Intestinal obstruction and ileus: role of computed tomography scan in diagnosis and management

A significant proportion of patients with intestinal obstruction will be evaluated with a CT scan of the abdomen. This study presents a group of 97 patients diagnosed with mechanical obstruction or ileus on CT scan over a 16-month period at a community based teaching hospital and follows the further management of these patients. Our study shows that 43.3 per cent of patients with mechanical obstruction, diagnosed by CT scan, eventually needed surgical treatment. On the other hand, even when CT indicates ileus, 20 per cent of these patients may still require surgical intervention.     

Meconium ileus: a review 1972-1990.

This article reviews the management and mortality of 53 neonates with meconium ileus and cystic fibrosis treated in one paediatric surgical centre from 1972 to 1990. Forty-four patients (83 per cent) presented with simple meconium ileus and 26 of 40 patients in this group were successfully treated with Gastrografin enemas. Four patients suffered a perforation as a result of the enema (perforation rate 5 per cent). The 1-year survival rate for simple meconium ileus was 81 per cent and for complicated meconium ileus 75 per cent.     

Gallstone ileus

Twenty patients with gallstone ileus were treated over a 20-year period. The demographics were typical: mean age 76, female to male ratio of 5:1, and 60 per cent incidence of concomitant medical ailments. An 85 per cent preoperative diagnostic rate was unusually high. An analysis of the study halves demonstrated a stable preoperative diagnostic rate, decrease in preoperative delay (7.5 vs. 4.7 days), and a rise in mortality rate (0 vs. 11%) without an unfavorable effect from a 26 per cent incidence of single-stage procedures (0% mortality). Gallstone ileus still carries a mortality rate of five to ten times that of all other nonmalignant mechanical small bowel obstructions. Anticipated improvements related to augmented preoperative diagnostic yields shortened preoperative delays, and selective surgical management have not been substantiated. Improved mortality rates may await refinements in resuscitation, monitoring, and surgical skills.     

Incidence of postoperative adhesion obstruction following neonatal laparotomy

Of 649 neonates undergoing laparotomy in a 10 year period, 54 (8.3 per cent) developed adhesion related intestinal obstruction requiring surgical treatment. In 16 infants the obstruction followed a period of prolonged postoperative ileus, while the remaining 38 had completely recovered from the previous surgical procedure before the development of obstruction. The adhesion obstruction occurred after a single neonatal laparotomy in 35 cases but the remaining 19 had undergone subsequent laparotomies; 75 per cent of the obstructions developed within 6 months and 90 per cent within 1 year of surgery. The highest risk groups were infants undergoing correction of gastroschisis (15.4 per cent) and malrotation (15 per cent). There were nine deaths, two of which were a direct consequence of the adhesion obstruction.     

Smooth muscle tumours of the digestive tract: report of 160 cases

Of 160 patients seen in the period 1951-84 with smooth muscle tumours of the digestive tract, 71 proved to have leiomyomas, 87 had leiomyosarcomas and 2 had leiomyoblastomas. Tumour diameter was frequently greater in patients with leiomyosarcoma. The surgical mortality was 2.8 per cent after treatment of leiomyoma and 10.3 per cent after treatment of leiomyosarcoma. After resection of leiomyosarcoma the 2-year survival rate was 86 per cent and the 5-year survival rate was 43 per cent. The only hope of cure of these malignant lesions lies in surgical resection but, even when the lesion is incurable, resection may allow worthwhile palliation.     

Acute complications of colorectal cancer

Surgery was applied to 152 cases for colorectal carcinoma at the Surgical Department of Friedrichshain Hospital through a period of two years (1986/1987). Emergency laparotomy had to be performed on 31 patients (20 per cent) for acute complications, with colonic ileus being the most common problem. Primary lethality amounted to 25.8 per cent.     

A study of functional recovery for urination and defecation in patients with myelodysplasia: a modified seromuscular ileal flap fixation to the bladder

From 1978 to 1985, 57 myelodysplasia patients with urinary and defecatory dysfunction underwent surgical treatment by modified seromuscular ileal flap fixation to the bladder. Followup was 1 to 88 months. Bladder capacity did not decrease, and voiding time and urine flow rate significantly improved. A urinary substitute sensation appeared in 45 of 46 patients (97.8 per cent) and urinary incontinence improved in 36 of 37 (97.3 per cent). A fecal substitute sensation appeared in 31 of 46 patients (67.4 per cent) and constipation improved in 22 (47.8 per cent). Operative complications were encountered in 5 of 57 patients (8.8 per cent), including 3 cases of prolonged paralytic ileus, 1 obstructive ileus and 1 wound herniation. Modified seromuscular ileal flap fixation to the bladder appears to be indicated for patients with the lower type of neurogenic bladder with neither a low compliance bladder nor high grade vesicoureteral reflux.     

Gallstone ileus

Aetiopathogenesis, diagnosis as well as typical and atypical courses are described and discussed with regard to 50 patients with gallstone ileus. Overall lethality amounted to 36 per cent, including 15 per cent for patients with enterotomy alone and 53 per cent for patients who had undergone enterotomy with faecal aspiration. Postoperative complications were recorded from 78 per cent of the survivors.     

Mesenteric injuries after blunt abdominal trauma: delay in diagnosis and increased morbidity

Mesenteric injuries after blunt abdominal trauma are infrequent and difficult to diagnose. We investigated whether a delay in diagnosis of more than 6 hours had a significant impact on morbidity, mortality, and length of stay at our Level I trauma center. A retrospective chart review spanning the period from January 1995 to September 2005 identified 85 patients with laparotomy-confirmed mesenteric injuries, 81 of whom survived to hospital discharge. Nineteen (23%) of the 81 patients had a delay in diagnosis of greater than 6 hours. After controlling for identified confounders, we found that the delayed diagnosis group experienced 30 per cent longer hospital stays (P = 0.03), 55 per cent longer intensive care unit stays (P = 0.006), and 38 per cent longer duration of mechanical ventilation (P = 0.05). Patients in the delayed group also had significantly higher odds of developing acute respiratory distress syndrome, as well as trends toward higher odds of wound infection, pneumonia, multiple organ dysfunction syndrome, abdominal compartment syndrome, renal failure, and ileus. No significant difference in mortality was observed among all 85 patients (P = 0.67). Thus, in contradiction to some previous studies, our review indicates that a delay in the diagnosis of mesenteric injuries results in significantly increased morbidity and hospital and intensive care unit lengths of stay.     

M-VAC (methotrexate, vinblastine, doxorubicin and cisplatin) for advanced transitional cell carcinoma of the urothelium

Of 92 patients who received methotrexate, vinblastine, doxorubicin and cisplatin complete and partial remissions were observed in 69 +/- 10 per cent of 83 adequately treated measurable and evaluable patients with advanced stages (N+M0 and N0M+) transitional cell urothelial cancer. Complete remission was achieved in 37 +/- 10 per cent of the patients clinically, pathologically and after surgical resection of residual disease. With 17 of 31 complete responders (55 per cent) surviving for 26+ to 49+ months, the estimated probability of survival at 2 and 3 years was 71 and 55 per cent, respectively. Partial remission occurred in 31 +/- 10 per cent of the patients, while 8 per cent had a minor response and 23 per cent had progression with median survivals of 11, 11 and 7 months, respectively. Whereas all metastatic sites responded, including the bone and liver, complete tumor regression was observed more frequently with nodal, pulmonary and local-regional lesions. Brain metastases occurred within 6 to 42 months in 18 per cent of the responders, half of whom never had systemic relapse. Of the remaining 9 patients 2 with nontransitional cell histological tumors did not respond, 5 (5 per cent) were inadequately treated and 2 were excluded from response data because of inevaluable disease parameters but they were free of disease at 16+ and 31+ months. Toxicity was significant, with 20 per cent of the patients experiencing nadir sepsis, 4 per cent a drug-related death, 31 per cent +1 renal toxicity and 41 per cent +1 mucositis. The applications and advantages of the newly proposed international response criteria for bladder cancer are discussed in reference to 25 patients who underwent surgical re-staging, indicating that the disease was understaged clinically in 24 per cent (T less than P), as well as in reference to attainment of true (pathological) complete remission and to other urothelial tract trials. While this therapy seems to have limited antitumor activity against nontransitional cell histological cancer, stage Tis disease and later development of de novo lesions, the regimen is efficacious in selected patients with advanced urothelial tract transitional cell carcinoma.     

Internal intubation of the small intestine for preventing ileus in peritonitis and recurrent adhesions

Preventive intestinal intubation for ileus prophylaxis in cases of diffuse peritonitis and extended adhesion ileus had often been discredited for the technically demanding and thus time-consuming technique involved. Yet, tube-related complications in the context of tube insertion or removal can be minimised by the experienced surgeon who stringently observes a number of precautions and provided that the indication had been accurate. Fifty-three intestinal intubations on 49 patients were accompanied by three iatrogenic perforations intraoperatively and by four instances of postoperative fistulation of the small intestine which, however, were all properly controlled by suturing or conservative action. Ileus recurred in three patients because of too early tube removal and due to progressive peritonitis against the background of inadequately cured primary disease and due to peritoneal mesothelioma in one case. Periods of intestinal intubation ranged from six to 14 days. Postoperative lethality was relatively high (30.6 per cent) and had been exclusively caused by progressive sepsis or cardiopulmonary insufficiency. It amounted to 50 per cent of all cases of diffuse peritonitis and only to 4.7 per cent of patients with recurrent adhesion ileus.     

Anastomotic aneurysms of the femoral artery: aetiology and treatment

The aetiology and treatment of 35 femoral false anastomotic aneurysms in 29 patients presenting over the 4-year period 1984-88 were reviewed retrospectively. The mean interval between primary anastomosis and false aneurysm repair was 6 years (range from 2 weeks to 16 years). Twenty-two (63 per cent) false aneurysms had occurred after previous aortobifemoral bypass grafting for occlusive aortoiliac disease. Seven (20 per cent) presented as acute surgical emergencies. Review of the records of the initial operations revealed that superficial wound infections with positive bacteriological cultures had been present in eight cases (23 per cent) and a further two (6 per cent) had lymph fistulae. Thirty-two false aneurysms were repaired, by simple reanastomosis in 14 cases, interposition grafting in 17 cases and in one case by complete revision to an aortobifemoral bypass graft. The risk of a further operative repair was less (P less than 0.05) following interposition grafting, than after simple revision. False aneurysm repairs, when compared with primary reconstructions done during the same period, were associated with more superficial wound infections (37 versus 10 per cent) and more explorations for haemorrhage within 30 days (19 versus 7 per cent).     

Cytoreductive surgery in disseminated non-seminomatous germ cell tumours of testis.

Between 1977 and 1988, 67 patients underwent surgical removal of residual metastatic deposits following an aggressive chemotherapy regimen (cisplatin, vincristine, methotrexate and bleomycin alternating with etoposide, actinomycin D and cyclophosphamide) for disseminated germ cell tumours of the testis (stage IIB or above). Ninety-one surgical procedures were performed. There were 63 (69 per cent) retroperitoneal lymph node dissections, 16 (18 per cent) thoracotomies, three (3 per cent) hepatic resections, three (3 per cent) craniotomies, five (5 per cent) delayed orchidectomies and one anterolateral decompression of the vertebral column. Nine (13 per cent) patients required a repeat retroperitoneal node dissection and one patient needed a repeat thoracotomy to remove recurrent metastatic deposits during the period of follow-up. Multivisceral resections and vascular reconstruction procedures were required in 20 (30 per cent) patients undergoing retroperitoneal node dissection. Fifty-five (82 per cent) patients remain in complete remission with a mean follow-up period of 49.6 months (range 2-121 months). Nine (13 per cent) patients died with metastatic disease between 2 months to 4 years after operation. There were three deaths in the perioperative period (4 per cent). The histology of the resected metastases revealed undifferentiated active tumour in 20 (30 per cent) patients, differentiated mature teratoma in 29 (43 per cent) patients and fibrosis/necrosis in 18 (27 per cent) patients. Twelve (60 per cent) patients with undifferentiated elements and 15 patients (60 per cent) with raised preoperative tumour markers (poor prognostic categories) are in complete remission. Cytoreductive surgery in patients with metastatic germ cell tumours offers the best chance of remission following chemotherapy even in poor prognostic group categories.     

Gallstone ileus

Thirty-seven patients (33 women and four men, median age 78 years) were operated on for gallstone ileus over a 12-year period with a median follow-up of 6.2 years. Twenty-three patients (62 per cent) had serious concomitant diseases. Plain abdominal radiographs performed at admission were diagnostic in only 17 patients (46 per cent) and other procedures such as ultrasonography, gastrointestinal contrast studies and computed tomographic scan were required in ten patients (27 per cent). The diagnosis was made before operation in 27 patients (73 per cent) but in only 17 (46 per cent) at admission. Obstructing stones were located in the terminal ileum in 27 patients (73 per cent), in the proximal ileum or jejunum in five (14 per cent), in the duodenum in two (5 per cent), and in the colon in three (8 per cent). In six instances (16 per cent), more than one stone was involved. Cholecystduodenal fistula was the most frequent fistula type (n = 25, 68 per cent), followed by cholecystcolonic (n = 2, 5 per cent) and cholecystduodenocolonic (n = 2, 5 per cent) types. The site of the fistula was not established in the other eight instances. A one-stage procedure consisting of the removal of the impacted stone, fistula repair and cholecystectomy was performed in eight patients, two of whom died. A second group of six patients underwent a two-stage procedure consisting of enterolithotomy followed by elective biliary surgery, with no mortality. Removal of impacted stones was the only surgical treatment in the remaining 23 patients, with five deaths. Operative mortality and morbidity rates associated with the initial procedure did not differ significantly among the three therapeutic groups, which were comparable in terms of patient age, associated concomitant diseases and APACHE II score. However, later biliary complications were prominent in patients treated only by enterolithotomy. These results support the view that a one-stage procedure is, when feasible, a valid option and may be the procedure of choice. When local or surgical conditions argue against a one-stage procedure, biliary surgery at a second stage should be considered, if residual stones are present. In poor risk patients, non-operative methods should be considered.     

Autopsy-verified pulmonary embolism in a surgical department: analysis of the period from 1951 to 1988

A retrospective analysis was undertaken of all surgical patients in Malm?, Sweden, during the period from 1951 to 1988 in whom pulmonary emboli were found at autopsy. The analysis included a comparison with the earlier analysed and reported time period from 1951 to 1980. A continued high frequency of pulmonary embolism at autopsy was seen during the 1980s (20.3 per cent of deaths, 31.7 per cent of autopsies). Of the 391 autopsy-verified pulmonary emboli found between 1981 and 1988, 113 (28.9 per cent) were considered fatal, 104 (26.6 per cent) contributed to death and 174 (44.5 per cent) were incidental. Few patients had symptomatic deep vein thrombosis or pulmonary embolism before death. The overall frequency of major pulmonary embolism in surgical patients remained unchanged (0.3 per cent). The frequency of major postoperative pulmonary embolism showed an increase during the 1950s and 1960s (maximum 0.4 per cent) but a decrease in the last 5-year period of the 1970s (0.3 per cent), which has earlier been reported upon. This decrease continued during the 1980s (0.2 per cent) (P less than 0.05). An increase was found in the number of patients operated on who had autopsy-proven pulmonary embolism and who received thromboprophylaxis. Pulmonary embolism continues to be a major cause of death in surgical patients; however, postoperative major pulmonary embolism has shown a reduction in the last 15-year period.     

Emergency interventions in complicated colonic diverticulosis

An account is given in this paper of 480 patients who had been hospitalised for colonic diverticulosis or diverticulitis in the surgical department of the Municipal Waid Hospital of Zurich, between 1970 and 1986. Laparotomy had to be performed on 219 of them (45.6 per cent), among them 84 emergency interventions. The average age of these patients was 70.7 years. Indications for emergency surgery included diffuse or locally delimited peritonitis with abscess development in 72 patients, ileus in ten cases, and massive colon haemorrhage in two. The latter two cases were handled with good success by subtotal colectomy with ileorectostomy and, one of them with the source of bleeding known, by colotomy and suturing of that source of bleeding. Sigmaincontinence resection according to Hartmann has been considered the optional approach since 1977 to diffuse peritonitis and to many cases of ileus (n = 39). In more recent time, anastomosis has been used as primary approach to some patients who survived fibrinous abdominal peritonitis (n = 4). The mortality rate associated with drainage operations according to expectation, has been clearly higher than that following resection, the comparable figures being 32.3 and 17.2 per cent. That has been attributable to non-removal of the septic focus. After all, nowadays combined antibiotic therapy is commonly used for seven to ten days for simultaneous control of both aerobic and anaerobic pathogens. This has become routine practice and involves aminoglycoside, metronidazole, and ampicillin. Overall mortality associated with emergency interventions is clearly higher than that after planned operations, the figures being 22.6 and 4.4 per cent.(ABSTRACT TRUNCATED AT 250 WORDS)     

Left intrahepatic cholangio-enteric anastomosis (round ligament approach): an effective palliative treatment for hilar cancers

Palliation of obstructive jaundice in patients with hilar cancer can be achieved either by surgical bypass or by intubation and drainage. A simple and effective technique is presented which gives excellent palliation without the need for tubes or stents: left intrahepatic cholangio-enteric anastomosis, using the duct of segment III (i.e. the inferolateral segment of the left liver). The procedure is performed by using the round ligament approach to the duct of segment III in the base of the umbilical fissure. A defunctioned loop of jejunum is then anastomosed to this duct. Over a period of 25 years, 48 patients with hilar cancer had this procedure in this unit. The operative mortality (death within 2 months) was 6 per cent and the complication rate was 17 per cent. Seventy-three per cent of patients had complete relief of jaundice and a further 23 per cent had partial relief. The mean survival was 9.2 months and the quality of life was excellent. These data suggest that this is a very satisfactory palliative technique for patients with hilar cancer who are not suited for radical tumour excision.     

Stomach cancer following gastroenterostomy

Treatment was applied to 279 cases of gastric carcinoma at the authors' hospital, within a period of six years. Fourteen of these patients (five per cent) had received surgical treatment for peptic ulcer, between seven and 44 years back (23.6 years on average). Bilateral truncular vagotomy and pyloroplasty had been applied as primary operation to 6.9 per cent. The remaining 93.1 per cent had undergone either exclusive gastrojejunostomy or, in addition, partial gastrectomy. Partial or residual resection of the stomach could be performed on six patients only.     

Nonoperative management of small-bowel obstruction with endoscopic long intestinal tube placement

Intestinal obstruction remains a major cause of morbidity and mortality in surgical patients. We reviewed the records of 77 patients with mechanical small-bowel obstruction who were treated with endoscopically and fluoroscopically placed Leonard long intestinal tube decompression. Most patients (59%) had failed a trial of nasogastric tube or Miller-Abbott tube decompression. Overall, 29 per cent of patients were able to resolve their obstruction with Leonard tube decompression alone. Subdivision of patients on the basis of the etiology of their obstruction demonstrated a much higher rate of success for tube decompression in adhesive obstruction (37%) versus malignant obstruction (12%) or inflammatory obstruction (no successes). Patients with radiographic and clinical evidence of complete intestinal obstruction were significantly less likely to respond to long intestinal tube treatment (13%). The long intestinal tube was easily passed in all patients. There were no complications of the intubation procedure in our series, and the incidence of tube-related complications was four per cent. We conclude that an initial period of long intestinal tube decompression allows a significant percentage of patients with mechanical small-bowel obstruction to be treated nonoperatively, particularly if a partial obstruction from postoperative adhesions is present. Patients who have failed a trial of nasogastric tube decompression and are poor operative risks should also be considered for long intestinal tube placement.     

Prospective study of colorectal cancer in the west of Scotland: 10-year follow-up.

Six hundred and forty-five patients presenting with colorectal cancer over a 6-year period were studied prospectively. At the time of presentation almost half the patients had clinical evidence of local tumour fixity and over one-quarter had distant metastases. The overall resectability rate was 70.8 per cent, apparently curative resection being obtained in 52.5 per cent. Overall operative mortality rate was 13.8 per cent, increasing in the elderly. Approximately 70 per cent of patients undergoing 'curative' resections survived for 2 years, 50 per cent survived for 5 years and 40 per cent survived for 10 years. After palliative resection approximately 10 per cent of patients survived for 5 years; only six of 133 patients (4 per cent) undergoing palliative diversion survived for 2 years. This prospective study confirms the advanced stage of colorectal cancer as it presents to a non-specialist centre. Although the poor outlook is largely a consequence of the advanced nature of the disease, there is evidence to suggest that the results of surgical intervention could be improved.