Muhlenberg Regional Medical Center

One hundred twenty-six patients underwent 130 end colostomies, 44 for benign and 86 for malignant disease, and were followed for an average of 35 months. The left or sigmoid colon was used in 99 and the transverse colon in 31. Stomas were made electively in 98 patients and urgently in 32. Seventy-six stomas were brought out through the incision and 54 from separate sites. There were 69 complications in 55 patients (44 percent) including 11 strictures, 9 wound infections, 14 hernias, 9 small-bowel obstructions, 4 prolapses, 2 abscesses, 1 peristomal fistula, 17 skin erosions, and 2 poor stoma locations. Fifteen complications required reoperation. Five of these procedures included stoma revision. Total numbers of complications were not related to the stoma site, the disease process, the urgency of the procedure, or the segment of colon used. Wound infections, however, were increased in urgently made stomas. The incidence of hernia was equivalent in stomas brought out through the incision or at a separate site. Forty-one patients (30 percent) had 43 colostomies closed an average of 3.5 months after creation. Thirteen patients had 14 complications--5 wound infections, 6 hernias, 2 small-bowel obstructions, and 1 rectovaginal fistula. One patient died. Four patients required reoperation. There were no anastomotic leaks. Complications were equivalent in Hartmann closures and transverse colostomy closures. Complications were similar in stomas created for cancer and those created for diverticular disease.

The levator syndrome consists of the symptoms of pain, pressure or discomfort in the region of the rectum, sacrum, and coccyx. The patients often have gluteal discomfort and high rectal distress. Sitting may aggravate the disorder. Tenderness upon motion of the coccyx is not an important part of this syndrome. Therefore, the term “coccygodynia” should not be used. The syndrome affects women more frequently than men, and occurs most often in the fourth, fifth and sixth decades of life. Although the symptoms are at times vague, the diagnosis is easily made by those who suspect its presence. Tenderness of the levators is always present and most often unilateral and on the left. Its etiology is unclear. In a significant proportion of patients concomitant anorectal disease such as fissure and hemorrhoids is present. Massage with or without diathermy, hot sitz baths, and muscle relaxants such as diazepam have proven to provide effective treatment, and the recurrence rate after therapy is low.

PURPOSE: This study was designed to assess the results of a minimally invasive surgical procedure for the correction of complete rectal prolapse in a poor surgical risk group. METHODS: Over a ten-year period, 40 patients underwent 41 Delorme operations when advanced age and/or poor overall health mitigated against an abdominal approach. Mean age was 82 (range, 30-100) years. Eighty-eight percent were females. Surgery was performed in the prone jackknife position utilizing intravenous sedation and local anesthesia. RESULTS: Follow-up ranges from 1 year to 2 years (mean, 47 months). There have been 9 recurrences in 8 patients (22 percent). Mean time to recurrence was 13 months (range, 1 month to 6 years). One death occurred in an 81-year-old patient within 24 hours of surgery from cardiopulmonary arrest. Minor complications occurred in 25 percent of patients. CONCLUSION: Satisfactory prolapse repair was safely performed in 78 percent of this high-risk group. Pitfalls in performing this procedure relate primarily to associated perineal and colonic conditions. Most prominent among these conditions are weak or absent and sphincter tone, perineal descent, and previous sphincter injury. Extensive diverticular disease may prohibit effective and complete proximal mucosectomy. An inadequate mucosectomy sets the stage for early recurrence of prolapse.

Lysyl oxidase (LOX), a copper-dependent amine oxidase, has been implicated in tumor suppression and cell growth regulation. The chromosomal locus of LOX, 5q23, is affected by loss of heterozygosity (LOH) in colon cancer, suggesting that the LOX gene could be affected by LOH and consequently, loss or reduction of LOX function contribute to the tumorigenic process. Identification of microsatellite markers within the LOX locus has allowed us to map the LOX gene within the 5q23.1 region. Analysis of this locus and flanking loci in matched tumor and blood DNA samples from a panel of colorectal cancer patients, demonstrated that 38% (16/42) of informative samples were affected by LOH or allelic imbalance. Furthermore, 75% (6/8) of these tumor samples were shown to have significantly reduced LOX mRNA levels. Similar reduction in LOX levels were detected in a panel of matched normal colon and colon tumor samples. Tumor samples demonstrating LOH by RFLP, were subject to mutational analysis, including RT-PCR, exonic deletion detection by PCR, cDNA and genomic DNA sequencing, and were found to have a spectrum of alterations and mutations affecting the LOX gene. These results confirm that loss or reduction of LOX function during tumor development is a direct consequence of somatic mutations and is associated with colon tumor pathogenesis.

Two hundred thirty-two patients with anal abscesses were followed from six months to 13 years after incision and drain-age was done as an office procedure. Most of these (88 per cent) were evaluated more than two years after the onset of their initial disease. One hundred fifty-four (66 per cent) went on to develop fistula-in-ano, while 78 (34 per cent) had no further problem. Our study encourages us to continue to incise and drain these abscesses in the office, reserving hospitalization for those who later develop fistulas.

Two variant spectrins have been described in hereditary elliptocytosis (HE) and pyropoikilocytosis (HPP). Both are characterized by increased susceptibility of the alpha I (N-terminal) 80-kD domain to mild tryptic digestion, yielding peptides of 46-50 or 65-68 kD (T50a and T68 in our terminology). In this report we add a third unstable spectrin alpha I domain found in three kindreds with HE; alpha IT80 in this type of spectrin is cleaved by mild tryptic digestion to a 50-kD peptide (T50b) distinguished from T50a by its more basic isoelectric point. All three spectrins show impaired self-association to form oligomers. Intermediate tryptic peptides of the three unstable alpha I domains from HE spectrins were characterized by monoclonal immunoblotting and I125 limit peptide mapping and affinity purified using polyclonal anti-alpha IT80. Partial amino acid sequences of alpha I domain peptides were obtained from two unrelated patients for each of the three variant spectrins. T50a results from cleavage at arginine 250 or lysine 252 of alpha IT80; a proline replaced the normal leucine or serine at residues 254 and 255, respectively. T50b and a 19-kD peptide result from cleavage at arginine 462 or arginine 464; a proline replaced the normal residue 465 (in T19b) in one of the two patients studied. T68 results from cleavage at arginine 131. In both 68-kD peptides examined, a leucine is inserted at residue 150. The relationship of the sequence changes to the new tryptic cleavages, to the current model of alpha I domain structure, and to defective spectrin self-association is discussed.

Summary There are many technics for treating condyloma acuminatum. None is entirely satisfactory. The viral etiology and the probable venereal transmission make most methods difficult at best. Our method of using bichloracetic acid has given us a more satisfactory cure rate, with a minimum of discomfort, no scarring, and less prolonged convalescence. Future improvement in the management of condyloma acuminatum will depend upon the development of a suitable vaccine based on the positive identification of these growths as specific infectious lesions caused by a virus. Oral or injectable medication would attack the lesion directly, be easier to apply, be less painful, and allow vectors to be treated more easily. However, until such a vaccine is introduced, the clinician will continue to see condyloma acuminatum and will need therapeutic tools that cause few complications and minimum discomfort and have a reasonable degree of success in removing the warts.

Presented is the authors' experience with 182 patients treated primarily by the one-stage primary resection or two-stage resection. (Hartmann operation). One hundred thirty five patients undergoing primary resection had an associated mortality rate of 2.2 per cent. Of 44 patients operated upon using the Hartmann operation for complicated diverticulitis (obstruction, perforation, abscess formation, or fistula formation) the mortality rate was 4.5 per cent. Primary resection in an elective setting is associated with the lowest mortality and morbidity; however, marked inflammation, obstruction and/or peritonitis preclude primary anastomosis. In the urgent setting the staged operation is associated with acceptable morbidity and mortality.

Three hundred and ninety-three patients who had anal fissures were followed continuously for approximately five years. More than 44 per cent of them were cured nonsurgically within a four-to-eight-week period. There was an 8 per cent complication rate, consisting of abscesses and fistulas, necessitating surgical treatment. The recurrence rate following healing was 27 per cent, but a third of these patients had recurrent fistulas that healed in response to further conservative treatment. The authors feel that conservative treatment of anal fissure is justified unless there is advanced anal stenosis.

Intraspinal air: a CT finding of epidural abscessH Kirzner, YK Oh and SH LeeAudio Available | Share

The use of a Dacron-reinforced Silastic graft in the perineal repair of rectal procidentia offers a simple technique for elderly and debilitated patients. Experience with this procedure in nine patients, followed for two years, indicates that this elastic material appears to have substantial advantages over wire or synthetic mesh in the perineal repair of rectal procidentia.

OBJECTIVE: To determine in adult medical patients the incidence of deep venous thrombosis (DVT) resulting from femoral venous catheterization (FVC). METHODS: A prospective, observational study was performed at a 420-bed community teaching hospital. Heparin-coated 7-FR cm femoral venous catheters were inserted unilaterally into a femoral vein. Each contralateral leg served as a control site. Age, gender, number of FVC days, DVT risk factors, administration of DVT prophylaxis, and DVT formation and site were tabulated for each patient. Venous duplex sonography was performed bilaterally on each patient within 7 days of femoral venous catheter removal. RESULTS: Catheters were placed in 29 men and 13 women. Femoral DVT was identified by venous duplex sonography in 11 (26.2%) of the FVC legs and none (0%) in the control legs. Posterior tibial and popliteal DVT was identified in both the FVC and control legs of 1 patient. DVT formation at the site of FVC insertion was highly significant (p = 0.005). There were no statistically significant associations with age (p = 0.42), gender (p = 0.73), number of DVT risk factors (p = 0.17), number of FVC days (p = 0.89), or DVT prophylaxis (p = 0.99). CONCLUSION: Placement of femoral catheters for central venous access is associated with a significant incidence of femoral DVT as detected by venous duplex sonography criteria at the site of femoral venous catheter placement. Physicians must be aware of this risk when choosing this vascular access route for adult medical patients. Further studies to assess the relative risk for DVT anf its clinical sequelae when using the femoral vs other central venous catheter routes are indicated.

BACKGROUND: Some forms of gastric intestinal metaplasia (GIM) may be precancerous but the cellular phenotype that predisposes to gastric carcinogenesis is not well characterised. Mucin staining, as a means of differentiating GIM, is difficult. A monoclonal antibody, mAb Das-1 (initially called 7E(12)H(12)), whose staining is phenotypically specific to colon epithelium, was used to investigate this issue. METHODS: Using mAb Das-1, by a sensitive immunoperoxidase assay, we examined histologically confirmed GIM specimens from two countries, the USA and Japan. A total of 150 patients comprised three groups: group A, GIM (fields away from the cancer area) from patients with gastric carcinoma (n=60); group B, GIM with chronic gastritis (without gastric carcinoma) (n=72); and group C, chronic gastritis without GIM (n=18). RESULTS: Fifty six of 60 (93%) patients with GIM (both goblet and non-goblet metaplastic cells) from group A reacted intensely with mAb Das-1. Cancer areas from the same 56 patients also reacted. In contrast, 25/72 (35%) samples of GIM from patients in group B reacted with mAb Das-1 (group A v B, p<0.0001). None of the samples from group C reacted with the mAb. CONCLUSIONS: Reactivity of mAb Das-1 is clinically useful to simplify and differentiate the phenotypes of GIM. The colonic phenotype of GIM, as identified by mAb Das-1, is strongly associated with gastric carcinoma.

Seven patients with necrotizing soft tissue infections of the perineum are described. Predisposing factors related to infection were present in four patients (diabetes mellitus, multiple myeloma, HIV, and a poorly defined immunodeficiency syndrome). Anaerobic and facultative anaerobic bacteria were cultured in each case. Two patients required skin graft closure of the debrided wounds, with the remaining wounds closed by contracture and epithelialization. A diverting sigmoid colostomy to facilitate wound care was performed on one patient who had complete dissolution of all anal sphincters. The role of hyperbaric oxygen therapy in four patients was of uncertain value.

Dowling, Edmund A. M.B., B.Ch.; Johnson, Inceborg M. M.D.; Collier, Fred C. D. M.D.; Dillard, Richard A. M.D. Author Information

A procedure for the outpatient management of acute hemorrhoidal disease is presented. Treatment, using local anesthesia with hyaluronidase, is directed to (1) relieve pain, (2) decrease edema, (3) treat appropriately the internal hemorrhoidal disease, and (4) treat the external thrombosis if present. Adequate treatment of the acute disease will, in a significant proportion of patients, avoid further surgical intervention. Eperience with results of this modality of treatment in patients is presented.

Summary The Hartmann procedure would appear to offer many advantages and few disadvantages in treating those cases of sigmoid diverticulitis complicated by obstruction or pelvic or intraperitoneal abscesses, with or without perforation and diffuse peritonitis.

A series of 126 patients treated by inhospital pilonidal cystotomy is reviewed. One hundred twenty-four were treated using local anesthesia with supplemental diazepam or Innovar. Most patients spent only three days in the hospital, with healing occurring in less than two months. Recurrences occurred in 20.9 per cent of the patients. The recurrences were treated by office procedures in all but one instance. Most patients were pain-free and back to work within two weeks after operation.

OBJECTIVE: To test an alternative flexible approach to traditional fixed intermediate and intensive care to minimize transfers of patients. METHODS: Patients admitted to a 28-bed nursing unit with intermediate care potential and a 12-bed intensive care unit at a 300-bed teaching community hospital were studied. The group included 524 patients with a discharge diagnosis code for mechanical ventilation. During eight 3-week cycles, 1073 transfers of patients were tabulated. A plan-do-study-act method was used to improve weaning from mechanical ventilation and reduce the number of inappropriate days in intensive care. Admissions and transfers to the 2 units for all patients during the eight 3-week cycles were compared over time. Length of stay and mortality were noted for all patients treated with conventional and noninvasive ventilation. RESULTS: Direct admissions to the flexible intermediate unit increased with no overall change in admissions to the intensive care unit. Fewer patients needed conventional ventilation, and more in both units were treated with noninvasive ventilation. The median number of transfers per patient treated with mechanical ventilation decreased from 1.94 to 1.20. Length of stay and mortality also decreased among such patients. Some cost savings were attributable to the decrease in the number of transfers. Transfers out of the hospital directly from the intensive care unit increased from 2.24% to 4.43%. CONCLUSIONS: In a community teaching hospital, flexible care policies decreased the number of in-hospital transfers of patients treated with mechanical ventilation.

A 39-year-old woman presented with a vermiform superior conjunctival mass that progressively enlarged during 4 years of follow-up. Although magnetic resonance imaging suggested that the lesion was located in the superior forniceal conjunctiva, surgical exploration disclosed a vascular anomaly (varix) that extended deep into the orbit. The clinical features and management of orbital varices are discussed.