Eugene P. Salvati

Sigmoidoscopic examinations with rigid and flexible fiberoptic sigmoidoscopes in the surgeon's office: A comparative prospective study of effectiveness in 1,012 cases

SummaryThe results obtained from 1,012 examinations in an on-going, cooperative study indicate that the overall yield provided by use of the flexible fiberoptic sigmoidoscope is 3.2 times greater than that of examinations with the rigid sigmoidoscope. More than twice (2.4 times) the number of polyps and more than three times the number of cancers were detected with the flexible fiberoptic sigmoidoscope. Experienced endoscopists can perform an examinaton with the flexible fiberoptic sigmoidoscope expeditiously in the office with minimal patient preparation, a high level of patient and physician acceptance, and relative safety when the usual mandatory colonoscopic precautions and guidelines are obeyed. The extraordinary advantages demonstrated by this study warrant wide clinical application of the flexible fiberoptic sigmoidoscope. We strongly recommend provision be made for appropriate training of physicians in the use of the instrument.

Seton management of complex anorectal fistulas in patients with Crohn's disease.

Anorectal fistulas associated with Crohns disease are difficult to manage, particularly when the rectum is diseased. Significant morbidity has been associated with both medical and surgical therapy. Although conventional therapy is acceptable in the management of simple fistulas in Crohns disease, these approaches often exacerbate rather than ameliorate problems in patients with complex fistulas. The authors report ten cases of complex fistulas in patients with Crohns disease managed with their technique of long-term, indwelling setons. These setons are placed through the fistula tract and tied loosely to maintain the patency of the fistula without cutting through the sphincters. At the time of insertion, although abscesses are incised and drained, no attempt is made to divide the superficial tissues or sphincter overlying the fistulous tract. The patients ranged in age from 23 to 81 years and had a history of Crohns disease for 1 to 20 years. All cases resulted in excellent palliation. No patient required a proximal colostomy. These patients have been followed for four months to seven years. Despite severe proctitis in six of these patients at the initial operation, no patient has required a proctectomy. The authors believe this technique achieves adequate palliation and should be employed as the procedure of choice in patients with complex anal fistulas associated with Crohns disease.

Levator syndrome: An analysis of 316 cases

ConclusionsThe levator syndrome consists of the symptoms of pain, pressure or discomfort in the region of the rectum, sacrum, and coccyx. The patients often have gluteal discomfort and high rectal distress. Sitting may aggravate the disorder. Tenderness upon motion of the coccyx is not an important part of this syndrome. Therefore, the term “coccygodynia” should not be used. The syndrome affects women more frequently than men, and occurs most often in the fourth, fifth and sixth decades of life. Although the symptoms are at times vague, the diagnosis is easily made by those who suspect its presence. Tenderness of the levators is always present and most often unilateral and on the left. Its etiology is unclear. In a significant proportion of patients concomitant anorectal disease such as fissure and hemorrhoids is present. Massage with or without diathermy, hot sitz baths, and muscle relaxants such as diazepam have proven to provide effective treatment, and the recurrence rate after therapy is low.

Complications of colostomies

One hundred twenty-six patients underwent 130 end colostomies, 44 for benign and 86 for malignant disease, and were followed for an average of 35 months. The left or sigmoid colon was used in 99 and the transverse colon in 31. Stomas were made electively in 98 patients and urgently in 32. Seventy-six stomas were brought out through the incision and 54 from separate sites. There were 69 complications in 55 patients (44 percent) including 11 strictures, 9 wound infections, 14 hernias, 9 small-bowel obstructions, 4 prolapses, 2 abscesses, 1 peristomal fistula, 17 skin erosions, and 2 poor stoma locations. Fifteen complications required reoperation. Five of these procedures included stoma revision. Total numbers of complications were not related to the stoma site, the disease process, the urgency of the procedure, or the segment of colon used. Wound infections, however, were increased in urgently made stomas. The incidence of hernia was equivalent in stomas brought out through the incision or at a separate site. Forty-one patients (30 percent) had 43 colostomies closed an average of 3.5 months after creation. Thirteen patients had 14 complications-5 wound infections, 6 hernias, 2 small-bowel obstructions, and 1 rectovaginal fistula. One patient died. Four patients required reoperation. There were no anastomotic leaks. Complications were equivalent in Hartmann closures and transverse colostomy closures. Complications were similar in stomas created for cancer and those created for diverticular disease.One hundred twenty-six patients underwent 130 end colostomies, 44 for benign and 86 for malignant disease, and were followed for an average of 35 months. The left or sigmoid colon was used in 99 and the transverse colon in 31. Stomas were made electively in 98 patients and urgently in 32. Seventy-six stomas were brought out through the incision and 54 from separate sites. There were 69 complications in 55 patients (44 percent) including 11 strictures, 9 wound infections, 14 hernias, 9 small-bowel obstructions, 4 prolapses, 2 abscesses, 1 peristomal fistula, 17 skin erosions, and 2 poor stoma locations. Fifteen complications required reoperation. Five of these procedures included stoma revision. Total numbers of complications were not related to the stoma site, the disease process, the urgency of the procedure, or the segment of colon used. Wound infections, however, were increased in urgently made stomas. The incidence of hernia was equivalent in stomas brought out through the incision or at a separate site. Forty-one patients (30 percent) had 43 colostomies closed an average of 3.5 months after creation. Thirteen patients had 14 complications-5 wound infections, 6 hernias, 2 small-bowel obstructions, and 1 rectovaginal fistula. One patient died. Four patients required reoperation. There were no anastomotic leaks. Complications were equivalent in Hartmann closures and transverse colostomy closures. Complications were similar in stomas created for cancer and those created for diverticular disease.

Use of ureteral catheters in colonic and rectal surgery

Injury to the ureters is a serious complication of colonic and rectal surgery. The experience of the authors with routine use of ureteral catheters to minimize this complication is reviewed. It was found that there are minimal complications associated with their use. Injuries to the ureters were not completely avoided. However, unrecognized injuries (except ischemia) did not occur.

Delorme's procedure for complete rectal prolapse in severely debilitated patients

PURPOSE: This study was designed to assess the results of a minimally invasive surgical procedure for the correction of complete rectal prolapse in a poor surgical risk group. METHODS: Over a ten-year period, 40 patients underwent 41 Delorme operations when advanced age and/or poor overall health mitigated against an abdominal approach. Mean age was 82 (range, 30–100) years. Eighty-eight percent were females. Surgery was performed in the prone jackknife position utilizing intravenous sedation and local anesthesia. RESULTS: Follow-up ranges from 1 year to 2 years (mean, 47 months). There have been 9 recurrences in 8 patients (22 percent). Mean time to recurrence was 13 months (range, 1 month to 6 years). One death occurred in an 81-year-old patient within 24 hours of surgery from cardiopulmonary arrest. Minor complications occurred in 25 percent of patients. CONCLUSION: Satisfactory prolapse repair was safely performed in 78 percent of this high-risk group. Pitfalls in performing this procedure relate primarily to associated perineal and colonic conditions. Most prominent among these conditions are weak or absent anal sphincter tone, perineal descent, and previous sphincter injury. Extensive diverticular disease may prohibit effective and complete proximal mucosectomy. An inadequate mucosectomy sets the stage for early recurrence of prolapse.

Incidence of fistulas subsequent to anal abscesses

SummaryTwo hundred thirty-two patients with anal abscesses were followed from six months to 13 years after incision and drain-age was done as an office procedure. Most of these (88 per cent) were evaluated more than two years after the onset of their initial disease. One hundred fifty-four (66 per cent) went on to develop fistula-in-ano, while 78 (34 per cent) had no further problem. Our study encourages us to continue to incise and drain these abscesses in the office, reserving hospitalization for those who later develop fistulas.

Is preoperative computerized tomography useful in assessing patients with colorectal carcinoma

PURPOSE: Controversy exists over the appropriate preoperative evaluation of colorectal cancer patients. Most surgeons agree that basic laboratory studies are indicated. Computerized tomography of the abdomen and pelvis has been used in our practice to augment the preoperative evaluation of these patients. METHODS: One hundred fifty-eight consecutive patients with primary colorectal carcinoma underwent computerized tomography (CT) of the abdomen as part of their preoperative evaluation. Their medical records were retrospectively reviewed. RESULTS: In 88 patients, 120 findings present on CT were otherwise unknown. Of these, 35 percent were clinically significant in that they allowed the surgeon to alter the proposed operative procedure or added additional technical information for consideration preoperatively. Findings include liver metastasis (26), atrophic kidney (3), and abdominal wall or contiguous organ invasion (11). In addition, two other solid organ carcinomas were detected. In the remaining 70 patients, CT contributed no additional pertinent information about the patient prior to this initial operative procedure. CONCLUSIONS: CT aids in the preoperative evaluation of individuals with colorectal carcinoma. It provides important clinical information that is useful to the surgeon planning the procedure. Additionally, CT permits the patient and his family to be aware of their overall status and to subsequent treatment options. Computerized tomography eliminates the need for preoperative intravenous pyelogram, improves the preoperative staging for metastatic disease, and provides a baseline for comparison during the postoperative follow-up period should recurrence be suspected or adjuvant therapy be planned.

Five year survival in patients with carcinoma of the rectum treated by electrocoagulation

Sixty-eight patients with rectal cancer treated by electrocoagulation are reviewed. All were followed up for a minimum of 5 years. The survival rate in patients with small exophytic cancers is greater than 70 percent. However, the recurrence rate after electrocoagulation is 40 percent. Electrocoagulation offers an alternative for the primary treatment of rectal cancer, particularly in older patients with small lesions.

The role of nasointestinal intubation in elective colonic surgery

On hundred thirty-eight consecutive patients undergoing elective colonic resections were treated prospectively and randomly with either a long intestinal (Cantor) tube preoperatively, a nasogastric tube placed intraoperatively, or no gastrointestinal tube at all. Patients were evaluated for length of hospital stay, duration of postoperative ileus, adequacy of intraoperative intestinal decompression, gastric dilatation, and operative complications. No significant difference could be seen in the tubed or no-tube group.