Julian E. Losanoff

Ingested Foreign Bodies of the Gastrointestinal Tract: Retrospective Analysis of 542 Cases

Abstract. Ingested foreign bodies (FBs) present a common clinical problem. As the incidence of FBs requiring operative removal varies from 1% to 14%, it was decided to perform this study and compare the data with those from the world literature, as well as to outline an algorithm for management, including indications for surgery. We reviewed all patients with FB ingestion from 1973 to 1993. There were 542 patients with 1203 ingestions, aged 15 to 82 years. Among them, 69.9% (n = 379) were jail inmates at the time of ingestion, 22.9% (n = 124) had a history of psychosis, and 7.2% (n = 39) were alcoholics or denture-wearing elderly subjects. Most foreign bodies passed spontaneously (75.6%;n = 410). Endoscopic removal was possible in 19.5% (n = 106) and was not associated with any morbidity. Only 4.8% (n = 26) required surgery. Of the latter, 30.8% (n = 8) had long gastric FBs with no tendency for distal passage and were removed via gastrotomy; 15.4% (n = 4) had thin, sharp FBs, causing perforation; and 53.8% (n = 14) had FBs impacted in the ileocecal region, which were removed via appendicostomy. Conservative approach to FB ingestion is justified, although early endoscopic removal from the stomach is recommended. In cases of failure, surgical removal for gastric FBs longer than 7.0 cm is wise. Thin, sharp FBs require a high index of suspicion because they carry a higher risk for perforation. The ileocecal region is the most common site of impaction. Removal of the FB via appendicostomy is the safest option and should not be delayed more than 48 hours.

RECONSTRUCTIVE RENAL SURGERY USING A WATER JET

PURPOSE We describe the successful application of a water jet to reconstructive renal surgery. MATERIALS AND METHODS Two consecutive patients underwent reconstructive renal surgery using a waterjet apparatus for a 4.0x6.5 cm. well encapsulated tumor of the lower pole of the left kidney and a 4.5x2.5 cm. staghorn calculus of the left kidney, respectively. The water jet apparatus (Parenchimotom 01) consists of a pressure generating pump and a flexible hose connected to the hand piece, and a nozzle with a pinhole opening of 0.3 mm. RESULTS Both patients underwent surgery through a left lumbar incision. Partial nephrectomy was performed in 1 patient and anatrophic nephrotomy for stone removal in the other. Dissection time was 25 and 12 minutes, with blood loss of 150 and 100 ml., respectively. No temporary vascular clamping or local hypothermia was necessary. Both patients were discharged home 10 days after surgery and at followup no negative sequelae were attributable to the procedure. CONCLUSIONS The operative procedures proved easy, fast and effective. No temporary vessel clamping or hypothermia was required. Using a water jet is a novel approach that is helpful in renal surgery.

Palisade dorsoventral lavage for neglected peritonitis

A modification of the procedure of laparostomy with palisade dorsoventral lavage for treating neglected peritonitis is described. It consists of adding a polyethylene foil to cover the intestines and thus avoiding the direct contact between them from one side, and the suction drains and the palisade laparostomy screen from the other. Between 1988 and 1995, 19 patients with neglected peritonitis (APACHE II scores from 12 to 42; mean 22.3) were managed using this modified technique. A total of 81 reexplorations were done (average, 4.3 reexplorations per patient). The technique proved effective (21% mortality, n = 4). No intestinal perforations, fistulas, or residual pus collections occurred among survivors or among those who died. Primary fascial closure was achieved in all survivors and during an 18-months followup, no incisional hernia occurred. Based on these results, we believe this technique is extremely useful when both laparostomy and continuous peritoneal irrigations are considered in patients with neglected peritonitis.

Posttraumatic intra-gallbladder hemorrhage

We read with interest the article by Nishiwaki and colleagues1 on posttraumatic intra-gallbladder hemorrhage which appeared in the April 1999 issue of the Journal. This is an impressive first case report of a massive intragallbladder clot occuring after blunt trauma and requiring surgery because of persisting abdominal pain. Nishiwaki and colleagues1 should be congratulated for their excellent review of other causes of hemorrhage into the gallbladder—a rare but important entity. In the Introduction section of their article, Nishiwaki and colleagues1 state that gallbladder injuries include laceration, avulsion, and contusion. In general, this may be true; however, this is not a detailed listing of all known types of gallbladder injury. A detailed classification system of all known types of traumatic gallbladder injury, recently appeared, under our authorship, in the English-language literature2 (Table 1). As seen from the Table, to date there are five different types (divided into ten subtypes) of gallbadder injury, which may lead to a myriad of presentations. We were pleased to realize that the report of Nishiwaki and colleagues1 presented a new, as yet undescribed type of gallbladder injury; in this respect their report further broadens readers’ knowledge regarding this rare type of injury. We believe that the injury they described could possibly be classified as subtype 1C or 4C according to the recent classification we proposed,2 or possibly, as type 6. We would greatly appreciate the opinion of Nishiwaki and colleagues regarding whether they agree with this idea.

Zoophilia: a rare cause of traumatic injury to the rectum

A 62-year-old farmer presented with generalized abdominal pain of eight hour’s duration. Past medical history was negative. Physical examination revealed marked abdominal distension with diffuse rebound. Digital rectal examination was unremarkable. Chest and abdominal X-ray film revealed free gas below the diaphragm and multiple gas-fluid levels consistent with paralytic ileus. Laboratory findings were significant for peripheral leukocytosis of 16,500 mm3. Laparotomy revealed diffuse feculent peritonitis and a 0.5 cm anterior tear of the rectum located 5 cm above the pelvic peritoneal reflection. The edges of the tear were ragged but without necrosis. No other pathology or foreign body was found. The abdomen was cleaned and the perforation closed. Intraoperative anoscopy and sigmoidoscopy were unremarkable except for several minute mucosal hematomas on the luminal aspect of the tear. A diverting transverse colostomy was constructed. The abdomen was irrigated copiously with warm saline, drained and closed in layers. Post-operative treatment consisted of nasogastric suction, total parenteral nutrition and broad-spectrum antibiotics. The patient recovered uneventfully.

Toxic shock syndrome and necrotizing fasciitis complicating neglected sacrococcygeal pilonidal sinus disease

PURPOSE: This study was conducted to report the rare combination of necrotizing fasciitis and toxic shock syndrome, which both complicated neglected sacrococcygeal pilonidal sinus disease. METHODS: A case report is presented. RESULTS: We describe the rare case of a previously healthy adult male patient who developed necrotizing fasciitis and toxic shock syndrome associated withStreptococcus pyogenesandBacteroides fragilis.Patients response to emergency surgery followed by repeated debridements of necrotic tissue, together with aggressive fluid resuscitation, broad-spectrum antibiotic coverage, and hyperbaric oxygenation was good. CONCLUSION: This case serves again as a clear reminder that neglected pilonidal sinus disease can lead to unusual and life-threatening consequences.

Abdominoperineal resection and perineal colostomy for low rectal cancer

PURPOSE: We sought to evaluate a new technique for creation of a continent perineal colostomy following abdominoperineal resection (APR) of the rectum for low rectal cancer. METHODS: Nine selected patients with low rectal cancer (two males; median age, 55.6 years; classified as Dukes A, 6 patients and as Dukes B, 3 patients) underwent APR. Following this, the original Lazaro da Silva technique was used as follows: 1) for performance of three circular myotomies in the distal sigmoid with a distance between each couple of no more than 8 cm; 2) repair of the myotomies, thus creating three circular colonic valves, the most distal of which remained extraperitoneally; 3) for construction of a perineal colostomy lying flush with the perineal skin; 4) after the patient starts consuming a regular diet, enemas through the perineal stoma are done, usually twice per week, to achieve defecation. Functional outcome was assessed by evaluation of bowel movements and neoanal continence. RESULTS: There were no deaths. From January 1994 until October 1995, no tumor recurrence has occurred, and fecal continence has been good. Four of the patients were able to defecate without enemas (2–4 times per week), and in five patients the self-administration of enemas (2–4 times a week) were necessary to accomplish defecation. CONCLUSION: Initial results with the Lazaro da Silva technique have been encouraging.

Stercoral perforation of the normal colon: report of five cases.

A series of five consecutive patients with stercoral perforation of the colon is presented. Four of the patients had free perforation and one had an abscess between the splenic flexure, spleen and surrounding organs, a yet unreported entity. All patients underwent emergency surgery including laparostomy with repeated explorations and lavages in two of them. The ethiology, pathophysiology and treatment of the condition are updated. A graphic algorithm for decision-making in appropriately dealing with stercoral perforation of the colon is proposed.

Water jet cholecystectomy and common bile duct lavage under videolaparoscopic guidance

A new method for performing laparoscopic cholecystectomy, using a water jet dissector, is described. This technique was employed in two patients who were considered suitable candidates for laparoscopic surgery. The use of the water jet dissector proved to be very efficient and safe. No intraoperative bile leak or hemorrhage occurred in any patient. In one of the two patients, choledochotomy and common bile duct lavage were performed, using the same water jet apparatus in combination with extraction of a residual large calculus and T-tude drainage. In both patients the postoperative course was uneventful.

Extension of McBurney's Incision: Old Standards Versus New Options

To The Editor: We read with interest the article by Moneer on avoiding muscle cutting while extending McBurneys incision which appeared in a recent issue of the Journal. 1 While this article is concise and wellillustrated, we would like to make the following comments. Moneer described two techniques for facilitating exposure during appendicectomy: the first technique consisted of placing of another muscle-splitting incision made parallel to the original incision; in his second technique, extension was performed medially and vertically through the lateral aspects of both laminae of the rectus abdominis sheath. A total of 126 patients underwent surgery using these techniques, 78 (61.9%) requiring a second muscle split and 48 (38. 1%) vertical extension through the rectus abdominis sheath. A follow-up of 76.2% was achieved ranging between 8 and 42 months; in none of the patients did postoperative hernia occur. ~ Moneer did not provide even a brief review of alternative techniques designed for extension of McBurneys incision, thus detailed comparison seems difficult for the less experienced reader of his article. In brief, there are two well-known techniques for extending McBurneys incisionY Rutherford-Morrison originally described a muscle-cutting incision extended laterally in the right iliac fossa. 2 Weirs technique consists of transversely incising both laminae of the rectus abdominis sheath which allows for a freer medial access) If there is need for larger lateral access, too, both techniques can be combined? In such a way an almost entirely transverse laparotomy is fashioned and in our extensive experience as emergency abdominal surgeons, the length of such an incision in the average adult fits the dimensions of the surgeons fist. Any appendix and even the ascending colon can be easily delivered into the wound; more-