Micha Rabau

Gracilis muscle transposition for fistulas between the rectum and urethra or vagina.

PurposeThis study was designed to assess the efficacy of gracilis muscle transposition in repairing rectovaginal and rectourethral fistulas.MethodsData were retrieved from a retrospective chart review of patients who underwent gracilis muscle transposition for fistulas between the rectum and urethra/vagina. All patients had fecal diversion as a preliminary or concurrent step to fistula repair. Follow-up data were gathered from outpatient clinic visits. Success was defined as a healed fistula after stoma closure.ResultsSix females and three males, aged 30 to 64 years, underwent gracilis muscle transpositions from 1999 to 2005. One pouch-vaginal, three rectourethral, and five rectovaginal fistulas were repaired. The etiologies were Crohns disease (n = 2), iatrogenic injury to the rectum during radical prostatectomy (n = 2), previous pelvic irradiation for rectal cancer (n = 2) or for cervical cancer (n = 1), recurrent perianal abscesses with fistulas (n = 1), and obstetric tear (n = 1). Seven patients underwent previous medical and surgical repair attempts. There were no intraoperative complications. Postoperative complications included perineal wound infection (n = 1) and at the colostomy closure (n = 2). There were no long-term sequelae. At a median follow-up period of 14 (range, 1–66) months since stoma closure, the fistula healed in seven patients. One patient refused ileostomy closure. One patient with severe Crohns proctitis has a persistent rectovaginal fistula.ConclusionsGracilis muscle transposition is a viable option for repairing fistulas between the urethra, vagina, and the rectum, especially after failed perineal or transanal repairs. It is associated with low morbidity and a good success rate. Underlying Crohns disease and previous radiation are associated with poor prognosis.

The correlation between quality of life and functional outcome in ulcerative colitis patients after proctocolectomy ileal pouch anal anastomosis.

Objective  The aim of this study was to evaluate functional outcome and quality of life (QOL) in patients undergoing proctocolectomy ileal pouch anal anastomosis (IPAA), to assess the correlation between functional outcome and QOL, and to identify factors influencing functional outcome and QOL in these patients.

Reduction of Surgery-induced Peritoneal Adhesions by Methylene Blue

BACKGROUND The possible involvement of inflammatory mediators such as nitric oxide (NO), and reports of protective effects of antioxidants, led us to test the effectiveness of methylene blue and NO synthesis inhibitor in reducing adhesion formation. METHODS Generation of adhesions in rats, by scraping the anterior uterine horn wall, was followed by intraperitoneal administration of saline methylene blue, or N alpha-t-BOC-omega-nitro-L-arginine. Additional rats received identical treatments, but without the serosal damage. Two weeks later, formation of adhesions was quantitatively graded. RESULTS Adhesions were found in <5% of the rats with the sham surgery, regardless of treatment. In the experimental group, >95% of the rats treated with saline or NO synthetase inhibitor had severe adhesions, in contrast to 5% of the methylene blue treated rats. Severity of adhesion was lower in the methylene blue group (P <0.001). CONCLUSIONS Methylene blue was very effective in preventing formation of peritoneal adhesions. Its activity is probably through inhibition of free-radical generation and not of nitric oxide action.

Wound infection after ileostomy closure: a prospective randomized study comparing primary vs. delayed primary closure techniques

BackgroundClosure of ileostomy is considered a contaminated operation. The infection rate of the stoma wound is ≥30%. Several ileostomy–closure techniques intended to reduce the high rate of infection have been described in the literature. Among them, delayed primary closure of the stoma wound is a commonly used method that was reported to reduce the infection rate according to several retrospective studies. We therefore conducted the first prospective randomized trial comparing primary with delayed primary closure of a stoma wound.MethodsDuring 2003, 40 patients were admitted to our ward for closure of ileostomy. The ileostomies were taken down by the same team using the same surgical technique except for the technique of wound closure. We randomly divided the patients into two groups. In Group 1 (n = 20), the wound was left open for delayed primary closure and not closed until postoperative day 4. In Group 2, the wound was primarily closed at the end of the procedure.ResultsThe total wound infection rate was relatively low (15%). Infection occurred more frequently (4 cases, 20%) in Group 1 than in Group 2 (2 cases, 10%). The length of hospital stay was similar for both groups.ConclusionsIn this first prospective comparison of two techniques during ileostomy take down, primary closure unexpectedly produced less wound infection than delayed primary closure.

Prospective, Multicenter Evaluation of Highly Concentrated Fibrin Glue in the Treatment of Complex Cryptogenic Perianal Fistulas

PURPOSEThe surgical management of complex perianal fistulas is challenging and may be associated with the risk of sphincter injury. Instillation of fibrin glue to the fistula tract is a simple procedure that does not involve any muscle division, and potentially results in healing of the fistula. This study was designed to assess the use of highly concentrated fibrin glue with intra-adhesive antibiotics in the treatment of complex cryptogenic perianal fistulas.METHODSPatients with complex perianal fistulas of cryptogenic origin were prospectively included in this multicenter study. Injection of the fibrin glue mixed with antibiotics was performed in a uniform fashion. After the procedure, patients were actively examined at fixed time intervals; in cases of recurrent fistula, reinjection of fibrin glue was offered.RESULTSSixty patients were enrolled; complete healing of the fistula was achieved in 32 patients (53 percent). Eight of 28 patients (29 percent) who were not completely healed had significant symptomatic improvement. All patients resumed normal daily activity the day after surgery and none had any deterioration in continence related to the procedure. The majority of the 26 (43 percent) adverse events were considered mild and spontaneously resolved; 2 patients (3 percent) with perianal septic complications were successfully treated by drainage.CONCLUSIONSInjection of fibrin glue for the treatment of perianal fistulas is safe, simple, and associated with early return to normal activity. Although moderately successful, it may preclude extensive surgery in more than one-half of these patients.

Methylene Blue Prevents Pulmonary Injury after Intestinal Ischemia-reperfusion

OBJECTIVE To investigate the effect of methylene blue, an inhibitor of oxygen radicals, on lung injury caused by reperfusion of ischemic tissue. METHODS Intestinal ischemia-reperfusion injury was induced in rats by clamping the superior mesenteric artery for 1 hour. Thereafter, the experimental group was administered 1% methylene blue intraperitoneally and the control group received saline. After 4 hours, pulmonary histopathologic features were assessed, and lung wet-weight to dry-weight ratios and tissue xanthine oxidase were determined. RESULTS The control group suffered from severe pulmonary parenchymal damage, compared with slight damage in the experimental group. The number of sequestered neutrophils was significantly higher in the control group (319 +/- 60 polymorphonuclear cells per 10 high-power fields) than in the methylene blue-treated group (91 +/- 8 polymorphonuclear cells per 10 high-power fields; p < 0.001). The wet-weight to dry-weight ratio was significantly increased in the saline-treated rats compared with the methylene blue-treated group (6.19 +/- 0.28 vs. 5.07 +/- 0.21; p < 0.001). Xanthine oxidase activity was similar in both groups. CONCLUSION Methylene blue attenuated lung injury after intestinal ischemia-reperfusion. Inhibition of oxygen free radicals may be the protective mechanism.

Colorectal carcinoma in inflammatory bowel disease: a comparison between Crohn’s and ulcerative colitis

Aim  The study assessed the clinicopathological features and survival rates of inflammatory bowel disease (IBD) patients with colorectal carcinoma (CRC), which accounts for ∼15% of all IBD associated death.

Crohn's disease isolated to the appendix:: Truths and fallacies

Twenty-five cases of Crohns disease confined to the appendix were reported in eight hospitals in Israel during a 15-year period. Review of the histologic slides confirmed the diagnosis in 22 cases. Re-evaluation of these 22 patients included physical examination and radiologic studies of the small and large bowel. Rectosigmoidoscopy was performed in 16 patients. Signs and symptoms of Crohns disease at other sites in the gastrointestinal tract did not occur during follow-up periods of two to 15 years (mean, 6.4 years) after appendectomy. This study and a review of the literature indicate that in most cases (93 per cent) Crohns disease initially limited to the appendix is not a predictor of subsequent involvement of another portion of the bowel. It is concluded that the so-called Crohns disease isolated to the appendix is a form of chronic granulomatous and follicular appendicitis of unknown etiology that is unrelated nosologically in the majority of the cases to Crohns disease proper.

Colonic metastases from lobular carcinoma of the breast

Metastatic involvement of the gastrointestinal tract secondary to breast cancer is rare. A case of diffuse infiltration of the colon by metastatic infiltrating lobular breast cancer is reported. Awareness of this condition may lead to proper investigations including intestinal biopsy, thus avoiding unnecessary surgery.

Reduction in formation of peritoneal adhesions by methylene blue in rats: a dose response study

OBJECTIVE To find out if the ability of methylene blue given intraperitoneally to reduce surgically-induced adhesions in rats is concentration dependent. DESIGN Random, controlled prospective study. SETTING Teaching hospital, Israel. ANIMALS Seventy female Wistar rats. INTERVENTIONS Intraperitoneal adhesions were generated in rats by scraping the anterior wall of the uterine horn. They were then given either saline or serially diluted methylene blue intraperitoneally. Additional rats received identical treatments, but without the serosal damage. OUTCOME MEASURES Graded formation of adhesions, two weeks later. RESULTS In the rats treated with methylene blue 1%, adhesion formation was similar to that in sham operated rats and was significantly lower (p < 0.001) than in all other groups. CONCLUSION Methylene blue 1%, and to lesser degree 0.5%, had the best anti-adhesion potential. Lower methylene blue concentrations were only partially effective, and much high concentrations may cause adverse effects.