Biomedical subjects
Publications and source records attributed to N H Hyman.
A 40-year-old man with ganglioneuromatous polyposis and an aggressive coexisting colorectal cancer is described. Contrary to previous reports, we believe that ganglioneuromatous polyposis should be considered a premalignant condition.
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BACKGROUND: Ogilvie's syndrome, or acute colonic pseudo-obstruction, is a common and relatively dangerous condition. If left untreated, it may cause ischemic necrosis and colonic perforation, with a mortality rate as high as 50 percent. Neostigmine enhances excitatory parasympathetic activity by competing with acetylcholine for attachment to acetylcholinesterase at sites of cholinergic transmission and enhancing cholinergic action. We hypothesized that neostigmine would restore peristalsis in patients with acute colonic pseudo-obstruction. METHODS: Twenty-eight patients at Fletcher Allen Health Care and The Cleveland Clinic Foundation were treated for acute colonic pseudo-obstruction with neostigmine 2.5 mg IV over 3 minutes while being monitored with telemetry. Mechanical obstruction had been excluded. RESULTS: Complete clinical resolution of large bowel distention occurred in 26 of the 28 patients. Time to pass flatus varied from 30 seconds to 10 minutes after administration of neostigmine. No adverse effects or complications were noted. Of the two patients who did not resolve, one had a sigmoid cancer that required resection and one patient died from multiorgan failure. CONCLUSION: This study supports the theory that acute colonic pseudo-obstruction is the result of excessive parasympathetic suppression rather than sympathetic overactivity. We have shown that neostigmine is a safe and effective treatment for acute colonic pseudo-obstruction.
PURPOSE: Topical nitrates have been shown to cause nitric oxide-mediated relaxation of the internal anal sphincter. Previous reports have suggested initial efficacy in the treatment of anal fissures. The aim of this study was to assess the longer-term usefulness of this treatment. METHODS: Thirty-three patients with an anal fissure were treated with topical 0.3% nitroglycerin ointment, applied to the anoderm three times per day and after bowel movements. Patients were followed up by office visits and telephone calls until symptoms were completely resolved or treatment was noted to be ineffective or intolerable. RESULTS: Thirty-three patients were treated, 16 with acute fissures, and 17 with chronic fissures. Nitroglycerin was effective in 9 of 16 acute fissures (56%), and 7 of 17 chronic fissures (41%). Even when effective, 75% of patients reported an adverse reaction. CONCLUSIONS: Topical nitroglycerin was only effective in approximately one-half of patients with an anal fissure. There was a very high incidence of adverse reactions. In our experience nitroglycerin more often causes a headache than treats the symptoms of anal fissure.
PURPOSE: Most general surgery residents obtain scant exposure to anorectal disease during training. The aim of this study was to determine whether adding a colon and rectal surgeon to the faculty of a general surgery training program improves the amount or quality of the anorectal surgical experience. METHODS: The surgical experience of all graduating residents from our university teaching program was reviewed during a ten-year period. Complete case data were obtained from the Residency Review Committee for surgery. The total small-intestine, colon and anorectal caseload was analyzed during the five-year period preceding the arrival of the colon and rectal surgeon and compared with the subsequent five-year period after the surgeon's arrival. RESULTS: There was a substantial increase in small-intestine (470 vs. 306) and anorectal cases (462 vs. 338). There was a particularly dramatic increase in anorectal cases performed during the chief resident year (159 vs. 36), which held true for all categories of anorectal cases. CONCLUSIONS: The addition of a full-time colon and rectal surgeon to a university general surgery residency program was associated with an increase in small-intestine and especially anorectal cases. However, most striking was the greater than fourfold increase in the number of anorectal cases performed during the chief resident year. This seems to reflect an increase in complexity of anorectal cases and an increased interest in anorectal surgery among general surgery residents.
PURPOSE: Ileal pouch-anal anastomosis is widely claimed to have replaced total proctocolectomy with ileostomy as the "procedure of choice" for ulcerative colitis, largely on the basis of a perceived improved quality of life. There exists relatively little support for this assertion in the literature. Our aim was to determine if educated patients choosing total proctocolectomy with ileostomy have a similar quality of life as with ileal pouch-anal anastomosis. METHODS: All patients with ulcerative colitis referred to a single surgeon and deemed an appropriate surgical candidate were educated and then offered ileal pouch-anal anastomosis or total proctocolectomy with ileostomy. Age, gender, and complications (including pouchitis) were recorded prospectively, and all patients were questioned regarding functional outcome and level of satisfaction. They were then asked to complete a slightly modified Inflammatory Bowel Disease Questionnaire, which was analyzed by categoric and overall scores. RESULTS: Sixty-seven patients underwent elective surgery for ulcerative colitis during the study period. Fifty-five patients chose ileal pouch-anal anastomosis, and 12 had total proctocolectomy with ileostomy. The groups were similar except for younger age and longer follow-up in the ileal pouch-anal anastomosis group. Patients undergoing ileal pouch-anal anastomosis had significantly more short-term or long-term complications (49 vs. 8 percent), with pouchitis being the most frequent complication. There was no difference in level of satisfaction between the two groups, and no patient in either group wishes they had undergone the other procedure. There was no difference in the overall or any categoric Inflammatory Bowel Disease Questionnaire score. CONCLUSION: Patient satisfaction with both procedures was similarly high. Patients who undergo ileal pouch-anal anastomosis can expect a high level of satisfaction, with a good quality of life. However, educated patients choosing an ileostomy can achieve the same quality of life, without the higher complication rate associated with a pelvic pouch.
Anorectal diseases such as hemorrhoids, anal fissures, and anorectal abscesses are common in older patients. These conditions-along with and incontinence, rectal prolapse, and pruritus ani-cause considerable suffering and morbidity. The key to diagnosis remains the patient history, with confirmation by visual inspection and anoscopy. Expensive workups are usually not required. Most anorectal diseases can be easily treated in the outpatient setting with dietary changes and/or relatively minor procedures. Patients with more severe disease may require referral for surgery. Although uncommon, carcinomas do occur in the anorectal area, and lesions that cannot be identified by inspection should be biopsied.
The management of anorectal disease remains a major component in the practice of the general surgeon. To assess the adequacy of general surgery residencies in addressing this educational need, data were obtained from the Residency Review Committee (RRC) for surgery on the anorectal experience of all graduating residents in accredited United States programs for a recent five-year period (1987-1991). The mean number of anorectal procedures in which a resident participated throughout the residency was 30.0. This is then further subdivided by type of procedure. It is concluded that general surgery residency programs tend to provide an inadequate training experience in anorectal surgery.