Loop Ileostomy Closure After Restorative Proctocolectomy: Outcome in 1,504 Patients

PURPOSE Routine use of a temporary loop ileostomy for diversion after restorative proctocolectomy is controversial because of reported morbidity associated with its creation and closure. This study intended to review our experience with loop ileostomy closure after restorative proctocolectomy and determine the complication rates. In addition, complication rates between handsewn and stapled closures were compared.METHODS Our Department Pelvic Pouch Database was queried and charts reviewed for all patients who had ileostomy closure after restorative proctocolectomy from August 1983 to March 2002.RESULTS A total of 1,504 patients underwent ileostomy closure after restorative proctocolectomy during a 19-year period. The median length of hospitalization was three (range, 1–40) days and the overall complication rate was 11.4 percent. Complications included small-bowel obstruction (6.4 percent), wound infection (1.5 percent), abdominal septic complications (1 percent), and enterocutaneous fistulas (0.6 percent). Handsewn closure was performed in 1,278 patients (85 percent) and stapled closure in 226 (15 percent). No significant differences in complication rates and length of hospitalization were found between handsewn and stapled closure techniques.CONCLUSIONS Our results demonstrated that ileostomy closure after restorative proctocolectomy can be achieved with a low morbidity and a short hospitalization stay. In addition, we found that complication rates and length of hospitalization were similar between handsewn and stapled closures.Published online: 28 January.Read at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.     

Turnbull-Blowhole Colostomy for Toxic Ulcerative Colitis in Pregnancy

PURPOSE: Surgical intervention for toxic ulcerative colitis in pregnancy is associated with a high morbidity and mortality for both mother and her fetus. A limited surgical procedure may be desirable to reduce the risk of maternal and fetal mortality. We describe the use of "blowhole" colostomy and loop ileostomy (Turnbull procedure) in the management of toxic dilation of the colon complicating ulcerative colitis in pregnancy. METHODS: The medical records of two pregnant females with toxic ulcerative colitis were reviewed. The presentations, management, and outcomes of these patients and their neonates are described. RESULTS: The Turnbull-Blowhole colostomy and ileostomy was used in the acute management of toxic ulcerative colitis in two pregnant females. Both mothers and neonates had successful outcomes with resolution of the acute process. Completion proctocolectomy and ileal pouch-anal anastomosis was later performed in both patients. CONCLUSIONS: The colonic decompression and fecal diversion procedure provided minimal operative trauma to the mother and fetus and resulted in successful outcome in the management of toxic ulcerative colitis in pregnancy. We believe the procedure is safe, effective, and relatively simple, which may reduce the morbidity and mortality of toxic colitis in pregnancy.     

Effect of age on angiotensin II-mediated downregulation of adrenomedullary catecholamine biosynthetic enzymes

Expression of catecholamine biosynthesizing enzymes, tyrosine hydroxylase (TH) and dopamine beta hydroxylase (DbetaH) increase with age in the adrenal medulla, however, the underlying mechanisms are unclear. In the present study, we examined the effect of peripheral angiotensin II (AngII) on the expression of TH and DbetaH, in the adrenal medulla of young (6 mo) and old (23 mo) Fischer-344 rats. Saline or AngII (230 ng/kg/min sc) was infused for 3 days using osmotic minipumps. Adrenomedullary TH and DbetaH mRNA levels increased significantly with age, and while AngII reduced the expression of these enzymes in young animals, it had no such effect in the old animals. Neuropeptide Y (NPY), which is co-released with catecholamines in the adrenal medulla and stimulates the synthesis of TH and DbetaH, was also upregulated with age and downregulated in response to AngII in young rats. However, in the old animals, the already elevated NPY expression remained unchanged following AngII treatment. This data indicate that the hypertensive effect of peripheral AngII is compensated by an inhibition of adrenomedullary catecholamine biosynthesis in young animals, but this mechanism is impaired in senescence, potentially contributing to the age-related increase in catecholamine biosynthesis.     

Factors associated with the location of local rectal cancer recurrence and predictors of survival

Purpose

The location of locally recurrent rectal cancer (LRRC) may influence survival. This study examines factors affecting the location of LRRC, the effect of LRRC location on survival, and predictive factors for survival in patients with LRRC.

Methods

Patients undergoing initial proctectomy and subsequent management of LRRC at the Cleveland Clinic (1980–2011) were included. Data regarding index surgery, LRRC, and survival were obtained from a prospectively maintained database.

Results

One hundred and fifty-seven patients were identified with a mean follow-up 59.8?±?50.1 months and time to LRRC of 31.7?±?30.1 months. Sixty patients underwent surgery with curative intent. Anastomotic leak and retrieving less than 12 lymph nodes at index proctectomy were associated with posterior (P?=?0.019) and lateral (P?=?0.036) recurrences, respectively. Having an axial relative to an anterior, posterior, or lateral recurrence was associated with improved overall survival (P?=?0.001). On multivariable analysis, undergoing primarily palliative treatment (OR, 5.2; 95 % confidence interval (CI), 3.2–8.4; P?<?0.001), age at LRRC >60 years (OR, 1.9; 95 % CI, 1.3–2.7, P?<?0.001), advanced primary tumour stage (OR, 1.5; 95 % CI, 1.1–2.1; P?=?0.021), and anastomotic leak at index surgery (OR, 1.8; 95 % CI, 1.2–2.7; P?=?0.008) were associated with reduced LRRC 5-year survival.

Conclusions

The current study suggests that features of the primary tumour and technical factors at the time of index proctectomy influence both the location of LRRC and survival.

     

Effects of P-wave dispersion on atrial fibrillation in patients with acute anterior wall myocardial infarction

Backround: P‐wave dispersion (P dispersion), defined as the difference between the maximum and the minimum P‐wave duration (P minimum), and maximum P‐wave duration (P maximum) have been used to evaluate the discontinuous propagation of sinus impulse and the prolongation of atrial conduction time respectively. The aim of this study was to investigate whether early assessment of P dispersion predicts paroxysmal atrial fibrillation (AF) in patients with acute anterior wall myocardial infarction (MI). Methods: We prospectively evaluated 147 consecutive patients (45 women, 102 men; aged 55 ± 9 years) with a first acute anterior wall MI. All patients were evaluated by echocardiography to measure the left atrial diameter and left ventricular ejection fraction (LVEF). Electrocardiography was recorded from all patients on admission and every day during hospitalization. Results: AF occurred in 25 patients. In 122 patients, AF did not occur. P maximum was found to be significantly higher in patients with AF than in patients without AF (115 ± 17.3 ms vs 101 ± 14.7 ms, P = 0.001 ). P dispersion also was significantly higher in patients with AF than in patients without AF (50 ± 12.5 ms vs 43 ± 10.1 ms, P = 0.01 ). There was no significant difference between the two groups in P minimum (64 ± 12.5 ms vs 59 ± 11.7 ms, P = 0.057 ). The echocardiographically left atrial diameters were not significantly higher in the patients with AF than those without (25 ± 3.38 mm and 23 ± 3.36 mm , respectively, P = 0.76 ). LVEF was found to be significantly different in the patients who developed AF and in those who did not (37.96 ± 6.18% vs 47.70 ± 6.01%, P = 0.0001 ). Conclusions: Although P maximum and P dispersion are significant predictive factors of AF in patients with acute anterior wall MI in the univariate analysis, on the basis of multivariate analysis, only age and LVEF were independent predictive parameters for AF.     

Clinical approach to diseases of ileal pouch-anal anastomosis

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for ulcerative colitis (UC) patients with medically refractory disease or dysplasia. IPAA significantly improves quality of life in UC patients who require surgery. However, certain inflammatory and noninflammatory diseases can develop after the surgery, including pouchitis, Crohn's disease of the pouch, cuffitis, and irritable pouch syndrome. The etiology and pathogenesis of these disease conditions of IPAA are largely unknown. Accurate diagnosis and classification are important for appropriate management. Endoscopic evaluation is the most important tool for the diagnosis and differential diagnosis.     

Fungal pneumonias in transplant recipients

Fungi are ubiquitous in the environment. Opportunistic fungal pneumonias in the immunocompromised host continue to increase most commonly due to Aspergillus sp. Affected patients are usually hematopoietic stem cell and lung transplant recipients. Clinical presentation is protean, and the diagnosis is challenging. Culture of respiratory specimens has limited utility. The detection of circulating fungal antigens and DNA seems promising, but more studies are needed. Value of prophylactic strategies or preemptive therapy remains contentious. New antifungal drugs for managing invasive pulmonary aspergillosis continue to emerge, with better safety, efficacy, and pharmacologic profiles.