James G. Petros

Factors influencing postoperative urinary retention in patients undergoing surgery for benign anorectal disease

One hundred eleven patients who had undergone surgery for benign anorectal disease under spinal anesthesia were studied retrospectively to determine the incidence of postoperative urinary retention requiring catheterization and to assess possible influences on that incidence. The age group and sex of the patients did not affect the rate of retention. However, the use of a long-acting anesthetic agent and the administration of at least 1,000 mL of intravenous fluid perioperatively each produced a significant increase in postoperative urinary retention.

Factors influencing postoperative urinary retention in patients undergoing elective inguinal herniorrhaphy

We retrospectively studied 295 men who had undergone herniorrhaphy under spinal or general endotracheal anesthesia to determine the incidence of postoperative urinary retention and to assess factors influencing it. The type and location of hernia had no effect on retention. In contrast, the use of general anesthesia, patient age above 53 years, and perioperative administration of more than 1,200 mL of fluid were significantly associated with an increase in retention. Our results suggest that urinary retention after herniorrhaphy may be prevented by limiting the amount of fluid given perioperatively and by using a spinal anesthetic, especially in older patients.

Patient-controlled analgesia and prolonged ileus after uncomplicated colectomy

BACKGROUND Because the duration of postoperative ileus after uncomplicated colon surgery has increased at our institution in the past 4 years, thereby prolonging length of hospital stay for some patients, we assessed several clinical factors to determine which were responsible for the increase. PATIENTS AND METHODS We retrospectively studied a cohort of 358 patients who underwent uncomplicated colon resection to investigate risk factors for prolonged postoperative ileus. Postoperatively, all patients received an analgesic agent, delivered either intramuscularly (IM) or by patient-controlled analgesia (PCA) pump, until their postoperative ileus resolved, as indicated by the passage of flatus and tolerance of a clear liquid diet. RESULTS There was no significant relationship between the length of postoperative ileus patient age or gender, the operating time, or the type or amount of analgesic agent used postoperatively. A significantly larger proportion of the patients who received PCA than those given an IM agent had ileus at 7, 6, and 5 days after surgery (P < 0.0001 for all comparisons after controlling for confounding factors), however. Overall, the use of PCA was associated with a delay in return of normal bowel function of 0.9 days. Patients who underwent a right colectomy had a significantly shorter ileus than those who had other procedures. CONCLUSIONS Our findings indicate that the use of PCA after uncomplicated colectomy increases the risk of prolonged postoperative ileus. We suggest that the routine use of PCA after colon surgery be reevaluated.

Pelvic exenteration for carcinoma of the colon and rectum.

Carcinoma of the colon and rectum is one of the most common causes of cancer deaths in the United States. The mortality of patients treated by surgery alone is 55% within 5 years of surgery. Despite efforts to decrease local recurrence and their concomitant problems of pain and disability, a significant number of patients will still have pelvic recurrences that carry a significant morbidity. In selected cases, pelvic exenteration may cure or provide palliation of the symptoms of colorectal carcinoma. Pre-operative evaluation is performed to detect signs of unresectability. During surgery, exploration is performed for evidence of metastases to the liver, omentum, and peritoneum, followed by an assessment of the local extent of the tumor. The margins of resection must be clear even if resection of contiguous organs or bony structures is necessary. The urinary tract is resected with an ileal loop, sigmoid or transverse colon conduits, or continent urinary diversion. Depending upon the involvement of neighboring structures, exenterative pelvic surgery can be modified for organ preservation. Semin. Surg. Oncol. 17:206–212, 1999.

Enterovesical fistula from Meckel's diverticulum in a patient with Crohn's ileitis

SummaryFormation of a fistula from a Meckels diverticulum to the bladder is extremely rare and may not be recognized, especially in patients with other gastrointestinal disease. We describe a patient with Crohns ileitis who was assumed to have two enterovesical fistulae from his diseased ileum. Laparotomy revealed a Meckels diverticulum with fistulization to the bladder. The diverticulum contained inflamed and ulcerated ectopic gastric mucosa but was not affected by Crohns disease.We know of only one other report of an enterovesical fistula resulting from a Meckels diverticulum.

Development and evolution of pelvic exenteration: Historical notes

Fifty years after the development of pelvic exenteration, the operation remains a gold standard in the surgical management of advanced pelvic malignancy. The operation has evolved through several predictable phases including technical improvements, lowered morbidity and mortality, and improved patient selection. Despite progress in supportive peri-operative care, pelvic exenteration is a major undertaking that should be performed in centers with proven interest and expertise in the field. We trace the early developments of the operation, the period of maturation, and the current place of this procedure in the armamentarium of the oncologic surgeon.

Complete intraoperative small bowel endoscopy in the evaluation of occult gastrointestinal bleeding

OBJECTIVE To review our experience with intraoperative small-bowel Sonde enteroscopy in evaluating occult bleeding in the small intestine. DESIGN Retrospective study with 100% follow-up. SETTING University-affiliated, tertiary-care teaching hospital. PATIENTS Sixteen consecutive patients referred with occult gastrointestinal bleeding in whom esophagogastro-duodenoscopy , push enteroscopy, and colonoscopy had failed to identify the source of bleeding. Fourteen of the 16 patients had required one or more transfusions. MAIN OUTCOME MEASURE Completeness of visualization, diagnostic accuracy, and complications of the procedure and follow-up for recurrent bleeding. RESULTS In all 16 patients, intraoperative Sonde enteroscopy allowed visualization of the entire small bowel. In 14 of the 16, it revealed the cause of bleeding, which was ileal angiodysplasia in three patients, ileal ulcers in six patients, neoplasia in two patients, and ileal ulcers caused by Crohns disease, small-intestinal enteropathy and varices caused by portal hypertension, and radiation stricture in one patient each. Two patients had normal small bowel mucosa. The patients with mucosal disease underwent small-bowel resection or oversewing of bleeding sites. Two surgical complications occurred: prolonged postoperative ileus (one patient) and small-bowel obstruction that resolved without surgery (one patient). Two of the patients with angiodysplasia had recurrent bleeding postoperatively. CONCLUSIONS Intraoperative Sonde enteroscopy is safe and effective in localizing small-intestinal bleeding sites, providing complete visualization of the small-bowel mucosa without enterotomy while avoiding the trauma that can be caused by push endoscopy. It is the diagnostic assessment of choice in selected patients with occult gastrointestinal bleeding of presumed small-bowel origin.

Patient-Controlled Analgesia and Postoperative Urinary Retention After Open Appendectomy

We retrospectively studied 279 patients who had undergone uncomplicated open appendectomy for acute appendicitis to determine risk factors for postoperative urinary retention. The gender of the patients, the operating time and the amount of fluid given perioperatively had no influence on the occurrence of retention. The amount of analgesic agent administered postoperatively and the age of the patient were significantly associated with urinary retention (p = 0.01 and p < 0.0001, respectively, after adjustment for potential confounding factors). The use of meperidine hydrochloride as compared with morphine and of patient-controlled analgesia as compared with intramuscular delivery were initially found to be significantly related to retention (p = 0.014 and p < 0.0001, respectively). After the effects of the age of the patient, the drug type and the amount of fluid and analgesic agent administered were controlled for, patient-controlled analgesia remained significantly associated with retention (p < 0.0001), whereas the type of drug given was no longer significant after controlling for potential confounding factors. Because we found that urinary retention was 13 times more likely to occur in the patients who had patient-controlled analgesia, we recommend that the use of this form of analgesia delivery be avoided after open appendectomy.