Biomedical subjects
Publications and source records attributed to J M Church.
A case of an aorto-appendicular, aorto-enteric fistula diagnosed by colonoscopy after presentation with colonic haemorrhage is reported. The role of colonoscopy in such patients is discussed and reported experience is reviewed.
The major complications of rectal surgery that are wholly or partially avoidable by the use of an anatomically based dissection are haemorrhage from presacral veins, perforation of the rectum, damage to pelvic autonomic nerves and inadequate clearance of a rectal cancer. Important technical points in minimising the incidence of these complications are: (1) posterior dissection in the presacral space; (2) entry to this space by sharp dissection immediately posterior to the superior rectal artery; (3) deliberate incision of the rectosacral fascia; (4) anterior dissection posterior to Denonvilliers fascia in benign disease; (5) removal of the entire mesorectum for low rectal cancer. Other anatomical points not widely appreciated are: 1. The middle rectal artery does not run in the lateral ligaments of the rectum, but below them, on levator ani. It reaches the rectum by penetrating Denonvilliers' fascia. 2. The lateral ligaments may contain an accessory middle rectal artery in 25% of cases. 3. The pelvic autonomic nerves are buried in endopelvic fascia on the pelvic side wall, but come to lie close to the anterior aspect of the rectum at the level of the prostate or upper vagina.
The records of 93 patients with colocutaneous fistulas associated with diverticulitis treated at the Cleveland Clinic between 1965 and 1983 were reviewed. There were 56 males and 37 females with an age range of 19 to 80 years (median, 57 years). Eighty-eight fistulas followed surgery for diverticulitis while five developed spontaneously. The presence of a diverting stoma in 34 patients did not prevent fistula formation but did decrease morbidity (x2 = 12.75, P less than 0.001). Initial investigations showed a high incidence of recent weight loss (in 40 percent) and hypoalbuminemia (47 percent), although these factors did not influence outcome. Patients with high output (greater than 200 cc/day) fistulas (n = 9) fared significantly worse than those with low outputs. There were 28 patients with fistulas to other organs, 20 involving small bowel. Factors leading to persistence of the fistulas included sepsis (42 cases) and sigmoid colon distal to an intended colorectal anastomosis (38 cases). Ninety-two patients underwent surgery, 80 percent having a one- or two-stage resection and anastomosis. There was one postoperative death and complications occurred in 44 patients (48 percent). Surgery was successful in producing patients without stoma or fistula in 71 cases (77 percent). There were five recurrent fistulas, 14 new fistulas, and 13 patients retained their stomas. A diagnosis of Crohn's disease was made in ten patients who had a high rate of complicated fistulas, recurrent fistulas, and retained stomas. Patients with carcinomas (n = 5) also did poorly, but those on systemic steroids (n = 7) fared no worse than patients not receiving them. This study emphasizes the role of diversion of the fecal stream in reducing the morbidity of colonic fistulas. It is clearly important to carry out a true colorectal anastomosis after resection for diverticulitis, and in patients with unusually complicated clinical courses, the diagnosis of Crohn's disease should be entertained.
Between January 1982 and December 1985, 355 fiberoptic pouchoscopies were performed in 123 patients with a continent ileostomy. These examinations have been reviewed to determine the effectiveness of the technique as a diagnostic and therapeutic tool. The Olympus GIF-XP pediatric endoscope was used after pouch lavage, and the afferent loop of ileum, the pouch, and (by retroflexion) the nipple valve were examined on each occasion. There were 63 males and 60 females, with a median age of 35 years (range, 16 to 71 years). The median length of follow-up after pouch construction was 36 months (range, 6 to 120 months), and an average of three examinations were performed per patient (range, 1 to 12). Of 127 examinations performed in asymptomatic patients, the pouch was normal in 117 cases, and there was mesh erosion into the pouch in 10 cases. The remaining 228 examinations were for symptoms that included pouchitis (56), difficulty in intubation (47), incontinence (35), follow-up of treated pouchitis (18), parastomal sepsis (22), blood in the stool (13), anemia (8), excess mucus discharge (6), valve prolapse (4), and purulent discharge from the stoma (1). Eighty-four examinations were normal; 144 revealed a likely cause for the symptoms and led to appropriate treatment, which in 45 patients was surgical. Fiberoptic endoscopy was therapeutic in 6 patients in whom it was used on 10 occasions to intubate a pouch with a slipped valve. Radiographic studies were seldom used, with pouchograms being carried out in 16 patients and fistulograms in 5. Only the fistulograms contributed to the assessment of each patient.(ABSTRACT TRUNCATED AT 250 WORDS)
Malnourished patients without cancer have abnormal glucose metabolism, low activities of the key enzymes of glycolysis in muscle, and abnormal muscle fiber-type distribution. Malnutrition in cancer is also associated with altered glucose metabolism, and therefore muscle enzyme activities and fiber types were measured in 17 malnourished patients with gastrointestinal cancer (weight loss, 18.1% +/- 7.9 SD). These patients were matched with 17 depleted noncancer patients (weight loss, 22.8% +/- 10.25 SD) and 17 normal controls. Results of in vitro measurement of the maximal activity of phosphofructokinase (PFK), hexokinase (HK), and oxogluterate dehydrogenase (OGD) were similar in both undernourished groups and lower than that of normal controls. Both groups also had reduced Type II fiber size and number. The activity of fructose bisphosphatase (FBP) was significantly higher in cancer patients (0.62 mu ml min-1 g +/- 0.26 SD) than in noncancer patients (0.39 +/- 0.15), but similar to that in controls (0.65 +/- 0.29). As FBP is involved in substrate cycling, inappropriately high activity reflects an inability to adapt to malnutrition that could lead to high rates of cycling and wasteful energy expenditure at times of maximal activation of the cycle.
The records of 133 consecutive patients (65 men, 68 women; age range, 15 months to 88 years; median, 57 years) with either a positive Clostridium difficile stool culture or toxin assay from 1982 to 1984 were reviewed in order to assess the pattern of this disease in a large hospital and to examine the type of patient at risk. All patients had diarrhea and/or bloody stools (121 and 36, respectively). Less specific symptoms were common. Most patients had been exposed to multiple antibiotics, but of those who had received only one agent, cephalosporins were most common (21/43). Nineteen patients had cancer chemotherapy. C. difficile toxin assay was positive in 106, culture was positive in 74, and pseudomembranes were seen in six of the 39 patients who underwent endoscopy. Treatment consisted of stopping antibiotic therapy alone (86 percent response), oral vancomycin (88 percent response) or metronidazole (82 percent response). The overall mortality rate was 23 percent, due to C. difficile colitis in three of 31 cases. Many patients were receiving medications or had other diseases associated with fecal stasis. There is much circumstantial evidence to support a role for fecal stasis in the pathogenesis of C. difficile disease. Patients predisposed to colonic stasis who are receiving antibiotics should be considered at risk for this disease, and preventative measures should be taken to decrease stool transit times.
Colon perforation in renal transplant recipients is a potentially lethal condition that is amenable to appropriate medical and surgical treatment. The 11 cases seen at the Cleveland Clinic (incidence 1.1% of all renal transplant patients) and previous reports in the literature have been reviewed. The pathogenesis is related to a high incidence of diverticular disease in patients with polycystic kidneys and/or chronic renal failure, the effects of long-term immunosuppression, and the transplant procedure itself. The high mortality of this condition (61% overall) is related to the effects of immunosuppression on the response to sepsis and the surgical procedure used. Mortality has fallen from 88% (1970-1974) to 53% (1975-1979), and there are indications that it is continuing to fall. All four cases operated on here since 1980 have survived, giving a total operative mortality of 2/6, and all have maintained excellent allograft function. A high clinical index of suspicion, prompt exteriorization of the perforated colon, reduction of immunosuppression to minimal levels, and effective antibiotic coverage have all contributed to the declining mortality.
The clinical courses of 114 patients with positive Clostridium difficile cultures or toxin assays performed between 1981 and 1984 were reviewed to determine the relationship between outcome of treatment and quantitative bacteriologic test results. C. difficile culture was positive in 60 of 91 patients while toxin assay was positive in 99 of 114. One third of the patients received supportive therapy only, and 30 percent of these failed to resolve their symptoms. Ninety-one percent of the patients treated with vancomycin resolved, although 11 percent of these suffered relapse. Patients with high toxin titers receiving supportive treatment alone showed a lower response rate than patients with lower toxin titers. This effect was not seen in patients treated with specific therapy nor with different culture quantities. C. difficile colitis has a range of clinical and microbiologic manifestations. Endoscopy is not always diagnostic, both culture and toxin assays are needed for diagnosis, and toxin titer may help in planning treatment. Patients with low toxin titers may be treated supportively, but high toxin titers are an indication for specific therapy. Quantitative culture results have little diagnostic or therapeutic value.
Patients with carcinoma involving chronic fistulizing Crohn's disease may have developed the malignancy due to chronic epithelial irritation at either end of the fistula tract. Alternatively, the carcinoma may be the cause of the fistula. Examples of each type of relationship are presented in the reports of four patients from our institution and supported by a review of the literature. The diagnoses of such carcinomas are often delayed due to lack of specificity of symptoms and signs. A high index of suspicion and regular surveillance of high-risk patients are recommended.
Malnourished surgical patients have metabolic and functional abnormalities of skeletal muscle and it has been suggested that these are due to reduced activities of glycolytic enzymes associated with abnormalities of muscle fibres. We have measured the activities of four key enzymes of glucose utilization and the size and distribution of muscle fibre types in vastus lateralis biopsies from 14 undernourished patients awaiting surgery (mean weight loss 24 +/- 10 per cent). These results were compared with those from 14 normally nourished controls, comparable in age, sex, race and habitual activity. Fructose bisphosphatase activity was reduced in undernourished patients by 44 per cent (P less than 0.01), phosphofructokinase by 40 per cent (P = 0.005) and hexokinase by 37 per cent (P less than 0.001). Both fibre types were smaller in patients than controls (area I, 41.4 micron2 X 10(-2) +/- 0.4 vs. 73.3 micron2 X 10(-2) +/- 0.6, less than 0.001; area II, 27.7 micron2 X 10(-2) +/- 0.4 vs. 72.5 micron2 X 10(-2) +/- 0.5, P less than 0.001), and there was a smaller proportional number of type II fibres in patients (35 per cent vs. 65 per cent, P less than 0.01). This loss of type II fibre numbers and preferential type II atrophy may account for the enzyme depression associated with it and could produce the syndrome of impaired glucose tolerance, muscle weakness and fatigue seen in undernourished patients. In a subgroup of 11 patients, biopsy was repeated after 14 days of intravenous nutrition. Only phosphofructokinase activity rose significantly (19.62 +/- 1.85 to 30.74 +/- 2.99 mumol min-1 g-1, P less than 0.01) and both type II fibre size (40.6 +/- 18.5 to 47.4 micron2 +/- 20.3 X 10(-2), P less than 0.05) and number (42 per cent +/- 6 to 56 per cent +/- 5, P less than 0.05) also rose. Intravenous nutrition may therefore increase maximum glycolytic rate and improve muscle function in undernourished surgical patients.
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Colonoscope insertion from anus to cecum requires a sound basic technique that minimizes looping and maintains a straight scope. Four adjunct techniques may help advance insertion but none has been carefully evaluated. Accordingly, data were collected prospectively from 417 patients undergoing colonoscopy by the author. There were 223 males and 194 females with a median age of 60 years (range 12-94 years). Colonoscopy was complete in 405 cases (97.1%). The incidence and effectiveness of the four maneuvers were: hold breath (63%, 32%), abdominal pressure (65%, 60%), turn on left side (36%, 42%), turn on right side (19%, 77%). All 4 techniques were used in 54 patients (13%); 3 were used in 98 (24%); 2 in 98 (24%); 1 in 53 (13%); and none in 114 (27%). These ancillary techniques were more often used in females than males (P = 0.01); in intact colons more often than those after left colectomy (P = 0.001); and in patients of slim build than those of normal build (P = 0.04). Of the four techniques, abdominal pressure was most often used and turning on the right side was most often effective.
Endoscopic ultrasound (EUS) was performed prospectively to stage 45 patients with rectal cancer. Patients were staged utilizing the TNM staging system. All patients subsequently underwent surgical resection with independent histopathologic staging. Depth of invasion was accurately predicted in 40 of 45 patients (89%). Presence or absence of lymph node metastasis was correctly determined in 34 of 45 patients (79%). EUS is an accurate method for local staging of rectal cancer.
We have compared the direction of changes in four plasma transport proteins measured weekly with the direction of nitrogen balance in general surgical patients receiving intravenous nutrition (IVN). Fifty four patients had IVN for 2 weeks, and 15 had IVN for 3 or 4 weeks. Change in plasma prealbumin followed the direction of nitrogen balance in both weeks of IVN in 39 of 54 of the former group, whereas none of the other plasma proteins achieved 50% accuracy. A weekly rise in plasma prealbumin had a sensitivity of 88%, specificity of 70%, positive predictive value of 93%, and negative predictive value of 56% in detecting positive nitrogen balance. Results in the patients who received 3 or 4 weeks of IVN showed an improvement in negative predictive value to 79%. None of the other plasma proteins performed as well. Twelve patients suffered a major complication of their disease or died, following their course of IVN. Nitrogen balance was the best prognostic indicator of these patients, whereas a fall in prealbumin was the best of the plasma proteins, with a sensitivity of 67%, specificity of 79%, positive predictive value of 40%, and negative predictive value of 92% in determining the incidence of complications. Prealbumin was the most suitable plasma protein for use as a dynamic index of nutritional progress in the type of patient seen in this study.
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