after ileostomy closure in 52 patients whose continuity had been restored for longer than 3 months. In an overall assessment, 94 percent of all patients with restored intestinal continuity (73 percent of entire patient group) rated the pouch as being superior to a permanent ileostomy and 92 percent (71 percent of entire group) would go through another pouch procedure. These results support the continued recommendation of this procedure as an acceptable alternative to proctocolectomy and permanent ileostomy in patients with ulcerative colitis or familial polyposis.

Scintigraphic assessment of the anorectal angle in health and after ileal pouch-anal anastomosis.

To determine whether the anorectal angle was preserved after ileal pouch-anal anastomosis, a simple, safe, low-radiation, real-time method of imaging the anorectum was developed. A cylindrical balloon was placed in the neorectum and anal canal and filled with a solution of 99mTc in water. A gamma camera then imaged the angulation of the balloon while the subject was at rest, during sphincteric squeeze, and during a Valsalva maneuver. Thirteen healthy volunteers and six patients were studied after ileal pouch-anal anastomosis. An angle was identified in all controls and patients. In the lateral decubitus position at rest, the mean anorectal angle in controls (102 +/- 18 degrees; SD) and anopouch angle in patients (108 +/- 19 degrees) were similar (p = 0.3). Sitting straightened the angle in both groups (p less than 0.03), whereas sphincteric squeeze and a Valsalva maneuver sharpened the angle in both the sitting and standing positions (p less than 0.03). In the lateral decubitus position, however, the pouch group was less able to sharpen the angle than were the controls (p = 0.04). In controls, the anorectal junction descended during sitting and elevated during squeeze (p less than 0.03), but this did not occur in the pouch group. In conclusion, maneuvers favoring or stressing continence (squeeze, Valsalva) sharpened the anorectal angle and elevated the pelvic floor, whereas a maneuver favoring defecation (sitting) straightened the angle and caused the pelvic floor to descend. After ileal-anal anastomosis, the angle and its movements (except those while lying) were similar to controls. Elevation of the pelvic floor during squeeze, however, was decreased, indicating a decreased mobility of the pelvic floor after operation.

Sphincter repair for fecal incontinence after obstetrical or iatrogenic injury.

Forty patients with fecal incontinence underwent sphincter repair between 1975 and 1984. Divided sphincter musculature resulted from obstetrical injury in 23 and previous anorectal surgery in 17. Eighteen had undergone a previous attempt at repair. Fifteen patients experienced seepage of stool and 25 had gross incontinence. In nine patients, reconstruction of the external sphincter was by overlap of the muscle ends. Twenty-four others underwent accurate approximation of the external sphincter muscle and anterior plication of the levator muscles, and in seven the anal canal was made smaller by narrowing the anal orifice. Follow-up was an average of 67 months after operation (range, 2.4 to 166 months). Continence was objectively improved in 62 percent (P less than .01) when performance criteria were analyzed by Wilcoxon signed-rank test, although 85 percent of the patients reported subjective improvement. Requirements for protective pads were reduced in 57 percent (P less than .01) and fewer social limitations were experienced in 52 percent (P less than .01). There was no significant correlation between outcome and type of operation.

Closure of postproctectomy perineal sinus with gracilis muscle flaps.

Between 1975 and 1985, 21 patients underwent muscle-flap repair of a persistent perineal sinus. All had previously undergone a proctectomy for ulcerative colitis (7 patients), Crohn's disease (10), trauma (2) or cancer (2). A total of 133 (mean 6.8, range from 1 to 25) previous surgical attempts had been made to eradicate the sinus. At follow-up after muscle-flap repair (mean 47 months), the sinus was completely healed in 14 patients. However, 10 of these patients had required further perineal operations (mean 1.9, range from 0 to 9). In those with a successful result, the average time taken for the sinus to heal was 2.3 months (range from 1 to 24 months). In three patients, a wound that had initially healed reopened (mean 7 months) and has remained unhealed. Although a gracilis flap will likely cure a refractory perineal sinus, the healing period may be prolonged, and reoperation is frequently required.

Perforation of terminal ileal appendage of J-pelvic ileal reservoir.

If, during restorative proctocolectomy, the most distal segment of the terminal ileum is not incorporated into the reservoir during J-pouch construction, it will remain as an appendage and may twist upon itself and obstruct. Two cases in which this resulted in significant complications are described.

Enteric continence and the ileal pouch-anal procedure.

The ileal pouch-anal procedure maintains enteric continence by preserving critical physiological mechanisms. The reservoir, although possessing somewhat different physiologic characteristics than the rectum, provides sufficient storage capacity to enable the patient to resume most daily activities. The intact anorectal angle continues to perform its pivotal role in the maintenance of gross fecal continence, while the functioning anal sphincter muscles fine-tune the system. The success of the procedure has shown that certain widely held "principles" of continence may be less important than previously believed. These include the requirement for a long rectal stump, the preservation of the rectosphincteric inhibitory reflex, and the maintenance of sensation to the upper half of the anal canal. Yet, results are not perfect, and it is possible that while these mechanisms are not required for gross fecal continence, their transgression results in a subtle reduction in function from that of the normal state. When one considers, however, that the only other curative procedure for patients with familial polyposis is total proctocolectomy with permanent ileostomy, the ileal pouch-anal operation represents an important advance. The disease is removed, yet reasonably effective control of enteric continence is restored such that quality of life appears to be enhanced when compared to that achieved after proctocolectomy and Brook ileostomy.

Carcinoma of the rectum: current management.

In recent years, various approaches have been used to improve survival and the quality of life in patients after surgical treatment of rectal carcinoma. These approaches include earlier detection, sphincter-saving procedures, and adjuvant therapy, intraoperative therapy for locally advanced tumors, and a more aggressive approach for locally recurrent or distal but isolated spread of the disease.

Restorative proctocolectomy with ileal reservoir for ulcerative colitis and familial adenomatous polyposis: a comparison of three reservoir designs.

One hundred and four patients were treated by restorative proctocolectomy with ileal reservoir for ulcerative colitis and familial polyposis. Three different designs of reservoir were used (triple loop 68, double loop 13, quadruple loop 23). There were no postoperative deaths but six (5.8 per cent) had the reservoir removed. Rates for pelvic sepsis were 25, 15 and 13 per cent, and for intestinal obstruction requiring laparotomy 14.7,0 and 8.6 per cent. Function was assessed in 88 patients (58, 12 and 18) after mean intervals from closure of the ileostomy of 23.7, 12.7 and 4.5 months. Frequency of defaecation per 24 h was 3.7 +/- 1.6, 5.5 +/- 1.6 and 4.1 +/- 1.3, being significantly greater for double loop reservoirs; night evacuation was more prevalent in the same group (26, 58 and 22 per cent). Significantly fewer patients with triple than with double loop reservoirs required antidiarrhoeal medication (19 and 58 per cent). Normal continence occurred in 67, 75 and 89 per cent of patients in the three groups. All patients with double or quadruple loop reservoirs defaecated spontaneously while only 41 per cent with triple loop reservoirs did so. Mean intra-operative reservoir volumes were 177 +/- 64, 172 +/- 58 and 325 +/- 37 ml and volumes after closure of the ileostomy were 416 +/- 176, 197 +/- 69 and 322 +/- 33 ml respectively. Double loop reservoirs were significantly smaller than the other two designs after ileostomy closure. There was an inverse relationship between reservoir volumes and frequency. A quadruple loop reservoir directly connected to the anal sphincter preserved spontaneous evacuation and resulted in function similar to that obtained with the triple loop reservoir.

Quality of life after restorative proctocolectomy with pelvic ileal reservoir.

Fifty-five patients who had undergone restorative proctocolectomy with a pelvic ileal reservoir between 3 and 82 months previously were sent a detailed questionnaire to assess their quality of life. All patients had experienced an ileostomy at some time. Fifty-one (94 per cent) returned completed questionnaires. The average frequency of evacuation from the reservoir was four times per 24 hours. Antidiarrhoeal medication was required by 14 (27.4 per cent). Continence was normal in 32 (62.7 per cent) and only 3 (5.9 per cent) had troublesome faecal leakage. Twenty-two (43.1 per cent) evacuated stool spontaneously, while 24 (47.1 per cent) needed to catheterize the reservoir for each evacuation. Four patients who had had the reservoir removed were added to the 51 responders to give a total number of 55 whose quality of life was considered in this study. The reservoir was preferred to an ileostomy with regard to confidence (87 per cent), cleanliness (89 per cent), sexual self-image (87 per cent), social (85 per cent) and sport activity (87 per cent), and ease of carrying out work (84 per cent). The overall preference was 87 per cent. Thirty-four (66.7 per cent) felt there was no significant disadvantage associated with the reservoir, while 10 (19.6 per cent) saw the long convalescent period and 9 (17.6 per cent) the requirement for catheterization as drawbacks.

Survival after high or low ligation of the inferior mesenteric artery during curative surgery for rectal cancer.

In an attempt to determine whether "high ligation" of the inferior mesenteric artery during surgery for cancer of the rectum and rectosigmoid confers any significant 5-year survival advantage over "low ligation," the outcome of 1370 patients was reviewed. There were 784 patients in whom the inferior mesenteric artery was ligated below the origin of the left colic artery (low ligation) and 586 in whom it was ligated above this level (high ligation). The distribution of histologic grades of the tumors and incidence of venous invasion were similar in both groups. Five-year follow-up was complete in 98.5%. No difference in the crude or age-corrected 5-year survival was found for patients with Dukes A, B, C overall, or C1 tumors, whether having had a low or high ligation. In hopes of identifying a population that benefited from high ligation, C1 patients were further subgrouped according to tumor location and number of involved lymph nodes. However, in no such subgroup was any significant high ligation advantage seen. In conclusion, high ligation of the inferior mesenteric artery has not been found to improve 5-year survival in patients with cancer of the rectum or rectosigmoid.

Restorative proctocolectomy with a three-loop ileal reservoir for ulcerative colitis and familial adenomatous polyposis. Clinical results in 66 patients followed for up to 6 years.

The results of restorative proctocolectomy with a three-loop ileal reservoir were reviewed. Of 66 patients treated between 1976 and 1982, 52 had ulcerative colitis and 14 had familial adenomatous polyposis. The temporary ileostomy was closed between 2 and 78 months previously in 63 cases. Of these, three patients had had the reservoir removed and two were lost to follow-up. One other patient was subsequently found to have Crohn's disease. Function was assessed in 55 patients who had undergone closure of the ileostomy more than 8 weeks previously. Mean frequency of defecation was 3.7 per 24 hours (range 1-9.5) and 11 patients (20%) were taking antidiarrheal medication. Spontaneous defecation occurred in 22 patients (40%) while 29 (52.7%) had to use a catheter passed per anum. Four patients defecated spontaneously but sometimes used a catheter. Continence was normal in 36 (65.4%) and minor leakage once every 2 to 3 days occurred at night in 16 (29.1%). Three patients (5.4%) had some soiling during day and night. Troublesome perianal soreness (five patients, 9.1%) necessitated a defunctioning ileostomy in one. Fifty-four of the 55 patients assessed preferred their quality of life to that with an ileostomy.