Surgical options in ulcerative colitis

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tubes also has been suggested as an alternative to the performance of a Nissen fundoplication with G-tube placement. A chart review of 28 patients with percutaneously placed gastrojejunal tubes (GJT) was performed. At the time of tube insertion, the mean age was 47.2 months and the mean weight was 11.7 kg (range, 2.28 to 42.7 kg). The mean duration of follow-up was 17.3 months. The patients were evaluated for the persistence or new development of vomiting, hematemesis, abdominal pain, constipation, diarrhea, pain at the site of G-tube insertion, stridor during feeding, and dumping. One or more of these symptoms were present or developed de novo in 20 children (71.4%), with vomiting being the most common. Major complications occurred in 11 patients, with fundoplication being required in seven patients. Children without complications were significantly older and heavier at the time of GJT placement than the children who had major complications. The authors conclude that ongoing or new gastrointestinal symptoms and minor complications are common in children with GJT, and that several problems in maintaining the GJT in a functional state compromised its utility.-Richard R. Ricketts Laparotomy or Drain for Perforated Necrotizing Enterocolitis: Who Gets What and Why? KS. Azarov, S.H. Ein, B. Shandling, et al. Pediatr Surg Int 12:137-139, (February), 1997. The authors compare 86 neonates with perforated necrotizing enterocolitis treated with laparotomy versus peritoneal drain inserted under local anesthesia. Treatment was decided according to the surgeon’s preference. Forty-two patients underwent laparotomy, and44 had drainage. The average weight was 1,700 g for the laparotomy group and 1,100 g for the drainage-only group. Of the babies who weighed less than 1,000 g, 22% survived laparotomy and 69% survived drainage. Of those between 1,000 and 1,500 g, 60% survived laparotomy and 33% survived drainage. Of those heavier than 1,500 g, 72% survived laparotomy and 50% survived drainage. The overall survival rates were 57% with laparotomy and 59% with peritoneal drainage. It is concluded that treatment of perforated necrotizing enterocolitis with peritoneal drainage in neonates who weigh less than 1,000 g may result in improved survival rates-l? Wester Crohn’s Disease: Influence of Age at Diagnosis on Site and Clinical Type of Disease. J.M. Polito II, B. Childs, E.D. Mellits, et al. Gastroenterology 111580-586 (September), 1996. The aim of this study was to examine the influence of age at the time of diagnosis of Crohn’s disease on disease, type, and clinical course. Patients younger than 20 years at the time of onset were compared with those older than 40 years at onset. The younger patients had a greater prevalence of family history of Crohn’s disease (29.9% v 13.6%), greater likelihood of small bowel involvement (88.7% v 57.5%), more stricturing-type disease (45.8% v 28.8%), and a higher frequency of surgery (70.6% v 55.3%). Older age at diagnosis was associated with a greater prevalence of colonic disease (84.8% v 71.2%), and of the inflammatory type of Crohn’s disease (54.5% v 34.4%). In summary, Crohn’s disease occurring at an early age is associated with more complicated disease and a greater likelihood of having affected relatives.-Richard R. Ricketts Surgical Therapy for Crohn’s Disease of the Colon and Rectum. VU! Fazio and J.S. Wu. Surg Clin North Am 77:197-210 (February), 1997. When Crohn’s disease is confined to the colon at initial presentation, both the recurrence rate and the site of recurrence after surgery are influenced by the type of procedure performed. The authors discuss the common operations performed for Crohn’s disease of the colon and rectum, including (1) subtotal colectomy and ileostomy, (2) ileostomy, (3) total proctocolectomy and ileostomy, (4) abdominal colectomy and

ileorectal anastomosis, (5) segmental colectomy. and (6) surgery for internal fistulas. Recurrence rates are lowest after total proctocolectomy and end ileostomy and are highest after segmental colonic resection. Total proctocolectomy is the most appropriate operation for treatment of Crohn’s colitis, especially if there is significant anorectal disease. The two most common complications after this procedure are proximal small bowel recurrence and nonhealing of the perineal wound. Reports of small bowel recurrence after total proctocolectomy vary from 3% to 46%. Abdominal colectomy and ileorectal anastomosis in patients with Crohn’s disease is appropriate if the rectum is spared of the disease and anal sphincter function is normal. Contraindications to ileorectal anastomosis include the presence of active perineal disease, rectal cancer or dysplasia, and a poorly distensible rectum. Both the surgeon and the patient should realize that there is distinct likelihood of further surgery, directed toward the rectum, in patients who have ileorectal anastomosis. Approximately 23% of patients will require a later proctectomy, and 13% may require proximal diversion. Segmental colectomy in patients with Crohn’s disease has a limited role. It is appropriate when only short segments of colon or rectum are involved and the rest of the colon is absolutely normal. Attempts at saving the rectum when obvious disease is present by using a Hartman procedure or a mucous fistula are not likely to be successful.-Richard R. Ricketts The Long-Term Outcome of Ulcerative Colitis Treated With 6-Mercaptopurine. .I. George, D.H. Present, R. Pou, et al. Am J Gastroenterol91:1711-1714 (September), 1996. Chronic refractory cases of ulcerative colitis can achieve 40% complete response rate and 30% partial response rate when treated with 6-MP. However, the duration for which 6-MP must be maintained once remission has been achieved is not clear. Long-term follow-up data on 10.5 patients with ulcerative colitis were reviewed. The initial dose of 6-MP was 50 mg/d, with gradual increases depending on the clinical response. Complete clinical remission was defined as the ability to discontinue oral steroids, and partial remission was defined as a 50% reduction in the steroid dose. The average age of onset of ulcerative colitis in these patients was 30.8 years (range, 11 to 68 years), and the average age at 6-MP initiation was 38.6 years (range, 13 to 76 years). Sixty-five percent of the patients achieved complete clinical remission, and 24% achieved partial remission. Of those who achieved complete clinical remission, 35% had a breakthrough while still on 6-MP. Eighty-seven percent of patients who electively discontinued 6-MP at various intervals after achieving complete clinical remission had a relapse. The estimated mean time until relapse was 14 months. Therefore, 6-MP is effective in the treatment of refractory ulcerative colitis. Patients who discontinue 6-MP after successful treatment have a high relapse rate, and therefore 6-MP must be maintained long-term to sustain remission.-Richard R. Ricketts Surgical Options in Ulcerative ton. Surg Clin North Am 77:85-94

Colitis. R. Faroukand (February), 1977.

J.H. Pember-

The following surgical questions in the management of ulcerative colitis are discussed, using experience from the Mayo Clinic as a basis for the discussion: (1) Which pouch design is best? (2) Is there a role for defunctioning ileostomy? (3) When should the anal transition zone be excised? (4) When should a stapled anastomosis be avoided? (5) How does the finding of cancer of the colon influence the decision to create a pouch? The authors believe that there is little difference in functional outcome between the S, W, J, K, and H reservoirs if approximately 30 to 40 cm of ileum are used for reservoir construction. Because of the relative ease in constructing the J pouch, this is the option preferred by the authors. Use of a loop ileostomy does not appear to fully protect the patient from pelvic sepsis, but it is much easier to manage a patient with sepsis if an ileostomy is in place. Because of this, the authors recom-

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mend using a defunctioning ileostomy in patients who receive steroid treatment at the time of surgery, in patients who are nutritionally compromised, and if there are concerns about pouch blood supply or anastomotic tension. Leaving the anal transition zone intact improves functional outcome but leaves rectal mucosa at risk for continued inflammation and neoplastic change. Therefore, the transition zone should be excised in all patients who have familial adenomatous polyposis. If the transition zone is not excised in patients with ulcerative colitis, lifelong surveillance is advised. With respect to a stapled anastomosis versus a hand-sewn anastomosis after mucosectomy, the authors favor complete mucosectomy and a hand-sewn anastomosis in patients who are at risk for malignancy. This includes patients with ulcerative colitis and mucosal dysplasia as well as all patients with polyposis. When cancer is present, the decision to perform an ileoanal anastomosis should be based on the stage of the tumor and the subsequent need for radiation therapy. Patients with early-stage tumors that do not require radiation therapy can attain long-term functional results comparable to those of patients with benign disease.--Richard R. Ricketts Urolithiasis in Patients With Hirschsprung’s Disease. A. Surioglu, RC. Tanyel, N. Biiyiikpamukcu, et al. Eur J Pediatr Surg 7:149-151, (June), 1997. Although patients with Hirschsprung’s disease carry some factors that increase the risk of urolithiasis, this fact appears to be underestimated. Among 302 patients with Hirschsprung’s disease, four patients (1.32%) with urolithiasis were encountered. Because factors that increase the risk of urolithiasis (such as urinary tract infection, constipation, vesicoureteral reflux, enteric resections, and malabsorption) may be associated with the course of the disease, an increased risk of urolithiasis in these patients should be expected.--Thomas A. Angerpointner Comparison of Hepaticoantrostomy and Hepaticojejunostomy for Biliary Reconstruction After Resection of a Choledochal Cyst. G. Schimpi, R. Aigner; E. Sorantin, et al. Pediatr Surg Int 12:271-275, (April), 1997. The authors report on 12 patients who underwent surgery for choledochal cysts. Seven underwent hepaticojejunostomy (Roux-en-Y) and five underwent hepaticoantrostomy. At follow-up (24 to 35 months after surgery), four infants who had undergone hepaticojejunostomy had recurrent cholangitis, episodes of diarrhea, and increased serum gastrin levels. Of the patients who underwent hepaticoantrostomy, none had cholangitis and their serum levels were normal. All patients who had undergone hepaticojejunostomy had normal passage of bile to the Y-loop, but emptying into the distal jejunum was delayed in all cases when scintigraphy was performed. Hepaticoantrostomy resulted in good hepatobiliary drainage in all but one case, in which a left hepatic duct stenosis developed postoperatively. The authors suggest that hepaticoantrostomy is a safe procedure with low risk for complications. However, the authors conclude that the effects of bile exposure to the mucosa of the antrum is not known and recommend long-term observation of these patients postoperatively.-T. Wester Gastroschisis: J.E. Harding, 1997.

Can the Morbidity Be Avoided? R.l: Blakelock, A. Kolbe, et al. Pediatr Surg Int 12:276-282, (April),

The authors report the results for 44 cases of gastroschisis treated between 1969 and 1995. The aim was to determine factors that influence morbidity. Two babies were excluded from the analysis: one with Beckwit-Wiedemann’s syndrome and one with small bowel atresia and massive small bowel infarction. Of the remaining 42, five died, all of whom were treated before 1978. Twenty-eight neonates were delivered vaginally, two by elective caesarean section, and 12 by emergency cesarean section. Of the survivors, 19 underwent primary repair and 18

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were treated with staged procedures. Ten were born before 37 weeks’ gestation, and 27 were full term. Gestational age did not significantly influence the morbidity. From their data the authors conclude that full-term delivery and primary closure of the gastroschisis are associated with a lessened morbidity.-? P&

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Is the Ascending Testis Actually “Stationary”? Normal Elongation of the Spermatic Cord Is Prevented by a Fibrous Remnant of the Processus Vaginalis. ZD. Clalaette and J.M. Hutson. Pediatr Surg Int 12:155-157, (February), 1997. The authors discuss “pathogenesis” of ascending testis, which probably is an acquired form of undescended testis. They note that older boys who undergo operation for ascending testis often have a fibrous remnant within the spermatic cord, which represents a closed but not obliterated processus vaginalis. It is suggested that this fibrous band prevents normal elongation of the vas and testicular vessels, which occurs with increasing age.--P Puri Undescended Testes: Early Versus Pediatr Surg Int 12:165-167, (February),

Late Maldescent. 1997.

R.B. Davey.

The author reviewed 468 orchidopexies performed in 421 patients to compare cases of persisting hernial sac and cases without a hernial sac. Cord length was measured in 313 orchidopexies. The finding of a hernial sac was age-related. Of the children under 5 years of age, 84% had a hernial sac; of those over 5 years of age, 23% had a hernial sac. Cord length increased with age (about 0.5 cm per year). A classification of undescended testis is suggested: early maldescent and late maldescent. With early maldescent, antenatal factors are supposed to cause the abnormality and a hernial sac is persistent. On the other hand, with late maldescent, only a remnant of processus vaginalis is found and prepubertal factors are proposed to be causative. Ascending testis is not believed to be caused by a short processus vaginalis.--l: Wester Gender Reversal plasia. I! Sripathi, (May), 1997.

in 46,Xx Congenital Virilizing Adrenal HyperS. Ahmed, N. Sakati, A. et al. Br .I Urol79:785-789,

Six of 51 patients seen in an S-year period with 46,xX congenital virilizing adrenal hyperplasia (CVAH) were managed as males. The decision was based largely on parental choice after counseling, but was influenced by delay in diagnosis in four patients. After gonadectomy, excision of mullerian duct structures, and staged hypospadias repair, all six boys were well adjusted to their gender of rearing (at 3 to 16.5 years of age). Two have normal penises and four a satisfactory result from genital reconstruction. Although the authors emphasize the desirability of female rearing, they conclude that gender reversal can be achieved, with satisfactory results, in highly selected situations.-M.N. de la Hunt Acute Epididymitis in Boys: Are Antibiotics Indicated? PA. Anderson, J.M. Giacomantonio, et al. Br .I Ural 79:797-800, 1997.

I? Lau, (May),

The authors review the results of treating acute sterile epididymitis without antibiotics. Fifty boys presented with acute epididymitis between 1991 and 1995. Two were excluded from the study: one because of a complex urinary tract malformation and one because of a postsurgical urethral stricture. The diagnosis was confirmed by radionuclide scan in 43 cases, ultrasonography in one, surgical exploration in one, and clinical examination alone in three. Urine was collected for microscopy and culture, and antibiotics were used only if pyuria was detected. Five boys had pyuria, and seven with either negative or no urine testing had antibiotics. The remaining 36 received supportive therapy only, with a mean follow-up of 87 days. None showed evidence of testicular atrophy or other complications. The authors conclude that epididymitis without