Robert W. Beart

Randomized prospective evaluation of the EEA stapler for colorectal anastomoses

A randomized, prospective study should be done to evaluate any new procedure or instrument. Our experience with the end-to-end anastomosis (EEA) stapler suggests that an anastomosis can be created in a shorter time than is required for the traditional hand-sewn technique. This difference is even greater when the anastomosis is technically difficult and located deep within the pelvis. There appears to be little difference in the security of a hand-sewn anastomosis compared with that of stapled anastomosis. Postoperative complications appear similar. With the stapler, however, there is an increased risk of intraoperative complications that are not apparent with the traditional hand-sewn technique. These include rectal tears and anastomotic defects. It appears that the EEA stapler can save as many as 12 percent of rectums that otherwise might have to be removed because of technical inability to perform an anastomosis.

Improving survival in adenocarcinoma of the duodenum.

The records of 104 patients with primary adenocarcinoma of the duodenum were reviewed. All patients were followed up to the date of this report, 91 for at least 5 years. Melena was an ominous preoperative finding. Survival was directly related to nodal status, the grade of the lesion, and the ability of the surgeon to minimize or eliminate operative mortality. Fifty percent of the lesions were resectable for cure, and the 5 year survival rate for patients with resectable lesions was 46 percent. All eight patients treated with segmental resections for lesions in the third and fourth portions of the duodenum survived at least 5 years. These data are a great improvement over those in previous reports and suggest that this disease may be much more treatable than previously believed.

Elective colon and rectal surgery without nasogastric decompression: a prospective, randomized trial

Nasogastric (NG) decompression after colorectal surgery is practiced commonly. Our aim was to determine whether routine NG decompression benefitted patients undergoing this type of surgery. Five hundred thirty-five patients were randomized prospectively to either NG decompression or no decompression. Stratification was by type of operation and patient age. Excluded were patients who had emergency surgery with peritonitis, extensive fibrous adhesions, enterotomies, previous pelvic irradiation, intra-abdominal infection, pancreatitis, chronic obstruction. prolonged operating times, or difficult endotracheal intubation. Two hundred seventy-four patients received NG decompression (Salem sump, Argyle Co., Division of Sherwood Medical, St. Louis, MO) and two hundred sixty-one did not. There were 33 protocol violations included in the 535 patients. Patients who were not decompressed experienced significantly more abdominal distention, nausea, and vomiting than did those patients who were. Moreover, 13% required subsequent NG decompression as opposed to a reinsertion rate of 5% for patients routinely decompressed. The mean length of hospitalization for both groups was 11 days. There were no significant differences in nasopharyngeal or gastric bleeding, inability to cough effectively, respiratory infections, wound disruptions, reoperation, and wound infection rates (5%) between the two groups. We conclude that even though there is an increase in the rate of minor symptoms of nausea, vomiting, and abdominal distention, routine nasgastric decompression is not warranted after elective colon and rectal surgery.

Colonoscopic decompression for acute pseueteobstruction of the colon (Ogilvie's syndrome)

This report has described a series of 22 patients who underwent colonoscopic decompression for acute pseudoobstruction of the colon and summarizes those cases previously reported in the literature. Twenty of the 22 patients (91 percent) were successfully treated by decompression initially. Fifteen patients (68 percent) were cured with the initial procedure, and 4 patients (18 percent) experienced recurrence. Overall, in 17 patients (77 percent), the pseudoobstruction resolved completely with colonoscopic decompression. Three patients (14 percent) underwent operation because of cecal dilatation refractory to colonoscopic decompression, and in one patient (4.5 percent), the colonic dilatation resolved spontaneously after a failed colonoscopy. Complications resulted in the death of one patient (4.5 percent). Our data are similar to those in the literature and indicate that colonoscopic decompression is a safe and efficacious first line of treatment for acute pseudoobstruction of the colon.

Rectal preservation in nonspecific inflammatory disease of the colon.

Sixty-three patients with chronic ulcerative colitis and 80 patients with Crohns disease underwent abdominal colectomy and primary ileorectal or ileosigmoid anastomosis and were followed up for between five and 17 years. No patient developed carcinoma of the rectal stump. The interval proctectomy rate was similar in both groups (24 and 29%, respectively), the rate being influenced by age in the group with chronic ulcerative colitis. The young patients with ulcerative colitis required proctectomy more often than did the patients with onset later in life. The proctectomy rate was not influenced by the level of the anastomosis. In patients with nörmal or moderately diseased rectal mucosa, the preoperative condition of the rectum did not influence the proctectomy rate. Functional results were satisfactory in 55% of the patients with chronic ulcerative colitis who survived and in 35% of the patients with Crohns disease who survived. Because of the non-curative nature of surgery for Crohns disease, a conservative posture should be maintained, with preservation of normal or moderately diseased rectal segments. If sigmoidoscopic examination and biopsy are done periodically, abdominal colectomy and ileorectal or ileosigmoid anastomosis appears to be a viable option to proctocolectomy in selected patients with chronic ulcerative colitis.

Sphincter repair for fecal incontinence after obstetrical or iatrogenic injury

Forty patients with fecal incontinence underwent sphincter repair between 1975 and 1984. Divided sphincter musculature resulted from obstetrical injury in 23 and previous anorectal surgery in 17. Eighteen had undergone a previous attempt at repair. Fifteen patients experienced seepage of stool and 25 had gross incontinence. In nine patients, reconstruction of the external sphincter was by overlap of the muscle ends. Twenty-four others underwent accurate approximation of the external sphincter muscle and anterior plication of the levator muscles, and in seven the anal canal was made smaller by narrowing the anal orifice. Follow-up was an average of 67 months after operation (range, 2.4 to 166 months). Continence was objectively improved in 62 percent (P<.01) when performance criteria were analyzed by Wilcoxon signed-rank test, although 85 percent of the patients reported subjective improvement. Requirements for protective pads were reduced in 57 percent (P<.01) and fewer social limitations were experienced in 52 percent (P<.01). There was no significant correlation between outcome and type of operation.

A continent ileostomy device.

The feasibility of achieving fecal continence by mechanical occlusion of an end-ileostomy is explored. Accordingly, progressive stomal occlusion with an indwelling occluding device was evaluated in four healthy patients with Brooke ileostomies. Pre-occlusion clinical and physiologic tests were done, including fat balance, intestinal transit time, ileal motility and absorption, ileal compliance, ileal radiography, and ileoscopy. Progressive stomal occlusion was then employed until periods of occlusion of 5 to 8 hours were achieved after 10 to 16 weeks. Pre-occlusion tests were then repeated. Patients mastered use of the occluding device rapidly, and the device achieved reliable stomal continence in each patient. Whereas ileal capacity was small initially, intermittent occlusion resulted in a large, capacious ileal reservoir. Fasting ileal motility was increased slightly by stomal occlusion, although intestinal transit during feeding was not altered. Also, ileal absorption of glucose, electrolytes, vitamin B-12, and fat were not changed, and ileal mucosa at the site of occlusion remained intact endoscopically. The authors concluded that chronic intermittent occlusion of a Brooke ileostomy with an indwelling stomal device achieved enteric continence without impairing intestinal function.

Indwelling ileostomy valve device

Complications after construction of a continent ileostomy may require reoperation to restore continence. Although most patients accept another operation, a few refuse further operative intervention. In such patients we have employed an indwelling ileostomy valve device. A Silastic tube with a circumferential balloon to provide a leakproof seal functionally replaces the nipple valve that has failed. In 14 patients, the valve device has maintained continuous and voluntary control over evacuation without untoward local or systemic effects. If further investigation continues to support this approach to maintaining continence, use of an indwelling ileostomy valve device might be preferable to continued creation of the nipple valve.

Cholecystostomy for noninflammatory disease

Cholecystostomy in patients with noninflammatory disease of the biliary tract has rarely been evaluated. Our experience with 124 patients suggests that, in addition to being helpful in inflammatory conditions, cholecystostomy is helpful in performing cholangiography, in removing stones and in decompressing an otherwise obstructed biliary tree. The mortality associated with this procedure is minimal, and the morbidity is 4.5 percent.