Michael A. Weinstein

Transanal hemorrhoidal dearterialization is an alternative to operative hemorrhoidectomy

BACKGROUND Transanal hemorrhoidal dearterialization (THD), a new approach for patients who would otherwise require an operative hemorrhoidectomy, accomplishes hemorrhoidal symptom relief with far less postoperative pain than an operative hemorrhoidectomy. METHODS THD, an ambulatory procedure, employs a specially designed proctoscope coupled with a Doppler transducer to allow identification and suture ligation of the hemorrhoidal arteries. RESULTS Sixty patients between ages 22 and 87 were treated. Bleeding was fully corrected in 88%, protrusion in 92%, and pain in 71%. Two patients (3%) failed to improve with THD. Complications included pain resulting in greater than 2 days loss of work in 5 patients, postoperative perirectal thromboses developed in 4 patients, and an anal fissure developed in 1 patient. CONCLUSIONS THD was an effective alternative to operative hemorrhoidectomy. It may be the only option for patients where an operative hemorrhoidectomy is contraindicated because of incontinence.

Social injuries of the rectum

Eleven patients with injuries of the rectum and sigmoid colon secondary to the insertion of the clenched fist are presented. Six patients sustained mucosal lacerations of the rectum and four patients had rectosigmoid perforations requiring laparotomy. One patient sustained a severe sphincter laceration producing complete anal incontinence. The management of these conditions is discussed.

EBV-associated anorectal lymphomas in patients with acquired immune deficiency syndrome.

Primary lymphomas of the gastrointestinal tract represent 9% of all non-Hodgkin lymphomas, and of these only 3% arise in the rectum or anus. In contrast to their rare occurrence in the general population, the incidence of anorectal lymphomas in patients with acquired immune deficiency syndrome (AIDS), particularly homosexual patients, may be as high as 26% as reported in our own series of AIDS-associated lymphomas. To determine the characteristics of this entity, we studied 15 cases of primary anorectal lymphoma in AIDS patients and compared them with four cases of anorectal lymphoma unrelated to AIDS. The cases in our study were also compared with the reports of rectal lymphoma in the medical literature over the past 30 years. In the present series, the AIDS patients were all male with a median age of 34 years, human immunodeficiency virus (HIV)-positive, with homosexuality as the main risk factor. The four non-AIDS patients included a woman and had a median age of 66.5 years. Histologically, the anorectal lymphomas in AIDS patients were all high grade, predominantly immunoblastic, and polymorphous. In the non-AIDS patients, only two of four lymphomas were high grade, including one Burkitt type. All tumors were of B-cell phenotype. In the AIDS-associated anorectal lymphomas, the presence of Epstein-Barr virus (EBV) in a latent form was demonstrated by an abundance of Epstein-Barr-encoded RNA (EBER) in 14 of 15 cases and latent membrane protein (LMP) in four cases. All anorectal lymphomas unrelated to AIDS were negative for EBV. The unusual anorectal location of AIDS-associated lymphomas is explainable by the high incidence of preceding traumatic lesions and chronic infections in the area. As a result, EBV-carrying B cells may be attracted to the field providing the cell population that, under the conditions of immune deficiency, is able to give rise to high-grade lymphomas.

Primary anorectal lymphoma. A new manifestation of the acquired immune deficiency syndrome (AIDS).

Non‐Hodgkins lymphomas with particular clinicopathologic features occur with a high incidence in homosexual men affected by AIDS. More frequently than in the general population, these lymphomas have an extranodal location including the gastrointestinal tract. We have recently observed four cases of AIDS‐associated lymphomas whose primary location is in the lower rectum and anus. The patients were 27 to 44 years of age, had greatly depressed helper‐suppressor T‐cell ratios, and antibodies to human immunodeficiency virus (HIV). All four presented with anorectal symptoms and originally had surgery for anorectal fistulas or tumor masses. When staged, three patients had no other organ involvement, the fourth only had lymphoma in an axillary lymph node, and all four had large tumor masses confined within the rectum. In terms of histology, the lymphomas were of undifferentiated or of large cell type and of B‐cell phenotype. Lymphomas with primary or major location in the rectum are a rare occurrence in the general population, and until recently, are rare even among the lymphomas associated with the immune deficiency syndrome. At the Lenox Hill Hospital in New York City, no rectal lymphoma among the 58 cases of AIDS‐related lymphoma diagnosed during the past 4 years was recorded until 10 months ago. The recognition of the new feature in presentation, a neoplasm associated with AIDS, is obviously important for its early diagnosis and treatment. Its unusual occurrence at the suspected portal of entry of the HIV infection is of interest because it may provide new clues to the association between AIDS and neoplasia.

Tracking respiratory therapy in the trauma patient

The respiratory index (RI), P(AaDO2)/PaO2, was investigated in a retrospective study of 177 intubated patients treated at the Maryland Institute for Emergency Medicine. An RI of 0.1 to 0.37 is normal. Patients with an RI of 2 or greater were intubated. Those patients who reached an RI of 6 or more had an associated 12 per cent probability of survival. The RI reflects the presence of pulmonary shunting in a variety of circumstances including atelectasis, pulmonary contusion, and pulmonary emboli. A nomogram that allows the course of the patient with respiratory problems to be followed is described. Movement along the same isobars or between isobars can be followed by plotting the PaO2 against the FI0-2. Thus, the rationale and effect of respiratory therapeutic manipulations may be recorded graphically.

The dilemma of pilonidal disease: Pilonidal cystotomy, reappraisal of an old technique

SummaryA series of 126 patients treated by inhospital pilonidal cystotomy is reviewed. One hundred twenty-four were treated using local anesthesia with supplemental diazepam or Innovar®. Most patients spent only three days in the hospital, with healing occurring in less than two months. Recurrences occurred in 20.9 per cent of the patients. The recurrences were treated by office procedures in all but one instance. Most patients were pain-free and back to work within two weeks after operation.

The dilemma of pilonidal disease

PILONIDAL DISEASE, s ince its original des c r i p t i on more than a century ago, has generated widespread controversy as to its etiology and surgical treatment. However, it remains a frequent problem for patient and surgeon. The object of this paper is to present favorable results obtained in a large number of patients treated by simple excision of the pilonidal tissue, allowing the wound to ~anula te and heal by secondary intention.

Management of the Poorly Prepared Colonoscopy Patient: Colonoscopic Colon Enemas as a Preparation for Colonoscopy

PurposeColonoscopic colon enema is an option for the management of patients who are suboptimally prepared for colonoscopic examination because of retained fecal material.MethodsAfter colonoscopy is performed and the colonoscopist has reached the right colon and the colon is deemed to be inadequately prepared, the contents of two commercially available bisacodyl enemas are combined and instilled into the right colon via the colonoscope biopsy channel. Patients are allowed to recover from propofol sedation, expel the lumenal contents, resedated, and examined.ResultsIn this fashion, 21 patients during a 19-month period were successfully cleansed of their retained fecal contents, permitting satisfactory colonoscopic examinations. This avoided the need for postponement of the procedure.ConclusionsColonoscopic colon enema is an innovative and simple option available to the colonoscopist to manage the patient with an inadequately prepared colon.

Two prognostic indices for the trauma patient

Abstract This paper attempts to further the quest for an acceptable, practical system for measuring and tracking the response to injury in patients. A general trauma index, (the CHOP index) and a respiratory index were used in combination to define prognosis regions based on a retrospective study of 172 consecutive intubated multiple trauma victims. A discussion is included of the planned computer-assisted bed-side use of the indices.

Use of total parenteral nutrition as a “Medical colostomy” in management of severe lacerations of the sphincter: Report of a case

SummaryA case of anal-sphincter injury with total fecal incontinence is presented. The use of total parenteral nutrition (TPN) as a “medical colostomy” is stressed. After four weeks of support by TPN, the perineal wound had healed and successful sphincteroplasty was performed. TPN was used in the postoperative period to delay bowel movements for one week. The general concept of the use of TPN in sphincter injury is presented, giving the surgeon an option in management of these injuries without resorting to a preliminary colostomy.