Citations

AbstractSubstitution of the anorectum by a reservoir fashioned from the distal ileum can achieve the highly desirable goal of enteric continence after proctocolectomy and, not surprisingly, appears to enhance significantly the patient's quality of life. The potential price to be paid for this advance relates largely to uncertainties concerning the absence of the usual barriers to coloileal reflux and the presence of a stagnant, fecal pouch at the end of the small intestine. Moreover, positive experiences with conventional incontinent ileostomies over many years dictate that the Brooke ileostomy still remains the standard against which all other procedures must be judged. In the majority of patients, the presence of an ileal reservoir does not appear to have major adverse consequences; fecal volumes, fat excretion, overall gut function, and general health appear to be well maintained for the 10–15 years that patients with continent ileostomies have been followed. The follow‐up for ileo‐anal anastomoses is somewhat shorter. The pouches develop a fecal flora and mucosal histology is altered but, in most, no adverse sequelae have been noted. Nonspecific inflammation (“pouchitis”) occurs and is sometimes of major clinical significance, especially when also associated with systemic symptoms. The etiology of these conditions is unknown but bacterial overgrowth is suspected since antimicrobial therapy is often curative.

AbstractThe motor function of the ileal J pouch after ileal pouch‐anal anastomosis has a key role in the clinical outcome. The pouch forms a neorectum that aids in the maintenance of reasonable continence. The maximum capacity of the pouch (mean, 320 ml) is similar to that of the healthy rectum (330 ml). The pouch accommodates to distension, keeping intrapouch pressure low as the pouch gradually fills with stool. The change in pouch volume with each change in pressure (15 ml/mm Hg) approximates that of the healthy rectum (19 ml/mm Hg). When a threshold volume of about 150 ml is reached, large‐amplitude (>25 mm Hg), prolonged (40–60 sec), propulsive waves appear in the pouch. They initiate the call to stool. With continuing distention of the pouch to its functional capacity, which is about 200 ml, reflux of stool into the distal ileum begins, the large pressure waves become more frequent, and the urge for defecation more intense. Defecation is voluntary, spontaneous, and rapid (11 ml/sec), with the pouch and distal ileum emptying concurrently. About 60% of the pouch content, a volume of about 100 ml of stool, is discharged with each bowel movement. The greater the threshold volume and the more complete the evacuation, the fewer the bowel movements per day. After evacuation, the large pressure waves subside, and the next cycle of pouch filling and emptying begins.

AbstractThe experience at the Mayo Clinic, Rochester, Minnesota, U.S.A., with abdominal colectomy, mucosal proctectomy, and ileo‐anal anastomosis is now approaching 600 patients. The procedure is safe and, with careful timing and selection of patients, can be performed with minimal mortality. Postoperative morbidity, however, is still considerable, even in the most experienced hands. Increasing experience with the procedure has been shown to be associated with a continuing decline in the incidence of postoperative complications, and a defunctioning ileostomy is still a necessity in the majority of patients.Long‐term functional results of the procedure are satisfactory and have been shown to improve both with the experience of the operator and with the passage of time after surgery. Patient acceptance remains the ultimate sanction, and it appears that the majority of patients are satisfied with their outcome after ileo‐anal anastomosis, with only very few being prepared to consider an alternative. The operation appears to provide a superior quality of life relative to that expected after proctocolectomy and Brooke ileostomy.Not all patients with chronic ulcerative colitis or adenomatosis coli are potential candidates for this procedure, however. The problems of age, obesity, indeterminate colitis and Crohn's disease, co‐existing colorectal neoplasia, technical difficulties at the time of the operation, and the wishes of the patient all must be taken into consideration when assessing the optimal operation in a particular situation. Proctocolectomy with Brooke ileostomy or continent ileostomy and total abdominal colectomy with ileo‐rectal anastomosis both still have roles in the management of diseases such as chronic ulcerative colitis and adenomatosis coli. For a patient who is young, relatively fit, and well motivated and in whom there is little or no doubt about the diagnosis, ileo‐anal anastomosis must be considered as the possible treatment of choice. Increasing experience with the procedure and improvements in functional results seem to be confirming this position.

AbstractAmong 454 operations done for peptic ulcer between 1956 and 1985 on residents of Rochester, Minnesota, U.S.A. in whom ulcer size could be determined accurately, 50 operations (11% of the total) were performed for giant ulcers and 404 (89%) for nongiant ulcers. The annual operation rate per 100,000 residents for giant ulcer did not clearly decline during the 30‐year period in contrast to the dramatic fall in operation rates for nongiant ulcers. Nonetheless, the ratio of operation rates for giant ulcer compared to nongiant ulcer changed relatively little. Giant ulcers required emergency operation for massive bleeding more often than nongiant ulcers. Also, giant ulcers presented with unusual and severe complications such as gastrocolic fistula. Survival after surgery for giant ulcer was poorer than survival after an operation for nongiant ulcer. We conclude that giant ulcers are operated on somewhat less often today than in the past, while operations for nongiant ulcers are much less frequent. The giant ulcers that are operated on, however, are more prone to massive bleeding and are associated with poorer postoperative survival than their nongiant counterparts.

AbstractDuring a 30‐year period (1951–1981), seventeen patients underwent bilateral adrenalectomy for established adrenal medullary disease with catecholamine excess. Fourteen patients had the MEN IIa syndrome and 3 had the MEN IIb syndrome. There was no major operative morbidity and no operative mortality.One patient died 23 months after initial operation because of metastatic pheochromocytoma. The remaining patients were followed for a mean of 129 months and all were personally interviewed. Three patients had 7 uneventful pregnancies. Twelve patients underwent 23 other surgical procedures requiring general anesthesia during the followup period without any morbidity. Two patients have metastatic pheochromocytoma; 3 have clinical metastatic medullary thyroid carcinoma; 5 patients have high calcitonin values and 6 patients are in excellent health at intervals of 15, 27, 58, 110, 134, and 373 months following resection. The need for adrenal replacement therapy has not caused significant problems in any patient.The results of this study confirm that bilateral total adrenalectomy is a safe modality for the treatment of adrenal medullary disease in this syndrome and that it does not produce significant long‐term morbidity.

AbstractMost of what has been learned about resection of hepatic metastases comes from the study of colorectal cancer because such lesions are so common. One‐fourth or more of patients who have liver metastases from such lesions have hepatic tumors that can be removed, but only about 25% of these patients will live 5 years or more after such tumors have been removed. When resection so often fails to improve survival, there is a need to know when metastatic lesions should be removed. Study of determinants of prognosis, patterns of failure, and the natural history of the disease have shown that surgical failure is determined by the presence of extrahepatic metastases (even when removed) and limited resective margins. The patient's gender and the locoregional stage of the primary resected lesions influence survival, but not so much as to withhold resective treatment from these less favored groups. Studies of size, site, and number of hepatic metastases removed show therapeutic limitations associated with extremes, but these determinants of prognosis after resection must be studied in better ways. Although, at times, palliation is a reasonable goal, this aspect of resective treatment has not been studied well. When there are no good therapeutic alternatives to resection of hepatic metastases and when risk is low, such palliative operations may be justified. Only with further study will absolute contraindications to surgical therapy be well defined. There is an obvious need for biologic control of cancer.