Management of perforated diverticular disease.
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Biomedical subjects
Publications and source records attributed to A Senapati.
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Systemic amyloidosis results in diffuse deposition of amyloid proteins in various organs. Localized deposits in the form of nodules also occur but are rare in the gastrointestinal tract. A localized amyloid deposit in the rectum that was clinically indistinguishable from carcinoma of the rectum or prostate is described.
PURPOSE: This study was designed to examine the results of Delorme's procedure. METHODS: Thirty-two patients (24 males and 8 females, mean age, 70 years) underwent Delorme's procedure between 1978 and 1990 following symptoms lasting between two weeks and ten years. Thirteen patients had had 21 previous operations for prolapse. RESULTS: The mean operation time was 65 minutes. No blood transfusions were needed, there was no operative mortality, and only two patients had complications (one chest infection and one anastomotic dehiscence). No patients were lost to follow-up. Over a mean follow-up of 24 months (4 months to 4 years), 9 patients died of unrelated conditions. There were four recurrences (12.5 percent), two in patients who had each had two previous procedures. Incontinence improved in 46 percent. No patient became constipated and 50 percent of those constipated preoperatively improved. CONCLUSION: Although abdominal rectopexy is safe and has a low recurrence rate (< 5 percent), it involves the hazards of a laparotomy. In addition, up to 40 percent of patients become constipated after rectopexy which may be debilitating. Delorme's procedure has a low morbidity, results in good bowel function, and has a low recurrence rate. It can be performed on unfit patients with possible advantages over rectopexy and perhaps should be used more readily.
AIMS: To investigate a female patient with a tumour mass of the terminal ileum, to define the nature of the tumour, and to correlate its morphology and behaviour with similar types of tumours of the large intestine and stomach. METHODS: Tissues obtained at colonoscopy, from hemicolectomy specimens, and from liver and peritoneal biopsy specimens were studied macroscopically, microscopically, histochemically, and immunohistochemically for epithelial membrane antigen (EMA), carcinoembryonic antigen (CEA), neuron specific enolase (NSE), and S100 protein. RESULTS: Macroscopic examination showed a tumour of the terminal ileum protruding into the caecum. Microscopically the tumour showed two components, one adenoma with moderate dysplasia and the other carcinoid tumour. The adenomatous component stained positively for EMA and CEA and negatively for NSE. The carcinoid component stained positively for NSE and negatively for EMA and CEA. Histochemically the carcinoid area was argyrophil positive and argentaffin negative. Only the carcinoid had metastasised, to the liver, peritoneum, and the lymph nodes, at the time of diagnosis. CONCLUSION: The morphological, histochemical, and immunohistochemical findings confirm the diagnosis of a composite adenoma-carcinoid tumour of the terminal ileum.
The aim of a defunctioning ileostomy after restorative proctocolectomy is to mitigate the consequences of pelvic sepsis, should it occur. However, there are complications related to the ileostomy itself. Of 310 patients (174 male and 136 female; mean age 33.2 years) who underwent restorative proctocolectomy between 1976 and 1990, 296 had a covering ileostomy and 14 did not. The stoma has been closed in 263 (88.9 per cent) at a median interval from formation of 12.0 weeks. Ileostomy-related complications before closure occurred in 17 patients (5.7 per cent). Laparotomy for obstruction due to the ileostomy was required in seven patients (2.4 per cent). Retraction requiring revision occurred in three patients (1.0 per cent), an abscess behind the stoma in one (0.3 per cent) and miscellaneous appliance problems in seven (2.4 per cent). Following closure, 59 patients overall (22.4 per cent) developed an ileostomy-related complication. There were 30 cases of small bowel obstruction, treated conservatively in 19 (7.2 per cent) and by laparotomy in 11 (4.2 per cent). Peritonitis requiring laparotomy occurred in three patients (1.1 per cent) and two (0.8 per cent) developed an enterocutaneous fistula. There were 14 (5.3 per cent) wound infections and 16 (6.1 per cent) other miscellaneous problems. Significant complications associated with a temporary ileostomy were less frequent in this series than in some other reports. Obstruction was the most common complication and fistula was rare.
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An operative technique for performing a permanent end sigmoid colostomy without recourse to laparotomy is presented. The results from 16 patients have shown a very low morbidity. The technique was unsuccessful in three patients, each needing a formal laparotomy.
This paper reviews the technique, indications and results of parathyroid autotransplantation. Autotransplantation is most commonly indicated following parathyroidectomy for renal osteodystrophy, but can also be used in primary hyperplastic hyperparathyroidism, re-exploration of the neck and radical neck surgery. The success of the technique ranges from 75 to 100 per cent.
Zinc is essential for protein synthesis and reduced levels may impair recovery from surgery. To study this prospectively, clinical, anthropometric, haematological and biochemical indices of malnutrition were measured in 46 patients undergoing elective surgery and were related to the frequency and type of post-operative complications. In addition, leucocyte zinc levels, which are an estimate of tissue zinc levels, were measured. The diagnoses of the patients did not correlate with any of these parameters. Many patients were malnourished. 39% of the patients had a post-operative complication, of whom 8 had a wound complication. The frequency of complications as a whole was inversely related to serum albumin and transferrin levels, while wound complications were in addition associated with low leucocyte zinc levels. Malnutrition may therefore increase post-operative complications in general, but tissue zinc deficiency may contribute to wound problems.
Although day case surgery is recommended, its widespread feasibility in an urban environment is unclear. We studied 100 consecutive unselected patients admitted for surgical procedures considered to be suitable for day case surgery. Their age, fitness and social details were recorded and they were asked both before surgery and after discharge by a postal questionnaire, whether they would have preferred treatment as an outpatient. There were 47 men and 53 women with a mean age of 42.5 years. Ninety-six were considered to be medically fit for day case surgery but 10 patients lived alone, seven had no suitable companion, 22 had too many stairs to climb, 13 lived too far from the hospital and two could not provide a lift home. Thus 58 of the patients were unsuitable for day case surgery. Seventy-eight of the patients replied to the postal questionnaire. Before the operation 51 patients preferred the idea of day care but only 14 felt the same way afterwards. The single postoperative complication was one case of acute retention after a hernia repair. In our experience, over half the patients initially deemed suitable for day case surgery would be unsuitable.
Zinc levels in plasma and leucocytes of elderly patients with and without cutaneous ulcers and in hospital were compared with those of a group of healthy elderly living at home and of a younger group. The groups in hospital had lower levels of plasma and leucocyte zinc than the control groups, but these were not associated with cutaneous ulcers. The zinc intake of the patients in hospital was well below the recommended daily allowance. Tissue zinc levels were found to be low in elderly patients in hospital, probably due to poor intake, but their contribution to the formation of skin ulcers was unproven.
In a prospective randomised trial, 43 patients with bleeding haemorrhoids were allocated to receive either a bulk laxative with injection of phenol (5%) in arachis oil (20 patients) (Group 1), or a bulk laxative alone (23 patients) (Group 2). Treatment was given by one author and patients were assessed "blind" by the other at 6 weeks, 3 months and finally at 6 months. At 6 weeks 12 (48%) in Group 1 and 12 (57%) in Group 2 were still bleeding (NS; chi 2 = 0.54). At 3 months 10 (40%) in group 1 and 6 (35%) in group 2 (NS; chi 2 = 0.10), and at 6 months 10 (43%) in group 1 and 7 (47%) in group 2 were still bleeding (NS; chi 2 = 0.04). No significant difference in bleeding at 6 months after either injection sclerotherapy with bulk laxative or bulk laxatives alone was found.
The baboon is the only animal in which alcoholic fibrosis and cirrhosis of the liver has been produced with a nutritionally adequate diet. Zinc deficiency is associated with alcoholic liver disease and may contribute to liver damage. We have therefore investigated whether zinc supplementation would reduce liver damage in ten baboons receiving ethanol and an adequate diet. Eight received ethanol at up to 25 g/kg/day (70% of calories) for up to 60 months (four were supplemented with 50 mg zinc/day). All animals gained weight, and blood concentrations of ethanol were 63-342 mg/dl. Changes in liver blood tests were slight. Liver histology only showed fatty change in six animals, severe in two, and minor inflammatory changes but no significant fibrosis or cirrhosis. In one of the animals with severe fatty change there were also degenerative changes in parenchymal cells. There was thus no significant hepatic fibrosis or cirrhosis in baboons given large amounts of ethanol and an adequate diet for up to 5 years.
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Whole-gut transit time was measured by the time taken for an orally administered dose of brilliant blue dye to disappear from the stool in 20 patients with ulcerative proctitis and in 20 age- and sex-matched controls. Ten of the patients had active, and 10 inactive disease. The dye usually appeared in the stool with the next bowel movement after ingestion in both patients and controls; however, the time at which the dye disappeared from the stool (transit time) was prolonged to 76.1 h in the patients, compared with 50.2 h in the controls (p less than 0.01). This delay occurred both in patients with active disease at 70.5 h (p less than 0.05) and in those with inactive disease at 81.8 h (p less than 0.05). This prolongation of transit time may be relevant to both the pathogenesis and treatment of ulcerative proctitis.
The peptides substance P, calcitonin gene-related peptide and somatostatin are present in nerve fibres in mammalian, including human, skin. There is evidence that in addition to having a putative neurotransmitter role, they may be trophic agents: a study was therefore undertaken of peptide changes during wound healing in rat skin. A significant depletion of the neuropeptides was found in the region of the wound within two days, and this persisted for two weeks. A smaller and delayed depletion also occurred in intact skin of the same dermatome, but not in an adjacent dermatome.
Twenty-five patients with ingrowing toenails were treated conservatively by inserting cotton wool under the ingrowing nail edge. Seventy-nine percent were relieved of their symptoms after follow up for a mean of 23.7 weeks. Thirty-six percent had a history of previous surgery to the nail, 75% of whom had a good or excellent result. Although conservative management was first described in the eighteenth century and has been reported sporadically since, only a few doctors treat their patients in this way. There is, however, a distinct place for this highly effective, low cost method as the initial treatment of these patients without the need for hospital referral.