Stephen R. Gorfine

Treatment of benign anal disease with topical nitroglycerin

PURPOSE: Fissure-in-ano and acutely thrombosed external hemorrhoids are common, benign anal conditions, usually characterized by severe anal pain. Internal anal sphincter hypertonia appears to play a role in the etiology of this pain. Nitric oxide has recently been identified as the “novel biologic messenger” that mediates the anorectal inhibitory reflex in humans. This report documents a therapeutic role for nitroglycerin, a nitric oxide donor, in the treatment of acutely thrombosed external hemorrhoids and anal fissure. METHODS: Five patients with thrombosed external hemorrhoids and fifteen patients with anal fissure or ulcer were identified. A treatment regimen that included 0.5 percent nitroglycerin ointment applied topically to the anus was instituted. After one week of therapy, all patients were re-examined and questioned regarding pain relief and side effects of treatment. Fissure patients were followed for eight weeks or until healing occurred. RESULTS: All patients reported dramatic relief of anal pain following application of nitroglycerin. Pain relief lasted from two to six hours. Complete healing of fissures occurred within two weeks in ten patients and within one month in two patients. One patient, whose fissure had not healed completely within two weeks requested surgical sphincterotomy. Two patients remained with persistent anal ulcers despite two months of therapy. Both, however, were pain-free. Side effects were limited to transient headache in 7 of 20 patients. CONCLUSION: Topically applied nitroglycerin ointment appears to have a therapeutic role in the treatment of thrombosed external hemorrhoids and anal fissure.

Rives-Stoppa procedure for repair of large incisional hernias: experience with 57 patients

AbstractBackground. The use of prosthetic materials in tension-free incisional hernia repairs has diminished reherniation rates markedly; however, infection, intestinal fistulization, and seroma formation have been reported after repairs. Use of the Rives-Stoppa procedure for incisional hernia repair, in which the prosthesis is placed between the rectus abdominis muscle and the posterior sheath, may reduce occurrence of these problems.n Methods and materials. Over a 6-year period 57 open abdominal wall incisional hernia repairs were performed using the Rives-Stoppa technique; 15 (26.3%) had previously undergone incisional hernia repair. The prosthetic materials used were polypropylene, expanded polytetrafluoroethylene (ePTFE), and ePTFE with perforations. The prosthesis size ranged from 8×8xa0cm to 20×28xa0cm (mean area 199.6xa0cm2). Follow-up consisted of an office visit 12xa0months postoperatively and at least one subsequent office visit or telephone interview; mean follow-up time was 34.9xa0months (range 11.7–81.9).n Results. There were no hernia recurrences (except in one patient whose prosthesis was removed), gastrointestinal complications, fistulas, or deaths. Seromas occurred postoperatively in seven patients (12.3%). Two patients (3.5%) had wound infections that required removal of the prosthesis.n Conclusions. In this series the Rives-Stoppa technique had excellent long-term results, with minimal morbidity, in patients with large primary or recurrent incisional hernias. The absence of serious complications and hernia recurrences in patients with grafts in place suggests that the Rives-Stoppa procedure is the repair of choice in such patients.

Restorative proctocolectomy without diverting ileostomy

PURPOSE: Restorative proctocolectomy (RPC) by abdominal colectomy and ileal pouch-anal anastomosis (IPAA) in the setting of chronic ulcerative colitis (CUC) and familial adenomatous polyposis (FAP) has gained widespread popularity among surgeons and patients. Traditionally, temporary loop ileostomy has been established proximal to the ileal pouch in an effort to mitigate the effects of any suture line complications that may occur. This study compares functional results and complications encountered after RPC with mucosectomy with and without temporary ileostomy. METHODS: One hundred forty-three consecutive patients with either CUC or FAP underwent RPC including mucosectomy and ileal “J” reservoir. Proximal loop ileostomy was performed in 69 patients, and ileostomy was omitted in 74. Ileostomy was omitted if the patient was taking no immunosuppressives and less than 20 mg of prednisone daily in the month preceding surgery, the anastomosis was absolutely tension-free, and blood supply to the pouch was excellent. RESULTS: There were no perioperative deaths. There were two instances of pelvic abscess, one in the diverted group and one in the nondiverted group. Occurrence of IPAA suture line dehiscence was not significantly different between the two groups (ileostomy, 4/69 (6 percent),vs.no ileostomy, 6/74 (8 percent);P>0.05). Comparison of 129 patients with colitis with and without diversion also failed to demonstrate a significant difference with regard to IPAA suture line dehiscence (ileostomy, 4/69 (6 percent)vs.4/60 (7 percent);P>0.05). Frequency of bowel movements and continence were the same in both groups and were comparable with results obtained without mucosectomy. Mean hospital stay at the time of RPC for the nondiverted group was significantly longer (12 daysvs.10 days;P=0.0004). Significantly fewer patients without an ileostomy were hospitalized for partial intestinal obstruction (ileostomy, 13/69 (19 percent),vs.no ileostomy, 3/74 (4 percent);P=0.02), and significantly fewer required enterolysis (ileostomy, 7/69 (10 percent),vs.no ileostomy, 1/74 (1 percent);P=0.04). On average, patients without an ileostomy spent significantly fewer total days in the hospital (17vs.24;P=0.002). CONCLUSION: Restorative proctocolectomy with mucosectomy and without ileostomy is the procedure of choice for selected patients with FAP and CUC. Septic complications and functional results are similar to those seen in patients managed with a stoma. Anastomotic leakage, when it occurs, can be safely managed in most cases without surgery. RPC without ileostomy results in significantly fewer episodes of intestinal obstruction, fewer instances of re-exploration, and fewer total days in the hospital.

Laparoscopic-assisted intestinal resection for Crohn's disease

PURPOSE: The inflammatory process associated with Crohns disease often makes dissection difficult, even in “open” surgery. This study was undertaken to determine if dissection and resection could be performed laparoscopically and whether it would benefit this group of patients. METHODS: Between November 1992 and November 1994, laparoscopic-assisted intestinal resection was attempted in 18 patients with Crohns disease and was successfully completed in 14. One patient had ileal disease, requiring ileal resection with ileoileal anastomosis. The remainder had disease requiring ileocolic resections. Muscle-splitting incisions averaging 5 cm in length were made to facilitate removal of specimens. RESULTS: Commencement of oral alimentation was possible at an average of 3.6 (range, 1–7) days postoperatively. Discharge occurred at an average of 6.6 (range, 4–9) postoperative days. In comparison, 14 patients operated on by the authors for the same disease in the open manner during the past six months stayed an average of 8.5 (range, 5–14) postoperative days. Postoperative complications were minimal. CONCLUSIONS: On the basis of this initial study, it appears that laparoscopic-assisted intestinal resection can be readily performed in patients with Crohns disease. In our early experience, we have found that laparoscopic mobilization and resection may be difficult or impossible in patients with large fixed masses, multiple complex fistulas, or recurrent Crohns disease. Extraction incisions are frequently so large in these patients that they do not derive the same benefits from laparoscopic surgery that are enjoyed by patients without these findings. Most patients having laparoscopic resections eat earlier, may require fewer narcotics, and are able to be discharged from the hospital an average of two days earlier than patients operated on in an open manner. In addition, it appears that laparoscopic-assisted intestinal resection results in a shorter, easier convalescence and an earlier return to full activity.

Efficacy profile of liposome bupivacaine, a novel formulation of bupivacaine for postsurgical analgesia

Background Liposome bupivacaine is a novel formulation of the local anesthetic bupivacaine, designed to provide prolonged postsurgical analgesia. This analysis examined pooled efficacy data as reflected in cumulative pain scores from 10 randomized, double-blind liposome bupivacaine clinical studies in which the study drug was administered via local wound infiltration. Methods A total of 823 patients were exposed to liposome bupivacaine in 10 local wound infiltration studies at doses ranging from 66 mg to 532 mg in five surgical settings; 446 patients received bupivacaine HCl (dose: 75–200 mg) and 190 received placebo. Efficacy measures were assessed through 72 hours after surgery. Results Overall, 45% of patients were male and 19% were ≥65 years of age. In the analysis of cumulative pain intensity scores through 72 hours, liposome bupivacaine was associated with lower pain scores than the comparator in 16 of 19 treatment arms assessed, achieving statistically significant differences compared with bupivacaine HCl (P < 0.05) in five of 17 treatment arms. These results were supported by results of other efficacy measures, including time to first use of opioid rescue medication, proportion of patients avoiding opioid rescue medication, total postsurgical consumption of opioid rescue medication, and patient/care provider satisfaction with postoperative analgesia. Local infiltration of liposome bupivacaine resulted in significant systemic plasma levels of bupivacaine, which could persist for 96 hours; systemic plasma levels of bupivacaine following administration of liposome bupivacaine were not correlated with local efficacy. Liposome bupivacaine and bupivacaine HCl were generally well tolerated. Conclusion Based on this integrated analysis of multiple efficacy measures, liposome bupivacaine appears to be a potentially useful therapeutic option for prolonged reduction of postsurgical pain in soft tissue and orthopedic surgeries.

Early postoperative small-bowel obstruction: a prospective evaluation in 242 consecutive abdominal operations.

AbstractPURPOSE: Early postoperative small-bowel obstruction is a common but poorly defined complication of abdominal surgery. This prospective cohort study was undertaken to examine a reproducible definition of early postoperative small-bowel obstruction, determine its incidence, evaluate potential risk factors for its development, and delineate management strategies. nMETHODS: Two hundred twenty-five patients undergoing 242 consecutive abdominal operations during a 9-month period were prospectively evaluated from the time of admission until Postoperative Day 30. Early postoperative small-bowel obstruction was present if, within 30 days of surgery, all of the following criteria were met after the return of intestinal function: development of crampy abdominal pain, vomiting, and radiographic findings consistent with intestinal obstruction. Patients with early postoperative small-bowel obstruction were followed up until discharge or reexploration. All patients with early postoperative small-bowel obstruction were initially treated with nasogastric decompression. nRESULTS: Two hundred forty-two abdominal procedures were performed on 119 males and 123 females aged 13 to 98 (mean, 51) years. Ulcerative colitis (n = 70), malignancy (n = 59), and Crohn’s disease (n = 41) were the most common diagnoses. One hundred nineteen patients (49.2 percent) had undergone previous laparotomy, and 45 patients (18.6 percent) had previously been diagnosed with intestinal obstruction. Early postoperative small-bowel obstruction occurred in 23 cases (9.5 percent). Patients with and without early postoperative small-bowel obstruction were similar with respect to diagnosis, preoperative immunosuppression, previous laparotomy or obstruction, surgery performed, and time to return of intestinal function. Twenty episodes (87 percent) resolved with nasogastric decompression alone; all but one resolved within six days or less. Three patients (13 percent) required relaparotomy; one required small-bowel resection. Two of three patients whose symptoms did not resolve with six days of nasogastric decompression required reexploration. There were no deaths and no major morbidity. nCONCLUSIONS: Early postoperative small-bowel obstruction, defined by an objective data set, was observed in 9.5 percent of cases. No independent risk factors predisposing to early postoperative small-bowel obstruction were identified. Early postoperative small-bowel obstruction was safely and effectively managed by nasogastric decompression in the majority of cases, with low morbidity and no mortality. In general, reexploration should be reserved for those patients whose symptoms do not resolve within six days of nasogastric decompression.

Restorative proctocolectomy in patients older than fifty years

PURPOSE: This study was undertaken to compare functional results, complications, preoperative durations of disease, and rates of dysplasia and neoplasia between older and younger chronic ulcerative colitis patients undergoing restorative proctocolectomy (RPC) with mucosectomy. METHODS: A total of 392 patients with a preoperative diagnosis of chronic ulcerative colitis underwent elective RPC with mucosection and handsewn ileoanal anastomosis. Pathologic reports were reviewed, with specific reference to findings of dysplasia or cancer. Functional results concerning the number of bowel movements per 24 hour period and the incidence of fecal soilage were obtained by direct or telephone patient interview. FINDINGS: Group I consisted of 326 patients aged 5 to 49 (mean, 30.9) years and 160 women. Group II comprised 66 patients aged 50 to 74 (mean, 56.9) years and 29 women. Duration of disease was significantly longer in the older group (6.2vs.15.6 years;P<0.001). The older group had significantly higher rates of dysplasia (29/326vs.19/66;P<0.0001) and malignancy (14/326vs.9/66;P=0.003). Rates of complication, hospital days following RPC, and total hospital days for all causes were comparable between groups. Perfect daytime continence was observed in 81.6 percent of Group I and 80 percent of Group II patients (213/261vs.40/50;P= 0.79). Perfect continence during sleep was observed in 65.1 percent of Group I and 62 percent of Group II patients (170/261vs.31/50;P=0.67). Mean number of bowel movements per 24 hour period for Group I was 6.3±0.2 and for Group II was 7.4±0.5. Mean difference, one movement per 24 hours, was not significant (95 percent confidence interval, −0.02 to 2.1;t=1.95,P=0.055). CONCLUSIONS: We conclude that patients older than 50 years are suitable candidates for RPC with mucosectomy. Functional results and complication rates are similar to those observed among younger patients. Patients older than 50 years have a significantly higher rate of concurrent dysplasia and malignant degeneration than younger patients, most probably because of a longer duration of disease. RPC with mucosal excision potentially lowers this risk by elimination of all colorectal mucosa.

Postoperative mesenteric pseudoaneurysm in a patient undergoing bowel resection for Crohn’s disease

presented with pain and a perianal lump at the base of a penile implant, which remained following the implant’s removal. Biopsies showed adenocarcinoma with pools of mucus. On MRI of the pelvis there was a mass to the left of the neorectum that extended 6 cm inferiorly below the bladder. There was no normal prostatic tissue visible and the prostatic urethra was involved. After a course of neoadjuvant chemoradiotherapy the patient was treated by abdomino-perineal excision of the neorectum, bladder and prostate. The tumour was a mucinous adenocarcinoma. The main tumour mass was situated left antero-lateral to the neorectum within the soft tissue at the level of the seminal vesicles and prostate. The tumour infiltrated through the muscle coat into the submucosa of the neorectum but the mucosa was not involved (Fig. 1b). The patient had a nonhealing perineal wound and repeat biopsy identified recurrent tumour. He is now 20 months after operation and is currently being treated with palliative chemotherapy.

Pelvic Cancer Ten Years after Restorative Proctocolectomy in Indeterminate Colitis: Report of a Case

Restorative proctocolectomy is generally accepted as the procedure of choice for patients with chronic ulcerative colitis requiring surgery. Restorative proctocolectomy for patients with indeterminate colitis is somewhat more controversial because the reported complication rate is higher after this procedure. 1-4 For either diagnosis, most surgeons believe that restorative proctocolectomy greatly reduces or even eliminates the risk of inflammatory bowel disease-associated colorectal cancer. Although restorative proctocolectomy does seem to lower the cancer risk, it is not eliminated. Eighteen cases of postoperative pouch-related cancers after restorative proctocolectomy have been reported in the literature. 5-22 Most of these cancers were discovered fairly soon after restorative proctocolectomy, and all but two were found in patients with chronic ulcerative colitis. There have been no reports of pouch-related cancer in patients with indeterminate colitis. We present a patient with indeterminate colitis who developed pouch-related adenocarcinoma ten years after restorative proctocolectomy despite on-going pouch surveillance.