Israel Nudelman

Anal pressure measurements in the study of hemorrhoid etiology and their relation to treatment.

The etiology of hemorrhoids has been explained in the past based on anatomic principles, but this study examines the relationship of resting anal pressures to hemorrhoid etiology in 38 patients with hemorrhoids and 29 controls with no perianal symptoms. Three months after treatment by elastic band ligation, anal pressures were again measured in the hemorrhoid group. Anal pressures were significantly higher in the hemorrhoid group before treatment (102±26.33 mmHg) as compared with the controls (76.75±19.56 mmHg) (P<.001). Three months following elastic band ligation there was a small drop in anal pressure (100±26.84 mmHg) but it remained significantly higher than the control group. There was also a significant correlation between symptoms and level of anal pressures. The results indicate that persons with hemorrhoids have higher anal pressures than controls. Elastic band ligation relieves the symptoms but should not affect the anal sphincter pressure. The fact that the anal pressures remained high after treatment could imply that higher pressures are an etiologic component in the formation of hemorrhoids.

Cholecystectomy for Octogenarians

Fifty-eight patients, above the age of 80, underwent surgery for benign gallbladder disease between 1965 and 1984. They are compared to 2,017 patients under this age operated on over the same period. There were equal numbers of men and women. Acute presentations were more frequent and life-threatening. Immediate definitive surgical intervention which included cholecystectomy, fluorocholangiography and common bile duct (CBD) exploration, when indicated, offered an acceptable chance for cure. There was a 13.8% mortality in the acute cases. Infected bile was present in 76% of cases, extensive CBD pathology (widening 62%, stones 43%), and severe concomitant diseases (e.g. cardiac) in 60% of the cases. As a result, CBD explorations (52%) and choledochoenterostomies (26%) were much more frequent. Cholecystostomy is unjustified because definitive procedures in the aged in our series have achieved equal, if not better results, compared to series of cholecystostomies reported by others. The mortality rate in elective cases above 80 years is high (6.9%) and we think that asymptomatic gallbladder stones should not be operated on in this age group.

Cholecystocolonic Fistula: A Complication of Untreated Cholelithiasis

Cholecystocolonic fistula comprises 10–20% of cholecystoenteric fistulae. A case is described to illustrate the methods of diagnosis and possible complications. Surgical treatment consists of cholecys

Surgery for Acute Cholecystitis in the Elderly (> 80 Years)

In the last 15 years we operated on 618 patients for acute cholecystitis, of whom 60 were 80 years of age or more. Most of the ever-increasing number of patients within the hospital population who suf

Residual Stones in the Common Bile Duct: Critical Analysis following 2,700 Consecutive Cholecystectomies

A follow-up of 2,700 cholecystectomies disclosed 33 cases of residual stones (1.2%). A significant decrease in the rate of residual stones occurred in the last 2 years of the study (0.4%). Most residu

Incidental Cholecystectomy Does Not Increase the Risk of Surgery for Gastrointestinal Malignancy

From 1975 to 1994, 291 incidental cholecystectomies were performed in our department, 143 of them during surgery for gastrointestinal tumors. The number of incidental cholecystectomies has increased gradually each year, mainly after preoperative sonographic screening of the gallbladder became routine in our department. We have found that mortality, morbidity and duration of surgery were not significantly influenced by the addition of incidental cholecystectomy. The risk of the gallbladder becoming symptomatic during the expected survival of the patients who were operated upon for gastrointestinal tumors is higher than the added risk, morbidity or mortality as well as additional cost of incidental cholecystectomy. Therefore, the authors recommend the performance of incidental cholecystectomy during elective laparotomies for gastrointestinal tumors.

Malignant Obstruction of the Large Bowel: One-Stage Subtotal Colectomy

Thirty-eight patients with obstructing carcinoma of the left colon were treated by subtotal colectomy and ileocolic or ileorectal anastomosis. There were 21 males and 17 females aged 51-83 years (mean age 71 years). The mean symptomatic period was 90 h. All patients had abdominal pains and constipation, 47% vomited, and 6% bled rectally. Abdominal distention was pronounced in 70%. There was an abdominal mass in 11 % and a rectal lesion in 6%. The site of the tumor was rectum 3%, and colon in the remainder. The tumors, adenocarcinomas, were well or moderately differentiated in 94%. Twenty-three percent had liver metastases. Postoperative complications included wound infections (8%) and intra-abdominal infections (24%). Fourteen percent had anastomotic complications requiring surgery. Seven patients died (18%), in 3 cases mortality was connected to anastomotic complications. Mean follow-up on 25 patients was 4.6 years (1-12 years). Bowel movements averaged 3.5 daily at 3 months and 1.5 at 1 year. Ten died of extension of their disease and 5 of unrelated causes. Survival was 39% at 5 years and 25% at 10 years. Subtotal colectomy relieves obstruction, resects the tumor, restores continuity and eliminates the risk of additional tumors. Morbidity and mortality rates are acceptable in this high-risk group. In very low rectal tumors, there is still a place for a Hartmann’s operation or possibly laser or other decompression procedures.