A better bridge for loop stomas.
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Humans↗
Biomedical subjects
D A Rothenberger
Publications and source records attributed to D A Rothenberger.
Computed tomography-guided percutaneous abscess drainage in intestinal disease: factors associated with outcome.
PURPOSE: This study was designed to assess the efficacy of computed tomography-guided percutaneous abscess drainage in intestinal disease. METHODS: Retrospective chart review of patients who underwent percutaneous abscess drainage for complications of intestinal disease with or without surgery between 1990 and 1994. RESULTS: Eighty-two patients with 111 abscesses were identified. Causes of abscess included anastomotic leaks (35 percent), postoperative complications without leak (30 percent), and diverticular disease (23 percent). Complete success (no surgery necessary) was achieved in 53 of 82 patients (65 percent). Nine patients (11 percent) who underwent interval surgery were classified as having partial successes. Twenty-six of 26 (100 percent) well-defined unilocular collections containing pus were successfully drained. Complex abscesses (loculated, poorly defined, multiple, associated with fistula, draining feces) were successfully drained in 35 of 55 patients (63 percent). Success rates varied inversely with the number of complicating factors present. Apache II scores of 15 or higher were associated with decreased success rates. CONCLUSION: Percutaneous abscess drainage is a highly successful technique for treatment of patients with intra-abdominal infection related to intestinal disease. Although several factors are associated with decreased success rates and multiple complicating factors combine to reduce success rates, no identifiable factor or combination of factors preclude the possibility of a successful outcome.
Abscess↗
Rectovaginal fistulas. Therapeutic options.
The management of RVF depends on size, location, and cause; anal sphincter function and overall health status of the patient; and the skill and judgment of the surgeon. Careful preoperative assessment of the fistula, surrounding tissues, and anal sphincter and exclusion of associated disease are essential. With thorough evaluation, thoughtful consideration of treatment options, and meticulous operative technique, patients can be assured of an optimal outcome. Success in treatment of patients with RVF should be measured not just in terms of successful closure of the fistula but also in terms of patient satisfaction with postoperative anal continence.
Algorithms↗
Immunohistochemical localization of insulin-degrading enzyme along the rat intestine, in the human colon adenocarcinoma cell line (Caco-2), and in human ileum.
Insulin-degrading enzyme (IDE) has been implicated in the intracellular degradation of insulin in insulin target cells. Knowledge of the existence of this enzyme in the intestine will be beneficial to the achievement of clinical oral efficacy of insulin. A comparative study was conducted with rat intestine, human colon adenocarcinoma (Caco-2) cells, and human ileum. Confocal microscopy analysis using the anti-IDE antibody showed that IDE was localized in the mucosal cells of rat and human intestines, as well as in Caco-2 cells. Immunostaining of this enzyme was homogeneous throughout the cell excluding nucleus, indicating a typical cytosolic distribution in rat and human enterocytes and in Caco-2 cells.
Adenocarcinoma↗
Osmotic therapy for acute irreducible stoma prolapse.
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Colonic Diseases↗
Experimental model of pudendal nerve innervation of a skeletal muscle neosphincter for faecal incontinence.
BACKGROUND: Faecal incontinence is difficult to treat. A variety of reconstructive procedures has been described, but none is entirely satisfactory. This study evaluated the feasibility of cross-innervating a skeletal muscle neosphincter with the pudendal nerve in a canine model. METHODS: Thirty dogs were rendered surgically incontinent (the pudendal nerve was cut and the external sphincter was partially excised). A neosphincter was then created using the semitendinosus muscle. In ten dogs pudendal nerve transposition (PNT) to the nerve to the semitendinosus muscle was performed. Ten dogs were given a dynamic neosphincter by inserting a pulse generator at 6 weeks. The remaining ten dogs served as controls with passive semitendinosus wraps. Anal manometry was performed before operation and monthly for 5 months. Muscle biopsies, performed at the initial operation and at 5 months, were stained for slow- and fast-twitch fibres, and were examined histologically. RESULTS: At 1 month, mean sphincter function was 32 per cent of the preoperative value in the control animals, 34 per cent in the PNT group and 27 per cent in the electrostimulation group; all dogs were incontinent. At 5 months the mean recovery of sphincter function was 42 per cent of the preoperative value in controls, 100 per cent in dogs with PNT (P < 0.001) and 63 per cent in dogs having electrostimulation (stimulator on) (P = 0.02). Six dogs with PNT had squeeze pressures equal to or greater than preoperative levels. At 5 months the ratio of slow to fast fibres was significantly greater in all dogs (control P = 0.01, PNT P < 0.005, electrostimulation P < 0.001). CONCLUSION: Use of the pudendal nerve to innervate a canine skeletal muscle anal wrap produced a functional anal sphincter that was superior to electrically stimulated and passive wraps.
Anal Canal↗
The Hartmann procedure. First choice or last resort in diverticular disease?
OBJECTIVE: To critique changing trends in the surgical management of diverticular disease. DESIGN: Case series. Two hundred twenty-seven consecutive patients required surgery for diverticular disease from 1988 to 1993. Patient records were reviewed retrospectively. Operative procedures included primary resection in all patients with either anastomosis, anastomosis with proximal ileostomy, or the Hartmann procedure. Morbidity, mortality, and length of stay were then compared with each operative procedure and stage of disease. Patients were categorized according to the following pathologic stages: stage 0, no inflammation; stage I, chronic inflammation; stage II, acute inflammation with or without microabscesses; stage III, pericolonic or mesenteric abscess; stage IV, pelvic abscess; and stage V, purulent or feculent peritonitis. SETTING: A university hospital and private affiliated hospitals in a large metropolitan area. MAIN OUTCOME MEASURES: Study outcome parameters included mortality, morbidity, length of hospital stay, and leak rates. These outcomes were then compared with different disease stages and treatments. RESULTS: Mean patient age was 66 years (range, 25-98 years). Male-female ratio was 84:143. Mean follow-up was 23 months (range, 1-132 months). There were 50 fistulas: 24 colovesical, 21 colovaginal, 3 colocolonic, 1 coloenteric, and 1 colouterine. Surgery was categorized as elective for 196 patients (86%), urgent for 12 (5%), and emergent for 19 (8%). Primary resection was performed in all cases. Primary anastomosis was performed in 200 patients (88%), 183 without and 17 with proximal diversion. Twenty-seven patients (12%) underwent a Hartmann procedure with colostomy; 19 patients (70%) have since undergone colostomy closure. Morbidity occurred in 52 patients (23%), including 4 anastomotic leaks (2%). There were 3 perioperative deaths (1%). Mean length of initial hospital stay was 11 days (range, 4-59 days). Length of stay was 5 days (range, 4-7 days) for ileostomy closure (7% morbidity) and 13 days (range, 7-35 days) for the colostomy closure after the Hartmann procedure (33% morbidity). CONCLUSIONS: Primary resection is virtually always possible in complicated diverticular disease. Primary anastomosis, with or without proximal diversion, is safe for patients with no abscesses or localized abscesses and should be considered on an individual basis for patients with pelvic abscesses and peritonitis. Colostomy closure after the Hartmann procedure is associated with significant length of hospitalization and morbidity and leaves one third of patients with permanent stomas.
Adult↗
Carcinoid tumor: an extremely unusual presacral lesion. Report of a case.
PURPOSE: Use of endorectal ultrasonography in preoperative evaluation of a presacral lesion is demonstrated. METHOD: The natural history, presentation, evaluation, and treatment of presacral lesions in adult patients are presented. The case of a female patient with a presacral carcinoid tumor is presented and discussed. RESULTS: The patient underwent preoperative evaluation including physical examination, hematologic studies, proctosigmoidoscopy, magnetic resonance imaging, computed tomographic scanning, and endorectal ultrasonography. Ultrasonography proved to be extremely valuable in differentiating tumor compression from tumor invasion of the rectal wall. The patient underwent en bloc excision of the lesion, surrounding tissue, and coccyx. Pathologic diagnosis was carcinoid tumor, possibly replacing a presacral lymph node. Postoperative complete gastrointestinal tract work-up and urinary 5-hydroxyindoleacetic acid analysis along with preoperative imaging revealed no evidence of synchronous lesions or additional metastases. CONCLUSIONS: Presacral lesions are extremely rare entities. The role of endorectal ultrasonography has not been clearly defined. This case demonstrates the value of this simple and safe imaging procedure in detecting bowel wall compression vs. invasion, greatly assisting in planning an operative approach.
Carcinoid Tumor↗
Artificial anal sphincter.
PURPOSE: This study was undertaken to evaluate the use of a fully implanted artificial anal sphincter for management of severe fecal incontinence. METHODS: An artificial anal sphincter was implanted in 12 patients who failed conventional management for severe fecal incontinence. Careful patient follow-up was recorded during a mean 58-month follow-up. Patients underwent preoperative and postoperative manometric assessment. Functional and patient satisfaction evaluations were obtained by mailed questionnaire. RESULTS: Three infections and three mechanical complications occurred in four patients (33 percent). A successful outcome was achieved in nine patients (75 percent). Postoperative manometric studies documented establishment of an elevated high-pressure zone compared with preoperative resting pressures. Seven patients returned a detailed functional assessment and patient satisfaction questionnaire at a mean of 40 months postsphincter activation. All seven patients reported continence to solid stool. Two patients had some problems with control of liquid stool, and three had occasional incontinence to flatus. Six of the seven patients rated their bowel control as good to excellent. All seven respondents were satisfied with their functional improvement. CONCLUSIONS: Early experience with an artificial anal sphincter has demonstrated that continence can be restored with acceptable morbidity in patients with severe fecal incontinence.
Activities of Daily Living↗
The presence of insulin-degrading enzyme in human ileal and colonic mucosal cells.
The aim of this research is to characterize the presence of insulin-degrading enzyme in human colon and ileal mucosal cells. Biochemical studies, including the activity-pH profiles, the effects of enzyme inhibitors, immunoprecipitation and western blots, were conducted. The majority of insulin-degrading activity in colon mucosal cells was localized in the cytosol. In both colon and ileum, cytosolic insulin-degrading activities had a pH optimum at pH 7.5, and were extensively inhibited by each of N-ethylmaleimide, p-chloromercuribenzoate, and 1,10-phenanthroline, but were very weakly affected by each of leupeptin, chymostatin, diisopropyl phosphofluoridate and soybean trypsin inhibitor. In the colon and ileum, more than 93% and 96%, respectively, of cytosolic insulin-degrading activities were removed by the mouse monoclonal antibody to human RBC insulin-degrading enzyme, as compared with less than 20% by the normal mouse IgG for both tissues. Further, a western blot analysis revealed that a cytosolic protein of 110 kD, in both human colon and ileum, reacted with the monoclonal antibody to insulin-degrading enzyme. It is concluded that insulin-degrading enzyme is present in the cytosol of human colon and ileal mucosal cells.
Animals↗
A method for predicting the volume of an ileo-anal pouch.
Functional outcome following restorative proctocolectomy depends, in part, on the volume of the pouch. This study investigates the relationship between the length of ileum and volume of saline required to distend the ileum to a set pressure, and the possibility of predicting the volume of an ileoanal pouch using these measurements. Measurements were made on the ileum of 8 mongrel dogs. There was a linear relationship between the length of ileum and volume of saline infused to produce an intraluminal pressure of 20 mmHg (r = 0.94-0.99). However, the capacity of ileum varied widely from animal to animal (100 cc of saline filled 15.5 cm to 43 cm of ileum). Twenty-four pouches (15J, 9S) were constructed from segments of ileum of known capacity. The capacity of a J pouch was 1.71 +/- 0.11 times greater than the capacity of the original length of bowel and an S pouch had a capacity 2.14 +/- 0.25 times greater. These changes in capacity are similar to a theoretical calculation of change in volume of ileum after pouch construction. This technique is a simple, quick method of predicting the volume of an ileo-anal pouch which will be useful in a clinical trial to compare function of pouches of different volumes.
Animals↗
Pouchitis and empiricism: can we progress?
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Humans↗
Relevant clinical information and tumor markers.
The preoperative clinical assessment of patients with colorectal cancer provides the surgeon with sufficient information to allow an accurate assessment of operative risks, to plan the extent of resection needed to remove the primary and any associated synchronous lesions, to determine whether perioperative care should be modified to enhance the safety of the proposed surgery (bowel preparation, ureteral catheters, or ostomy placement), to determine operability and probable intent of surgery (curative or palliative), and to determine whether additional, more sophisticated testing is needed to better stage the disease to determine prognosis and ideal treatment. The surgeon, through the process of informed consent, must properly balance these patient and disease factors to select and plan the appropriate treatment that maximizes the potential for cure while minimizing morbidity and mortality.
Biomarkers, Tumor↗
Surgery for complicated diverticulitis.
The surgical treatment of acute, complicated diverticulitis remains controversial. No randomized studies have been performed to clarify which operative procedure best fits each situation. As a result, the surgeon must use accumulated knowledge and judgment to make the correct decisions for an individual patient. The morbidity and mortality of patients with complicated diverticular disease in 1993 depend, not so much on the operative procedure, but on the severity of the disease and the associated comorbid conditions, namely the presence of fecal or purulent peritonitis, past medical problems, immune status, and nutritional status. However, adherence to the several principles detailed in this report will minimize morbidity and mortality. The surgeon should always attempt to convert the patient from an emergency to an urgent or elective operative status. In the absence of free perforation, this goal usually can be achieved. Rushing into surgery in patients with a normal immune system is generally ill advised. It is far preferable to stabilize the patient, percutaneously drain abscesses if possible, prepare the bowel before exploration, and thus keep the option of primary anastomosis open. A primary anastomosis done first thing in the morning is far preferable to an end-stoma created in the middle of the night in an emergency situation. The algorithm displayed in Figure 1 provides a useful guideline for treating patients with complicated diverticulitis.
Acute Disease↗
[Etiology of "pouchitis"].
"Pouchitis" remains an unsolved problem which affects the lives of significant numbers of patients who have undergone an ileal pouch-anal anastomosis procedure for ulcerative colitis or familial adenomatous polyposis. Conditions which mimic "pouchitis" include overflow incontinence, specific infections, ischemic enteritis, peri-pouch sepsis and Crohn's disease. Current theories of etiology and implications for treatment are examined in this review article.
Bacterial Infections↗
Ileal pouch-anal anastomosis. Patterns of failure.
During the period from 1980 through 1990, our institution constructed 253 ileoanal reservoirs in 253 patients, of whom 25 (9.9%) experienced pouch failure. A poor functional result was the most common cause of pouch failure (seven [28%] of 25 patients). Unsuspected Crohn's disease became manifest in 13 (5%) of the 253 patients, resulting in pouch loss due to perianal sepsis or pouch fistulas in six patients (24% of 25 failures), and resulted in a significantly increased risk of pouch failure compared with that of the non-Crohn's population. Pouchitis occurred in 78 patients (31%) and accounted for four (16%) of 25 failures, but patients with pouchitis were not at higher risk for pouch failure than were patients who did not have pouchitis (failure rates of 6.4% vs 10.4%, respectively; not significant). Significant pelvic sepsis in the absence of Crohn's disease developed in 13 patients, five (38%) of whom lost their pouches. Poor functional results, pelvic sepsis, and unsuspected Crohn's disease were the major causes of pouch failure, while pouchitis was not.
Age Factors↗
Treatment of rectal prolapse in the elderly by perineal rectosigmoidectomy.
The results and complications of perineal rectosigmoidectomy for complete rectal prolapse in 114 patients have been reviewed. Most patients were elderly and high risk by virtue of other concurrent medical conditions. Fourteen patients (12 percent) developed significant postoperative complications. Hospital stay was short (median, four days). Ten patients were lost to follow-up. The remaining 104 patients were followed for 3 to 90 months. Eleven patients (10 percent) developed recurrent full-thickness rectal prolapse, six of them underwent repeat perineal rectosigmoidectomy. Sixty-seven patients had fecal incontinence prior to surgery. Eleven patients underwent concomitant levatoroplasty; 10 of them either improved or regained full continence of feces postoperatively. Twenty-six of the 56 patients who underwent perineal rectosigmoidectomy alone improved or regained full continence. Rectal prolapse can be successfully treated by perineal rectosigmoidectomy in elderly, high-risk patients with minimal morbidity. Levatoroplasty dramatically improves fecal incontinence occurring in association with rectal prolapse.
Adult↗
Symptomatic hemorrhoids: current incidence and complications of operative therapy.
Hemorrhoidal disease affects more than one million Americans per year. We reviewed the treatment pattern for patients who presented with symptomatic hemorrhoids to our large university-affiliated group practice over a 66-month period. Over 21,000 patients presented to the practice with bleeding, thrombosis, or prolapse. Only 9.3 percent of patients required operative therapy. Conservative therapy was given to 45.2 percent of patients, while rubber band ligation was performed on 44.8 percent of patients. We retrospectively reviewed the complications and length of stay for a subset of patients undergoing operative therapy during the 66-month study period. Postoperative urinary complications (retention or infection) were seen in 20.1 percent of patients. Delayed hemorrhage was seen in 2.4 percent of patients. In-hospital length of stay was 2.5 days, which is approximately two days less than the length of stay found in a similar review of our practice in 1978. We conclude that over 90 percent of symptomatic hemorrhoids can be treated conservatively or with rubber band ligation, and, as surgery is reserved for only the most severe cases, complication rates may not decrease. However, we expect that in-hospital length of stay will continue to decrease over the ensuing years.
Female↗