Mark J. Pidala

Pneumoperitoneum following percutaneous endoscopic gastrostomy : does the timing of panendoscopy matter?

SummaryPercutaneous endoscopic gastrostomy (PEG) has had a significant impact on enteral alimentation in patients unable to maintain adequate oral caloric intake. PEG avoids the morbidity and mortality associated with the traditional feeding gastrostomies placed by celiotomy. Several authors have documented benign, self-limiting pneumoperitoneum following PEG placement. No study has addressed whether the timing of panendoscopy in relation to gastric puncture has an effect on the incidence of post-PEG pneumoperitoneum. The authors prospectively studied 30 patients undergoing PEG. Panendoscopy was either performed before or after gastric puncture, and each patient then had abdominal radiographs to determine the presence of pneumoperitoneum. Four of 16 patients (25%) having panendoscopy prior to gastric puncture had radiographic evidence of pneumoperitoneum compared to three of 14 patients (23%) having panendoscopy following gastric puncture. The authors conclude that the timing of panendoscopy in relation to gastric puncture does not significantly effect the incidence of post-PEG pneumoperitoneum.

The Difficult Colorectal Polyp

Difficult colorectal polyps represent lesions that pose a challenge to traditional endoscopic snare polypectomy. These polyps have historically been managed by surgical resection. Currently, several less invasive options are available to avoid colectomy. Repeat colonoscopy and snare polypectomy by an expert endoscopist, endoscopic mucosal resection, endoscopic submucosal dissection, and combined endoscopic and laparoscopic surgery have been developed to remove difficult polyps without the need for formal surgical resection. Patients with rectal polyps have the advantage of additional transanal minimally invasive techniques to enhance their resectability. Today, most colorectal polyps can be managed without the need for formal surgical resection.

Die Behandlung des schwierigen, zur Resektion überwiesenen Kolonpolyps: resezieren oder rekoloskopieren?

ZusammenfassungFragestellung und Hintergrund:Patienten werden häufig zur Resektion schwieriger Kolonpolypen überwiesen. Vor einer Kolonresektion hat der erfahrene Chirurg die Wahl, die Koloskopie zu wiederholen, um den Polypen erneut zu beurteilen, die Lokalisation zu markieren und evtl. den Polypen zu entfernen. Ziel dieser Studie war die Untersuchung der eigenen Ergebnisse anhand dieses Ansatzes.Patienten und Methodik:Es wurden alle neuen Patienten retrospektiv untersucht, die mit der Diagnose eines zuvor nicht entfernten Kolonpolypen (CPT 211.3) während eines Zeitraums von 5 Jahren zu einer elfköpfigen Gruppe kolorektaler Chirurgen überwiesen wurden. Patienten mit rektalen Polypen, entzündlicher Darmerkrankung, früheren Karzinomen oder familiärer adenomatöser Polypose wurden ausgeschlossen. Patientendemographie, Details des Polypen, Erfolg der Polypektomie, Gründe für eine chirurgische Resektion, Pathologie und Komplikationen wurden analysiert.Ergebnisse:Die Studienpopulation bestand aus 252 Patienten mit einem mittleren Alter von 65 Jahren. 80 Patienten erhielten nach Einweisung eine Resektion ohne Wiederholungskoloskopie. Bei der Resektion wurden in 13 Fällen invasive Karzinome gefunden. Insgesamt 172 Patienten unterzogen sich mindestens einer Wiederholungskoloskopie durch einen kolorektalen Chirurgen. Bei 101 Patienten dieser Gruppe war die Polypektomie erfolgreich, so dass eine größere Kolonresektion vermieden werden konnte. Die übrigen 71 Patienten unterzogen sich nach mindestens einer Wiederholungskoloskopie einer anschließenden Kolonresektion. In 26 Fällen wurde die Stelle, an der sich der Polyp befand, zur späteren Lokalisierung gekennzeichnet. Neun Blutungen nach einer Polypektomie und zwei Perforationen wurden nichtoperativ behandelt.Schlussfolgerung:Eine wiederholte Koloskopie durch einen erfahrenen Chirurgen führt zu einer kompletten Beseitigung des Karzinoms und zur Vermeidung einer größeren Kolonresektion in 58% dieser Fälle. Bei Patienten, die mit großen schwierigen Polypen zur Resektion überwiesen werden, sollte vor der Operation eine Wiederholungskoloskopie erwogen werden.AbstractPurpose:Patients are frequently referred for resection of difficult colon polyps. Before colectomy the experienced surgeon has the option of repeating the colonoscopy to assess the polyp, tattoo the site, and potentially remove the polyp. The purpose of this study was to review our results with this approach.Methods:All new patients referred during a five-year period to an 11-physician colon and rectal surgical group with the diagnosis of colon polyp (CPT 211.3) that was not previously removed were retrospectively reviewed. Patients with rectal polyps, inflammatory bowel disease, previous cancer, or familial adenomatous polyposis were excluded. Patient demographics, details of the polyps, success of polypectomy, reasons for surgical resection, pathology, and complications were analyzed.Results:The study population consisted of 252 patients with a mean age of 65 years. Eighty patients underwent resection upon referral without a repeat colonoscopy. Upon resection, invasive cancers were found in 13 cases. A total of 172 patients underwent at least one repeat colonoscopy by the colorectal surgeon. Of this group, 101 patients had successful polypectomy, thus avoiding major colectomy. The remaining 71 patients had a subsequent colon resection after at least one repeat colonoscopy. In 26 cases the polyp site was tattooed for later localization. There were nine postpolypectomy hemorrhages treated nonoperatively and two perforations.Conclusion:Repeat colonoscopy by an experienced surgeon leads to complete removal and avoidance of major colectomy in 58 percent of these cases. Patients with large difficult polyps referred for resection should be considered for repeat colonoscopy before surgery.

Spontaneous Rupture of the Iliac Vein A Case Report

Spontaneous rupture of the iliac vein is exceedingly rare. Only 10 cases have previously been reported in the world literature. Review of these cases revealed a female predomi nance (8/10), in their middle ages or elderly Presenting symptoms were acute abdominal pain, abdominal tenderness and fullness, and hypotension. A case report is presented along with a pertinent review of the world literature.

A Prospective Study on Intermittent Pneumatic Compression in the Prevention of Deep Vein Thrombosis in Patients Undergoing Total Hip or Total Knee Replacement

Three hundred and forty-six consecutive patients undergoing total hip or total knee replacement were prospectively studied to evaluate the effectiveness of intermittent pneumatic compression of the legs for the prevention of postoperative deep vein thrombosis. All patients were serially studied using impedance plethysmography and duplex ultrasound with color flow preoperatively and on the fourth and seventh postoperative day. The incidence of postoperative deep vein thrombosis in this series was 4 percent. Each patient with a postoperative duplex ultrasound had positive impedance plethysmography. Of the 14 patients who had postoperative deep vein thrombosis, seven had positive test results on postoperative day four and seven had positive tests on postoperative day seven. No patients were symptomatic. The results suggest that the high incidence of postoperative deep vein thrombosis after extensive orthopedic operation is significantly lowered by the use of intermittent pneumatic compression. Intermittent pneumatic compression, therefore, may be the preferred approach in prophylaxis of postoperative deep vein thrombosis.