Topical preparations for burns and their evaluation

Omission of a temporary ileostomy in patients undergoing restorative proctocolectomy is controversial. Although fewer operations may be required and some complications avoided, the risks of anastomotic dehiscence and pelvic sepsis may be greater. Patients undergoing restorative proctocolectomy with no ileostomy (Group NI, n = 72) were compared retrospectively with patients given a conventional loop ileostomy (Group I, n = 30). Criteria for avoiding faecal diversion included: absence of severe acute colitis, good nutritional status and favourable surgery with creation of a sound, tension-free anastomosis. Steroid intake was not a contraindication to single-stage surgery. Delayed stomas were necessary in 8% of Group NI. For Groups NI and I, the rates of anastomotic leak (3% vs 3%), pelvic sepsis without demonstrable leak (3% vs 0%), pouch fistula (3% vs 10%) and intestinal obstruction (8% vs 3%) were similar. Closure of the temporary ileostomy in Group I was associated with a 10% complication rate. Cumulative post-operative hospital stay was significantly less in Group NI (median 11 vs 16 days). Functional results at 1 year were similar. A temporary loop ileostomy can be safely avoided in carefully selected patients undergoing restorative proctocolectomy.     

Omission of temporary diversion in restorative proctocolectomy--is it safe?

PURPOSE: The aim of our study was to evaluate the safety and functional outcome of restorative proctocolectomy (RP) without diversion. METHODS: Fifty patients underwent RP without diversion for ulcerative colitis (82 percent), familial adenomatous polyposis (12 percent), and indeterminate colitis (6 percent). The perioperative course and functional outcome of these patients were compared with another group of 50 patients undergoing RP with diverting ileostomy during the same time period (1989-1991) and closely matched for age, gender, surgeon, diagnosis, extent and duration (median, 10 years) of colitis, prior colectomy (approximately 22 percent), steroid use (40 percent), type of pouch, distance of ileal pouch-anal anastomosis from the dentate line (median, 1.5 cm), and the duration of follow-up (median, 12 months). All patients had a stapled ileal pouch-anal anastomosis without mucosectomy and a smooth conduct of the operation. RESULTS: There was no operative mortality. Anastomotic leaks and pelvic abscess were more common in patients without ileostomy (7/50 or 14 percent vs. 2/50 or 4 percent); 8 of these 9 patients were taking > or = 20 mg of prednisone/day. Septic complications requiring relaparotomy (6 percent vs. 0 percent), prolonged ileus, and fever of unknown origin (10 percent vs. 4 percent) were also more common in patients without ileostomy. Despite similar functional results at 6 weeks and at 12 months after initial pouch function, patients without ileostomy had a poorer quality of life index (5 vs. 8; 10 being best) in the early period (0-6 weeks) of pouch function. CONCLUSION: In equally favorable cases, RP without diversion is not as safe as RP with diversion, especially in patients taking > or = 20 mg of prednisone/day.     

Urinary changes in patients following restorative proctocolectomy

Following restorative proctocolectomy, the physiological function of the large intestine to absorb water and electrolytes is lost. Therefore, the kidney plays an important role in adjusting the water and electrolyte balance along with the ileal pouch. The reservoir function of the ileal pouch, however, may affect the functional adaptation of urinary changes. To observe the functional adaptation of urinary changes in ileal pouch patients, their changes in urinary output and electrolytes were investigated. Urinary output, pH, and electrolytes were all measured at 1 month, 6 months, and 1 year after surgery in patients with a J-pouch (n = 30) and compared with those in patients who had undergone ileostomy (n = 11) and healthy controls (n = 22). In the patients with a J-pouch, the urinary output, pH, and sodium concentration were significantly lower than those of the controls at 1 month after the operation. However, they gradually increased to near the control values at 1 year. In patients with an ileostomy, the urinary output, pH, and sodium concentration were lower than the control values up to 1 year postoperatively, but the urinary uric acid concentration was higher than that in the controls in both groups up to 1 year. The patients who had persistent aciduria were given a citrate mixture (3g/day), which effectively normalized the aciduria and also possibly prevented urinary uric acid stone formation.     

Does the presence of a pre-ileostomy closure asymptomatic pouch-anastomotic sinus tract affect the success of ileal pouch-anal anastomosis?

Ileal pouch-anal anastomosis (IPAA) is the procedure of choice for patients with ulcerative colitis and familial adenomatous polyposis. This two-stage procedure with a temporary diverting ileostomy avoids the catastrophic consequences of anastomotic leakage. We set out to determine the incidence and effect of asymptomatic pouch sinuses detected prior to ileostomy closure on the outcome of IPAA. A total 1600 IPAAs performed at the Mayo Clinic were reviewed. Forty-one (2.6%) asymptomatic sinuses were treated expectantly. There were 22 males and 19 females who had a median age of 32 years (range 14 to 58 years). The median time to ileostomy closure was 5.9 months (range 4 to 11 months). Five patients required further surgery following closure of ileostomy. The pouch function in these five patients was similar to that in the remainder of the group. Patients with a persistent sinus at the time of ileostomy closure had the same function as the main cohort. This group had a median of five (range 2 to 12) stools during the day and two (range 0 to 4) at night. The total number of stools per 24 hours was seven (range 2 to 14). Frequent incontinence occurred in 9.7% and 7.3% during the day and at night, respectively. Only 2.4% (1/41) were disappointed with the results of the operation and 80.4% (33/41) found their quality of life improved. Functional outcomes were comparable to those achieved with uncomplicated IPAA. Radiologically detected asymptomatic sinuses can be treated expectantly with a low rate of pouch loss and subsequent surgery. This is not considered a serious setback inasmuch as long-term function and quality of life are comparable to that achieved with IPAA without sinus tracts.     

Attempts to aid the adaptation of pelvic pouch before temporary ileostomy closure

Most patients experience a high stool frequency immediately following the closure of the temporary ileostomy after total colectomy and ileoanal pouch reconstruction. Adaptation occurs within the ensuing weeks to reach a plateau in about three months. Increasing volumes of liquid nutrients were injected, twice daily for two months, into the pelvic pouch through a mucous ileal fistula proximal to the pouch before closing the temporary ileostomy. With this method the number of evacuations per 24 hours was significantly reduced during the first few weeks following the reestablishment of intestinal continuity, compared with a control group (average, 8.5 vs. 18.2, respectively). Patients also had better continence and less urgency to defecate. We suggest this technique in patients undergoing pelvic ileal reconstruction with temporary ileostomy.     

Nutritional status of gastric cancer patients after total gastrectomy

A number of causes of malnutrition after total gastrectomy have been proposed. The purpose of this study was to assess nutritional status and to determine the cause of malnutrition after total gastrectomy. We studied 20 gastric cancer patients who had undergone total gastrectomy and immunochemotherapy and 6 normal controls. Nutritional status was assessed by dietary history, anthropometric methods, and serologic measurements. Malabsorption tests included the fecal fat excretion test, D-xylose absorption test, glucose tolerance test, vitamin B12 absorption test using dual isotopes, bacterial culture of jejunal aspirates, and jejunal biopsy. Weight loss was compared to the preoperative status in all patients (average 15%: 59.0 +/- 9.9 vs. 50.2 +/- 7.8 kg, preoperatively vs. postoperatively). Average daily calorie intake was 1586.2 kcal, which is lower than the normal intake of Korean adults (1838 kcal). Malnutrition of skeletal and visceral protein was not found. There was, however, severe fat malnutrition and a deficit of body fat. Postoperatively the body mass index was considerably lower than that preoperatively (22.2 +/- 0.4 vs. 18.9 +/- 0.4 kg/m2; preoperatively vs. postoperatively). With malabsorption tests, the daily excreted amount of fecal fat was 28.6 +/- 3.4 g (mean +/- SD) in patients and 6.9 +/- 0.2 g in controls. There was no significant malabsorption of carbohydrates. In 64.3% (9/14) of patients, vitamin B12 absorption was abnormal; and the serum concentration of vitamin B12, which was significantly related to malabsorption of this vitamin, was lower than normal in 73.7% (14/19). Bacterial overgrowth was not found, and there were no abnormal histologic findings in the jejunal mucosa. These results suggest that poor oral intake and fat malabsorption following total gastrectomy cause malnutrition and that fat malabsorption may be related to relative pancreatic insufficiency.     

Factors related to the presence of IgA class antineutrophil cytoplasmic antibodies in ulcerative colitis

OBJECTIVES: Few studies have assessed the IgA antineutrophil cytoplasmic antibody (ANCA) positivity in ulcerative colitis patients and there is no information about factors related to its synthesis and its status after colectomy. The aims of the study were to assess the serum IgA ANCA prevalence in ulcerative colitis patients, both nonoperated and operated, and to determine the clinical factors related to this positivity. METHODS: Fifty-four ulcerative colitis patients, 63 ulcerative colitis colectomized patients (32 with Brooke's ileostomy and 31 with ileal pouch anal anastomosis), and 24 controls were studied. Antineutrophil cytoplasmic antibodies were detected by specific indirect immunofluorescent assays. RESULTS: The percentage of IgA ANCA was significantly higher in patients with ileal pouch anal anastomosis (45%) than in patients with Brooke's ileostomy (22%). There were no differences related to the presence of pouchitis in ileal pouch anal anastomosis patients. Patients with nonoperated extensive colitis (47%) had a significantly higher percentage of IgA ANCA than patients with proctitis (19%). Total percentage of ANCA (IgA and/or IgG) tended to be higher in ulcerative colitis and in patients with ileal pouch anal anastomosis than in patients with Brooke's ileostomy. However, in ileal pouch anal anastomosis patients, ANCA positivity was mainly due to exclusive IgA production. CONCLUSIONS: A substantial percentage of ulcerative colitis patients, and especially colectomized patients with ileal pouch anal anastomosis, had IgA ANCA, suggesting that ANCA production in ulcerative colitis might be stimulated by an immune reaction in the intestinal mucosa.     

Urodynamic assessment of patients with acute urinary retention: is treatment failure after prostatectomy predictable?

PURPOSE: Some patients with acute urinary retention due to benign prostatic hyperplasia do not have successful outcome after prostatectomy and require either a chronic indwelling urethral catheter or clean intermittent catheterization. Urodynamic and clinical parameters were examined preoperatively in 81 men 56 to 93 years old (mean age 72 years) in search of an outcome predictor after prostatectomy. MATERIALS AND METHODS: International Prostate Symptom Score, prostate volume, retention episodes, retention volume and urodynamic parameters from a multichannel pressure-flow study were analyzed preoperatively and postoperatively. All patients underwent transurethral prostatectomy and were reexamined 2, 4, 12 and 24 weeks after surgery. A multichannel pressure-flow study was performed preoperatively and 12 weeks postoperatively. RESULTS: At 24 weeks postoperatively 11 patients (13%) were unable to void and therefore classified as treatment failures while the remaining patients voided spontaneously and were classified as treatment successes. There were statistically significant differences (p < 0.005) between treatment failure and treatment success regarding age (83.5 +/- 7 versus 70.1 +/- 8 years), preoperative volume of retention (1,780 versus 1,080 ml.), and maximal detrusor pressure (24.4 versus 73.5 cm. water), but not to International Prostate Symptom Score, episodes of retention and prostate volume. The ability to void during preoperative pressure flow study and the presence of detrusor instability predicted good outcome. In treatment success patients postoperative urodynamic data showed significant decrease in detrusor pressure at maximum flow rate (from 80.8 +/- 33 to 34.6 +/- 10 cm. water). Those with treatment failure had an increase in maximal detrusor pressure (from 26 +/- 12 to 42.6 +/- 13 cm. water), suggesting detrusor recovery. CONCLUSIONS: Patients with acute urinary retention, age 80 years or older, with retention volume greater than 1,500 ml., no evidence of instability and maximal detrusor pressure less than 28 cm. water are at high risk of treatment failure. However, despite treatment failure the detrusor may recover in patients younger than 80. Therefore, prostatectomy should still be performed in this group (less than 80 years old) even if preoperative urodynamics suggest an unfavorable outcome.     

Surgical results for spinal metastases

Among a series of 740 spinal tumours treated in the Department of Neurosurgery at the Nordstadt Hospital in Hannover, Germany, between September 1977 and December 1996, 106 spinal metastases in 101 patients were operated on. After an average period of 4.0 +/- 6 months (2 days to 5 years) patients presented at an average age of 62 +/- 12 years. 79% of the tumours were operated on by a posterolateral approach, 12% by an anterior and the remaining 9% by an anterior and posterior approach. A complete resection was achieved for 43.4% of the metastases while 48.1% were removed partially, 7.5% were biopsied and one patient received an opiate pump. Operations were followed by radiotherapy, chemotherapy or hormone treatment. The overall local recurrence rates as determined by the Kaplan Meier method were 57.9% after 6 months, 69.3% after 1 year and 96% after 4 years. Multiple regression analyses revealed that an independent preoperative status of ambulation, favourable tumour histology, cervical level, complete resection, low number of affected vertebral bodies, and elective surgery were significant, independent predictors of a low rate of local metastatic recurrence. Postoperative neurological outcome was related to preoperative neurological deficits. 96% of patients walking preoperatively kept this ability for at least 3 months postoperatively. However, only 22% of patients unable to walk regained walking capacity for 3 months. Correspondingly, 89% of patients remained continent of urine postoperatively for 3 months while only 31% regained sphincter control for this amount of time postoperatively. In terms of postoperative survival, multiple regression analyses showed longer survival times for patients with a favourable tumour histology, independent ambulation, long history, male sex, cervical level, complete resection, posterior approach, no additional metastases in other organs, and no instability. The overall survival rates were 58.8% after 6 months, 48% after 1 year and 19.5% after 5 years postoperatively. In conclusion, surgery has a place in the treatment of patients with metastatic disease of the spine and neurological symptoms and/or spinal instability. The surgical strategy should be tailored according to the general health of the patient and expected time of survival. Primary radiotherapy should be administered to patients without neurological deficits or instability and to patients who cannot undergo or do not accept surgery.     

Fundoplication and gastrostomy

BACKGROUND: There are conflicting reports on the value of cyclocryotherapy and it seems that the success rate is depending on glaucoma conditions, the period of follow-up and the technique. This retrospective study was carried out to assess the efficacy and complication rate of cyclocryosurgery for advanced glaucoma with and without neovascularization. PATIENTS AND METHODS: We induced 76 eyes of 75 patients with inadequately controlled glaucoma, which underwent cyclocryotherapy during the period of 1993 and 1996 (treatment time 60 seconds with -80 degrees C, 6-12 applications (mean 9.8 +/- 2.3), 180-360 degree (median 270 degree), diameter of the probe tip 2.5 mm, 1-2 mm distance from the limbus). Depending on the etiology we distinguished between neovascular (NVG) and non-neovascular glaucoma (nNVG). Pre- and postoperative data from all patients were studied retrospectively, for follow-up after 12-36 months patients were examined. RESULTS: Intraocular pressure (IOP) decreased in all patients from 44.7 +/- 12.6 mm Hg preoperatively to 15.6 +/- 6.5 mm Hg postoperatively after a follow-up of 12-36 months. In 88.2% IOP was lowered to < or = 25 mm Hg. NVG showed a mean IOP reduction from 49.1 +/- 12.5 mm Hg before cyclocryotherapy to 15.6 +/- 5.0 mm Hg at follow-up. In the nNVG group IOP was 40.5 +/- 11.3 mm Hg and 15.7 +/- 7.6 mm Hg after cyclocryotherapy. Pressure was controlled (< or = 25 mm Hg) for 83.8% of NVG and 92.3% of nNVG. A cyclocryotherapy-induced intense inflammation was seen more frequent in NVG (43.2%) than in nNVG (17.9%). 2 patients with NVG and 3 with nNVG developed phthisis postoperatively (total 6.7%). CONCLUSIONS: Cyclocryosurgery is an effective method to reduce IOP in advanced, refractory glaucoma, when other methods have failed. The risk/success rate seems to be acceptable.     

Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root

OBJECTIVES: There is still no agreement about the best method of dealing with malfunction of the aortic valve caused by aneurysm or dissection of the aortic root. The experience, rationale, and development of a valve-preserving technique introduced and used since 1979 is described. METHODS: During this period 158 patients (78% of all patients undergoing resection of aneurysm of the ascending aorta) were operated on using this technique. Their ages ranged from 2 to 72 years (mean 46.6 years). Of the patients 107 were male and 51 were female. A total of 68 patients had skeletal manifestations of Marfan's syndrome. The original disease was chronic aneurysm of the ascending aorta or root in 92 (58.2%), chronic dissection in 17 (10.8%), and acute dissection in 49 (31%) patients. One hundred eleven additional procedures were performed in 84 patients. In all there were five early deaths (4.6% +/- 2%) in the 109 patients with chronic aneurysm and one death in the 103 patients operated on electively (0.97% +/- 0.9%). Actuarial survival for patients operated on for chronic aneurysm was 93.3%, 88.0%, 79.0%, and 57.9% at 1, 5, 10, and 15 years and 96.8%, 91.2%, 82.0%, and 60.0% for those operated on electively. Actuarial survival for patients operated on for acute dissection was 72.8%, 63.4%, and 53.3% at 1, 5, and 10 years. The probability of needing reoperation was 3.0% +/- 2%, 11% +/- 0.5%, and 11% +/- 0.5% at 1, 5, and 10 years. There were no instances of infective endocarditis or thromboembolic complications except in two patients operated on early in the series who had cusp extension. No anticoagulants were used. Echocardiography showed reduction in left ventricular end-systolic and end-diastolic dimensions, which was maintained. At the end of follow-up trivial or no aortic regurgitation was demonstrated in 63.6%, mild to moderate in 33.3%, and severe in 3%. CONCLUSIONS: Valve-sparing operations are possible in a large proportion of patients with aneurysms of the ascending aorta and the medium and long-term results are encouraging.     

Pouch-related fistula following restorative proctocolectomy

Prognostic factors and outcome of pouch-related fistula were analysed from a series of 21 patients, 20 of whom had an ileal J pouch manually anastomosed to the dentate line following mucosectomy. Fistula occurred more often after pouch formation for ulcerative colitis than for familial adenomatous polyposis. In 6 patients the fistula occurred more than 5 months after closure of the diverting loop ileostomy. The origin of the leak was the anastomosis in 14 patients, the vertical staple line in two and the end of the efferent limb in five. Nine forms of treatment were utilized and these were successful in 11 patients and unsuccessful in ten including three pouch excisions. Adverse prognostic factors were late fistula, the presence of an enterocutaneous or a pouch-vaginal fistula track, and diagnosed or suspected Crohn's disease. Resolution of the fistula followed none of six diverting loop ileostomies performed alone, three of 33 attempted drainage procedures, four of ten direct closures, and four of five repeat ileal pouch-anal anastomoses. It is concluded that an aggressive therapeutic approach using repeat ileal pouch-anal anastomosis increases the success rate.     

Range of motion and complications after postburn heterotopic bone excision about the elbow

OBJECTIVE: To review the results of surgical management of heterotopic ossification about the elbow in burned patients. DESIGN: Retrospective analysis with long-term patient follow-up. MATERIALS AND METHODS: Eleven patients with 16 elbows requiring surgery were admitted between January 1, 1982 and December 31, 1993. A posterior approach to the elbow with release of the encased ulnar nerve +/- anterior transposition and transolecranon osteotomy to access extensive bone formation in the olecranon fossa was employed. Eight patients (11 elbows) were available for long-term follow-up conducted at mean 50 +/- 13 months after surgery. Long-term follow-up consisted of measurement of range of elbow motion, as well as clinical assessment of ulnar nerve function. MAIN RESULTS: For the 11 elbows examined postoperatively, the mean range of motion preoperatively in flexion-extension was 11 degrees +/- 5 degrees compared to 89 degrees +/- 12 degrees postoperatively (p < 0.001). Three patients with poor long-term results had ankylosis of the joint preoperatively. Of four patients with ulnar nerve paresis preoperatively, none had ulnar nerve dysfunction at follow-up. Of 16 elbows operated on, four (25%) had postoperative complications. Two suffered soft-tissue breakdown with hardware exposure requiring abdominal flap closure, one early failure of olecranon fixation, and one late infected hardware. CONCLUSIONS: Surgery for both limited range of motion as well as ulnar nerve compression is effective in cases of heterotopic ossification about the elbows of burned patients. Early operative intervention is indicated in progressive disease, particularly ulnar nerve palsy, if soft-tissue quality is adequate. Complications with 25% of elbows suggest that use of olecranon osteotomy for joint access may warrant review.     

Ileoanal pouch function and release of peptide YY

PURPOSE: This study evaluates peptide tyrosine-tyrosine (PYY), intestinal transit, fecal retention time, and anal sphincter manometry in colectomized patients with ileal pouch-anal anastomosis. METHODS: Plasma and pouch PYY, mouth-to-pouch transit time, fecal retention time, and anal canal pressures were studied in 27 patients with ileoanal pouches a mean of 50 (range, 3-84) months after loop ileostomy closure. RESULTS: Basal and peak postprandial plasma PYY were significantly reduced in patients with pouches compared with controls (P < 0.0001). Pouch PYY was decreased compared with control ileal PYY (P = 0.0003). No significant correlation was noted between intestinal transit and total integrated PYY response in patients with pouches (r=0.36; P=0.06). Fecal retention time was related to postprandial total integrated response of plasma PYY (r=0.43; P=0.02), mouth-to-pouch transit (r=0.87; P < 0.0001), and resting (r=0.44; P=0.02) and squeeze (r=0.62; P=0.0006) anal sphincter pressures. CONCLUSIONS: Colectomized ileoanal patients with pouches showed decreased plasma and pouch PYY compared with controls. Intestinal transit was not significantly related to PYY release. However, prolonged pouch fecal retention was associated with greater PYY release, mouth-to-pouch transit, and anal sphincter pressures.     

Typical complications and their control after restorative proctocolectomy

The overall rate of complications after ileal pouch-anal anastomosis is 60%. This rate, however, includes complications such as bowel-obstruction and hernias. Pouch-related complications occur after ileal pouch-anal anastomosis with a frequency of 15-25%. In an analysis of the recent literature the main risk factors are: tension of the ileal pouch-anal anastomosis, anastomotic leakage, lack of protective ileostomy, preoperatively undiagnosed Crohn's disease and the experience of the surgeon. We classified pouch related-complications into (1) surgical complications (leakage, bleeding, pelvic sepsis, fistulas); (2) technical problems (long S-pouch spout, rectal cuff stenosis, etc.); (3) functional problems (anal sphincter insufficiency, night incontinence, hypermotility, evacuation disorders); (4) pouchitis; (5) pouch neoplasias. Pathogenesis, diagnostic features, and medical and surgical therapy are discussed in detail. In our own series of 11 pouch-redo operations we had 6 pouch fistulas (3 related to Crohn's disease, 3 postoperative fistulas), 3 wrongly constructed pouches, 1 chronic pouchitis and 1 long S-pouch spout. In 3 cases the pouch had to be excised completely. Two patients remained with a permanent ileostomy. In 6 patients the pouch could be preserved on long term. Due to the technical complexity, the need to understand pathophysiology and the need for a differentiated diagnostic procedure, this operation should be performed only in specialised centers.     

Transformations of ileo-rectal anastomosis into ileo-anal anastomosis in hemorrhagic rectocolitis. Indications and results

In order to precise the indications and results of this procedure, we assessed 11 cases of transformation of ileorectal anastomosis (IRA) to ileal pouch-anal anastomosis (IPAA) in ulcerative colitis (UC). These 5 men and 6 women had undergone IRA at a mean age of 31 years, 33 months after the diagnosis of UC (range 3-120). Four of these IRA, excluded by an ileostomy, had never been in function: the cause was severe persistent proctitis in 2 cases and anastomotic leakage and peritonitis in 2 cases. The other 7 IRA had been in function during a mean period of 25 months (range 6-45) and were reoperated because of anal sepsis (1 case), low rectal stenosis (1 case), disabling proctitis (4 cases) and rectal dysplasia (1 case). No patient had specific pathologic signs of Crohn's disease. The 11 IPAA were complicated by pelvic sepsis in 3 cases; surgical drainage succeeded in 1 case, but the 2 others needed pouch excision and terminal ileostomy. The diagnosis of Crohn's disease was eventually made in these 2 patients. The 9 patients with functioning IPAA, at a mean follow-up of 40 months (range 12-60), had 5.2 stools per 24 h (range 2-12), 5 patients had no nocturnal stooling, and 6 had a perfect continence. One patient had disabling chronic pouchitis. In conclusion, proctectomy with IPAA is always feasible when a previous IRA for UC had failed or offers poor results, but should be rejected in case of anal involvement, as that may suggest Crohn's disease. This procedure is followed by similar functional results than after primary IPAA.     

Neurologic signs in lumbar disc herniation. Preoperative affliction and postoperative recovery in 150 cases

We studied prospectively 165 consecutive patients operated on for lumbar disc herniations. Neurologic examination was performed preoperatively and at 4, 12, and 24 months postoperatively according to a protocol. Preoperatively 69% of the patients showed a neurological disturbance corresponding to the level of disc herniation and 62% a corresponding sensory deficit. Recovery of the neurological deficit was seen in half of the cases at 2 years postoperatively, the main part of this improvement occurred within 4 months after the operation. Neurologic recovery correlated to a good surgical outcome, and a short history of disc herniation prior to the operation correlated to postoperative neurologic improvement. The straight leg raising test correlated to preoperative neurologic deficit, but not to postoperative recovery. Motor power disturbance of the extensor hallucis longus muscle recovered in more patients than reflex disturbances. Sensory disturbances had the lowest recovery rate. Our study demonstrates a correlation between routine postoperative neurologic findings and the patient's self-assessed outcome of surgery.     

Efficacy of the straight endorectal pull-through in the management of familial adenomatous polyposis--a 16-year experience

From 1979 to 1995, 27 patients who had familial adenomatous polyposis (FAP) were treated at the authors' institution. Most patients (n = 23) presented as a result of a previous family history of FAP. Eighteen patients presented with symptomatic colonic disease that included bloody stools (n = 14), diarrhea (n = 10), and abdominal pain (n = 6). Treatment consisted of a total colectomy, rectal mucosectomy, and straight endorectal pull-through (ERPT) in 26 of 27 patients. One patient preferred to undergo an ileoanal J pouch reconstruction. A temporary diverting loop ileostomy was performed in 25 patients and closed at an average of 100 days after the ERPT. Follow-up has been achieved in 100% of the patients and ranges from 6 to 182 months with an average of 48 months. Postoperative complications included partial bowel obstruction (two patients, one requiring enterolysis); and mild pouchitis (one patient). Two of the 27 patients required proctectomy and permanent ileostomy procedures, one for rectal cancer that was present microscopically in the initial rectal specimen from the ERPT and the other because of recurrent anastomotic complications. No patient required revision of the straight pull-through to a pouch or takedown of the pull-through as a result of persistent diarrhea or dissatisfaction. All of the patients are continent, and 80% deny any soiling during bouts of gastroenteritis. The mean number of bowel movements reported was 10 per day at the first postoperative clinic visit with a gradual decreased to six per day after 2 years. Initial use of bulking (62%) and antimotility agents (88%) decreased significantly over the course of follow-up to 29% and 67%, respectively at the most recent follow-up (average, 48 months) of each patient. Pelvic sepsis, which occurs in 8% of most series of patients who have pouches, did not occur in any of our patients. Pouchitis, a common complication with pouches (23%), occurred in only one of the patients and was mild and easily treated medically. This series demonstrates that total colectomy with rectal mucosectomy and straight ERPT eliminates the risk of colorectal cancer and achieves continence with a low complication rate and excellent functional results and patient satisfaction.     

Indications and outcomes of strabismus repair in visually mature patients

OBJECTIVE: To identify and examine the indications, outcomes and potential risks of strabismus surgery in visually mature patients. DESIGN: Case series. SETTING: University-based referral practice in Edmonton. PATIENTS: A total of 222 patients (115 females and 107 males) aged 9 to 69 (mean 29) years who underwent strabismus surgery for various types of strabismus (as grouped by original diagnosis). All patients were followed for at least 6 weeks postoperatively. OUTCOME MEASURES: Previous surgery and deviation in prism dioptres (delta) (distance and near), sensory status (measured by the Titmus stereotest at near) and the presence of symptoms (diplopia, abnormal head posture or asthenopia), recorded preoperatively, 6 weeks postoperatively and at the last postoperative visit. RESULTS: The patients were followed for an average of 14 months postoperatively. At the last postoperative visit 187 patients (84%) were aligned to within 15 delta of orthotropia. Overall, 116 patients (52%) demonstrated some degree of stereopsis postoperatively, compared with 78 (35%) preoperatively. A total of 116 patients (52%) had symptoms preoperatively, including diplopia, abnormal head posture or asthenopia; 88 (76%) of the 116 had complete resolution of their symptoms. Six patients (4%) without diplopia preoperatively were found to have this symptom postoperatively. CONCLUSIONS: The findings suggest that most visually mature patients under-going strabismus surgery can expect functional benefits, including improvement of alignment, preservation and occasionally restoration of sensory fusion, and elimination of diplopia, abnormal head posture and asthenopia.     

Antiepileptic drug treatment following temporal lobectomy

Antiepileptic drug use was documented before and after temporal lobectomy. Carbamazepine, phenytoin, and clobazam were the most commonly used drugs, both pre- and postoperatively. Preoperatively, polytherapy was used in 78% of patients; at 6 months follow-up, 47%; at 12 months, 18%; and at 24 months, 14%. Preoperatively, monotherapy was used in 20% of patients; at 6 months follow-up, 49%; at 12 months, 55%; and at 24 months, 42%. No medication was used preoperatively by 2% of patients; at 6 months follow-up, 2%; at 12 months, 27%; and at 24 months, 44% (p < 0.001). After 2 years, 53% of patients who were seizure free had stopped taking medication, as had 33% who had some seizures after surgery.