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Background: Despite major efforts in prevention, surgical site infections (SSIs) remain a burden on patients and the healthcare system and are associated with significant morbidity. SSIs are one of the costliest healthcare-associated infections. The diagnosis of SSIs is based mainly on clinical assessment, which may result in a delay in detection. The ability to detect SSIs in subclinical phase and initiate effective therapy earlier may reduce morbidity and hospital stay. In this study, we attempted to utilize long-wave infrared (LWIR) imaging to define the healing process of the surgical site and to detect abnormal healing., Methods: In this prospective study, 50 patients undergoing elective abdominal surgery had LWIR images of their incision obtained at determined intervals from their operation to discharge. Images were processed with proprietary algorithms to create a thermal topograph used to define the healing process., Results: Images of 45 patients were available for a final review. Of these 45 patients, 10 patients developed SSIs. Using the thermal topograph, 10 criteria for image analysis were defined, yielding a prediction of six out of the 10 SSIs and 35 out of the 35 normal healing wounds. Sensitivity was 60%, specificity was 100%, positive predictive value was 100%, and negative predictive value was 90.1%, with 92% accuracy. A preliminary program was created that allows trained users to methodically evaluate images providing them with a risk estimate., Conclusions: In this preliminary study, LWIR analysis of surgical wounds was able to identify normal and abnormal wound healing. Further large-scale studies are needed to validate results., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: An interactive mobile phone application was added to an established Enhanced Recovery After Surgery (ERAS) program to determine the impact on ERAS compliance as well as clinical outcomes., Methods: We identified patients undergoing elective colorectal surgery enrolled in our ERAS program from February 2017 to July 2018. Patients enrolled in a phone application were compared with those not enrolled in terms of age, sex, diagnosis, operative approach, bowel preparation, oral intake and solid food intake, ERAS pathway adherence, and clinical outcomes., Results: A total of 289 patients were included: 147 enrolled and 142 not enrolled in the phone application. The mean age of enrollees was 53.0 years, compared with 58.3 years for the non-enrollees (p = 0.003). The mean ERAS pathway medication adherence for enrollees was 82.1% versus 76.8% for those not enrolled (p = 0.005). The mean LOS and SSI rates for those enrolled versus not enrolled in the phone application was 4.4 days versus 6.4 days (p = 0.006) and 3.4% versus 11.3% (p = 0.019), respectively. There was no significant difference in readmission rates between enrollees and non-enrollees (15% versus 10.6%, p = 0.345). The mean total cost of patients enrolled was $11,560; total cost of those not enrolled was $13,946 (p = 0.024)., Conclusions: Use of an interactive phone application is associated with improved medication ERAS adherence along with significant reduction in length of stay and SSI rates without increasing total cost.

Background: Anastomotic leak (AL) increases costs and cancer recurrence. Studies show decreased AL with side-to-side stapled anastomosis (SSA), but none identify risk factors within SSAs. We hypothesized that stapler characteristics and closure technique of the common enterotomy affect AL rates., Methods: Retrospective review of bowel SSAs was performed. Data included stapler brand, staple line oversewing, and closure method (handsewn, HC; linear stapler [Barcelona technique], BT; transverse stapler, TX). Primary endpoint was AL. Statistical analysis included Fisher's test and logistic regression., Results: 463 patients were identified, 58.5% BT, 21.2% HC, and 20.3% TX. Covidien staplers comprised 74.9%, Ethicon 18.1%. There were no differences between stapler types (Covidien 5.8%, Ethicon 6.0%). However, AL rates varied by common side closure (BT 3.7% vs. TX 10.6%, p = 0.017), remaining significant on multivariate analysis., Conclusion: Closure method of the common side impacts AL rates. Barcelona technique has fewer leaks than transverse stapled closure. Further prospective evaluation is recommended., (Copyright © 2017. Published by Elsevier Inc.)

Iatrogenic colonic perforations are relatively uncommon but serious complications of diagnostic and therapeutic colonoscopies. Transanal endoscopic microsurgery (TEM) is an useful approach to the rectum and may be used for repair of a rectal perforation during colonoscopy. A 56-year-old male had an iatrogenic perforation of the rectum during a routine follow-up colonoscopy repaired by TEM with an uneventful and rapid recovery.

Parastomal hernia formation and ostomy prolapse are relatively common complications of intestinal ostomy construction. Underlay mesh placement with lateralization of the stoma limb appears to be the method of repair with the lowest recurrence rate. Prophylaxis of new stomas with mesh is advocated by many authors. We report the case of an 81-year-old man with chronic steroid-dependent COPD who presented to the emergency department with strangulated small bowel evisceration 9 days following completion abdominal colectomy, and creation of an end ileostomy reinforced with intraperitoneal mesh. This rare complication was related to this patient's risk factors for poor healing including poor nutrition, age, chronic COPD and coughing and steroid dependence with immunosuppression.

Background: Since 2008, multiple guidelines have endorsed incorporation of chest CT in the radiographic staging assessment of newly diagnosed colorectal cancer (CRC). Radiographic staging practices performed after CRC is detected have not been studied., Objective: To evaluate radiographic staging practices for newly diagnosed CRC between gastroenterologists versus non-gastroenterologists., Design: Observational cohort study., Setting: Single, tertiary-care referral center., Patients: Patients newly diagnosed with a T1 or higher stage CRC at time of colonoscopy between 2008 and 2013., Interventions: Radiographic staging., Main Outcome Measurements: Radiographic preoperative staging examinations ordered by gastroenterologists in comparison to those ordered by non-gastroenterology specialists., Results: This study included 277 patients with CRC newly diagnosed by colonoscopy. There were 141 total ordering physicians (68 gastroenterologists and 73 non-gastroenterologists). The majority of preoperative radiographic staging was performed by gastroenterologists (59.2% of patients, n = 164). Colorectal surgeons managed staging in 28.7% of patients (n = 47). Gastroenterologists were more likely to omit a staging chest CT than were non-gastroenterologists (64.6% vs 46.9%; P < .001). Physician practice setting, rectal location of tumor, and advanced endoscopic appearance of tumors were predictors of chest CT inclusion., Limitations: Single center, moderate sample size of both providers and patients., Conclusion: Gastroenterologists more frequently ordered the initial radiographic staging studies in newly diagnosed CRC patients. However, gastroenterologists were less likely to include chest CT in the initial staging of CRC despite current guideline recommendations to do so. If confirmed with further studies, educational efforts to improve compliance and standardization may be needed., (Copyright © 2015 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Pilonidal disease is a common condition affecting young patients. It is often disruptive to their lifestyle due to recurrent abscesses or chronic wound drainage. The most common surgical treatment, "cystectomy," removes useful tissue unnecessarily and does not address the etiology of the condition. Herein, we describe the etiology of pilonidal disease and our technique for definitive management of pilonidal disease using the cleft lift procedure. In this paper, we present our method of performing the cleft lift procedure for pilonidal disease including perioperative management and surgical technique. We have used the cleft lift procedure in nearly 200 patients with pilonidal disease, in both primary and salvage procedures settings. It has been equally successful in both settings with a high rate of success. It results in a closed wound with relatively minimal discomfort and straightforward wound care. We have described our current approach to recurrent and complex pilonidal disease using the cleft lift procedure. Once learned, the cleft lift procedure is a straightforward and highly successful solution to a chronic and challenging condition.

Background: Chronic intractable constipation (CIC) is a debilitating disease that is challenging to manage. Treatment options in children include medications, enemas, and surgical management in selected cases., Method: We reviewed medical records of pediatric patients diagnosed as having CIC at Tufts Medical Center from 2005 to 2012. Demographic variables, diagnostic procedures, and medical and surgical outcomes were collected. Clinical outcome was defined using the Rome III criteria., Results: A total of 14 patients were included in the study (10 boys). The age range was 10 to 21 years. All of the patients had the diagnosis of CIC. Eleven patients had cecostomy placement. During the follow-up period, 10 patients underwent total abdominal colectomy with ileorectal anastomosis, 1 had total colectomy with ileostomy, and 1 had partial colectomy with colorectal anastomosis. Successful clinical outcome was reported in 7 patients with 3 patients reporting persistent fecal incontinence. Colonic motility studies were performed on 12 patients (colonic neuropathy in 11 patients and normal study in 1 patient). Defecography was consistent with isolated pelvic floor dysfunction in 1 patient, abnormal motility and anatomy in 1 patient, pelvic floor dysfunction and abnormal motility in 2 patients, and found abnormal motility only in 5. Defecography study was normal in 5 patients. All of the patients with abnormal colonic manometry underwent a surgical procedure., Conclusions: Anorectal manometry, colonic manometry, and defecography help in understanding the pathophysiology of defecation disorders in children. The majority of patients with abnormal colonic manometry underwent TAC-IRA. There was no statistical correlation between individual investigations (anorectal manometry, colonic manometry, and defecography) with surgical intervention (P > 0.35). TAC-IRA may be safe and useful intervention in a subset of patients when other treatment options have failed.

Background: Wide excision of perineal lesions, often including the entire anal canal, may be necessary for benign and malignant conditions. Closure of these large defects is challenging, especially when continence is a goal. The aim of this study was to assess our experience with local flap closure of large perineal defects., Methods: From 1994 to 2009, 20 patients underwent wide perineal and/or anal canal excisions and reconstruction using local flaps. Mean age was 45 years (range 20-65 years), 13 were male, and 8 (40 %) were immunocompromised. Primary indications included anal or perineal squamous cell carcinoma-(n = 12), Buschke-Lowenstein tumor (n = 3), and anal intraepithelial neoplasia (n = 3), hidradenitis, stenosis, ectropion, and traumatic cloaca repair (n = 1 each). Primary procedures included wide local excision of large neoplastic lesions-(n = 15) (mean size 10 cm, range 5-18 cm), abdominoperineal resection (APR) (n = 2), perineoplasty with sphincteroplasty-(n = 1), and others-(n = 2). All were reconstructed with bilateral local flaps (V-Y 18, S 2). Thirteen had complete excision of the anal canal to the anorectal ring preserving the sphincters. Six (30 %) had ostomies; 2 with APR and 4 temporary., Results: There were no perioperative deaths. Mean hospital stay was 4.2 days. Follow-up averaged 35 months (range 3-87 months) in survivors. Five patients died during follow-up; 2 of complications of acquired immune deficiency syndrome (AIDS) and 3 of cancer (2 treated palliatively). Wound dehiscence occurred in 6 (30 %) patients: in 3 cases, this was minor dehiscence and healed quickly; in 3 cases, it was major dehiscence and occurred in the 2 radiation/APR patients and in one patient with advanced AIDS. Radiation was the only significant risk factor (P < .05). Twelve of 14 eligible patients with long-term follow-up and an intact anal canal are fully continent, and 2 are partially continent (1 traumatic cloaca; 1 the same as before surgery)., Conclusion: Local flap reconstruction of the perineum and anal canal is an excellent method of managing large perineal defects. Most heal primarily, even in immunocompromised patients, and continence may be preserved. Local flaps should be avoided in irradiated patients.

A perforated peptic ulcer in a child is a rare entity. Severe abdominal pain in an ill-appearing child with a rigid abdomen and possibly with signs of shock is the typical presenting feature of this life-threatening complication of peptic ulcer disease. We present a case of a 14.5-year-old adolescent girl who developed abdominal and shoulder pain that resolved after 1 day. She was then completely well for 2 days until the abdominal and shoulder pain recurred. On examination, she appeared well, but in pain. A chest radiograph revealed a large pneumoperitoneum. She underwent emergent laparoscopic omental patch repair of a perforated ulcer on the anterior wall of her stomach. Result of a urea breath test to detect Helicobacter pylori was negative. The differential diagnosis of pneumoperitoneum in children is discussed, as are childhood perforated peptic ulcer in general, and the unique clinical features present in this case in particular.

Preterm infants are highly susceptible to ischemic damage. This damage is most obvious in the brain, retina, and gastrointestinal tract. Studies focusing on the rheological properties of premature red blood cells (pRBCs) have consistently shown minimal or no RBC aggregation. Previously, measurements of pRBC aggregation kinetics indicated that specific plasma properties are responsible for the decreased RBC aggregation observed in the neonates, but that their specific RBC properties do not affect it. However, the strength of interaction in the pRBC aggregates as a function of medium composition has not been tested. In our previous research, we described clinically relevant parameters, that is, the aggregate resistance to disaggregation by flow. With the help of a cell flow property analyzer (CFA), we can monitor RBC aggregation by direct visualization of its dynamics during flow. We used the CFA to examine pRBC (from 9 premature babies) in the natural plasma and in PBS buffer supplemented with dextran (500 kDa) to distinguish between RBC intrinsic-cellular and plasma factors. pRBCs suspended in the native plasma showed minimal or no aggregation in comparison to normal adult RBC. When we transferred pRBCs from the same sample to the dextran solution, enhanced resistance to disaggregation by flow was apparent.

Brachytherapy has many potential roles in cancer therapy. However, major constraints are associated with placement and removal procedures of the brachytherapy machinery. An attractive approach would be the use of a biodegradable implant loaded with a radioisotope, thus enabling targeted radiotherapy, while reducing the need for surgical procedures for the removal of brachytherapy hardware. In this study, crosslinked chitosan (Ct) hydrogels were prepared and loaded with (131)I-norcholesterol ((131)I-NC). The radioactive hydrogels ((131)I-NC-Ct) were implanted adjacent to 4T1 cell-induced tumors in two different xenograft mice models either as primary therapy or surgical adjuvant therapy of breast cancer. Non-treated mice and mice implanted with naive (non-radioactive) hydrogels served as control groups. In the primary therapy model, the progression rate of the tumor was delayed by two weeks compared with the non-treated and the naive-implant control animals, resulting in a one-week extension in the survival of the treated animals. In the adjuvant therapy model, for the treatment of minimal residual disease, (131)I-NC-Ct implants were able to prevent 69% of tumor recurrence, and to prevent metastatic spread resulting in long-term survival, compared with 0% long-term survival of the non-treated and the naive control groups. Imaging of the hydrogel's in vivo elimination revealed a first order process with a half-life of 14 days. The degradation was caused by oxidation of the Ct as was assessed by in vitro H&E stain. Biodegradable radioactive implants are suggested as a novel platform for the delivery of brachytherapy. This radiotherapy regimen may prevent locoregional recurrence and metastatic spread after tumor resection.

The aim of the present study was to evaluate the toxicity of biodegradable hydrogels in the rat with a future aim of utilizing this hydrogel as a vehicle for brachytherapy delivery in cancer patients. Two types of chitosan hydrogels: fast degrading and slow degrading; were prepared and surgically implanted in rats. The adjacent tissue response to the gels after subcutaneous and intraperitoneal implantation was examined histologically and found to be identical to typical foreign body response and was milder than the response to absorbable surgical sutures (Vicril). Neither tissue damage nor gel fragments could be detected in distant organs (brain, heart, lungs, liver, spleen, kidney, and sternal bone marrow) after implantation of the hydrogels. The degradation mechanism of the gels was studied in vivo, and it was deduced that an oxidative process degraded the chitosan. Loading the hydrogels with a radioisotope (131I-norcholesterol) caused a severe tissue response and necrosis in adjacent tissues only at a distance of several microns. It is concluded that crosslinked chitosan implants could serve as alternative, biocompatible, and safe biodegradable devices for radioisotope delivery in brachytherapy for cancer., (Copyright (c) 2007 Wiley Periodicals, Inc.)

Background: The approach for treating contralateral pediatric inguinal hernias is still controversial. The options are delaying surgery on the contralateral side, automatic exploration, diagnostic laparoscopy through the ipsilateral hernia sac or laparoscopic repair. In children younger than 6 months, occult bilateral hernia is more prevalent, and the hernia sac is difficult for laparoscopic manipulation. We present our early experience with transabdominal laparoscopic hernia repair in infants younger than 6 months of age., Methods: Thirty four infants younger than 6 months and presenting with unilateral inguinal hernia were operated laparoscopically through a transabdominal approach. Patients were followed for a median of 11 months., Results: Thirty three of the operations were completed laparoscopically. There was a 38.2% incidence of occult bilateral hernia. There were 3 recurrences due to a technical mistake (6.4%), one minor operative complication (needle lost and retrieved) and one minor anesthetic complication (prolonged intubation). In one operation a mini laparotomy was performed to retrieve a needle that was disengaged whilst removed from the abdomen., Conclusions: Laparoscopic hernia repair is feasible in young infants. It may be particularly suitable for children younger than 6 months. Further studies are needed to assess long-term results.

Imperforate anus and malrotation rarely occur together. The conjoint occurrence of these with Hirschsprung's disease is exceedingly rare, but failure to recognize its existence may lead to catastrophic results. We present a case in which awareness to this possibility caused early detection and avoidance of possible complications.

We present the case of a premature baby who was born with the following conditions: an extensive atresia from the first part of the duodenum to the mid small bowel; malrotation of the distal part, in volvulus and in an "apple peel" configuration; no connection of the bile ducts to the bowel; and presence of a type II choledochal cyst. To our knowledge, this is the first case in which a combination of these anomalies is reported. A brief review of the relevant literature is also presented.

Compared with conventional external beam radiation, brachytherapy offers a superior therapeutic regimen. However, some major constraints are associated with its implementation, including the need of complicated procedures for device placement and removal. The purpose of this study was to examine whether crosslinked chitosan (Ct) implants could serve as potential biodegradable devices for brachytherapy. Ct was reacted with increasing amounts of glutaraldehyde to obtain hydrogels with different crosslinking densities, which were characterized chemically, thermally and mechanically. The effect of the dialysis medium conditions (ionic strength, osmolarity and pH) on the gel hydration and in vivo degradation was assessed. Two types of implants, slow and fast degrading gel (SDG and FDG, respectively), were prepared and implanted with or without Sudan Black (SB) in the rat. While SDG withstood for over a month, the FDG degraded within two weeks after implantation. The release kinetics of SB from the hydrogels verified their in vivo degradation properties. The incorporation of the radioactive compound (131)I-norcholesterol ((131)I-NC) into the SDG altered the degradation kinetics of the gel as reflected by the release kinetics of the radioactive marker. Eighty percent of (131)I-NC was released within a month after implantation, after which time, radioactivity was detected in the regional lymph nodes. Histological examination of the tissues surrounding the implants demonstrated negligible tissue response to the implants, when compared to biodegradable surgical sutures. It is concluded that hydrogels made of crosslinked Ct are potential novel, safe, degradable devices for brachytherapy.

Purpose: Anal carcinoma is being found in HIV-positive patients with increasing frequency. Most patients are treated with combined chemotherapy and radiation. It was our impression that HIV-positive patients do not fare as well as HIV-negative patients in terms of both response to and tolerance of therapy., Methods: To test this hypothesis, we reviewed our experience with anal carcinoma and compared HIV-positive to HIV-negative patients by age, gender, sexual orientation, stage at diagnosis, treatment rendered, response to treatment, tolerance, and survival. From 1985 to 1998, 98 patients with anal neoplasms were treated. Seventy-three patients had invasive squamous-cell carcinoma (including cloacogenic carcinoma), and this cohort was analyzed. Thirteen patients were HIV positive and 60 were HIV negative., Results: The HIV-positive and HIV-negative groups differed significantly by age (42 vs. 62 years, P < 0.001), male gender (92 vs. 42 percent, P < 0.001), and homosexuality (46 vs. 15 percent, P < 0.05). There were no differences by stage at diagnosis or radiation dose received. Acute treatment major toxicity differed significantly (HIV positive 80 percent vs. HIV negative 30 percent; P < 0.005). Only 62 percent of HIV-positive patients were rendered disease free after initial therapy vs. 85 percent of HIV-negative patients (P = 0.11). Median time to cancer-related death was 1.4 vs. 5.3 years (P < 0.05). A survival model did not show age, gender, stage, or treatment to be independent predictors., Conclusion: We found that HIV-positive patients with anal carcinoma seem to be a different population from HIV-negative patients by age, gender, and sexual orientation. They have a poorer tolerance for combined therapy and a shorter time to cancer-related death. A strong trend to poorer initial response rate was also seen. These results suggest that the treatment of HIV-positive patients with anal carcinoma needs to be reassessed.

Anorectal disorders are common and more than one half of the population will experience one at some time during their lives. It is important for the clinician to recognize the differences between internal and external hemorrhoids and other anorectal problems such as fissures, abscesses, fistulas, skin tags, and a variety of dermatologic conditions because the treatment is often different. This article will discuss the anatomy, pathophysiology, diagnosis, and treatment of internal and external hemorrhoids.

Objective: To determine CD4+ T-cell count and circulating and tissue levels of HIV before and after surgery in a patient with recent-onset ulcerative colitis., Study Design/methods: CD4 lymphocytes and circulating and tissue HIV RNA levels were measured in an HIV-infected patient with ulcerative colitis before and after proctocolectomy., Results: Approximately 3 weeks prior to surgery for ulcerative colitis that was unresponsive to corticosteroids, the patient's CD4 count was 930 cells/mm3 and fell to 313 cells/mm3 within 10 days; the viral burden was approximately 80,000 RNA copies/mL. Tissue macrophages and lymphocytes in biopsy and resection specimens were shown to express high levels of HIV RNA by in situ hybridization. Five days postoperatively, the patient became asymptomatic and was discharged on tapering prednisone without antiretroviral agents. After surgery, the patient's CD4 count progressively rose, while viral RNA levels precipitously dropped. At 3, 6, and 15 weeks postoperatively, CD4 and viral RNA counts were 622 cells/mm3 and 31,300 RNA copies/mL, 843 cells/mm3 and 11,400 RNA copies/mL, and 747 cells/mm3 and 1500 RNA copies/mL, respectively., Conclusions: Circulating levels of HIV and CD4+ cells, as well as tissue expression of HIV, apparently can be influenced by localized inflammatory processes such as those occurring in inflammatory bowel disease.

Purpose: Physiologic tests such as manometry, colonic transit times, balloon compliance, defecography, pudendal nerve latency, and electromyography are used to evaluate patients with severe constipation. Patients referred because of severe constipation between 1991 and 1996 were studied to examine the role that physiologic testing played in making a diagnosis and directing treatment., Methods: Of 139 patients referred for severe idiopathic constipation, physiologic testing was recommended in 127, and 104 patients underwent the studies. The pretesting impression was noted, and test results were evaluated to determine diagnostic accuracy. If a specific initial impression was documented, tests were classified as refuting it, confirming it or confirming and adding significant information. If there was no clear pretest impression, tests were evaluated for their ability to indicate a diagnosis. The patient's history also was evaluated to determine what information was most useful in making a diagnosis. Historical features including duration of constipation, symptoms consistent with outlet obstruction or dysmotility, age, associated urinary incontinence, and prior hysterectomy were analyzed. Data were collected prospectively, then reviewed by an independent observer., Results: Ninety-eight study patients remained after 29 were excluded who did not undergo the recommended studies (19) or because no initial impression was documented (10). In 43 patients (44 percent), testing did not provide additional useful information. In 8 patients, testing confirmed the initial impression and added information impacting the treatment plan. Test results clearly refuted the initial impression in only one patient. In 46 (47 percent) patients the initial impression was uncertain, and in 43 (94 percent) of these, testing aided in making the diagnosis. In three cases, the diagnosis remained uncertain after testing. Prior hysterectomy (P = 0.003), urinary incontinence (P < 0.001), and symptoms of pelvic outlet obstruction (P = 0.03) were associated with a high incidence of rectocele. Defecography and transit times were the most useful tests. Surprisingly, symptoms of outlet obstruction or dysmotility did not show an overall correlation with transit times., Conclusions: In one-half of these patients with severe constipation, physiologic testing added significant information, leading to a specific diagnosis. Pretesting history and symptoms did not predict which patients were most likely to benefit from these studies.

Purpose: Individuals infected with the human immunodeficiency virus often have disorders affecting the anorectum. These disorders may be complex and difficult to treat. We reported our early experience with 40 human immunodeficiency virus-positive patients with perianal disorders in 1990. We now present our series of 260 consecutive human immunodeficiency virus-positive patients with perianal disorders who underwent evaluation between 1989 and 1996 to examine the distribution of disorders, their treatments, and outcomes., Method: Patients were identified at initial presentation and followed prospectively., Results: Two-hundred forty-nine (96 percent) of 260 patients were male, with an average age of 34.9 (range, 19-58) years. Average duration of human immunodeficiency virus positivity was 5 years, 5 months, with a maximum of 11 years, 5 months. Median CD4 count was 175 (range, 2-1,100) cells/mm3. Only 89 (34 percent) patients satisfied the criteria of the Centers for Disease Control and Prevention's for acquired immunodeficiency syndrome at presentation. The most frequent major presenting symptoms were anorectal pain (55 percent), a mass (19 percent), and blood in the stool (16 percent). Risk factors included homosexuality (75 percent) and a prior history of sexually transmitted disease (45 percent). Forty different perianal disorders were identified, which were categorized as benign noninfectious (18), infectious (14), neoplastic (6), and septic (2). The most common disorders were condyloma (42 percent), fistula (34 percent), fissure (32 percent), and abscess (25 percent). Neoplasms were present in 19 patients (7 percent). One hundred seventy-one patients (66 percent) had more than one disorder, with an average of 2.9 disorders among these patients. Four hundred eighty-five procedures were performed on 178 patients (2.7/patient), with no mortalities and a 2 percent complication rate. Thirty-one patients (12 percent) died during the course of follow-up, but anorectal disease was the cause of death in only two patients., Conclusions: Perianal manifestations of human immunodeficiency virus infection are common, often multiple, and varied. Patients with perianal disorders seek treatment throughout the course of the human immunodeficiency virus infection, and a perianal condition may be this disease's initial manifestation. Although recurrence is common and healing delayed, improved overall management of human immunodeficiency virus infection and a healthier human immunodeficiency virus-positive patient population have improved the outcome of surgical intervention in human immunodeficiency virus-infected patients with perianal disorders.

A 49-year-old black woman with a 23-year history of Crohn's disease came to our clinic; she had a squamous cell carcinoma arising in an unhealed perineal wound 16 years after abdominoperineal resection (APR). We report this case to show the potential for malignant degeneration in such wounds. This patient had had multiple procedures for fistulotomies and incision and drainage of abscesses and, ultimately, an APR. After the APR, she had a persistent perineal wound, which did not fully heal despite extensive local and systemic therapy. Our examination revealed a chronic wound involving the entire perineum and vagina, including the labia, both inguinal folds, and the intergluteal cleft. Biopsies showed moderately differentiated squamous cell carcinoma throughout. We believe healing may be impaired in patients who have Crohn's disease, with a significant risk of unhealed perineal wounds after APR. Chronic unhealing wounds may progress to carcinoma, and this propensity toward transformation may be increased by immunosuppression. Complaints of persistent pain and unhealing wounds in the absence of infection in patients with Crohn's disease suggest the possibility of malignancy and biopsy is recommended.

We report a case of rare solitary neurofibroma of the transverse colon in a patient without neurofibromatosis. The patient was found to have an intussuscepting tumor prolapsing transanally, with massive lower gastrointestinal bleeding. This case represents only the second documented report of an isolated colonic neurofibroma.

Rectal prolapse remains a disorder for which the cause is not clearly understood and the best method of management is debated. Because the natural history of prolapse frequently leads to complications of incontinence and constipation, we believe that all patients presenting with internal and external prolapse should be considered for repair. Although the type of operative repair recommended may vary, it is clear that all patients with external rectal prolapse should be offered some type of repair. What is not clear from the literature is the appropriate management of those patients with internal prolapse. As shown in the George Washington University experience, surgery is rarely performed for isolated internal prolapse. Most patients who present with internal prolapse also have an associated enterocele, rectocele, or cystocele. Repair of the internal prolapse and the associated disorder may benefit many of these patients. If internal prolapse is an isolated finding, it is not clear to what extent the prolapse is responsible for the patient's symptoms, and repair is generally not advised. These guidelines are easy to enumerate but may be difficult to practice in some patients. Therefore, ongoing evaluation of clinical results is critical to improve our understanding of these disorders. This discussion has outlined the current theories of the cause of rectal prolapse, the symptoms and findings patients present with, and the possible approaches to repair.

Unlabelled: Transanal endoscopic microsurgery (TEM) was first used on a regular basis in the United States in 1990. Because there is a sole source of instrumentation, the surgeons who use this equipment are known to us. Thus, this earliest registry is a compilation of data based on most patients who underwent TEM in the United States from 1990 to 1994., Method: One hundred fifty-three cases were voluntarily registered by six surgeons. Pathology included 54 carcinomas, 82 adenomas, and 17 other entities. Most resections were full thickness. Fifty percent of cases were out of reach of standard instruments. Complication rate, hospital stay, and blood loss were recorded. Technical difficulties at time of surgery (9 percent), early complications (15 percent), and late complications (5 percent) have been tabulated., Results: Recurrence rates for carcinoma were 10 percent for T1, 40 percent for T2, and 66 percent for T3 stages. Failures were treated by abdominoperineal resection or low anterior resection. Adenomas recurred in 11 percent, but these recurrences were small and easily treatable., Conclusion: TEM has a low complication rate. By carefully selecting small, superficial cancers and adenomas, TEM results in superior outcome over other approaches to the mid and upper rectum.

Purpose: The aim of this study was to review our experience with patients with rectoceles using very selective criteria for operative repair and to critically review our surgical results., Methods: This is a review of patients selected for rectocele repair between 1989 and 1994., Results: Two hundred seventy-nine patients were evaluated for pelvic outlet symptoms in our clinic. Defecography was performed in 180 patients; rectocele was seen in 143 patients (79 percent; 135 females and 8 males). On physical examination, 132 patients had a palpable rectocele (73 percent). Rectocele repair was recommended for 35 patients (13 percent); 33 (32 females and 1 male) underwent this procedure. Mean age was 55 (range, 16-78) years. Although many patients complained of constipation, incontinence and pelvic pain, in these 33 patients criteria for repair included the sensation of a vaginal mass or bulge that required digital support and/or rectal digitizing for evacuation (58 percent), retention of barium in the rectocele on defecography (55 percent), or a very large rectocele with internal anterior rectal wall prolapse (6 percent). A hysterectomy had been performed previously in 47 percent of women repaired. Rectocele repair was performed by a standard transanal approach in 31 patients and transabdominally in 2 patients. Hospital stay averaged 3.7 (range, 1-8) days. Few postoperative complications occurred; urinary retention was the most common (18 percent). All patients were followed postoperatively, and 26 patients (79 percent) answered a standardized questionnaire. Mean follow-up was 31 (range, 5-64) months. Eighty percent of patients questioned who initially complained of a vaginal mass or bulge reported complete resolution (significant improvement by the sign test, P < 0.5). Subjectively, 92 percent of patients questioned reported improvement in their preoperative symptoms and satisfaction with the operation., Conclusion: Rectoceles are frequently identified during defecography, which is performed for pelvic floor complaints, yet are often asymptomatic. In contrast to other recent reports of rectocele repair, our data indicate that careful selection of patients using specific criteria may result in very good clinical results.

Purpose: Ileal pouch-anal anastomosis (IPAA) has become the operation of choice for most patients with chronic ulcerative colitis and familial adenomatous polyposis. However, because of technical or disease factors at the time of pouch construction, IPAA must sometimes be abandoned. A retrospective review was conducted to find reasons for IPAA failure or abandonment., Methods: Since 1981, 103 patients have had to have an IPAA procedure at the George Washington University Medical Center in Washington, DC. All charts were reviewed and data retrospectively collected., Results: Six of 103 patients (six percent) were unable to have IPAA constructed. Five patients ultimately received a standard end ileostomy, and one had an ileorectal anastomosis. The reasons for abandoning the IPAA procedure were an ischemic pouch, failure to reach the anus, poorly controlled presacral hemorrhage, desmoid of the mesentery, and finding incurable colon carcinoma., Conclusions: Information regarding the risk of failure or abandonment during the IPAA procedure should be discussed with the patient during preoperative counseling and must be included as an element of informed consent.

Purpose: Individuals who are seropositive for the human immunodeficiency virus are at high risk for opportunistic infection and anorectal disorders. Little prospective information is available regarding anorectal pathogens in these patients., Methods: One hundred sixty-three HIV-seropositive patients presented to the colorectal clinic between 1989 and 1992. Forty-seven (29 percent) patients were thought to have an infectious process and were prospectively studied using a standardized multiculture protocol., Results: Mean age was 33 (range, 19-59) years. All were male; high-risk behavior accounted for 87 percent of HIV transmissions. Presenting complaints included anorectal pain (79 percent), pus per anum (28 percent), and blood per anum (26 percent). Examination revealed perianal tenderness (60 percent), condyloma (38 percent), perianal ulcers (38 percent), and anal fissures (34 percent). Sixty-six sets of cultures were performed; 28 patients had one set, 15 had two sets, and 4 had three sets. Thirty-two of these 47 patients (68 percent) had positive cultures including herpes (50 percent), cytomegalovirus (25 percent), Neisseria gonorrhoeae (16 percent), chlamydia (16 percent), acidfast bacilli (2 percent), and others (9 percent). Six of 32 patients with positive cultures had more than one organism cultured. Sixteen (50 percent) patients with positive cultures were treated medically, 8 (25 percent) were treated surgically and 8 (25 percent) were treated with both modalities. Sixty-one procedures were performed on 17 patients for condylomata. Eighteen patients had 20 procedures for abscesses, 50 percent of whom had positive cultures for other than common bowel flora; all improved. Fourteen patients underwent 33 procedures for perianal fistulas. Mycobacterium fortuitum was cultured from one patient who required 13 procedures for abscesses and fistulas. Forty-five (96 percent) patients were followed for an average of 12.5 months +/- 2.9 SEM (range, 1-94 months). Symptoms were improved or resolved in 22 of 32 (69 percent) patients with positive cultures and in 11 of 13 (84 percent) with negative cultures., Conclusions: Specific pathogens may often be identified in human immunodeficiency virus-seropositive patients with anorectal disorders if aggressively sought. Although patients without specific pathogens identified may be expected to improve with planned empiric treatment, positive identification allows more directed therapy.

Transanal endoscopic microsurgery (TEM) has emerged as a minimally invasive means of resecting rectal tumors. Developed in Germany and now being used with increasing frequency in the United States, TEM utilizes a 40-mm operating rectoscope, which is sealed with an airtight facepiece. Carbon dioxide is constantly infused, thereby distending the rectum and maintaining visibility. A variety of instruments, such as tissue graspers, a high-frequency knife, suction, and needle holders, are inserted through the facepiece. Adenomas that are small, large, or even circumferential, as well as selected carcinomas up to 24 cm, can be removed with TEM instrumentation. The optics provide sixfold magnification, and this, combined with the constantly distended operative field, allows for a precise excision of the tumor as well as closure of the wound. For lesions in the mid and upper rectum, TEM is an alternative to a transsacral or transabdominal approach, with subsequently shorter hospital stay and fewer complications.

Individuals who are seropositive for the human immunodeficiency virus (HIV) frequently have disorders affecting the anorectum, yet little has been reported on this subject. We reviewed our initial experience with patients with HIV referred to the Division of Colon and Rectal Surgery. Forty patients (age range, 19-45 years; mean, 32.2 years) were seen between 1985 and 1989. The mean duration of symptoms was six months (range, one week to six years). In 25 patients (63 percent), more than one anorectal condition was identified. Condylomata were seen in 21 patients (52 percent), and in 11 these were associated with other pathologies. Fistulas and/or abscesses were identified in 15 patients (37 percent). Three had a "watering-can perineum," all without any identifiable predisposing factors. Nineteen patients had symptomatic hemorrhoids (seven), fissures (17), and/or perianal herpes infections (five), usually in combination with other lesions (89 percent). Three individuals developed neoplastic processes. Rectal disease was discovered in addition in nine patients. This included nonspecific proctitis in four, a rectal mass in four (polyps, two; rectal diverticulum, one; and Kaposi's sarcoma, one), and a nonspecific rectal ulcer in one. Four patients had other symptoms, including diarrhea, incontinence, soiling, frequency, and/or urgency, always in combination with other anal disorders. Seventy-one operative procedures were performed in 31 patients (78 percent). Only six (8 percent) of these were for diagnosis and biopsy alone. Mean follow-up was 15.5 months in the 23 patients followed for greater than one month. Only 6 of 23 (26 percent) had resolution of their problem. Nine (39 percent) developed new perianal conditions. Anorectal disorders are often seen in patients infected with HIV. They may be aggressive, cause significant morbidity, and be difficult to resolve.

Fecal incontinence at night may be a disturbing consequence of ileal pouch-anal anastomosis (IPAA). The hypothesis was that decreases in anal canal resting pressure occur as sleep deepens and that the decreases are more profound in pouch patients with incontinence than in controls. Using a sleeve catheter assembly for recording intraluminal and canal pressure and polysomnographic recordings of sleep stages, progressive decreases in anal canal resting pressure with deepening sleep occurred in 11 healthy controls (mean +/- SEM: 57 +/- 3 mm Hg to 43 +/- 3 mm Hg: P less than 0.05) and in 11 patients after IPAA (55 +/- 3 mm Hg to 42 +/- 4 mm Hg; P less than 0.05). Minute-to-minute variations in mean pressure were also found in both controls and IPAA patients, and they were greater at night in patients (P less than 0.05), except during rapid eye movement (REM) sleep. In three patients, resting pressure during REM sleep decreased markedly to 31 +/- 8 mm Hg. This decrease plus the variations in pressure during REM sleep led to incontinence. In conclusion, decreases in anal resting pressure coupled with marked minute-to-minute variations in pressure during sleep occurred in controls and in patients after IPAA and, when profound, led to nocturnal fecal incontinence in some patients.

The aim of this study was to determine whether the human anal sphincter responds dynamically to changing physiological states. In 19 healthy human subjects, intraluminal anal canal pressure was measured with a 5-cm perfused sleeve sensor during the day while fasting (3 hours) and after feeding (3 hours) and at night during sleep (8 hours). Daytime mean anal canal pressures (+/- SEM) while fasting (50 +/- 3 mm Hg) were similar to those after feeding (49 +/- 3 mm Hg) and to those at night during sleep (49 +/- 3 mm Hg). Marked minute-to-minute variations in mean pressure occurred in all three periods, however, as did large phasic increases and decreases in pressure (greater than 20 mm Hg) and small phasic changes in pressure less than 20 mm Hg (anal slow waves). The minute-to-minute variations in mean pressure were greater during the awake fed state (4 +/- 1 mm Hg/min) than at night during sleep (2 +/- 1 mm Hg/min; P less than 0.03), as were the number of large phasic waves per minute (increases in pressure: awake, fed = 0.5 +/- 1 waves/min, night = 0.3 +/- 0.1 waves/min, P less than 0.05; decreases in pressure: awake, fed = 0.4 +/- 0.1 waves/min, night = 0.2 +/- 0.1 waves/min, P less than 0.05). Anal small waves had a similar frequency of about 17 waves/min in all three states. In conclusion, the anal sphincter maintains a continuous pressure barrier to rectal outflow both during the day and at night during sleep. However, marked minute-to-minute variations in mean pressure and large phasic increases and decreases in pressure do occur. Both are fewer at night during sleep.

The authors' experience with children who have chronic ulcerative colitis was reviewed to compare their current surgical approach (ileoanal anastomosis) with earlier methods of management. Between 1960 and 1984, 137 children with chronic ulcerative colitis underwent surgery (mean duration of follow-up, 7.1 years). In 91 patients, the procedures were a total proctocolectomy with ileostomy or Kock pouch (66) or a lesser colectomy with either an ileostomy (16) or an ileorectal anastomosis (9) (group I). Forty-six patients underwent an ileoanal anastomosis procedure (group II). Children in group I were more likely to have significant preoperative loss of weight, a debilitated condition, and malnutrition. Urgent or emergency surgical intervention was required in 25 percent of patients in group I but in only 4 percent of patients in group II. Trends included 1) a younger age at operation in group II, 2) a higher mortality in group I (7.7 percent) than group II (0 percent), and 3) a higher perioperative mortality with emergency operations (23 percent) than elective procedures (1.6 percent). In group I, 98 percent of patients had an abdominal ostomy, but no patients in group II had an abdominal ostomy. The children with an ileoanal anastomosis had an average of 4.8 stools during waking hours and 1.3 stools each night. On the basis of this experience, the authors recommend use of the ileoanal anastomosis procedure in the surgical treatment of chronic ulcerative colitis in children.

A technique is described for intubation of the difficult, obstructed continent ileostomy. This procedure is safe and easily performed with commonly available materials. It initiates immediate primary treatment of the problem with decompression and catheter drainage, and also allows direct inspection of the pouch and valve to assist with planning of definitive treatment.

Based on clinical experience with 35 subjects younger than 21 years of age who underwent continuous ambulatory peritoneal dialysis (CAPD) during a two-year period at our institution, this procedure was found to be superior to hemodialysis in children because it allowed great freedom of activity and produced fewer complications requiring hospitalization. Moreover, CAPD appeared to be less expensive than hemodialysis, and no mortality or significant morbidity occurred during the 386 patient-months of catheter usage. Exit site infections, peritonitis, and abdominal hernias were the most common complications, often requiring minor surgical repairs. Using a specific operative technique for catheter placement and smaller volumes of dialysate during the first week after placement, these complications were minimized. Thus, CAPD is an effective, advantageous method for treatment of end-stage renal disease in children.

Cyclic 48-h unipolar depression is a rare form of recurrent affective disorder. We studied a single patient to determine (a) if there is an association between psychiatric status and migrating motor complex activity; and (b) if phase III of the migrating motor complex is in phase with rapid eye movement sleep in depression. There was marked reduction in phase III of the migrating motor complex during the depressed (n = 7) compared with the euthymic phase (n = 13), and a lack of coherence between phase III migrating motor complex activity and sleep stages in both depressed and nondepressed phases. The depressed state may be associated with altered upper gastrointestinal motor function.

Proctocolectomy with ileal pouch-anal anastomosis increases the frequency of stooling, perhaps due in part to the loss of an ileocecal or colonic braking effect on gastrointestinal transit. To assess whether colectomy with ileal pouch-anal anastomosis (IPAA) or with ileostomy accelerates gastrointestinal transit, we studied 16 IPAA patients (mean +/- SEM stool frequency, 8 +/- 1 stools/day), 5 patients after colectomy and Brooke ileostomy, and 8 healthy, unoperated controls (1 +/- 1 stools/day). Gastric emptying of liquids and small bowel transit of chyme were measured concurrently with a dual isotope technique. Gastric emptying was similar among all groups. In contrast, postprandial small bowel transit of the head of a duodenal marker was slowed, not accelerated, in IPAA patients (178 +/- 26 min) compared to Brooke subjects (80 +/- 32 min, P less than 0.05) and controls (75 +/- 15 min, P less than 0.01). Maximal filling of both the ileal pouch (341 +/- 19 min) and the ileostomy bag (348 +/- 12 min) occurred later than filling of the colon in controls (243 +/- 32 min, P less than 0.01). Overall stool frequency did not correlate with small bowel transit in the ileoanal patients, but the two ileoanal subjects with greatest stool frequency (11 and 18 stools/day) had the earliest arrival of marker at the pouch. In conclusion, removal of the colon markedly slowed small bowel transit in most patients, although it did not alter gastric emptying of liquids. Creation of an ileal pouch and ileoanal anastomosis further slowed transit of the head of the meal.(ABSTRACT TRUNCATED AT 250 WORDS)

To determine whether perianal Crohn's disease responds to resection of active intra-abdominal disease or to diversion, 273 cases of Crohn's disease in children (ages 4 to 18 years) were reviewed (all had been seen between 1970 and 1983). Of these, 104 patients underwent an intestinal operation, and 42 of the 104 (40%) had documented perianal disease at the time of their operation. Follow-up averaged 8 3/4 years from time of diagnosis. Three of the 42 died, at 1, 3, and 5 months postoperatively (mortality, 7%) and one was unavailable for follow-up. In these 42 patients with active perianal disease, an intestinal resection with primary anastomosis was performed in 19; one died postoperatively and one was unavailable for follow-up. Of the remaining 17 patients, five (29%) improved and 12 (71%) had continued perianal disease, either without change or worse. At least one further intestinal resection was needed in five of the 17 and two have needed proctocolectomy. A defunctionalizing procedure was done as part of the initial operation in 11 of the 42 patients. Two showed improvement; however, both needed proctocolectomy for rectal disease, and none of the 11 with fecal diversion have had reestablishment of intestinal continuity. In 12 of the 42 patients proctocolectomy was the initial procedure, usually for severe rectosigmoid disease. Of 38 children followed, 20 had proctocolectomy, 11 initially and nine after lesser procedures; overall rate of proctocolectomy was 53%. Resection of active intra-abdominal disease is not necessarily followed by resolution of perianal lesions. Defunctionalizing the rectum with fecal diversion does not appear to alter perianal disease.(ABSTRACT TRUNCATED AT 250 WORDS)

To determine the perioperative mortality and morbidity and the longterm prognosis of patients undergoing extended pelvic resections for localized advanced primary adenocarcinoma of the rectum, the authors reviewed their experience with 65 patients operated on between 1956 and 1984. Local invasion without distant metastasis was present in all patients at operation and en bloc resection of all involved organs was performed with intent of cure. Average age at operation was 61 years; 15 (23 percent) were men and 50 (77 percent) were women. Operations included abdominoperineal resection in 37 patients (57 percent), low anterior resection in 20 patients (31 percent), and Hartmann procedure in 8 patients (12 percent). Additionally, 34 of 42 women (81 percent) with intact uteri underwent en bloc hysterectomy, 37 of 48 women (77 percent) with intact ovaries had oophorectomy, and 25 of 50 women (50 percent) had partial vaginal resection. Seventeen of the 65 patients (26 percent) had a cystectomy, and 2 patients had a portion of small intestine resected in continuity with their tumor. Pathologic examination revealed lymph node involvement in 29 patients (45 percent) and histologic confirmation of adjacent organ extension in 37 patients (57 percent). There were no perioperative deaths, the average survival was 5.7 years, and 25 patients (38 percent) were alive after a mean follow-up period of 9.3 years. Overall five-year survival was 52 percent. Forty patients died during the follow-up period, with 26 (65 percent) of the deaths attributable to either recurrent carcinoma (25 patients) or a new primary lesion (1 patient). The cumulative probability of tumor recurrence at five years was 39 percent.