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PubMed2006

[Gonorrhea].

Infection with Neisseria gonorrhoeae is a frequent occurrence. It is almost always transmitted via sexual intercourse and the risk of infection is markedly higher for women than for men. Purulent secretion characterizes the clinical picture. After an incubation period of 2-6 days, for the most part urethritis, cervicitis, proctitis, pharyngitis, or conjunctivitis usually develops. Condoms offer good protection against gonococcal infection. The treatment of choice in Central Europe is a single dose of Cefixime.

Anti-Bacterial Agents↗
PubMed2001

Bone mineral density and body composition in ulcerative colitis: a six-year follow-up.

Reduced bone mineral density (BMD) has been reported in ulcerative colitis (UC), but there are no data concerning body composition (fat and lean mass) in such patients. We used whole body dual-energy X-ray absorptiometry (Hologic QDR 1000 W) at baseline and after 6 years of follow-up to study bone density, and fat and lean mass in 43 outpatients with mild UC (21 men, mean age 36 years, range 21-57 years, and 22 women, mean age 35 years, range 23-45 years at baseline; disease extent: 2 proctitis, 18 proctosigmoiditis, 8 left colitis, 5 substantial colitis, 10 pancolitis; mean disease duration 8 years, range 2-18 years; no hospitalization; few relapses during the follow-up) and 111 healthy volunteers matched by sex, age and body mass index. There were 5 drop-outs. We observed no significant difference in BMD, or fat and lean mass between the male patients and controls at baseline or after 6 years. The total lean mass (Z-score = -3.2, p = 0.001) and trunk lean mass (Z-score = -2.01, p = 0.03) of the female patients were lower than those of the controls at baseline, whereas their limb lean mass was higher at both the beginning and the end of the study (Z-score = 2.14, p = 0.03; Z-score = 2.8, p = 0.004, respectively). At baseline there was a significant negative correlation between lifetime steroid intake (enteral and parenteral) and lumbar spine BMD, obtained as whole body subregion (r = -0.53, p = 0.0006). After 6 years there was a significant negative correlation in women between whole body and lumbar spine BMD and both steroid intake (r = -0.53, p = 0.01; and r = -0.62, p = 0.003) and the number of relapses (r = -0.49, p = 0.02; and r = -0.44, p = 0.05). Mild UC thus does not represent a risk factor for osteopenia per se. The differences in lean mass between the female patients and controls do not seem to be clinically relevant.

Absorptiometry, Photon↗
PubMed1996

Chronic recurrent multifocal osteomyelitis: an evolving clinical and radiological spectrum.

OBJECTIVE: To describe unusual clinical and radiological features in patients with chronic recurrent multifocal osteomyelitis (CRMO). DESIGN AND SUBJECTS: Based on radiographic and microscopic findings, three patients were prospectively diagnosed as having chronic recurrent multifocal osteomyelitis (CRMO). They form the basis of this report because of either the unusualness of the clinical presentation, hitherto undescribed associated diseases or the unusual age of presentation and sites of lesions. RESULTS: One patient developed pyoderma gangrenosum at the site of one of the skeletal lesions and then went on to develop ulcerative proctitis. A second patient presented with a soft tissue mass, which on MRI mimicked a sarcoma. The final patient presented with lesions in the wrist and phalanges of the toes at the unusual age of 38. None of the patients was treated with steroids or antibiotics for the skeletal lesions. Steroids were administered to one patient for treatment of pyoderma gangrenosum. CONCLUSIONS: The pattern and distribution of skeletal lesions in CRMO are well recognized in the pediatric age group. The unusual clinical and/or radiological features discussed herein suggests that this is a disease that continues to evolve with a broader spectrum of features than recognized.

Adult↗
PubMed2005

Reappraisal of surgical treatment for radiation enteritis.

Although radiation enteritis is a well-recognized sequel of therapeutic irradiation, the standard surgical method is not universally agreed upon. Not only the short-term effect but also the long-term effect after a surgical intervention has been fairly well reported. To reassess the surgical therapy for radiation enteritis, we retrospectively analyzed 48 patients (5 males and 43 females, mean age 58.6 years) who had been operated on in our department. These patients were divided into two types according to the time of surgery or the clinical manifestation, and operative methods were analyzed. Patient's status such as bowel movement, body weight, and serum albumin value after surgery were analyzed, together with the patients survival. Our surgical methods were small intestinal resection for the intestinal obstruction, and pull-through reconstruction for proctitis. Two patients died of multiple organ failure caused by perforated peritonitis irrespective of emergent operation. Although the overall morbidity was 21.7%, there was no leakage when bowels were anastomosed. Overall survival after radiation-related complication in patients without previous neoplastic disease recurrence was 89%, 79%, and 69%, at 1, 3, and 5 years after surgery, respectively. Bowel motility, serum albumin level, and body weight recovered gradually soon after the operation and reached satisfactory levels within 6 months. Our analysis showed that small bowel injury should be treated by generous resection of the affected bowel followed by careful anastomosis of the disease-free ends, while rectal resection is best dealt with by restorative proctectomy. This may provide a good quality of life and minimize major postoperative complications such as leakage.

Adult↗
PubMed1997

Absorption kinetics of rectal formalin instillation.

Formalin instillation has become an accepted treatment of radiation-induced hemorrhagic cystitis and proctitis since the initial report by Brown in 1969 (Med. J. Aust. 1:23, 1969). Although its use is widespread, no studies have been performed to determine the safest, volume or duration of formalin exposure. The purpose of our study was to determine the optimum technique for instillation and the safety margin regarding the maximum time that formalin can be in contact with the rectal mucosa without causing serum toxicity. In a pilot canine study, 4% neutral buffered formalin was instilled into the rectum in 30 ml aliquots for 60 seconds each after which each aliquot was withdrawn; a total volume of 400 ml was used. Our subsequent experiment involved rectal instillation of a single formalin bolus of 100 ml for 1 hour without removal during this time. Formalin metabolites were measured in the blood and urine to assess toxicity. Results indicate that with the latter technique serum formic acid reaches toxic levels within 15 minutes of instillation and may stay elevated for several hours. Metabolites in the urine similarly increase within 15 minutes, lagging only shortly behind the rise in serum levels. Performing formalin instillation in a series of 30 ml aliquots appears to be a safer treatment, as toxic serum levels were not reached and their slight rise above baseline returned to normal within 3 hours.

Administration, Rectal↗
PubMed2002

Advances in interventional gastrointestinal endoscopy in colon and rectum.

BACKGROUND: Instrumental and procedural advances particularly in the therapeutic field have been achieved. REVIEW: Endoscopes with larger working channel, additional jet-channel, or variable stiffness allow more sophisticated interventional procedures. Higher resolution in endoscopic image quality helps to identify early lesions that can be treated endoscopically at this stage. Polypectomy and mucosectomy are no longer limited by the size of the lesion. Piecemeal technique is established, and a retrieval net is available for collecting all pieces obviating repeated introductions of the endoscope. In addition to snare polypectomy and mucosectomy, laparoscopy-assisted polypectomy and full-thickness resection are discussed. Self-expandable metal stents are used to decompress malignant colonic obstruction allowing for either preoperative bowel preparation and elective surgery or for noninvasive palliation. Argon plasma coagulation is an inexpensive and effective method for the treatment of bleeding from radiation proctitis.

Colon↗
PubMed2004

Ileocecal reservoir reconstruction after total mesorectal excision: functional results of the long-term follow-up.

BACKGROUND: The aim of this study is to obtain functional results of the long-term follow-up after TME and ileocecal interposition as rectal replacement. METHODS: The study included patients operated on between March 1993 and August 1997 who received an ileocecal interposition as rectal replacement. Follow-up was carried out 3 and 5 years postoperatively. For statistical analysis, the paired t-test, rank test (Wilcoxon), and chi-square or Fisher's exact test were applied; level of significance, P<0.05. RESULTS: Forty-four patients were included in the studies. Of these, five were not available and four patients could not be evaluated (dementia 1, radiation proctitis 1, fistula 1, pouchitis 1). Seventeen patients died during the observation period; 12 died of the disease. Recurrence of the disorder occurred in 2 of 35 patients (5.7%); 26 and 18 patients, 3 and 5 years postoperatively, respectively remained in the study. At 5 years, 78% of the patients were continent; mean stool frequency was 2.5+/-1.6 per day. CONCLUSIONS: Functional results and subjective assessment of ileocecal interposition were constant at 3 and 5 years postoperatively. If construction of a colonic J-pouch is not possible due to lack of colonic length, especially after prior colonic resections, the ileocecal interpositional reservoir may offer an alternative to rectal replacement.

Anastomosis, Surgical↗
PubMed2005

Complications and reoperations in stapled anopexy: learning by doing.

Although stapled anopexy for second and third degree hemorrhoids has been widely used since 1998, there are limited long-term data available. We performed an analysis of a prospectively accrued data set of all patients undergoing stapled anopexy in our practice from 1998 through August 2003. Patients were specifically assessed for early and late complications and long-term reoperation rates for anorectal pathology. We performed stapled anopexy in 654 patients (296 females) during the study period. Mean operation time was 21 min (5-70 min), and the postoperative stay was 3.6 days (1-13 days). Early postoperative complications: urinary retention, 42 patients (6.4%); fecal impaction, 18 (2.8%); postoperative hemorrhage, 26 (4.0%); thrombosed external hemorrhoid, four (0.6%); and fistula/abscess, nine (1.4%). Late postoperative complications: anastomotic dehiscence, 21 patients (3.2%); persistence of prolapse in three (0.5%); submucosal anastomotic cysts in four (0.6%); thrombosed external hemorrhoid in two (0.3%); skin tags in ten (1.5%); fissure in six (0.9%); proctitis in two (0.3%); and fecal incontinence in ten (1.5%). Reoperation was required in 50 patients (7.6%). Reoperation for complications within 30 days occurred in 42 patients (6.4%) for the following reasons: bleeding (23), dehiscence (five), thrombosed external hemorrhoid (three), fecal retention (two), fistula (three), fissure (five), and anal papilla (one). Reoperation for anorectal pathology after 30 days was required in 54 patients (8.3%) and was performed for the following: dehiscence/reprolapse (17), stenosis (two), submucous cyst (two), fistula (four), fissure (six), anal papilla (four), skin tags (five), persistent anal itching (five), and miscellaneous (seven). These data represent the largest series of patients with long-term follow-up following stapled anopexy and confirm that the operation is safe in experienced hands using appropriate patient selection. The early complication rate is low and similar to rates reported for excisional hemorrhoidectomy. Importantly, the procedure is associated with a low 3.4% rate of reoperation for persistence or recurrence of hemorrhoidal prolapse with good patient selection.

Adult↗
PubMed1997

Laparoscopic creation of stomas.

BACKGROUND: Some indications for laparoscopic bowel surgery are still controversial. However, the use of laparoscopic techniques for the treatment of benign disorders is less often challenged. Moreover, the morbidity of nonresectional procedures is less than that encountered with resectional cases. Therefore, stoma creation seems ideally suited to laparoscopy. The aim of our study was to assess the outcome of laparoscopic stoma creation. METHODS: All patients who underwent laparoscopic intestinal diversion were evaluated; parameters included age, gender, indication for the procedure, history of previous surgery, operative time, length of hospitalization, recovery of bowel function, and postoperative complications. RESULTS: Between March 1993 and January 1996, 32 patients of a mean age of 42.2 (range 19-72) years (14 males, 18 females) underwent elective laparoscopic fecal diversion (25 loop ileostomy, four loop colostomy, three end colostomy). Indications for fecal diversion were fecal incontinence (n = 11), Crohn's disease (n = 6), unresectable rectal cancer (n = 4), pouch vaginal fistula (n = 3), rectovaginal fistula (n = 2), colonic inertia (n = 2), radiation proctitis (n = 1), anal stenosis (n = 1), Kaposi's sarcoma of the rectum (n = 1), and tuberculous fistula (n = 1). Conversion was required in five patients (15.6%) due to the presence of adhesions (three), enterotomy (one), or colotomy (one). All of these five patients had undergone previous abdominal surgery and were operated on early in our experience. Major postoperative complications occurred in two patients (6%) and in both cases consisted of stoma outlet obstruction after construction of a loop ileostomy. One of the two patients had undergone prior surgery. This patient required reoperation, at which time a rotation of the terminal ileum at the stoma site was found. The other patient had a narrow fascial opening which was successfully managed with 2 weeks of self-intubation of the stoma. The mean operative time was 76 (range 30-210) min; mean length of hospitalization was 6.2 (range 2-13) days; stoma function started after a mean of 3.1 (range 1-6) days. Patients with previous abdominal surgery had a longer mean operative time (14/32; 117 min) compared to patients who had no previous surgery (18/32; 55 min) (p < 0.0002). These longer operative times and hospital stay were attributable to extensive enterolysis, which was required in some cases. CONCLUSION: In conclusion, laparoscopic creation of intestinal stomas is safe, feasible, and effective. Although the length of the procedure is longer in patients who have had prior surgery, previous surgery is not a contraindication, and even in these cases, a laparotomy can be avoided in the majority of patients. Lastly, care must be taken to ensure adequate fascial opening and correct limb orientation.

Adolescent↗
PubMed2006

Restorative proctocolectomy for pediatric patients with ulcerative colitis.

PURPOSE: A restorative proctocolectomy has become an elective surgical treatment for patients with ulcerative colitis (UC). In children with UC, however, the role of this procedure has not yet been well evaluated. We investigated the postoperative status of pediatric patients with UC regarding the side effects of steroids, postoperative complications, and growth. METHODS: The medical records of 15 patients with UC who underwent a restorative proctocolectomy between August 1993 and October 2003 were retrospectively reviewed. RESULTS: Their mean age was 12.6 +/- 3.4 years (range 5.7-15.7; boys: 9, girls: 6). All patients had total colitis, except for one who had left-sided colitis. The mean cumulative dose of preoperative prednisolone was 6201 +/- 7980 mg (mean +/- SD). The operative indications were an unsuccessful response to medical treatments in 12 patients (80%) and severe colitis in 3 patients (20%). Surgery was performed in one stage in 6 patients and in two stages in 9 patients. Seven patients (47%) demonstrated growth retardation at the time of operation. Steroid-related complications were seen in 3 cases, i.e., steroid myopathy, glaucoma, and cataracts, respectively. As early postoperative complications, an intestinal obstruction was seen in 2 patients, peritonitis in 1, and pancreatitis in 1. As late complications, anastomotic stenosis was observed in 5 patients, pouchitis in 4, residual proctitis in 3, and anal or proctovaginal fistula in 2. An intestinal obstruction, peristomal pyoderma gangrenosum, and dehydration each was seen in 1 patient. A growth "catch-up" was obtained for all but one patient. All patients became free of corticosteroids. CONCLUSION: A restorative proctocolectomy was found to be an effective treatment alternative even in children with UC when conservative therapy proves to be ineffective.

Adrenal Cortex Hormones↗
PubMed2005

The utilization of intraluminal formalin for intractable rectal haemorrhage in advanced rectal cancer: a case report.

A patient with a metastatic fixed low rectal carcinoma presented severe rectal bleeding requiring massive transfusion over with a 36-hour period. Bleeding was controlled with the instillation of a 4% intrarectal formalin solution permitting the completion of a course of neoadjuvant chemoradiotherapy. This technique has been reserved for intractable transfusion-dependent radiation proctitis and is presented as a primary alternative in severe rectal bleeding from inoperable rectal cancer.

Administration, Rectal↗
PubMed2004

Dye spraying and magnifying endoscopy for dysplasia and cancer surveillance in ulcerative colitis.

PURPOSE: The aim of this study was to investigate detection of dysplasia or colitic cancer with ulcerative colitis by use of magnifying endoscopic observation. METHODS: From 1986 through 2000, ulcerative colitis was diagnosed and treated in 886 patients at Kitasato University East Hospital. Of the total, we studied 25 patients in depth: 14 who had dysplasia alone, 5 in whom cancer was diagnosed during follow-up after the detection of dysplasia, and 6 who had colitic cancer. RESULTS: Dysplasia was detected in 11 (3.2 percent) of 345 patients with extensive colitis and in 8 (3.7 percent) of 217 with left-sided colitis. Colorectal cancer was diagnosed in nine patients (2.6 percent) with extensive colitis and in two (0.9 percent) with left-sided colitis. Neither dysplasia nor colitic cancer was found in patients with proctitis-type colitis. Endoscopically, dysplasia and early cancer were characterized by granular or nodular protruding mucosa or by lowly protruding or flat mucosa, often associated with redness. Dye-spraying endoscopy was useful for detection. Magnifying endoscopy of ten regions of dysplasia (7 patients) and five early cancers (4 patients) showed IIIS to IIIL type pits or IV type pits. Biopsy of sites showing tumorous pits on magnifying endoscopy revealed dysplasia and early cancer. Observation of the pit pattern was found to be diagnostically useful. CONCLUSIONS: Dye spraying and magnifying endoscopy are useful for the detection, targeted biopsy, and diagnosis of dysplasia and colitic cancer in patients with ulcerative colitis.

Adult↗
PubMed2003

Rectal ulceration as a result of prostatic brachytherapy: a new clinical problem: report of three cases.

INTRODUCTION: Prostate cancer is the most common cancer of males in the United States. One treatment modality for localized prostate cancer is brachytherapy, the implantation of radioactive seeds directly into the prostate. Although this is an effective treatment option, significant complications can result. More commonly these complications involve the genitourinary tract, but radiation proctitis is a well-recognized, less common complication. A specific complication of brachytherapy, the development of a rectal ulcer is not well recognized. The clinical course of this complication and results of treatment options are unknown. METHODS: Three cases of rectal ulceration as a consequence of prostatic brachyradiotherapy are presented, and the presumed course of disease and treatment options is discussed. RESULTS: Two patients were initially treated with local advancement flaps that both failed. These patients developed rectourethral fistulas. One patient was treated with diverting colostomy and suprapubic urinary diversion. The second underwent proctectomy and coloanal anastomosis. This also failed after multiple attempts to treat perianastomotic fistulas. The third patient was treated endoscopically for bleeding and has had no further interventions. CONCLUSION: In the small percentage of patients who develop rectal ulcerations from prostatic brachyradiotherapy, local medical or surgical treatments will often result in failure. They also may contribute to the eventual development of rectourethral fistulas, the likely natural progression of this disease. These fistulas should be treated with both urinary and fecal diversion. Earlier stages of ulceration may be treated with rectal resection and reconstruction, but selection criteria for these procedures have yet to be determined.

Aged↗
PubMed2006

Gracilis muscle transposition for fistulas between the rectum and urethra or vagina.

PURPOSE: This study was designed to assess the efficacy of gracilis muscle transposition in repairing rectovaginal and rectourethral fistulas. METHODS: Data were retrieved from a retrospective chart review of patients who underwent gracilis muscle transposition for fistulas between the rectum and urethra/vagina. All patients had fecal diversion as a preliminary or concurrent step to fistula repair. Follow-up data were gathered from outpatient clinic visits. Success was defined as a healed fistula after stoma closure. RESULTS: Six females and three males, aged 30 to 64 years, underwent gracilis muscle transpositions from 1999 to 2005. One pouch-vaginal, three rectourethral, and five rectovaginal fistulas were repaired. The etiologies were Crohn's disease (n = 2), iatrogenic injury to the rectum during radical prostatectomy (n = 2), previous pelvic irradiation for rectal cancer (n = 2) or for cervical cancer (n = 1), recurrent perianal abscesses with fistulas (n = 1), and obstetric tear (n = 1). Seven patients underwent previous medical and surgical repair attempts. There were no intraoperative complications. Postoperative complications included perineal wound infection (n = 1) and at the colostomy closure (n = 2). There were no long-term sequelae. At a median follow-up period of 14 (range, 1-66) months since stoma closure, the fistula healed in seven patients. One patient refused ileostomy closure. One patient with severe Crohn's proctitis has a persistent rectovaginal fistula. CONCLUSIONS: Gracilis muscle transposition is a viable option for repairing fistulas between the urethra, vagina, and the rectum, especially after failed perineal or transanal repairs. It is associated with low morbidity and a good success rate. Underlying Crohn's disease and previous radiation are associated with poor prognosis.

Adult↗
PubMed2006

Coloanal sleeve anastomosis (Soave procedure): the ultimate treatment option for complex rectourinary fistulas.

PURPOSE: Acquired rectourinary fistulas represent a therapeutic challenge. Multiple previous unsuccessful procedures increase the difficulty of successful repair, leaving many patients with no option other than permanent urinary and/or fecal diversion. We report our experience with coloanal sleeve anastomosis (Soave procedure) as a salvage procedure for complex rectourinary fistulas. METHODS: Between 1994 and 2005, eight males (median age, 60 (range, 33-72) years) had Soave procedure in our institution. Four fistulas were the result of radical prostatectomy and four followed anterior resection for rectal cancer after radiochemotherapy. The location of the fistulas was bladder (n = 5) and urethra (n = 3). Five patients had previous attempts at surgical repair (median, 2 (range, 1-3) operations). The Soave procedure was chosen as first-line treatment because of fistula size (20 mm and 30 mm) in two patients and because of concomitant severe radiation proctitis in one patient. RESULTS: Morbidity was 38 percent. All patients had a temporary ileostomy, which was successfully reversed in seven patients. One patient required ileal pouch-anal anastomosis on postoperative Day 1 because of necrosis of the descended colon. Two patients had recurrent fistulas at two and three months respectively. One patient had moderate problems with this recurrent fistula and had his stoma closed, but the other patient required a permanent ileostomy. CONCLUSIONS: Soave procedure is an effective treatment for complex rectourinary fistula in the setting of high-dose pelvic radiation or after failed previous repair attempts.

Adult↗
PubMed2002

Permanent seed implantation for localized adenocarcinoma of the prostate.

Prostate brachytherapy has become a popular treatment option for localized prostate cancer with over 44,000 procedures performed in 2000. Eighty-seven percent to 93% of patients who have a serum prostate-specific antigen less than 10 ng/mL, Gleason score of 6 or less, and low risk (disease stage < or = T2a) can be expected to have an 8 to 10 year disease-free rate. The radiation dose delivered by the implants should exceed 140 Gy in men implanted with I-125 monotherapy. Patients with intermediate- and high-risk prostate cancer would benefit from the addition of either hormonal therapy and/or external beam irradiation to the implantation of seeds. Postimplant incontinence and proctitis can be minimized by controlling high radiation doses to the urethra and rectum. Potency is preserved in 70% of men with good preimplantation erectile function. Advances in technology, such as intraoperative dosimetry, will continue to make brachytherapy an attractive treatment option for men with localized prostate cancer.

Adenocarcinoma↗
PubMed2000

Bacterial Infections of the Colon.

The colon is a common site of infection for a heterogeneous group of bacterial pathogens. The presentation of disease in the colon is generally in the form of distinct syndromes, and it is important for physicians to recognize the causative organisms, because specific treatment is highly effective. The flouroquinolones have emerged as the treatment of choice for most food-borne bacterial pathogens. Resistance to these agents is not a major issue at present except in Campylobacter. Clostridium difficile remains sensitive to both metronidazole and oral vancomycin. The majority of patients will respond to metronidazole, but oral vancomycin should be limited to severe cases of pseudomembranous colitis or treatment failures with metronidazole. Vancomycin is expensive and has the potential for the propagation of vancomycin resistance in other bacteria, notably enterococci. Patients appearing with proctitis should be screened for sexually transmitted diseases.

Journal Article↗
PubMed2005

Management of Perianal Crohn's Disease.

Perianal manifestations of Crohn's disease usually coexist with active inflammation of other primary sites of the disease. Although treatment of active proximal disease may sometimes alleviate perianal symptoms, it is reasonable to separately treat symptomatic perianal disease. The diversity of perianal manifestations in Crohn's disease mandates a tailored, individualized approach in every case. Medical therapy is the best treatment option for hemorrhoids and anal fissures. The medical management of patients with perianal Crohn's disease includes the use of systemic antibiotics, immunosuppressive agents, and infliximab. Infliximab is now recognized as a very efficacious agent for treating fistulizing Crohn's disease, including perianal fistulae. It may also reduce the need for surgical intervention in specific cases. Abscesses and fistulae are treated by control of sepsis, resolution of inflammation and optimal preservation of continence, and quality of life. Abscesses require surgical drainage that may need to be prolonged to achieve complete healing. Fistulae may be treated medically, especially in cases of concurrent proctitis. Refractory fistulae may require surgical treatment including an occasional need for fecal diversion or proctectomy. The role of new treatment options such as natalizumab and CDP571 is evolving and requires further investigation.

Journal Article↗