A postbiotic from Aspergillus oryzae attenuates the impact of heat stress in ectothermic and endothermic organisms

Heat stress is detrimental to food-producing animals and animal productivity remains suboptimal despite the use of heat abatement strategies during summer. Global warming and the increase of frequency and intensity of heatwaves are likely to continue and, thus, exacerbate the problem of heat stress. Heat stress leads to the impairment of physiological and cellular functions of ectothermic and endothermic animals. Therefore, it is critical to conceive ways of protecting animals against the pathological effects of heat stress. In experiments with endothermic animals highly sensitive to heat (Bos taurus), we have previously reported that heat-induced systemic inflammation can be ameliorated in part by nutritional interventions. The experiments conducted in this report described molecular and physiological adaptations to heat stress using Drosophila melanogaster and dairy cow models. In this report, we expand previous work by first demonstrating that the addition of a postbiotic from Aspergillus oryzae (AO) into the culture medium of ectothermic animals (Drosophila melanogaster) improved survival to heat stress from 30 to 58%. This response was associated with downregulation of genes involved in the modulation of oxidative stress and immunity, most notably metallothionein B, C, and D. In line with these results, we subsequently showed that the supplementation with the AO postbiotic to lactating dairy cows experiencing heat stress decreased plasma concentrations of serum amyloid A and lipopolysaccharide-binding protein, and the expression of interleukin-6 in white blood cells. These alterations were paralleled by increased synthesis of energy-corrected milk and milk components, suggesting enhanced nutrient partitioning to lactogenesis and increased metabolic efficiency. In summary, this work provides evidence that a postbiotic from AO enhances thermal tolerance likely through a mechanism that entails reduced inflammation.

Methyl donor supplementation suppresses the progression of liver lipid accumulation while modifying the plasma triacylglycerol lipidome in periparturient Holstein dairy cows

Co-supplementation of methyl donors may lower hepatic lipid content in transition cows. To define the ability of methyl donor supplementation (MDS) to reduce hepatic lipid content and modify the plasma lipidome, 30 multiparous Holstein cows (2.04 ± 0.69 lactations; 689 ± 58 kg of body weight; 3.48 ± 0.10 units of body condition score) were fed a ration with or without rumen-protected methyl donors (22 g/d of Met, 10 g/d of choline chloride, 3 g/d of betaine, 96 mg/d of riboflavin, and 1.4 mg/d of vitamin B₁₂) from d -28 before expected calving through d 14 postpartum. Cows were randomly enrolled based on predefined selection criteria (body condition score and parity). Base diets without MDS were formulated for gestation (15.4% crude protein with a predicted Lys-to-Met ratio of 3.25; 1.44 Mcal of net energy for lactation/kg of dry matter) and lactation (16.6% crude protein with a predicted Lys-to-Met ratio of 3.36; 1.64 Mcal of net energy for lactation/kg of dry matter). Blood sampling occurred from d -28 relative to expected calving through d 14 postpartum. Liver tissue was biopsied at d -28 relative to expected calving and on d 5 and 14 postpartum. In addition to routine analyses, serum AA concentrations on d 10 and 12 were quantified using mass spectrometry. Plasma triacylglycerol (TAG) and cholesteryl esters (CE) were qualitatively measured using time-of-flight mass spectrometry. Data were analyzed using a mixed model with repeated measures. Dry matter intake and milk yield were not modified by MDS. The transition from d -28 relative to expected parturition to d 14 postpartum was characterized by increased plasma fatty acid (0.15 to 0.71 mmol/L) and β-hydroxybutyrate (0.34 to 0.43 mmol/L) levels and liver lipid content (3.91 to 9.16%). Methyl donor supplementation increased the serum Met level by 26% and decreased the serum Lys-to-Met ratio by 21% on d 10 and 12, respectively. Moreover, the increase in hepatic lipid content from d 5 through 14 postpartum was suppressed with MDS relative to control (3.57 vs. -0.29%). Dietary MDS modified the TAG and CE lipidome. For example, MDS increased plasma TAG 46:3 (carbon number:double bond) by 116% relative to control cows on d 5 postpartum. Moreover, MDS tended to increase plasma CE 34:6. In contrast, MDS lowered plasma TAG 54:8 by 39% relative to control cows on d 5 postpartum. We concluded that in the absence of gains in dry matter intake and milk and milk protein yields, dietary MDS slows the progression of hepatic lipid accumulation and modifies the plasma TAG lipidome in transition cows.

Trends in laparoscopic colorectal surgery over time from 2005-2014 using the NSQIP database

BACKGROUND

Laparoscopy, originally pioneered by gynecologists, was first adopted by general surgeons in the late 1980s. Since then, laparoscopy has been adopted in the surgical specialties and colorectal surgery for treatment of benign and malignant disease. Formal laparoscopic training became a required component of surgery residency programs as validated by the Fundamentals of Laparoscopic Surgery curriculum; however, some surgeons may be more apprehensive of widespread adoption of minimally invasive techniques. Although an overall increase in the use of laparoscopy in colorectal surgery is anticipated over a 10-year period, it is unknown if a similar increase will be seen in higher risk or more acutely ill patients.

METHODS

Using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database from 2005-2014, colorectal procedures were identified by Current Procedural Terminology codes and categorized to open or laparoscopic surgery. The proportion of colorectal surgeries performed laparoscopically was calculated for each year. Separate descriptive statistics was performed and categorized by age and body mass index (BMI). American Society of Anesthesiology (ASA) classification and emergency case status variables were added to the project to help assess complexity of cases.

RESULTS

During the 10-year study period, the number of colorectal cases increased from 3114 in 2005 to 51,611 in 2014 as more hospitals joined NSQIP. A total of 277,376 colorectal cases were identified; of which, 114,359 (41.2%) were performed laparoscopically. The use of laparoscopy gradually increased each year, from 22.7% in 2005 to 49.8% in 2014. Laparoscopic procedures were most commonly performed in the youngest age group (18-49 years), overweight and obese patients (BMI 25-34.9), and in ASA class 1-2 patients. Over the 10-year period, there was a noted increase in the use of laparoscopy in every age, BMI, and ASA category, except ASA 5. The percent of emergency cases receiving laparoscopic surgery also doubled from 5.5% in 2005 to 11.5% in 2014.

CONCLUSIONS

Over a 10-year period, there was a gradual increase in the use of laparoscopy in colorectal surgery. Further, there was a consistent increase of laparoscopic surgery in all age groups, including the elderly, in all BMI classes, including the obese and morbidly obese, and in most ASA classes, including ASA 3-4, as well as in emergency surgeries. These trends suggest that minimally invasive colorectal surgery appears to be widely adopted and performed on more complex or higher risk patients.

Merging Medicare Parts A and B: potential effects on beneficiaries, surgeons, and other stakeholders

Describes the reasons Medicare Parts A and B are currently paid under different mechanisms Explains why the time is ripe to merge Parts A and B Examines the potential effects on delivery of patient care, the federal government, and providers

Local excision of rectal cancer followed by radical surgery because of poor prognostic features does not compromise the long term oncologic outcome

AIM

The outcome of patients undergoing full-thickness local excision (LE) of rectal cancers may be compromised if poor prognostic features are found in the LE specimen. Our aim was to evaluate the long-term results of radical surgery performed after LE because poor prognostic factors are identified.

METHOD

Patients with biopsy-proven rectal cancer who had undergone full-thickness LE followed by radical surgery because of a positive margin, T stage ≥3, lymphovascular invasion, poor differentiation or mucinous histology were identified from a prospective database. Their records were retrospectively reviewed and follow up was updated.

RESULTS

Between 1995 and 2003, 17 patients underwent LE followed by radical surgery because of poor prognostic features. Combined chemotherapy and radiotherapy was given to 11 (65%) patients before radical surgery. Patients underwent radical surgery after a median of 14 (range: 0-40) weeks from LE. Nine underwent a low anterior resection and eight an abdominoperineal resection. At the time of radical surgery, residual disease was found in six (35%) patients (in lymph nodes in three; intramural in two; and both lymph nodes and intramural in one). Four of the patients with residual disease had undergone neoadjuvant therapy before radical surgery. The mean follow up was 110 (95% CI: 92-129) months. Recurrence-free survival at 10 years was 88%. There was no case of local recurrence, and two patients died of metastatic disease.

CONCLUSION

In this series patients who underwent early radical surgery because of poor prognostic features found at LE had good overall and cancer-specific long-term survival. Even after neoadjuvant therapy, more than a third of patients had residual disease at the time of radical surgery. We therefore recommend radical surgery with neoadjuvant therapy when poor prognostic features are found at LE.

Non-consultant career grade doctors in genitourinary medicine – are they up to the job? National survey 2007

Non-consultant career grade doctors in genitourinary (GU) medicine have been called ‘a reliable silent backbone of the specialty’ and ‘a spare pair of hands‘ [Hiscock E. Non-consultant career grade staff in GU medicine; a reliable backbone or, a spare pair of hands? Int J STD AIDS 1996;7:375–7]. But are they adequate pairs of hands? This survey, conducted in July 2007, examined the work, qualifications and experience of these doctors. A summary of the 154 (19%) responses is presented. Respondents contributed 773 sessions per week, including 164 special interest sessions; 30 (19.5%) were doing regular HIV work. Non-clinical work was described by 134 (87%), especially teaching (132 [86%]) and management roles (26 [17%]). Postgraduate qualifications were cited by 148 (96%), including DipGUM or Dip Ven (51 [33%]), contraception qualifications such as DFFP, MFFP or FFFP (110 [71%]), MRCGP (43 [8%]) and qualifications in psychosexual medicine/therapy (10 [6.5%]). Over half were trained in general practice. Certificate of completion of specialist training or equivalent was held by 55 (36%), including two in GU medicine. These doctors are well qualified, and an asset to the specialty.

MRSA-related perianal abscesses: an underrecognized disease entity

PURPOSE

Methicillin-resistant Staphylococcus aureus (MRSA) in perianal abscesses represents an underrecognized condition. It is unclear whether these abscesses differ in presentation or other characteristics from their non-MRSA counterparts.

METHODS

Patients diagnosed with perianal abscess, who underwent incision and drainage between January 2003 and September 2005, were identified retrospectively. Demographics, abscess characteristics (induration, erythema, abscess size, amount of purulence), presence of MRSA on culture, MRSA susceptibilities, and clinical course were collected.

RESULTS

A total of 104 patients (62.5 percent male; mean age, 42.7+/-13.7 years) were treated for perianal abscess. For the 69 patients cultured at drainage, MRSA was present in 34.8 percent (24/69) of cases (95 percent confidence interval, 24.6-46.6 percent). MRSA-positive patients did not significantly differ from MRSA-negative patients with respect to age, MRSA risk factors, duration of symptoms, white blood cell count at admission, or length of stay. Patients were more likely to be MRSA-positive if they possessed extensive induration (odds ratio, 6.52; P=0.003), extensive erythema (odds ratio, 5.75; P=0.003), or small amount of purulence (odds ratio, 9.72; P=0.006). Ischiorectal abscesses were significantly less likely to be MRSA-positive (odds ratio, 0.34; P=0.016). No patients with MRSA-positive abscesses developed fistulas. All MRSA isolates were resistant to beta-lactam antibiotics and had limited susceptibility to quinolones.

CONCLUSIONS

The prevalence of MRSA in perianal abscesses has not been described previously and is higher in our group of patients than would be expected. MRSA-positive patients cannot be identified by risk factors alone. Antibiotic resistance spectra of MRSA vary from that of enteric bacteria typically seen in perianal abscesses. Therefore, it may be beneficial to culture all perianal abscesses with extensive induration and erythema or minimal purulence.

Rectal erosion of synthetic mesh used in posterior colporrhaphy requiring surgical removal

Treatment of pelvic organ prolapse with transvaginally placed synthetic mesh has recently increased. Several reports of complications have surfaced raising the overall question of safety regarding its use for vaginal prolapse repair. This case report describes a rectal erosion and dyspareunia that resulted from mesh placed into the posterior vaginal wall. A 47-year-old woman underwent a laparoscopic supracervical hysterectomy and a posterior repair with polypropylene mesh resulting in a rectal erosion. Despite removal of all of the mesh that could be excised rectally resulting in a healed rectal mucosa, the patient had persistent dyspareunia and pain requiring complete removal of the mesh using a vaginal approach. After surgery, the patient had resolution of all her symptoms. Further studies of transvaginally placed synthetic mesh need to be performed to determine its safety and efficacy.

The American College of Surgeons' closed claims study: new insights for improving care

BACKGROUND

All physicians must be vigilant in the pursuit of safe care for patients. While problems in care are identified, education that provides an understanding of these problems and guidelines for improvement can enhance patient safety. Our objective was to determine problematic aspects of surgical care, including care provided by surgeons before, during, after, and instead of surgery, that negatively affect patient safety.

STUDY DESIGN

Four hundred sixty malpractice claims against general surgeons were reviewed by surgeons (FACS). All claims were closed in 2003 or 2004. The data collection was completed at five medical liability companies representing a nationwide distribution of surgeons. Surgeons also dictated or wrote narratives for each case. The quantitative data and narratives were later analyzed to determine events responsible for unsafe care.

RESULTS

Surgeon-reviewers identified deficiencies in care that fell below accepted standards more often before and after operations than during them. These deficiencies were often the result of a failure to recognize surgical injuries, and many of these deficiencies were preventable. The quality of surgical care was satisfactorily met in 36% of cases. The most common procedures involving patient safety concerns were those involving the biliary tract, intestines, hernias, vascular system, esophagus, and stomach. The most frequent events leading to claims included delayed diagnosis, failure to diagnose, failure to order diagnostic tests, technical misadventure, delayed treatment, and failure to treat. Complications occurring most frequently were organ injuries, adult respiratory distress syndrome, and infection.

CONCLUSIONS

Closed claims reviews provide valuable data that may enhance provider performance through heightened awareness of common unsafe practices. Specifically, opportunities exist to improve surgical care provided during the preoperative and postoperative phases of treatment through continuing medical education to improve patient safety.

Application of 10 percent formalin for the treatment of radiation-induced hemorrhagic proctitis

PURPOSE

Rectal instillation of 4 percent formalin solution has been described as a successful treatment for hemorrhagic radiation proctitis recalcitrant to medical treatment. We present our experience with a new method of treatment involving the topical application of 10 percent buffered formalin, which is well tolerated and suitable for office use.

METHODS

Patients with marked or refractory rectal bleeding and clinical features consistent with radiation proctitis were reviewed. Treatment involved direct application of a 10 percent buffered formalin solution to the affected mucosa using a 16-inch cotton tip applicator applied through a proctoscope in the office setting.

RESULTS

A total of 100 patients with a mean age of 75 (range, 49-91) years were followed for 18 (range, 1-79) months. The interval from radiation exposure to formalin treatment was 21 months. Overall, 93 percent of patients had cessation of bleeding after an average of 3.5 formalin applications at two-week to four-week intervals. Patients with severe (Grade 3) proctitis and those taking aspirin required an average of 1.5 additional treatments. A total of eight patients rebled at a mean of 24 months from treatment; however, all responded to further applications of formalin. Three patients complained of anal pain and one experienced dizziness postprocedure for a complication rate of 1.1 percent.

CONCLUSIONS

We present a simple, cost-effective, and well-tolerated method of controlling hemorrhagic radiation proctitis. It is performed by using materials readily available in the office of a colon and rectal surgeon, eliminating the need for bowel preparation, anesthesia, or a surgical suite.

Reduction in adhesive small-bowel obstruction by Seprafilm adhesion barrier after intestinal resection

INTRODUCTION

Although Seprafilm has been demonstrated to reduce adhesion formation, it is not known whether its usage would translate into a reduction in adhesive small-bowel obstruction.

METHODS

This was a prospective, randomized, multicenter, multinational, single-blind, controlled study. This report focuses on those patients who underwent intestinal resection (n = 1,701). Before closure of the abdomen, patients were randomized to receive Seprafilm or no treatment. Seprafilm was applied to adhesiogenic tissues throughout the abdomen. The incidence and type of bowel obstruction was compared between the two groups. Time to first adhesive small-bowel obstruction was compared during the course of the study by using survival analysis methods. The mean follow-up time for the occurrence of adhesive small-bowel obstruction was 3.5 years.

RESULTS

There was no difference between the treatment and control group in overall rate of bowel obstruction. The incidence of adhesive small-bowel obstruction requiring reoperation was significantly lower for Seprafilm patients compared with no-treatment patients: 1.8 vs. 3.4 percent (P < 0.05). This finding represents an absolute reduction in adhesive small-bowel obstruction requiring reoperation of 1.6 percent and a relative reduction of 47 percent. In addition, a stepwise multivariate analysis indicated that the use of Seprafilm was the only predictive factor for reducing adhesive small-bowel obstruction requiring reoperation. In both groups, 50 percent of first adhesive small-bowel obstruction episodes occurred within 6 months after the initial surgery with nearly 30 percent occurring within the first 30 days. Additionally no first adhesive small-bowel obstruction events were reported in Years 4 and 5 of follow-up.

CONCLUSIONS

The overall bowel obstruction rate was unchanged; however, adhesive small-bowel obstruction requiring reoperation was significantly reduced by the use of Seprafilm, which was the only factor that predicted this outcome.

A study to determine the nitroglycerin ointment dose and dosing interval that best promote the healing of chronic anal fissures

PURPOSE

The aim of this study was to determine the optimal dose and dosing interval of nitroglycerin ointment to heal chronic anal fissures.

METHOD

A randomized, double-blind study of intra-anally applied nitroglycerin ointment (Anogesic) was conducted in 17 centers in 304 patients with chronic anal fissures. The patients were randomly assigned to one of eight treatment regimens (0.0, 0.1, 0.2, 0.4 percent nitroglycerin ointment applied twice or three times per day), for up to eight weeks. A dose-measuring device standardized the delivery of 374 mg ointment. Healing of fissures (complete reepithelialization) was assessed by physical examination using an observer unaware of treatment allocation. The subjects assessed pain intensity daily by completing a diary containing a visual analog scale for average pain intensity for the day, the worst pain intensity for the day, and pain intensity at the last defecation.

RESULTS

There were no significant differences in fissure healing among any of the treatment groups; all groups, including placebo had a healing rate of approximately 50 percent. This rate of placebo response was inexplicably higher than previously reported in the literature. Treatment with 0.4 percent (1.5 mg) nitroglycerin ointment was associated with a significant (P < 0.0002) decrease in average pain intensity compared with vehicle as assessed by patients with a visual analog scale. The decreases were observed by Day 4 of treatment. At 8 weeks the magnitude of the difference between 0.4 percent nitroglycerin and control was a 21 percent reduction in average pain. Treatment was well tolerated, with only 3.29 percent of patients discontinuing treatment because of headache. Headaches were the primary adverse event and were dose related.

CONCLUSION

Nitroglycerin ointment did not alter healing but significantly and rapidly reduced the pain associated with chronic anal fissures.

The safety and efficacy of the artificial bowel sphincter for fecal incontinence: results from a multicenter cohort study

PURPOSE

The aim of this trial was to evaluate the safety, efficacy, and impact on quality of life of the Acticon trade mark artificial bowel sphincter for fecal incontinence.

METHODS

A multicenter, prospective, nonrandomized clinical trial was conducted under a common protocol. Patients were evaluated with anal physiology, endoanal ultrasonography, a fecal incontinence scoring system, fecal incontinence quality of life assessment, and overall health evaluation. Patients with a fecal incontinence score of 88 or greater (scale, 1-120) were considered candidates for the study. Implanted patients underwent identical reevaluation at 6 and 12 months postimplant.

RESULTS

One hundred twelve of 115 patients (86 females) enrolled were implanted. Mean age was 49 (range, 18-81) years. A total of 384 device-related or potentially device-related adverse events were reported in 99 enrolled patients. Of these events, 246 required no intervention or only noninvasive intervention. Seventy-three revisional operations were required in 51 (46 percent) of the 112 implanted patients. Infection rate necessitating surgical revision was 25 percent. Forty-one patients (37 percent) have had their devices completely explanted, of which 7 have had successful reimplantations. In patients with a functioning neosphincter, improvement in quality of life and anal continence was documented. Mean matched fecal incontinence scores in 63 patients at 6 months follow-up was improved from 105 preimplant to 51 postimplant. In 55 patients at 12 months follow-up, mean matched fecal incontinence scores were 105 preimplant 48 postimplant. A successful outcome was achieved in 85 percent of patients with a functioning device. Intention to treat success rate was 53 percent.

CONCLUSIONS

Although morbidity and the need for revisional surgery are high, the artificial bowel sphincter can improve anal incontinence and quality of life in patients with severe fecal incontinence.

Safety and efficacy of dynamic graciloplasty for fecal incontinence: report of a prospective, multicenter trial. Dynamic Graciloplasty Therapy Study Group

PURPOSE

Dynamic graciloplasty has been used for intractable fecal incontinence, and good results have been reported. The aim of this study was to assess prospectively the safety and efficacy of dynamic graciloplasty for intractable fecal incontinence in a prospective, multicenter trial.

METHODS

A total of 123 adults were treated with dynamic graciloplasty at 20 institutions. Continence was assessed preoperatively and postoperatively by use of 14-day diaries.

RESULTS

There was one treatment-related death. One hundred eighty-nine adverse events occurred in 91 patients (74 percent). Forty-nine patients (40 percent) required one or more operations to treat complications. One hundred seventy (90 percent) events were resolved. Sixty-three percent of patients without pre-existing stomas recorded a 50 percent or greater decrease in incontinent events 12 months after dynamic graciloplasty, and an additional 11 percent experienced lesser degrees of improvement. Twenty-six percent were not improved, worsened, or exited. In patients with pre-existing stomas, 33 percent achieved successful outcomes at 12 months. This number increased to 60 percent at 18 months. Seventy-eight percent of patients had increased enema retention time, and mean anal canal pressures improved significantly at 12 months. Significant changes in quality of life were also observed.

CONCLUSIONS

Objective improvement can be demonstrated in the majority of patients with end-stage fecal incontinence treated with dynamic graciloplasty. Reduction in incontinence episodes can be correlated with improved quality of life. Adverse events are frequently encountered, but most resolve with treatment.

Single-layer continuous colon and rectal anastomosis using monofilament absorbable suture (Maxon): study of 500 cases

PURPOSE

The study purpose was to evaluate the results of continuous, single-layer colon and rectal anastomoses using a monofilament absorbable suture material (Maxon).

METHODS

Four hundred ninety-two consecutive patients undergoing five hundred colon and rectal anastomoses with the above technique were evaluated for outcome, including anastomotic leakage, stricture, and other complications, by means of chart review.

RESULTS

Three patients (0.6 percent) died after surgery and 7 (1.4 percent) developed clinical evidence of anastomotic leakage. Twenty-four percent developed some postoperative complications, most of which were minor.

CONCLUSIONS

Continuous, single-layer colorectal anastomosis using monofilament absorbable suture can be performed safely, quickly, and with a favorable cost ratio. Handsewn anastomoses should still be part of the armamentarium of the well-trained surgeon.

Incidence of small-bowel obstruction and adhesiolysis after open colorectal and general surgery

PURPOSE

The study contained herein was undertaken to establish the incidence of small-bowel obstruction, adhesiolysis for obstruction, and additional abdominal surgery after open colorectal and general surgery.

METHODS

A retrospective cohort study was performed using patient-specific Health Care Financing Administration data to evaluate a random 5 percent sample of all Medicare patients who underwent surgery in 1993. Of these, 18,912 patients had an index abdominal procedure. Two-year follow-up data documented outcomes of hospitalizations with obstruction, adhesiolysis for obstruction, and/or additional open colorectal or general surgery.

RESULTS

Within two years of incision, excision, and anastomosis of intestine (International Classification of Dis eases (ICD)-9 code 45), 14.3 percent of patients had obstructions, 2.6 percent required adhesiolysis for obstructions, and 12.9 percent underwent additional open colorectal or general surgery. After other operations of intestine (ICD code 46), 17 percent of patients had obstructions, 3.1 percent required adhesiolysis for obstructions, and 20.2 percent underwent additional open colorectal or general surgery. After operations of rectum, rectosigmoid, and perirectal tissue (ICD code 48), 15.3 percent of patients had obstructions, 5.1 percent required adhesiolysis for obstructions, and 16.4 percent underwent additional open colorectal or general surgery. After other operations on the abdominal region (ICD code 54), 12.4 percent of patients had obstructions, 2.3 percent required adhesiolysis for obstructions, and 8.8 percent underwent additional open colorectal or general surgery.

CONCLUSIONS

In this retrospective study of Medicare patients, we learned that bowel obstruction, adhesiolysis for obstructions, and additional abdominal surgery occurred more often after abdominal surgery than was previously published.

Development of invasive adenocarcinoma in a long-standing Kock continent ileostomy: report of a case

The first case of adenocarcinoma developing in a continent ileostomy is reported. A healthy, 39-year-old man with a continent ileostomy for 17 years developed subacute obstructive symptoms and was found on endoscopy to have a large adenocarcinoma involving the intussusception valve. At operation, he was found to have a large tumor originating in the valve, extending through the reservoir, and involving the afferent ileal limb. A number of metastatic lymph nodes were identified in the mesentery of the small bowel. He underwent excision of the pouch and formation of an end ileostomy. He is currently undergoing adjuvant chemotherapy. Biochemical and morphologic changes in the ileal pouch, both in the pelvis and the continent ileostomy, are discussed. The implications of this apparent de novo cancer arising in an ileal pouch are discussed.

Enhancement of melphalan toxicity by octanol in ovarian adenocarcinoma cell lines: effects of altered cell-cell communication, glutathione levels, and plasma membrane fluidity

A2780 and COLO-316 ovarian adenocarcinoma cell lines were exposed to 1.0 mM 1-octanol for 12 hr in order to evaluate the potential effects of inhibition of gap junction-mediated intercellular communication (GJIC) on cellular responses to the chemotherapeutic drug melphalan. Other cellular endpoints relevant to drug-resistance mechanisms which were monitored after treatments included cellular glutathione levels, glutathione S-transferase activity, mitochondrial membrane potential, and plasma membrane lipid mobility. In cells which were sensitive to melphalan, octanol enhanced melphalan toxicity in the GJIC-competent (A2780/S) but not GJIC-incompetent (COLO-316/S) sensitive cells. Although octanol increases plasma membrane lipid mobility in A2780/S and COLO-316/S, it appears that enhancement of A2780/S sensitivity to melphalan may be due to inhibition of GJIC. In melphalan-resistant cells (A2780/R and COLO-316/R), 1.0 mM octanol treatment for 12 hr combined with melphalan reversed the resistance of the cells to the drug. Therefore, alterations in cellular glutathione metabolism and effects on the plasma membrane in addition to uncoupling of GJIC may be involved in sensitizing communication-competent and communication-incompetent resistant cells because COLO-316/R lacks gap junction-mediated intercellular communication. Further, analysis of mitochondrial membrane potential provided an index of acquired drug resistance and the efficacy of melphalan and combined octanol/melphalan toxicity.

Ambulatory surgical hemorrhoidectomy--a solution to postoperative urinary retention?

PURPOSE

The most frequent complication of surgical hemorrhoidectomy is urinary retention. This study evaluates the incidence of urinary retention in a series of patients undergoing surgical hemorrhoidectomy in an ambulatory setting.

METHODS

The records of all patients undergoing anorectal surgical operative procedures during the calendar year 1990 were reviewed, with particular emphasis on urinary retention and other postoperative complications.

RESULTS

Of 201 patients undergoing full surgical hemorrhoidectomy by Colon and Rectal Clinic, 91 percent had operations performed on an ambulatory basis (discharge less than four hours following surgery). Of these 190 patients, only 1 (0.53 percent) required urinary catheterization during the postoperative period.

CONCLUSIONS

The ambulatory setting, when combined with careful patient education and perioperative fluid restriction, allows surgical hemorrhoidectomy to be performed with a very low incidence of urinary retention to the benefit of both patient and surgeon.

Aggressive surgical management for advanced colorectal endometriosis

PURPOSE

The aim of this study was to evaluate the results of aggressive surgical management in patients with advanced colorectal endometriosis.

METHODS

The medical records of 130 women who had undergone aggressive surgical management of advanced colorectal endometriosis were reviewed. They were then interviewed a mean of 60 months following surgery and asked to rank relief of their symptoms.

RESULTS

The most common symptoms before surgery were pelvic pain, dyspareunia, rectal pain, change in bowel habit, and cyclic rectal bleeding. Colorectal operations included low anterior resection, sigmoid resection, disc excision of the rectal wall, right colectomy, appendectomy, and small bowel resection. At follow-up symptom relief was high, ranging from 100 percent in cyclic bleeding to 91 percent for rectal pain. Mortality and clinical leakage rates were 0 percent, small bowel obstruction 3 percent, and abscess 1 percent. The crude pregnancy rate following surgery was 49 percent.

CONCLUSIONS

These findings strongly support the use of aggressive surgical extirpation of all visible colorectal endometriosis for patients with advanced disease.

Autonomic dysreflexia resulting from prolapsed hemorrhoids. Report of a case

PURPOSE

This article reports a case of autonomic dysreflexia associated with hemorrhoidal disease in a patient with high spinal cord lesions and successful treatment by surgical hemorrhoidectomy.

METHODS

Following an unsuccessful attempt at conservative treatment which included bulk agents and warm compresses, the patient subsequently underwent three-column, closed surgical hemorrhoidectomy.

RESULTS

The patient was symptom free and had normal bowel activity six weeks postoperatively, and five-year follow-up showed no recurrence of the hemorrhoidal prolapse or dysreflexia.

CONCLUSION

Carefully controlled hemorrhoidectomy, when conservative measures fail, may be effective in managing autonomic dysreflexia in high spinal cord transection patients when prolapse serves as the stimulus.

Local excision of carcinoma of the rectum for cure

During the past 10 years, we have treated 63 patients with invasive adenocarcinoma of the rectum by full-thickness local excision. Rigid criteria were employed in patient selection. None of the tumors was pedunculated or in situ carcinoma. Of the 63 lesions, 53 were confined to the bowel wall and constitute the basis for this report. Thirty-five lesions penetrated only the submucosa and 18 invaded the muscularis propria. Twenty-four patients underwent full-dose postoperative radiotherapy with minimal complications. Follow-up ranged from 12 to 130 months, with a median of 44 months. Four tumors recurred locally (8%). Of these, two patients apparently have been salvaged by reexcision. One patient died 32 months after abdominoperineal resection of brain metastases (without local tumor). One patient who did not receive close follow-up died of local recurrence. Seven have died of unrelated causes. The 5-year corrected disease-free survival is 90%. Local excision combined with radiotherapy for selected rectal cancers yields a high rate of cure with minimal morbidity and is now our preferred mode of treatment for all patients whose tumors meet our rigid criteria.

Results of 1,000 single-layer continuous polypropylene intestinal anastomoses

Between 1979 and 1988, we created intestinal anastomoses in 1,000 patients using a single-layer, continuous suturing technique and a polypropylene suture. The technique is easily learned, flexible in its application, and incurs less cost than most other techniques. The anastomoses involved all levels of the colon and the upper (intraperitoneal and extraperitoneal) rectum. All patients were followed for a minimum of 1 year. The clinically suspected anastomotic leak rate was 1%. Other morbidity included would complications (2%), obstruction of the small intestine (2%), anastomotic stricture (1%), and death (1%). No death was due to anastomotic complications. These rates of complications are comparable with, and in many instances lower than, those reported with other techniques of intestinal anastomosis.

Surgical treatment of symptomatic colorectal endometriosis

The approach to the treatment of bowel endometriosis has varied greatly. In this paper we present 77 consecutive patients with deep colorectal endometriosis treated with a full-thickness resection. Gynecologic procedures included conservative laparotomies for preserving fertility (39 patients); hysterectomy with bilateral salpingo-oophorectomy (29 patients); bilateral salpingo-oophorectomy (2 patients); left salpingo-oophorectomy (1 patient) and resection of pelvic endometriosis in patients with previous ablative surgery (6 patients). A low anterior bowel resection was performed in 68 patients (88.3%); a disc excision of the anterior rectal wall in 5 (6.5%); sigmoid resection in 3 (3.9%), and partial cecal resection in 1 (1.3%). The postoperative febrile morbidity was 10.4%, with no apparent anastomotic leaks. Of 33 patients who attempted to conceive postoperatively, 13 achieved a term pregnancy (39.4%). Complete relief of pelvic symptoms was obtained in 38 patients (49.4%); improvement in 30 (39%); no improvement in 8 (10.4%); and worsening of symptoms in 1 (1.2%). There has been no recurrence of symptomatic bowel endometriosis during 1 to 9 years of follow-up. Full-thickness resection of the colon for the treatment of deep bowel endometriosis is a safe procedure with low morbidity, good postoperative relief of symptoms, and favorable pregnancy rates.

The single-layer continuous polypropylene colon anastomosis. A prospective assessment using water-soluble contrast enemas

Fifty consecutive unselected patients with anastomoses to the left side of the colon were studied. Each patient had an anastomosis constructed with a single layer of continuous 4-0 polypropylene. On the seventh postoperative day, or sooner, a water-soluble contrast enema was obtained to evaluate the integrity of the anastomosis. Two patients developed radiographic and clinical evidence of anastomotic leakage, and one patient developed a late pelvic abscess and colocutaneous fistula. The documented leak rate of 6 percent attests to the safety of this method of colonic anastomosis.

Closure of the internal opening for treatment of complex fistula-in-ano

The surgical management of complex fistula-in-ano can be difficult, and often requires a seton suture or a colostomy. An alternative procedure is presented, based on principles that have been used successfully in the treatment of rectovaginal fistulas. The essential components of the technique are closure of the internal opening (when possible by an endorectal advancement flap), wide external drainage, and curettage of the fistulous tract. Seven patients with complex fistulas-in-ano were treated by this method. Six were cured and had excellent functional results up to 32 +/- 36 months postoperatively. The time to complete healing was 2.1 +/- 0.75 months. One patient developed a recurrent abscess. The procedure described is an alternative to conventional methods used in the treatment of complex fistula-in-ano.

Metabolic changes during the defunctionalized stage after ileal pouch-anal anastomosis

Metabolic changes between the preoperative period and the defunctionalized stage after ileal pouch-anal anastomosis were investigated in 21 patients. Aspects studied included weight change, renal function, liver function, lipid metabolism, and two hematologic parameters. Of 21 patients, 19 lost weight. Cholesterol levels decreased from 183 +/- 30 IU/1 to 122 +/- 48 IU/1 (P less than .0001). Triglyceride levels rose from 95 +/- 29 IU/1 to 190 +/- 86 IU/1 (P less than .01). Significant elevations were seen in values of four liver function tests: SGOT, SGPT, lactic dehydrogenase, and alkaline phosphatase (P less than .05). Blood urea nitrogen levels increased from 11.1 +/- 4.7 mg/100 ml to 21.8 +/- 24.8 mg/100 ml (P less than .05). Serum creatinine levels rose from 0.97 +/- .18 mg/100 ml to 1.5 +/- 1.2 mg/100 ml (P less than .05). Uric acid levels increased from 5.6 +/- 1.8 mg/100 ml to 7.5 +/- 2.3 mg/100 ml (P less than .001). Hemoglobin values did not change significantly. Platelet counts rose from 304,000 +/- 79,000 to 447,800 +/- 189,000 (P less than .05). Identification of these systematic alterations in metabolic parameters during the defunctionalized stage can aid the physician in management of these patients.

Single-layer polypropylene colorectal anastomosis. Experience with 100 cases

The technique of single-layer continuous polypropylene colorectal anastomosis is described. The authors' experience with their initial 100 cases is analyzed in detail. No clinical leaks or anastomotic strictures were noted in a two-year follow-up period. The technique is safe, easily learned, rapidly performed, and it does not add significantly to the cost of medical care. The authors' total experience with this anastomosis now exceeds 350 cases.

Diverticulitis of the midrectum

Diverticulitis of the rectum is a rare condition. This report covers patient history, diagnosis, and treatment involved in such a case. The patient presented with a history of rectal pain and muscle spasm of six months' duration. After several available examinations had been completed, i.e., digital examination, sigmoidoscopy, and barium-enema examination, the diagnosis of a rectal diverticulum was made. Initially, conservative treatment, including high-fiber diet and sitz baths, proved effective. Approximately nine months later, the patient developed severe rectal pain, unrelieved by previously effective measures. After the above-described examinations had been repeated, the rectal wall was found to be ulcerated and inflamed, and a diagnosis of diverticulitis of the rectum was made. Antibiotic therapy and evacuation of the 3- to 4-cm mass under anesthesia resulted in subsidence of symptoms and resolution of the mass. Segmental resection will be considered if the diverticulum becomes infected again.

Single-layer continuous colorectal anastomosis

Since the first successful resection of a colonic neoplasm was carried out in 1823, many attempts have been made to find the ideal technique for bowel anastomosis, in respect both of the surgical technique employed and the suture material used. We have finally adopted a single layer anastomosis with a continuous polypropylene suture. To out knowledge, no series of such anastomoses has so far been reported, and we now review our technique, first described by Allen in 1979, and our very satisfactory experiences following our adoption of it for virtually all colorectal anastomoses above the peritoneal reflection.

Oxazepam in the treatment of anxiety associated with depression: results of treatment in 1600 cases (Studies in depression, VI)

A total of 1600 patients suffering from depression and anxiety was treated in one consultant practice over an 8-year period. In most cases, the depressive component was treated by monoamine oxidase inhibitors, but oxazepam was used as the anxiolytic in all cases in the series. Patients were encouraged to regulate their own dosage of oxazepam, and no difficulties occurred with this technique. The results showed the overall effectiveness of oxazepam as an anxiolytic to be better than 87% in those cases where depression co-existed.

Localized tissue reduction

A faradic muscle stimulator (the Hawkins EBA machine) for localized tissue reduction is described. Forty patients undergoing a course of treatment with the machine all lost significant amounts of weight. No side effects were noted.

Prevention of urinary retention by fluid restriction following anorectal operations

In a carefully controlled prospective randomized study of 500 patients, the postoperative catheterization rate following anorectal surgical procedures was dramatically reduced by a combination of severe dehydration of the patients and reorientation of the nursing personnel to delay catheterization until the bladder is distended. The effectiveness of fluid restriction was clearly demonstrated.