Citations

Abstract Anal canal length, anal canal resting and squeeze pressures, ileal pouch capacity and pouch compliance were measured in 104 patients after ileal pouch—anal anastomosis but before ileostomy closure. The intention was to determine if such parameters were associated with late functional outcome after re-establishment of intestinal continuity. Functional outcome in terms of stool frequency (day and night), incontinence (day and night), perianal pad use, perianal skin irritation, and the use of constipating agents was assessed for all 104 patients 1 year or more (median 438 days) after ileostomy closure. A low mean anal sphincter resting pressure before ileostomy closure was associated with subsequent nocturnal incontinence (P < 0·05) and, to a lesser extent, the need to use constipating agents (P = 0·08). Pouch compliance if low before ileostomy closure was associated with an increased frequency of nocturnal stool frequency after 1 year (P < 0·05). Anal canal length, anal sphincter squeeze pressure and pouch capacity before ileostomy closure were not related to subsequent functional outcome in these patients.

Abstract The management of pancreatic pain is a controversial subject and the treatment recommended varies from one extreme to the other. Some authorities advise simply waiting for chronic pancreatitis to ‘burn out’, while others practise removal of the entire gland. In this paper we present 141 patients who underwent surgery for chronic pancreatitis at the Mayo Clinic. The main indication for operation was pancreatic pain and the choice of operation was based on anatomical abnormalities in the gland. The long-term results of the policy are reviewed (mean follow-up 8·5 years). Length of history, aetiology of disease, pancreatic dysfunction and pathology, time after operation and continued alcohol abuse were computer analysed for a statistically significant influence on pain relief, ability to work, pancreatic function and survival. There was one operative death (mortality rate 0·7 per cent). Continued drinking was not shown to affect postoperative pain relief but 10-year survival was significantly less in alcoholics than in those with non-alcoholic pancreatitis (P < 0·02). Dilated ducts and duct calculi were associated with good results for pain relief although this association did not achieve statistical significance. Parenchymal calcification and time after operation did not influence the results of surgery. When the operation failed to relieve pain, spontaneous remission occurred in a few cases only. Seventy-seven per cent of patients had lasting relief of pain and operations selected on the basis of gross pathology were equally effective in relieving pain. Longitudinal pancreaticojejunostomy in those with dilated ducts and a Whipple operation for disease of the pancreatic head gave good results. However quality of life and pancreatic function were severely impaired by 80–95 per cent distal resections and by total pancreatectomy. An extended proximal resection is suggested for patients with diffuse disease and non-dilated ducts.

Abstract One hundred and ninety patients with Clostridium difficile toxin-associated colitis (CTAC) or pseudomembranous colitis (PMC) were identified, from microbiology records, disease index and proctoscopy service records, and studied retrospectively. CTAC was associated with cephalosporin antibiotic administration in 70 per cent of the patients. CTAC developed postoperatively in 108 patients after all types of surgery with no preponderance for abdominal surgery. Identification of cytotoxin in stool samples was the primary diagnostic test in 81 per cent of patients but cytotoxin was isolated in 98 per cent of all patients. Pseudomembranes visible on proctoscopy established the diagnosis in 19 per cent of patients and were more commonly seen in severe colitis (71 per cent) than in mild colitis (23 per cent). CTAC responded similarly to oral vancomycin and metronidazole with a relapse rate of 20–23 per cent, respectively. With its association with cephalosporin administration, CTAC is likely to occur with increasing frequency in surgical practice. Oral metronidazole is an effective, cheap, alternative to vancomycin therapy.

AbstractThe aim was to determine whether changes in enteric bacteriology, absorption, morphology, and emptying occur after ileal pouch–anal anastomosis for ulcerative colitis, and to relate any changes to the clinical result. Twenty patients were studied 26 ± 2 months (mean ± s.e.m.) after operation. Eight patients had a good result, six a poor result, and six a history of recurrent pouch ileitis. Anaerobic and aerobic overgrowth occurred in the jejunum of patients with a poor result, but not in those with a good result or with pouch ileitis. In contrast, ileal pouch bacterial overgrowth occurred in all patients regardless of the clinical result. Patients with jejunal overgrowth had increased 24 h stool volume and stool nitrogen, but other patients did not. The larger the stool volume, the greater the anaerobic overgrowth. Pouch biopsies showed chronic inflammation in all patients, while 45 per cent had colonic metaplasia. Neither the inflammation nor the metaplasia correlated with the clinical result, nor did the clinical result correlate with the efficiency of pouch emptying. In conclusion, jejunal bacterial overgrowth after ileal pouch–anal anastomosis was associated with an increased stool output, azotorrhoea, and a poor clinical result. A distinguishing bacterial, absorptive, morphological, or emptying abnormality was not found in patients with a history of recurrent pouch ileitis.

Abstract One hundred and one patients with benign, reflux-induced oesophageal stenosis were surgically treated at the Mayo Clinic during a recent 6 year period by the author. In 71 patients, the stenosis was readily dilated and treated by a variety of antireflux procedures, depending on presence or absence of oesophageal peristalsis or acquired shortening of the oesophagus. Thirteen additional patients were managed by gastric secretion suppression with duodenal diversion using the Roux-Y principle. Seventeen patients with undilatable stenoses were managed by resection and a variety of reconstructions. The modified Ivor–Lewis procedure with or without thoracotomy was the procedure employed in 12 of the 17 with the remainder managed with either substernal colon or upper digestive secretion suppression-diversion. These 101 operations were accomplished without mortality and all but one patient have resumed an oral diet and returned to their usual occupation. While 91 per cent of the 101 patients are free of reflux symptoms or demonstrable stenosis and are considered improved, only 83 per cent of all patients have ‘excellent’ to ‘good’ late results in terms of both oesophageal and gastrointestinal symptoms.

Abstract Of 500 consecutive patients who underwent cervical exploration for presumed primary hyperparathyroidism, 461 (92·2 per cent) were cured, as judged by an immediate return of serum calcium levels to normal. Thirty-nine patients (7·8 per cent) had persistent hypercalcaemia after the initial operation. The clinical profiles, operative and pathologic findings, surgical procedures performed and subsequent management of these 39 patients were reviewed. At re-evaluation, 4 patients were noted to have been cured of their hyperparathyroidism: Twenty-one patients had persistent hyperparathyroidism: in 6, all 4 parathyroid glands had not been identified at the initial operation and in 15, hypercalcaemia persisted after the identification of 4 glands. One patient had recurrent hyperparathyroidism after the removal of a 720 mg adenoma and the identification of 3 normal parathyroid glands. Nine patients had non-parathyroid causes for the hypercalcaemia: 2 had occult malignant neoplasms, 6 had benign familial hypocalciuric hypercalcaemia and 1 had immobilization hypercalcaemia. In 4 patients the reason for the persistent hypercalcaemia remained unclear. We suggest a schema that may be used as a guideline in the investigation and management of patients with persistent hypercalcaemia after primary neck exploration for presumed hyperparathyroidism.