Using the Gastroscope for Incomplete Colonoscopy.

PURPOSE: Reports of virtual colonoscopy demonstrate sensitivity similar to that of conventional colonoscopy for polyps 5 mm or larger, suggesting the validity of its use for colorectal cancer screening. Critical to the success of either procedure is the ability to evaluate the entire colon. Cecal intubation rates during diagnostic or screening colonoscopies vary from 53 to 99 percent. We describe the added value of using a gastroscope to perform a colonoscopic examination that would otherwise result in an incomplete colonoscopy. METHODS: From January 1, 2002 to December 31, 2002 a total of 1,979 colonoscopies were performed. A gastroscope was used in 1.3 percent (n = 26) of these colonoscopies in an effort to complete the index examination initially started with a standard or pediatric colonoscope. The success rate was defined as intubating proximal to the initial area of impasse and entering the cecum. RESULTS: Cecal intubation was achieved in 62 percent of patients. CONCLUSIONS: In patients with incomplete conventional colonoscopy, the gastroscope can usually advance through the initial area of impasse with a cecal intubation rate of 62 percent

Comparing Predictive Decision Rules in Postoperative CEA Monitoring.

To evaluate the usefulness of serial postoperative carcinoembryonic antigen (CEA) assays, seven previously published decision rules for predicting tumor recurrence were compared retrospectively using CEA values from 214 patients followed 36 to 120 months after surgery for colorectal carcinoma. Decision rules employing cutoff values to predict tumor recurrence were found inadequate for the asymptomatic patient. This attenuation of prognostic usefulness appeared attributable to inadequacies of CEA assays for predicting late recurrences. From these analyses, elevated CEA results without other objective evidence might be insufficient to justify second-look surgery. In addition, late recurring tumors tended not to cause elevated CEA levels

Dieulafoy\u27s lesion of the anal canal: a new clinical entity. Report of two cases.

Dieulafoy\u27s lesion is an unusual source of massive lower gastrointestinal hemorrhage. It is characterized by severe bleeding from a minute submucosal arteriole that bleeds through a punctate erosion in an otherwise normal mucosa. Although Dieulafoy\u27s lesions were initially described only in the stomach and upper small intestine, they are being identified with increasing frequency in the colon and rectum. To our knowledge, however, Dieulafoy\u27s lesion of the anal canal has not been described previously. We present two patients with Dieulafoy\u27s lesion of the anal canal who presented with sudden onset of massive hemorrhage. The clinicopathologic features of this unusual clinical entity are discussed and suggestions are made for diagnosis and management

Neoplasia After Ureterosigmoidostomy.

PURPOSE: The occurrence of neoplasia after ureterosigmoidostomy is well-documented in the literature. Because of its rarity, few general surgeons will gain significant exposure to this entity, and colorectal surgeons are likely to be involved with the care of these patients. The purpose of this article is to apprise colorectal surgeons about the management of neoplasia after ureterosigmoidostomy and to familiarize them with the unique anatomy of the reconstructed pelvis. METHODS: We performed a MEDLINE search to identify articles on ureterosigmoid tumors. The theories regarding the cause and pathology of these tumors were critically analyzed. A consensus was developed for screening patients with ureterosigmoidostomy and for treatment of neoplasia. RESULTS: The incidence of carcinoma after ureterosigmoidostomy ranges from 2 to 15 percent. Polyps are more common, and it seems that these tumors also follow the sequence of adenocarcinoma that is seen in the common variety of colorectal neoplasia. Neoplastic changes begin with the interaction of urine and feces and the healing colonic mucosa. Both production of nitrosamines by the action of bacteria on urine and DNA damage caused by reactive oxygen radicals produced by neutrophils at the healing anastomosis have been implicated in the pathogenesis of neoplasia. The latent period between formation of ureterosigmoidostomy and the appearance of carcinoma is between 20 and 26 years. Obstructive urinary symptoms that develop more than two years after ureterosigmoidostomy should be viewed with suspicion. The patient should be investigated with a CT scan and colonoscopy, and a barium enema may be required to delineate the anatomy further. If a benign tumor is encountered during colonoscopy, it may be removed by snare polypectomy. For a malignant tumor the segment of colon with ureteric implants should be excised, along with its lymphatic drainage. Bowel continuity is restored primarily, and the ureters are implanted in an ileal conduit. CONCLUSIONS: Patients with ureterosigmoidostomy should be followed closely for the rest of their lives. The aim of screening is to identify and treat neoplasia before malignancy develops. Furthermore, early detection of neoplasia by close screening will improve survival. Although urine cytology and occult blood are inexpensive tests, colonoscopy remains the criterion standard for follow-up of these patients. Annual colonoscopic surveillance should be started soon after the ureterosigmoidostomy but not later than five to six years after the procedure. Patients who are noncompliant with the vigorous follow-up schedule should be offered the option of resection of the colonic segment at risk with urinary diversion

Management of Anal Incontinence.

Anal incontinence can be attributed to anatomic and physiologic alterations in the external sphincter, internal sphincter and puborectalis muscle. Altered compliance or changes in the sensory threshold are contributing factors. In addition to history and physical examination, anal manometry and radiologic examination of the anorectal angle are helpful in determining the exact causative factors. Depending on the cause, either medical therapy or surgical repair can control anal incontinence

Endorectal Repair of Rectocele Revisited.

BACKGROUND: Transanal repair of rectocele involving the suprasphincteric portion of the rectovaginal septum has been shown to provide excellent results in up to 90 per cent of cases. Selection of patients suitable for repair is important. Rectocele with concomitant cystocele is best repaired transvaginally. An alternative approach is recommended for enterocele. METHODS: With the patient in the prone position and using local anaesthesia, a mucomuscular endorectal flap is raised and the underlying tissues are plicated. The excessive flap is excised, and the cut edges are approximated. A retrospective review of 123 consecutive cases of transanal repair of rectocele was conducted. Patient satisfaction and complications were compared with those in a previously reported study. RESULTS: Overall patient satisfaction improved from 63 per cent of 59 patients in an earlier study to 82 per cent in this report. The overall complication rate decreased from 7 to 3 per cent. CONCLUSION: This study demonstrates the validity of a simple technique of transanal repair of rectocele in an ambulatory setting. Minimal morbidity and successful outcome can be achieved with this procedure

Hyperplastic Polyps: More Than Meets The Eye ? Report of Sixteen cases.

The vast majority of hyperplastic polyps are small, left-sided, and inconsequential in nature. However, hyperplastic polyps that are large, right-sided, mixed, and found in association with a family history of carcinoma may represent an atypical group, and their clinical significance is uncertain. We believe that these atypical lesions should not be lumped together with the common variety of diminutive hyperplastic polyps. Rather, when such hyperplastic polyps are encountered, they should be excised and the patient should be placed on regular colonoscopic surveillance

Is Anorectal Surgery on Chronic Dialysis Patients Risky?

Patients on chronic hemodialysis for end-stage renal disease (ESRD) may develop anorectal problems necessitating surgery. From January 1984 to December 1987, 18 ESRD patients underwent anorectal surgery. During this period, a mean of 215 patients underwent dialysis. Patients with ESRD present with characteristic problems: chronic constipation, need for dialysis pre- and postoperatively with heparin infusion, anemia, anticoagulation secondary to the consequences of uremia, and significant medical problems including coronary artery disease, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease (COPD). Two patients had concomitant anal fissure, two had fistula-in-ano, and one had an acute perianal abscess. In two patients, the postoperative course was complicated by hemorrhage and, in one patient, by abscess formation. There was no delay in wound healing compared with a cohort group. The essentials of perioperative management are discussed with respect to timing of dialysis, methods of anesthesia and pain management, coagulation screening, and complications. Patients on well-managed chronic dialysis will tolerate anorectal surgery without undue jeopardy

Outcome of Delayed Hemorrhage Following Surgical Hemorrhoidectomy.

Delayed hemorrhage following surgical hemorrhoidectomy is a well-recognized complication. Emergency treatment may include suture ligation, anal packing, or other means of tamponade. At the Lehigh Valley Hospital, 27 patients were seen with the complication of delayed hemorrhage over an eight-year period from 1983 to 1990, for an incidence of 0.8 percent. Twenty-five patients (93 percent) underwent surgery primarily for hemorrhoidal disease; one patient had hemorrhoids removed in addition to a sphincterotomy for anal tissue, and the remaining patient had hemorrhoidectomy with fistulotomy. The mean interval from the operation to hemorrhage was six days. Treatment modalities included bedside anal packing in 20 patients (74 percent), observation alone in five patients (18 percent), and suture ligation in the operating room in two patients. Anal packing was successful in controlling postoperative hemorrhage in 20/20 patients, but late complications requiring reoperation developed in 15 percent