Aust N Z J Surg

Pancreatitis and primary hyperparathyroidism: forty cases.

Year 1998
Carnaille B. Oudar C. Pattou F. Combemale F. Rocha J. Proye C.
Department of General and Endocrine Surgery, University Hospital, Lille, France.
BACKGROUND: Pancreatitis is associated with primary hyperparathyroidism (PHPT) in 1.5-7% of cases. The relationship of cause and effect between the two diseases has been debated. METHODS: To evaluate this relationship, the clinical, biochemical and pathological data on 1435 patients operated on for hyperparathyroidism (HPT) over the past 30 years were retrospectively reviewed. A total of 1224 of these patients had biologically proven and cured PHPT and 211 patients had renal HPT (RHPT). The diagnosis of pancreatitis (PTS) was based on a high serum amylase level and/or abnormalities on ultrasound or computed tomography (CT) scan explorations. Only patients without biliary stones were included in the PTS group associated with HPT. RESULTS: A total of 3.2% (n = 40) of patients with PHPT had PTS, which was acute in 18 cases, subacute in 8 cases and chronic in 14 cases. This rate of PTS is higher than in a random hospital population. Surgical cure of HPT was followed by the spontaneous healing of 17/18 acute PTS, whereas six of the 22 patients with subacute or chronic PTS developed complications due to the evolution of their disease (diabetes, pancreatic duct stenosis treated by surgery). A single diseased gland was found in 27 patients with PTS, which is in favour of primary parathyroid disease, being responsible for, and not a consequence of, PTS. Only the serum calcium (13.0 vs 12.1 g/dL) level was significantly increased in PHPT patients with PTS, when compared to those without PTS. The calcium level is probably of major importance in the development of PTS, which was never encountered in 211 patients with RHPT, who had low calcium and high PTH levels. CONCLUSIONS: The data suggest that (i) the PTS-PHPT association is not incidental; (ii) PTS is the consequence and not the cause of PHPT; (iii) hypercalcaemia seems to be a major factor in the development of PTS in PHPT patients; and (iv) cure of PHPT leads to the healing of acute PTS, whereas it does not affect the evolution of subacute and chronic PTS.

Early feeding after elective open colorectal resections: a prospective randomized trial.

Year 1998
Stewart BT. Woods RJ. Collopy BT. Fink RJ. Mackay JR. Keck JO.
Department of Colorectal Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia.
BACKGROUND: A period of starvation after colorectal resections to allow for resolution of the clinical evidence of ileus has been an unchallenged surgical doctrine until recent times. A prospective randomized trial comparing early feeding to traditional management in patients undergoing open elective colorectal resections is reported. METHODS: Patients undergoing elective intraperitoneal colorectal resections without stoma formation were randomized to either an early feeding or control group. The early feeding group were allowed free fluids from 4 h postoperatively progressing to a solid diet from the first postoperative day as they tolerated it. The control group remained nil orally until passage of flatus or bowel motion and were then commenced on fluids progressing to solids over 24-48 h. RESULTS: There were 40 patients in each group well matched for age, sex, type and duration of operation, method of analgesia and mobilization. Thirty-two patients (80%) in the early feeding group tolerated a diet within 48 h. There was no significant difference in the rate of vomiting, nasogastric reinsertion or complications. The early feeding group tolerated a diet, passed flatus, used their bowels, and were discharged from hospital significantly earlier than the control group. CONCLUSION: Early feeding after elective open colorectal resections is successfully tolerated by the majority of patients, leading to earlier resolution of ileus and hospital discharge.

Acute colonic pseudo-obstruction.

Year 1998
Alwan MH. van Rij AM.
Department of Surgery, Medical School, Otago University, Dunedin, New Zealand.
BACKGROUND: Acute colonic pseudo-obstruction is an acute non-mechanical colonic obstruction. Twenty patients with this condition presenting between 1988 and 1996 were retrospectively reviewed to identify the incidence and potential aetiologic factors, and to establish a uniform therapeutic approach. METHODS: Patients who fulfilled the criteria of acute pseudo-obstruction of the colon were reviewed retrospectively from a computerized database, and from a study of the hospital notes. RESULTS: There were 12 men and eight women with a median age of 71 years. Seventeen patients (85%) had various coexisting medical conditions, and none of the cases had a recent surgical operation or trauma. Four patients had previous similar attacks. Patients had a median duration of symptoms and a hospital stay of 3 and 7 days, respectively. Diagnosis was based on the clinical features coupled with the findings on plain abdominal X-rays and contrast enema. Sixteen patients were successfully treated conservatively over a median time of 5 days. Three patients had a laparotomy: two patients had tube caecostomy (followed by complications), and one patient had no further treatment. One patient had colonoscopy with an unsatisfactory result. Two patients (10%) died and three (15%) developed complications. CONCLUSIONS: Acute colonic pseudo-obstruction is an uncommon but serious condition. The majority of our patients (17/20) had associated significant medical problems. Most of the patients were successfully managed conservatively. This was the preferred initial line of treatment in this department during the study period.

Management of colonic lipomas.

Year 1998
Chung YF. Ho YH. Nyam DC. Leong AF. Seow-Choen F.
Department of Colorectal Surgery, Singapore General Hospital, Singapore.
BACKGROUND: Little is known of colonic lipomas, especially in an Asian population, and their management is controversial. METHODS: A computerized colonoscopy database was analysed and patients with colonic lipomas were reviewed. RESULTS: There were 16 colonic lipomas (incidence of 0.15%) in a series of 10658 consecutive colonoscopies. There were seven men and nine women, with a mean age of 61.8 years (range: 28-80 years). The size of the lipomas ranged from 1.5 to 6 cm; all those larger than 3.5 cm were symptomatic (P = 0.05). The most common symptom was mild bleeding per rectum. Right-sided lipomas were palpable while left-sided lipomas presented with obstructive symptoms. Colonoscopic removal by hot biopsy or snare polypectomy was possible where the lipomas were 2.5 cm and pedunculated. Surgery was performed in six patients (four open, two laparoscopic) for symptoms and to exclude malignancy. There was no morbidity or mortality. CONCLUSIONS: Small or pedunculated lipomas may be safely removed colonoscopically and the diagnosis confirmed histologically. Larger lipomas require surgical resection for relief of symptoms or to exclude malignancy.

Rectal cancer following colectomy and ileorectal anastomosis for familial adenomatous polyposis.

Year 1998
Jenner DC. Levitt S.
Sir Charles Gairdner Hospital, Nedlands, Western Australia. www.brucej@pdo.net.au
BACKGROUND: Familial adenomatous polyposis (FAP) has historically been treated by colectomy and ileorectal anastomosis (IRA). Preservation of the rectum allows the subsequent development of cancer in the rectum. The risk of rectal cancer following ileorectal anastomosis in the Australian population has not been published to date. METHODS: An audit of the Familial Adenomatous Polyposis Registry of Western Australia was undertaken to assess patients who had undergone colectomy and ileorectal anastomosis. Fifty-five patients ranging in age from 13 to 65 years were studied. RESULTS: Seven patients (13%) developed cancer of the rectum with a median follow-up of 10 years (range: 1-31 years). Median interval to diagnosis of carcinoma of the rectum following colectomy and IRA was 10 years. All patients who developed cancer in the retained rectum had rectal polyps. Colon cancer was present in the initial colectomy specimen in 13 patients (of these, five patients developed rectal cancer). Flat polyps were noted in five patients. Four patients with flat polyps developed cancer of the rectum. CONCLUSIONS: Total colectomy and IRA should be considered as part 1 of a staged procedure in the patient with FAP. With the exception of the patient with no evidence of rectal polyps, completion proctectomy should be undertaken within 10 years of the initial colectomy.

Multiple laparotomies for severe intra-abdominal infection.

Year 1998
Jiffry BA. Sebastian MW. Amin T. Isbister WH.
Department of Surgery, King Faisal Specialist Hospital and Research Centre, Riyadh, Kingdom of Saudi Arabia.
BACKGROUND: Mortality rates for patients with severe peritoneal infection are high. The present study was undertaken in order to examine mortality rates in patients with severe peritoneal infection who were managed by planned re-laparotomy. METHODS: Retrospective analysis of patients presenting at the King Faisal Specialist Hospital and Research Centre between 1992 and 1994 with severe peritoneal infection was undertaken. RESULTS: A total of 52 patients underwent either single (n = 30) or multiple (n = 22) peritoneal lavage, and Acute Physiology and Chronic Health Evaluation (APACHE II) scores and predicted mortality rates were calculated for these patients. The predicted mortality rate for patients undergoing a single washout was 42.4%, actual mortality: 23%. The predicted mortality for patients undergoing multiple washouts was 55.6%, actual mortality: 36.3%. No patient with a predicted mortality of < 30% who underwent multiple washouts died. Of nine patients with a predicted mortality between 31 and 60%, one died (11.1%). For a predicted mortality of 61-80%, five of six patients died (83.3%), and for patients with a predicted mortality of > 80%, two of three died (66.7%). CONCLUSIONS: The utilization of planned re-look laparotomy and peritoneal lavage in patients with severe peritonitis may result in a significant decrease in mortality as predicted by APACHE II scoring.

Unplanned return to the operating room.

Year 1998
Isbister WH.
University Department of Surgery, Wellington, New Zealand. isbister@kfshrc.edu.sa
BACKGROUND: Unplanned return to the operating room (OR) has been suggested as one of the indicators that could be used to assess the quality of surgery in a hospital setting. The present study was undertaken in order to try to identify those factors that were important in determining the need for the return to the OR in patients undergoing a series of colorectal surgical procedures. METHODS: All patients who returned to the OR following an index colorectal procedure during a 15-year period on a colorectal service, were identified from the unit's database. The site of original disease, presentation, type of surgery performed, reason for re-operation and post-surgical morbidity and mortality were examined. RESULTS: Overall there were 2011 colorectal surgical admissions, and of these 19 males (61.2 years) and 18 females (67.4 years) underwent an unplanned return to the OR. In 34 patients the index operation was performed by a consultant surgeon. A total of 46% of index operations were performed in an emergency setting. The majority of patients had colorectal cancer. Most lesions were situated in the sigmoid colon or rectum. Postoperative adhesive obstruction was the commonest reason for return to the OR. No patient re-obstructed following re-operation. Overall eight wounds dehisced and five patients suffered anastomotic leakage. Intra-abdominal sepsis was found in 12 patients. Twenty-one patients developed urinary tract infections. Twenty-eight patients were discharged well, two patients were discharged dying with advanced malignancy and there were seven postoperative deaths (18.9%). CONCLUSIONS: Unplanned return to the OR is a function of both the patient's presenting problem and the surgical skill and judgement of the surgeon. It is thus in part determined by the patient casemix in a unit, service or institution.

Gastric cancer in Asia: progress and controversies in surgical management.

Year 1998
Branicki FJ. Chu KM.
Department of Surgery, University of Hong Kong, Queen Mary Hospital, Hong Kong. branicki@hkucc.hku.hk
Considerable controversy surrounds the management of gastric cancer and this has largely overshadowed recent progress in our understanding of the epidemiology and molecular pathogenesis of the disease, and improvements in diagnostic and staging techniques. Differences identifiable in the molecular pathogenesis of the 'intestinal' and 'diffuse' types of gastric cancer may help to unravel the biological behaviour of variants and ultimately influence therapeutic strategies. Endoscopic ultrasound is well established as being accurate for T staging and the introduction of laparoscopy, with or without ultrasound, is obviating unnecessary laparotomy in non-bleeding, non-obstructed patients. Controversies in surgery encompass the role of laparoscopic surgery in early gastric cancer, the extent of lymphadenectomy including para-aortic nodal dissection, resection of en bloc contiguous organ involvement, pancreatosplenectomy, left upper abdominal evisceration, and modes of reconstruction (pylorus-preserving gastrectomy, pouch formation) to enhance quality of life. Whereas adjuvant chemotherapy does not impact favourably on survival, emphasis has now shifted to neoadjuvant (induction) chemotherapy to downstage the disease. Preoperative regional chemotherapy and intra-operative hyperthermic chemotherapy or irradiation may prove to be of benefit in patients with resectable disease, but some scepticism still exists as to the usefulness of biological response modifiers (e.g. OK432, PSK) for adjuvant treatment. Ethical issues relating to cultural differences in Asia sometimes mitigate against adequate trial design (e.g. a surgery-alone control group or a no adjuvant therapy treatment group may be considered inappropriate) and this has understandably hindered acceptance in Western countries of the value of current management practices in Asia. These issues and the need for ongoing well-conducted randomized trials with prospective subset analysis are now being addressed.

Nm23 gene expression in gastric carcinoma: an immunohistochemical study.

Year 1998
Yeung P. Lee CS. Marr P. Sarris M. Fenton-Lee D.
Department of Surgery, Sutherland Hospital, Caringbah, New South Wales, Australia.
BACKGROUND: The gene Nm23 is thought to play a role in the suppression of tumour metastasis. Reduced expression of Nm23 is seen in a number of human cancers, and is associated with increased metastasis and reduced survival, most strongly in ductal breast and colorectal carcinomas. METHODS: Nm23 gene expression was compared in gastric carcinoma and normal gastric mucosa. Twenty-three gastric carcinomas were graded for differentiation as either well, moderately or poorly differentiated. Metastatic deposits from seven of the cases were also examined, along with 10 samples of normal gastric mucosa. Specimens were incubated with a murine monoclonal antibody against the protein product of Nm23, and examined by immunohistochemical staining. A semiquantitative immunostaining index was used. RESULTS: All normal mucosa showed moderate to strong staining; 8 of 15 poorly differentiated carcinomas showed absent or weak staining; 1 of 6 moderately differentiated carcinomas stained weakly. Both well-differentiated carcinomas stained strongly; 1 of 7 metastatic deposits stained weakly. The difference in Nm23 expression between normal mucosa and carcinomas was statistically significant (P=0.024). However, there was no statistically significant difference between the three grades of carcinomas (P=0.51), or between primary and metastatic tumour (P=0.25, all by Chi-squared test). CONCLUSIONS: These results suggest that Nm23 may have a role in gastric carcinoma pathogenesis, but do not show a correlation with metastasis. A larger study, involving detailed clinical staging and follow-up, may be of benefit.

Staging of oesophageal carcinoma by endoscopic ultrasound: preliminary experience.

Year 1998
Pham T. Roach E. Falk GL. Chu J. Ngu MC. Jones DB.
Gastrointestinal Ultrasound Research Unit, Concord Repatriation General Hospital, Sydney, Australia.
BACKGROUND: Endoscopic ultrasound (EUS) is a relatively recent imaging modality that is capable of visualizing oesophageal tissue layers and para-oesophageal structures. Current pre-operative staging of oesophageal cancer is less than satisfactory, and a modality which may improve pre-operative staging, thus allowing a more rational approach to choice of treatment, may be a welcome addition to current techniques. The purpose of the present study was to evaluate the accuracy of EUS in the staging of oesophageal carcinoma in a consecutive cohort of patients. METHODS: Forty-three patients with oesophageal cancer were prospectively staged with EUS using the radial scanning Olympus EUM-3 echo-endoscope. In the 28 patients who underwent surgery EUS staging was correlated with operative and histological findings to evaluate the EUS accuracy rate of assessing tumour depth (T stage), and the presence of nodal involvement (N stage) using internationally accepted TNM staging criteria. RESULTS: Endoscopic ultrasound accuracy rates for overall T-staging was 61% whereas that of N-staging was 75%. The overall TNM pathological staging was 75% accurate by EUS. CONCLUSIONS: Compared to published literature figures for oesophageal staging by computed tomography scanning (39-54%) these results demonstrate that EUS has a reasonable accuracy rate for staging. Endoscopic ultrasound may prove to be a useful additional modality in the management of oesophageal cancer.

Laparoscopic underrunning of bleeding duodenal ulceration: a minimalist approach to therapy.

Year 1998
Martin I. O'Rourke N. Bailey I. Branicki F. Nathanson L. Fielding G.
Department of Surgery, Royal Brisbane Hospital, Queensland, Australia.
Surgical management of bleeding duodenal ulcer has traditionally included a procedure to reduce gastric acid production to enable ulcer healing and reduce the likelihood of rebleeding. The availability of intravenous proton pump inhibitors in the peri-operative period may promote rapid ulcer healing and as a component of anti-Helicobacter eradication therapy greatly reduces the incidence of ulcer recurrence. Using this approach, six patients with actively bleeding duodenal ulcer underwent laparoscopic duodenotomy and attempted suturing of the bleeding site. One patient required conversion to open surgery and subsequently re-bled at 60 h, necessitating a partial (Billroth II) gastrectomy. In the remaining five patients suture control of bleeding and luminal closure were completed laparoscopically without complications. Laparoscopic repair of acutely bleeding duodenal ulcers is technically feasible and had a low complication rate in this small series.

Routine cholecystocholangiography: a viable alternative during laparoscopic cholecystectomy.

Year 1998
Young C. Moont M.
Liverpool Hospital, New South Wales, Australia.
BACKGROUND: The advantages of cholangiography during laparoscopic cholecystectomy (LC), including identification of biliary anatomy and biliary calculi, are well known. The usefulness of cholecystocholangiography (CCC), by direct injection through the gall-bladder, compared to the more popular cystic duct cholangiography (CDC), however, is not so well known. METHODS: Two hundred consecutive patients who underwent LC were included in a prospective study of routine CCC. Between 5 and 60 mL of contrast is injected through the gall-bladder fundus, using image intensifier control. RESULTS: Cholecystocholangiography was attempted in 194 cases and was successful in 157 (80.9%). Twenty-one of the 37 cases with a failed CCC proceeded to have a successful CDC, giving an overall cholangiography success rate of 91.8%. The presence of acute inflammation decreased the success rate. Eleven (6%) true positive cases of common bile duct (CBD) calculi were demonstrated (nine on CCC and two on CDC after failed CCC). There was one case of false positive CBD calculus and no false negatives. CONCLUSIONS: We have found that the routine use of CCC during LC is safe, successful, quick to perform, and does not prevent conversion to attempted CDC in the cases where it fails. Cholecystocholangiography may have advantages over CDC and be an alternative as the preferred imaging technique.

Laparoscopic colectomy for cancer: a review.

Year 1998
Luck A. Hensman C. Hewett P.
Division of Surgery, Queen Elizabeth Hospital, Woodville South, South Australia, Australia.
BACKGROUND: The success of laparoscopic cholecystectomy in providing patient benefits in the immediate postoperative period has led to laparoscopic techniques being used for many other intra-abdominal procedures. Colorectal resection for malignancy is one of the more contentious applications of this new technology, because the postoperative benefits are more subtle and the long-term onco logical results are as yet unknown. METHODS: A review of the English-language literature was undertaken in order to collate and analyse all published series where 20 or more laparoscopic colectomies were performed. and where the indication for resection in the majority of cases was adenocarcinoma of the colon. RESULTS: Laparoscopic colectomy for cancer can be performed safely by experienced surgeons, although there is a considerable learning curve for the procedure. The expected benefits of minimal access surgery are provided by laparoscopic colectomy, although to a lesser extent than that seen with other procedures. The oncological safety of the procedure is as yet unproven. It is clear that an equivalent resection can be performed, but not whether this translates to an equivalent recurrence and survival rate. Reports of isolated port site recurrences are of concern. CONCLUSIONS: Early results of laparoscopic colectomy for cancer are encouraging, although the fate of this procedure rests with the analysis of the large multicentre prospective randomized trials currently under way, particularly with regard to the long-term recurrence and survival rates.

Community (mis)understanding of colorectal cancer treatment.

Year 1998
Thomas RJ. Clarke VA.
Department of Surgery, University of Melbourne, Victoria, Australia.
BACKGROUND: A study was undertaken to assess community understanding of colorectal cancer symptoms and colorectal cancer treatment. METHODS: A computer-assisted telephone survey was undertaken to interview 1000 men and women aged 40-60 years. RESULTS: Overall there was a considerable lack of information in the community about colorectal cancer symptoms and treatment. Men were less knowledgeable than women, and 28% of men were unable to name any symptoms of bowel cancer. Although surgery was mentioned by 53% of the sample, a third could not name any treatments. Most responses to questions about the effects of treatment related to chemotherapy-related disturbances and the possibility of having a colostomy bag postoperatively. CONCLUSIONS: There is inaccurate information in the community about colorectal cancer symptoms and treatment. This may inhibit involvement in screening programmes or delay presentation for therapy, as a result of undue concern about the prospects of treatment.

Diagnostic failure in colonoscopies for malignant disease.

Year 1998
Miller BJ. Cohen JR. Theile DE. Schache DJ. Ku JK.
Colorectal Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia. b.miller@mailbox.uq.edu.au
BACKGROUND: While colonoscopy has become established as more accurate than double contrast barium enema for detecting colonic polyps and cancers, as well as offering the opportunity for therapy, there are occasional instances where colonoscopy is misleading. The present study is to determine what problems occur, with a view to finding a solution. METHODS: The records of the Colorectal Project at the Princess Alexandra Hospital indicate retrospectively that 346 patients have been correctly diagnosed with cancer of the colon and rectum by colonoscopy in the 5 years up to October 1996. During the same time eight patients (2.3%) were recorded at the same hospital as being misdiagnosed by colonoscopy, the lesion being either missed completely or misplaced. RESULTS: In five of these patients there was failure to recognize that the whole colon had not been examined endoscopically, thereby missing a more proximal lesion. In two patients the lesion was missed although the entire colon was examined. In one patient the lesion was discovered but inaccurately sited. Six of these mistakes would have been obviated by the routine use of fluoroscopy to confirm the totality of the colonoscopy and to site any lesions found. The other two cases occurred because of failure to remember that colonic examination during withdrawal should be performed meticulously back as far as the anal canal. Failure to diagnose a colon cancer on the initial colonoscopy led to an average delay of 6 months for definitive care. CONCLUSIONS: It is recommended that fluoroscopy be used routinely during colonoscopy to site accurately any lesions found, and to confirm the completeness of insertion if reliable landmarks, including terminal ileum, are not clearly identified.

Randomized controlled trial comparing same-day discharge with hospital stay following haemorrhoidectomy.

Year 1998
Ho YH. Lee J. Salleh I. Leong A. Eu KW. Seow-Choen F.
Department of Colorectal Surgery, Singapore General Hospital. HoYH@sgh.gov.sg
BACKGROUND: A randomized controlled trial was conducted to compare traditional hospital stay haemorrhoidectomy (STAY) with same-day discharge haemorrhoidectomy (DAY) with regard to costs, clinical outcome and patient satisfaction. METHODS: A total of 54 consecutive patients were randomized to either STAY or DAY groups. A standardized excision of three piles was performed and the wounds were left open. The DAY patients went home on the same day but the STAY patients remained in hospital until their bowels had opened. A linear analogue pain score and patient satisfaction questionnaire were administered. During a mean follow-up of 60.5 (standard error of mean = 1.2) weeks, the complications and the total medical costs were recorded RESULTS: There were no differences in the age and sex distributions in both groups (STAY: 11 men, 16 women; mean age 40.6 (+/- 1.8) years; DAY: 10 men, 17 women; mean age 40.6 (+/- 1.9) years). Despite accounting for any readmissions, the DAY patients accumulated shorter total hospitalization stays (P < 0.001) and incurred less total medical costs (P = 0.04). The pain scores, analgesia requirements, postoperative complications, patient satisfaction and time taken off work were not different between the two groups. However, more patients in both groups preferred to stay after surgery if they should need another haemorrhoidectomy. CONCLUSIONS: Haemorrhoidectomy (with excision of three piles) can be safely performed as a day procedure, with reduced hospitalization and medical costs.

Appendicitis in HIV-positive patients.

Year 1998
Bova R. Meagher A.
Department of Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia.
BACKGROUND: The aim of the present study was to review the experience of appendicitis in human immunodeficiency virus (HIV)-positive patients. METHODS: A retrospective analysis of all HIV-positive patients operated on for suspected acute appendicitis during a 10-year period at St Vincent's Hospital was performed. These patients were compared to a group of 60 age- and sex-matched patients with no HIV risk factors who were operated on during the same time period. RESULTS: On presentation the clinical findings were similar in both groups, with two notable exceptions. No HIV-positive patient had an elevated white cell count. The present study demonstrated a significant delay in presentation of the HIV-positive group to the Emergency Department, possibly explaining the higher appendiceal perforation rate in this group. There were no cases of HIV-related diseases mimicking acute appendicitis. There was no mortality, and morbidity was higher in the seropositive group. CONCLUSIONS: HIV-positive patients with a history suggestive of acute appendicitis should not be treated differently from the normal population. Morbidity and mortality can be minimized by prompt surgical treatment.

Peritonitis following percutaneous gastrostomy in children: management guidelines.

Year 1998
Kimber CP. Khattak IU. Kiely EM. Spitz L.
Institute of Child Health and Great Ormond Street Hospital for Children, London, United Kingdom.
BACKGROUND: To establish the incidence, timing and outcome of peritonitis following percutaneous gastrostomy (PEG) insertion in children. METHODS: Patients developing peritonitis after PEG insertion during a 5-year period (1990-95) were identified. Variables analysed included clinical presentation, management, operative findings and outcome. RESULTS: One hundred and twenty paediatric patients received 130 PEG in the 5-year period. Eight children developed peritonitis: 4 within 24 h of PEG insertion and 4 following routine PEG tube change (3-18 months later). All four patients developing early peritonitis underwent laparotomy in whom three had sustained major damage to adjacent viscera. The fourth patient had a negative laparotomy, but died from continued overwhelming sepsis. All four patients who developed peritonitis after a routine tube change underwent a tube contrast study. In two children a gastrocolic fistula was identified and surgically repaired. Contrast studies in two patients detected an intraperitoneal leak. This problem resolved with conservative management in both cases. CONCLUSIONS: Peritonitis immediately following PEG insertion is rarely due to the air leakage during insertion (benign pneumoperitoneum) and warrants early laparotomy to identify and correct the likely associated visceral trauma. Following PEG tube change peritonitis may result from stomal separation or tube malposition and an urgent study is indicated to identify the cause.

Peristalsis in an interposed colonic segment immediately following total oesophagogastrectomy.

Year 1998
Myers JC. Mathew G. Watson DI. Jamieson GG.
University Department of Surgery, Royal Adelaide Hospital, South Australia, Australia. jmyers@medicine.adelaide.edu.au
BACKGROUND: The motility pattern of colon used for oesophageal replacement in an oesophagogastrectomy is thought to be altered following interposition. Whether this is the result of adaptation or the removal of motor control mechanisms is unknown. Motility patterns of the interposed colon during the immediate postoperative period have not been previously studied. METHODS: A patient who had an oesophageal adenocarcinoma and an unhealed gastric ulcer, underwent total gastrectomy and oesophagectomy. A colonic segment oriented isoperistaltically was used for oesophageal replacement. During the surgery, a customized 10 channel motility catheter was introduced transnasally into the colonic segment, and 24 h after surgery measurement of motor activity was undertaken using a perfused manometric system. RESULTS: Peristaltic contractions were observed with a mean contraction amplitude of 39.6 mmHg in the proximal channel, 90.3 mmHg in the distal channel and a mean propagation velocity of 0.51 cm/s. CONCLUSIONS: Peristaltic colonic contractions continue to occur in the early postoperative period in the colonic segment used to replace the oesophagus. In view of this, colon replacing the oesophagus should always be arranged in an isoperistaltic fashion.