John C. Reilly

Colonoscopy: its role in cancer of the colon and rectum.

In order to determine the feasibility, yield, and impact of routine total colonoscopy on the management of large-bowel cancer 157 cancer patients underwent 175 colonoscopic procedures; 13.6 per cent of the cancers had been missed on double-contrast barium enema examination.Among 92 patients undergoing perioperative colonoscopy, the lesion was reached in 89 per cent and the cecum in 60 per cent; 7.6 per cent demonstrated synchronous cancers, all curable, and all missed on barium-enema examination.Seventy-eight patients underwent colonoscopy at an average of 3.7 years after treatment of the index cancer; 7.7 per cent demonstrated metachronous cancers, all curable, two-thirds of which were missed on barium-enema examination.Benign polyps were noted in 62 per cent of the patients studied; 77 per cent of those polyps, 1 cm or greater in size, were missed on barium-enema examination. Polyps were found proximal to the cancer in 60 per cent of the patients with polyps. Approximately 85 per cent of those with multiple cancers demonstrated benign polyps. Preoperative total colonoscopy with periodic postoperative colonoscopy at an interval of three to five years are essential in the reliable detection of synchronous cancers and for the detection of metachronous cancers at an earlier, more favorable stage.

Life-threatening hemorrhage and exsanguination from Crohn's disease

PURPOSE AND METHODS: From 1979 through 1991, four patients of 631 admissions (0.6 percent) for Crohns disease in Erie, Pennsylvania, presented with life-threatening gastrointestinal hemorrhage. These and 34 similar cases from the medical literature were reviewed to provide a composite of those at risk and elucidate appropriate diagnostic and therapeutic maneuvers. RESULTS: The study revealed a preponderance of young men (2∶1 ratio) with an average age of 35 (range, 14–89) years, the majority of whom had known Crohns disease (60 percent) for an average of 4.6 (range, 0–18) years. The site of bleeding resembled the general distribution for Crohns disease, with small bowel disease predominating (66 percent involved the ileum). The five cases of exsanguination (13 percent of the total) were all men with known Crohns disease (average, 58 years) involving the ileum alone or in part. Mesenteric arteriography was positive in 17 patients, providing precise preoperative localization resulting in no mortality in this group. Excluding those who presented with exsanguination, surgery was necessary to cease hemorrhage in 91 percent (30/33) of patients. Ileocolectomy was the most frequently performed procedure (53 percent). In follow-up, only one patient required further surgical resection for recurrent bleeding (3.5 percent), and two other patients (7 percent) required further therapy for nonhemorrhagic recurrence. CONCLUSION: Crohns disease may be responsible for life-threatening gastrointestinal hemorrhage and even exsanguination. Many of the characteristics of these patients resemble the general Crohns disease population. Surgical resection provides excellent palliation. A long-term benign course can be expected in this subgroup of Crohns disease patients.

The Delorme repair for full-thickness rectal prolapse: a retrospective review

BACKGROUND The purpose of this study was to assess our colorectal surgical training program experience with the Delorme procedure for complete rectal prolapse. METHODS Consecutive patients were identified from a surgical database and evaluated by chart review. RESULTS Seventy-six patients with a mean follow-up period of 3.6 years were included. Outcomes included a recurrence rate of 14.5%, an overall complication rate of 25%, and a surgical site-specific complication rate of 8%. For patients younger than 50 years old (mean age, 36 y; range, 19-49 y), the recurrence rate was 8% with a mean follow-up period of 4.1 years. Their total complication rate was 15%, with no surgery site-specific complications. CONCLUSIONS Our results are consistent with previously published experiences in that most preoperative evacuatory symptoms resolve with repair of the prolapse, and serious complications are uncommon. The observation that recurrence and complication rates may be lower in younger medically fit patients suggests the Delorme repair need not be restricted specifically to older, medically unfit patients.

Does sodium hyaluronate- and carboxymethylcellulose-based bioresorbable membrane (Seprafilm) decrease operative time for loop ileostomy closure?

AbstractBackgroundAdhesions can result in serious clinical complications and make ileostomy closure, which is relatively simple procedure into a complicated and prolonged one. The use of sodium hyaluronate and carboxymethyl cellulose membrane (Seprafilm®) was proven to significantly reduce the postoperative adhesions at the site of application. The aim of this study was to assess the incidence and severity of adhesions around a loop ileostomy and to analyze the lenght of time and morbidity for mobilization at the time of ileostomy closure with and without the use of Seprafilm.MethodsTwenty-nine surgeons from 15 institutions participated in this multicenter prospective randomized study. 191 patients with loop ileostomy construction were randomly assigned to either receive Seprafilm under the midline incision and around the stoma (Group I), only under the midline incision (Group II), or not to receive Seprafilm (Group III). At ileostomy closure, adhesions were quantified and graded; operative morbidity was also measured.ResultsAll 3 groups were comparable relative to gender, mean age and number of patients with prior operations (26, 25 and 19, respectively). Group II patients were significantly more likely to have pre-existing adhesions than Group III patients (30.6% vs. 14.1%, p=0.025). At stoma mobilization, significantly more patients in Group III than in Group I had adhesions around the stoma (95.2% vs. 82.3%, p=0.021). Mean operative times were 27, 25, and 28 minutes, respectively (p=0.38), with significant differences among sites. There was no significant difference in the number of patients needing myotomy or enterotomy (29, 27 and 24 patients, respectively), nor in the number of postoperative complications (7, 9 and 7 patients, respectively).ConclusionsWhen consistently applied, Seprafilm significantly decreased adhesion formation around the stoma but not operative times without any increase in the need for myotomy or enterotomy. These findings were not seen in the overall study population possibly due to the large number of surgeons using a variety of application techniques.

Bullous pemphigoid at colostomy site

PURPOSE: Pemphigoid is a well-recognized cutaneous lesion, occurring rarely in peristomal skin. We report the diagnosis and successful treatment of localized pemphigoid lesions adjacent to a colostomy. METHODS: We review the chart, immunofluorescence study, treatment, and follow-up of a patient with bullous lesions at a colostomy site. RESULT: Pemphigoid of the pericolostomy skin was diagnosed by immunofluorescence study and successfully treated with antibiotic. CONCLUSION: Diagnosis of bullous pemphigoid should be considered in the differential diagnosis of a bullous lesion adjacent to a colostomy site. Diagnosis is easily made, and treatment is simple and efficacious.

Male cryptoglandular fistula surgery outcomes: a retrospective analysis

PURPOSE The purpose of this study was to evaluate cryptoglandular fistula surgery outcomes in men with common types of fistulae. METHOD A database review identified study patients. Exclusion criteria included history of previous fistula, previous anorectal surgery, inflammatory bowel disease, pelvic radiation, complex fistula, age <21 years, and absence of follow-up. RESULTS Four hundred twenty-five patients met criteria for review. Mean follow-up was 5.8 years. Concurrent abscess at presentation was strongly associated with poorer outcomes. New-onset seepage is more common with seton treatment (P = 0.01), but seepage resolution occurred less commonly with fistulotomy (P <0.01). CONCLUSIONS Although both treatments are highly successful, men treated with primary fistulotomy are more likely to heal than seton patients. Fistulotomy patients have less early postoperative seepage than seton patients, but when this is present it is less likely to resolve. Presentation with concurrent abscess is strongly associated with poorer outcomes.