Philip P. Metzger

Prophylactic oophorectomy in colorectal carcinoma: Preliminary results of a randomized, prospective trial

Controversy exists regarding the role of prophylactic oophorectomy during resection for primary colorectal cancer. PURPOSE: A prospective, randomized trial was initiated to evaluate the influence of oophorectomy on recurrence and survival in patients with Dukes Stages B and C colorectal cancer. METHOD: Between November 1986 and March 1997, 155 patients were randomized to oophorectomy or no oophorectomy at laparotomy for resection of colorectal cancer. RESULTS: No incidence of gross or microscopic metastatic disease to the ovary was found among 77 patients randomized to oophorectomy, in contrast to previous reports. Preliminary crude survival curves suggested a survival benefit for oophorectomy between two and three years from surgery, but Kaplan-Meier survival analysis indicated that this was not statistically significant and the benefit does not appear to persist at five years. Kaplan-Meier curves of recurrence-free survival, however, suggest a more substantial separation of the curves, with 80 percentvs. 65 percent five-year disease-free survival for oophorectomyvs. nonoophorectomy, but further patient accrual is necessary to provide sufficient statistical power. CONCLUSIONS: Occult colorectal carcinoma metastatic to the ovaries has not been documented in this series of putative Dukes Stages B and C tumors. The possibility of a recurrence-free survival advantage emphasizes the need to continue this preliminary work.

Clostridium difficile Infection: Risk Factors, Medical and Surgical Management

Background:Clostridium difficile has become recognized as a cause of nosocomial infection which may progress to a fulminant disease. Methods: Literature review using electronic literature research back to 1966 utilizing Medline and Current Contents. All publications on antibiotic-associated diarrhea, antibiotic-associated colitis, and pseudomembranous colitis as well as C. difficile infection were included. We addressed established and potential risk factors for C. difficile disease such as an impaired immune system and cost benefits of different diagnostic tests. An algorithm is outlined for diagnosis and both medical and surgical management of mild, moderate and severe C. difficile disease. Results: Diagnosis of C. difficile infection should be suspected in patients with diarrhea, who have received antibiotics within 2 months or whose symptoms started after hospitalization. A stool specimen should be tested for the presence of leukocytes and C. difficile toxins. If this is negative and symptoms persist, stool should be tested with ‘rapid’ enzyme immunoabsorbent and stool cytotoxin assays, which are the most cost-effective tests. Endoscopy and other imaging studies are reserved for severe and rapidly progressive courses. Oral metronidazole or vancomycin are the antibiotics of choice. Surgery is rarely required for selected patients refractory to medical treatment. The threshold for surgery in severe cases with risk factors including an impaired immune system should be low. Conclusion:C. difficile infection has been recognized with increased frequency as a nosocomial infection. Early diagnosis with immunoassays of the stool and prompt medical therapy have a high cure rate. Metronidazole has supplanted oral vancomycin as the drug of first choice for treating C. difficile infections.

Small-intestinal enteroliths—Unusual cause of small-intestinal obstruction

PurposePurpose The aim of this study was to report on a rare cause of small-intestinal obstruction caused by small-intestinal enteroliths. METHODS: We present three different cases of enterolith formation in the small intestine. One occurred after nontropical sprue, one patient had multiple jejunal diverticula, and another patient had enterolith formation in a blind loop after a small-bowel side-to-side anastomosis. RESULTS: After initial conservative therapeutic approach all patients underwent surgery. In two patients the enteroliths were removed by ileotomy or jejunostomy. In the third patient the bowel anastomosis had to be revised after removal of the enterolith. CONCLUSION: Small-intestinal enteroliths may cause small-bowel obstruction. The first therapeutic approach is nonsurgical; however, if obstruction proceeds, surgical removal with or without revision of underlying pathology is necessary. We discuss the causes and therapeutic management of enteroliths and give a review of related literature.

Modified packing technique for control of presacral pelvic bleeding

A modification of pelvic packing to control presacral bleeding is described. This method makes removal of the packing less uncomfortable and usually does not require anesthesia.

Surgical management of a long efferent loop after J-pouch ileoanal reconstruction

PURPOSE: To demonstrate a simple and effective repair of a poorly constructed ileal J-pouch with an extensive long efferent limb. METHOD: A retrospective case review was performed. RESULTS: The surgical procedure described preserves additional ileum and enlarges the ileal reservoir. The procedure succeeded in resolving the patients complaints of partial obstruction, weight loss, and increased stool frequency. At five-month follow-up, the patient was doing well with three to six stools daily. Evaluation of the new ileal J-pouch showed no signs of inflammation, and the pouch size measured more than 20 cm compared with 12 cm preoperatively. CONCLUSIONS: Repair of a long efferent limb by this simple stapling technique is feasible, simple, and effective, with an excellent clinical result. It preserves valuable small intestine and enlarges the capacity of the reservoir, leading to better functional outcome.

Adenocarcinoma developing in a rectosigmoid conduit used for urinary diversion: Report of a case

Adenocarcinoma of the colon developing at or about the sites of ureterosigmoid anastomoses for urinary diversion has been documented in the literature. A case report is presented that illustrates that a carcinoma can develop in a large bowel urinary conduit not exposed to the fecal stream. Colonic bladders are being used with increasing frequency, making observation for this delayed complication necessary. How this neoplastic transformatin might occur is discussed. Suggestions for the management of this problem and guidelines for follow-up are also presented.

Persistent ischiorectal fistula with supralevator origin secondary to a chronic tubo-ovarian abscess: report of a case and review of the literature.

Background Chronic tubo-ovarian abscess is an uncommon finding in postmenopausal women. This abscess may rupture or fistulize to adjacent organs into the ischiorectal space. Case A gravida three, para three, postmenopausal woman with extensive sigmoid diverticulosis presented with perianal fistula of 2 years’ duration. Magnetic resonance imaging showed the tract to have a supralevator origin adjacent to the sigmoid colon. She had no recent instrumentation other than preoperative colonoscopy. Intraoperatively, the fistula tract origin was noted to be from a right tubo-ovarian abscess. She was treated with right salpingo-oophorectomy and tract excision/sealing. At 4-month follow-up, the fistula tract was healed with no further drainage. Conclusions Tubo-ovarian abscess should be considered in the differential diagnosis of supralevator fistula in postmenopausal women when no other source can be localized.