Faculty Bibliography

BACKGROUND AND AIMS: Because of improved medical care and surgical techniques blow-hole colostomy with loop ileostomy is now rarely performed to reduce operative risks in patients with toxic megacolon related to inflammatory bowel disease (IBD). We reviewed patient charts to identify continuing indications for this procedure. PATIENTS AND METHODS: Seventeen patients underwent blow-hole colostomy procedure with ( n=15) or without ( n=2) ileostomy (8 men, 9 women; median age 51 years, range 21-79) during the past 18 years (1983-2001). RESULTS: The indications for the procedure were: toxic megacolon related to IBD ( n=6), toxic megacolon related to IBD and associated with pregnancy ( n=2), Clostridium difficile colitis ( n=3), adult Hirschsprung's disease ( n=1), pancreatitis with obstructing pseudocyst ( n=1), and palliation for malignant bowel obstruction with metastases ( n=4). Patients were discharged home after a median stay of 10 days (range 4-32 days). The 4 patients who underwent a palliative blow-hole procedure had died secondary to their underlying disease by the time of follow-up. Of the remaining 13 patients 12 had their alimentary tract reconstituted, and one still awaits a definitive procedure. CONCLUSION: The blow-hole colostomy-ileostomy procedure is still indicated for select patients with toxic megacolon and large-bowel obstruction. The procedure acts as a bridge to definitive operation for toxic patients with benign disease and palliates those with malignant obstructions and metastasis.

PURPOSE: Several procedures have been described for the management of rectourethral fistula. There has been no consensus on the best method of repair. The aim of this study was to review our experience with treatment of rectourethral fistula, focusing on the outcomes of rectal advancement flap repair. METHODS: Data collected included demographics, cause, procedure type, presentation, operative details, and morbidity. Telephone follow-up was conducted to evaluate functional outcome and quality of life. RESULTS: From 1981 to 2001, 23 male patients (age, 54 +/- 15 years) were treated for rectourethral fistula. Fecal diversion alone was performed in seven patients (30 percent), and urinary diversion alone was performed in one patient (4 percent). Both fecal and urinary diversion were performed in 12 patients (52 percent), and no diversion was performed in 3 (13 percent). Four patients were managed conservatively with diversion only. Nineteen patients underwent definitive repair. Rectal advancement flap repair was used in 12 (52 percent) of the cases. Postoperative length of stay was 4.5 +/- 4 days. Patients were followed up for an average of 31 +/- 33.4 months. Rectal advancement flap achieved primary closure in 8 (67 percent) of 12 patients. There were four recurrences. Two patients underwent successful repeat repair, for a final success rate of 83 percent. Morbidity associated with rectal advancement flap was 8 percent (1/12 patients). Cleveland Global Quality of Life score averaged 0.82 +/- 0.13. CONCLUSION: The rectal advancement flap provides an effective repair for rectourethral fistula. Successful repair can be achieved in a majority of patients with minimal morbidity, short length of stay, and a good postoperative quality of life.

PURPOSE: Pouchitis is the most common complication of ileal pouch-anal anastomosis for ulcerative colitis. Our previous study suggested that symptoms alone are not reliable for the diagnosis of pouchitis. The most commonly used diagnostic instrument is the 18-point pouchitis disease activity index consisting of three principal component scores: symptom, endoscopy, and histology. Despite its popularity, the pouchitis disease activity index has mainly been a research tool because of costs of endoscopy (especially with histology), complexity in calculation, and time delay in determining histology scores. It is not known whether pouch endoscopy without biopsy can reliably diagnose pouchitis in symptomatic patients. The aim of the present study was to determine whether omitting histologic evaluation from the pouchitis disease activity index significantly affects the sensitivity and specificity of diagnostic criteria for pouchitis. METHODS: Ulcerative colitis patients with an ileal pouch-anal anastomosis and symptoms suggestive of pouchitis were evaluated. Patients with chronic refractory pouchitis and Crohn's disease were excluded. Patients with pouchitis disease activity index scores of seven or more were diagnosed as having pouchitis. Different diagnostic criteria were compared on the basis of the pouchitis disease activity index component scores. Nonparametric receiver-operating-characteristic curves were used to measure proposed pouchitis scores' diagnostic accuracy compared with diagnosis from the pouchitis disease activity index. The receiver-operating-characteristic area under the curve measured how much these diagnostic strategies differed from each other. RESULTS: Fifty-eight consecutive symptomatic patients were enrolled; 32 (55 percent) patients were diagnosed with pouchitis. With the use of the pouchitis disease activity index as a criterion standard, the use of only symptom and endoscopy scores (modified pouchitis disease activity index) produced an area under the curve of 0.995. Establishing a cut-point of five or more for diseased patients resulted in a sensitivity equal to 97 percent and specificity equal to 100 percent. CONCLUSIONS: Diagnosis based on the modified pouchitis disease activity index offers similar sensitivity and specificity when compared with the pouchitis disease activity index for patients with acute or acute relapsing pouchitis. Omission of endoscopic biopsy and histology from the standard pouchitis disease activity index would simplify pouchitis diagnostic criteria, reduce the cost of diagnosis, and avoid delay associated with determining histology score, while providing equivalent sensitivity and specificity.

BACKGROUND: The effect of surgery on quality of life (QOL) in the early postoperative period is important in Crohn's disease because of the multiple surgical procedures that patients undergo and the acute QOL benefits that might occur as a result of modifications of medical treatment. Earlier studies of the effect of surgery on QOL have been retrospective and assessed changes 3 to 24 months after surgery. This study prospectively assesses the effect of surgery on QOL in the early postoperative period. STUDY DESIGN: Patients requiring surgical management of sequelae of Crohn's disease were obtained from a prospectively entered database including data on QOL. Preoperative and 30-day postoperative QOL were determined in 82 patients using Cleveland Global Quality of Life (CGQL) scores (range from 0 [worst] to 10 [best possible] QOL). Preoperative and postoperative scores were compared using a paired t-test to determine the significance of any change in QOL after surgery. The effect of other variables on change in QOL after surgery was assessed using the t-test or analysis of variance. Multifactor analysis of variance was used to assess the effect of several independent variables. RESULTS: Eighty-two patients (41 women) of 142 patients who had had surgery (58%) had complete preoperative and 30-day postoperative scores. The incidence of complications was 23% (11% were major). There was a significant improvement in QOL 30 days after surgery as measured by CGQL (0.6 +/- 0.2 preoperative to 0.7 +/- 0.2 postoperative; mean +/- SD; p < 0.001). The mean preoperative CGQL was 0.56 +/- 0.24 and the mean improvement was 0.11 +/- 0.20 toward a better QOL. Female patients (p < 0.05) and those who did not develop complications within 30 days of surgery (p < 0.05) had a significantly greater improvement in CGQL after surgery than other groups. No other factor was predictive of improved outcomes. CONCLUSIONS: QOL as measured by CGQL improves early after surgery (30 days postoperatively). Improvement in CGQL is greater in female patients and patients who do not develop complications in the postoperative period. It is not affected by other patient characteristics, nature of disease, indication, or procedure performed. Most patients who undergo surgery for Crohn's disease feel that surgery has helped them and would undergo surgery again.

Recent developments in adhesion prevention have led to the introduction of a sodium hyaluranate-based bioresorbable membrane into clinical practice. Its application has been regarded as safe and efficient. We present three cases of postoperative acute aseptic peritonitis without an obvious etiology, which might have been related to this bioresorbable membrane during recent surgery. Surgeons should be aware of this kind of a complication that might be attributed to this product.

Nonspecific investigations resulting in treatment delays contribute to the 30 per cent mortality associated with acute mesenteric ischemia (AMI). As preliminary studies indicate that alpha-glutathione S-transferase (alpha-GST) is elevated in AMI we compare the ability of alpha-GST against conventional biochemical tests to predict AMI. There were 58 patients prospectively evaluated for AMI. Samples for alpha-GST (Biotrin International, Dublin, Ireland), lactate, pH, amylase, base excess, and white blood cell count (WBC) were evaluated. Intestinal ischemia was confirmed by colonoscopy, angiography, or laparotomy. Ischemia was present in 35 (60%) patients: small bowel (n = 14), colonic (n = 17), and global (n = 4). Four patients without autopsy were excluded. Alpha-GST was elevated in those with AMI [22.2 (7-126) ng/mL vs 2.2 (1-3) (P = 0.001)]. Alpha-GST was more accurate at predicting intestinal ischemia (74%) than conventional tests (47-69% accuracy). Accuracy was increased to 80 per cent by combination with lactate or WBC, which increased sensitivity to 97 to 100 per cent. Alpha-GST monitoring is a useful tool for the diagnosis of intestinal ischemia. A normal alpha-GST and WBC may exclude the presence of AMI.

Portal vein thrombosis is a very uncommon complication after laparoscopic surgery. Although only one case of portal vein thrombosis has been reported after laparoscopic colectomy, there are several reports of mesenteric vascular occlusion after other laparoscopic procedures. We present a case of portal vein thrombosis in a patient with no other demonstrable hypercoagulable states or risk factors, who underwent an uneventful laparoscopic sigmoid colectomy. Because alteration in coagulation may occur after establishing a pneumoperitoneum, we suggest that heparin prophylaxis may be advisable to avoid these kinds of complications, especially if a past history of coagulable disorders is present.

PURPOSE: To determine the presence and location of portal vein thrombi in patients who have undergone ileal pouch-anal anastomosis (IPAA) and who were scanned with computed tomography (CT). MATERIALS AND METHODS: During a 4-year period, 92 of 702 patients underwent contrast medium-enhanced CT after a total proctocolectomy with an IPAA. These CT scans were retrospectively reviewed for portal vein thrombus presence, location, and occlusive nature, as well as any accompanying enhancement abnormalities of the hepatic parenchyma. Only 13 patients who had initial CT scans that were positive for thrombi underwent follow-up examinations, and these were reviewed for resolution or progression of the original findings. RESULTS: Portal vein thrombi were present in 41 (45%) of the 92 patients; 24 (59%) of the 41 were isolated, often multiple, segmental right lobe thrombi. Five patients had both right and left segmental vein involvement. Eleven patients had various combinations of main portal vein, right and left portal vein, or segmental vein thrombi. One patient had an isolated superior mesenteric vein thrombus. Twenty-two of 25 superior mesenteric vein, main portal vein, and right and left portal vein thrombi were nonocclusive, while most (63 of 86) of the segmental vein thrombi were occlusive. Wedge-shaped, peripheral areas of hepatic parenchymal hyperenhancement that were distal to the thrombi were present in 30 (73%) of the 41 patients. Follow-up scans obtained in the 13 patients with portal vein thrombi showed thrombi resolved in five patients, progression to cavernous transformation occurred in one patient, and parenchymal enhancement changes persisted in seven patients. In the seven patients with persistent enhancement changes, four had complete resolution of thrombi. CONCLUSION: Portal vein thrombi appear to be relatively common after IPAA surgery and are most likely segmental, multiple, and occlusive. Peripheral wedge-shaped areas of hepatic parenchymal hyperenhancement commonly accompany these thrombi.

PURPOSE: Gastrointestinal bleeding in patients with Crohn's disease presents both a diagnostic and therapeutic challenge. The bleeding site may be difficult to localize preoperatively and multiple segments of gross disease can lead to uncertainty as to the precise source at the time of laparotomy. METHODS: We describe a patient with Crohn's disease and recurrent gastrointestinal bleeding in whom the combined use of provocative angiography and highly selective methylene blue injection was used preoperatively to accurately identify the site of hemorrhage and direct bowel resection. RESULTS: Provocative angiography identified the bleeding point in the jejunum. Methylene blue, which had been injected distally into the bleeding vessel during angiography, stained the bowel wall at the bleeding site. Segmental bowel resection was subsequently performed and no further bleeding occurred during the 18-month follow-up period. CONCLUSIONS: The combined use of provocative angiography and highly selective methylene blue injection may aid in the preoperative and intraoperative localization of occult bleeding sites in patients with Crohn's disease. This allows the bleeding lesion to be removed with a limited resection, thus preserving bowel length.

PURPOSE: Intra-abdominal administration of antiadhesive barriers may reduce the extent and severity of postoperative adhesions. This study aimed to compare the effectiveness of a novel liquid antiadhesive barrier with a conventional sheet (Seprafilm) antiadhesive barrier in a murine cecal abrasion model. METHODS: One hundred fifty Swiss-Wister mice underwent laparotomy and cecal abrasion and were randomly assigned to receive Adcon-P (n = 30) or Seprafilm (n = 30) or to a control group (n = 90). At postoperative Day 21, the mice underwent relaparotomy and complete adhesiolysis. An investigator who was blinded to the group assignment scored the extent of adhesion formation and the difficulty of adhesiolysis using a 6-point scale that ranged from 0 (no adhesions) to 5 (full-thickness intestinal injury with adhesiolysis). Results are reported as median (range). RESULTS: Median adhesion scores in mice receiving Adcon-P (0 (range, 0-1)) and Seprafilm (1 (range, 0-3)) were lower than in mice in the control group (2 (range, 0-5); P < 0.0001 for both comparisons). In addition, the median adhesion score for the Adcon-P group was significantly lower than that of the Seprafilm group (P = 0.02). CONCLUSION: This study suggests that both Adcon-P and Seprafilm trade mark decrease the incidence of postoperative adhesions and the difficulty of adhesiolysis in the murine cecal abrasion model. However, Adcon-P appeared to be superior to Seprafilm. This agent is an attractive device that requires additional studies.