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Seven patients with necrotizing soft tissue infections of the perineum are described. Predisposing factors related to infection were present in four patients (diabetes mellitus, multiple myeloma, HIV, and a poorly defined immunodeficiency syndrome). Anaerobic and facultative anaerobic bacteria were cultured in each case. Two patients required skin graft closure of the debrided wounds, with the remaining wounds closed by contracture and epithelialization. A diverting sigmoid colostomy to facilitate wound care was performed on one patient who had complete dissolution of all anal sphincters. The role of hyperbaric oxygen therapy in four patients was of uncertain value.
Dis Colon Rectum 1992 Jul
PMID:Synergistic soft tissue infections of the perineum. 161 51

We identified 47 patients with nonocclusive ischemia of the large intestine over a seven-year period. The mean age at presentation was 56.2 years, with a 2:2:1 male predominance. Associated medical illnesses were diabetes (17 percent), renal failure (5 percent), and hematologic disorders (5 percent). Six patients developed ischemic colitis after aortic surgery. The mean delay in diagnosis was 1.8 days (range, three hours to 23 days). The right colon was involved in 21 patients (46 percent). Overall, 15 of 16 patients were successfully treated nonoperatively with bowel rest and antibiotics; one patient who was managed nonoperatively died. Among the 31 requiring intestinal resection, enteric continuity was reestablished in 14. Second-look laparotomy in eight patients revealed further ischemia in two (20 percent). Mortality in the operative group was 29 percent (9 of 31). No patient has developed recurrent ischemia (mean follow-up, 5.3 years). Ischemic colitis often occurs without an obvious predisposing event, may involve all segments of the large intestine, and frequently requires surgery. While its course may be self-limited, elderly and diabetic patients, as well as those developing ischemia following aortic surgery or hypotension, continue to have a poor prognosis.
Dis Colon Rectum 1992 Aug
PMID:Ischemic colitis: patterns and prognosis. 164 95

Patients on chronic hemodialysis for end-stage renal disease (ESRD) may develop anorectal problems necessitating surgery. From January 1984 to December 1987, 18 ESRD patients underwent anorectal surgery. During this period, a mean of 215 patients underwent dialysis. Patients with ESRD present with characteristic problems: chronic constipation, need for dialysis pre- and postoperatively with heparin infusion, anemia, anticoagulation secondary to the consequences of uremia, and significant medical problems including coronary artery disease, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease (COPD). Two patients had concomitant anal fissure, two had fistula-in-ano, and one had an acute perianal abscess. In two patients, the postoperative course was complicated by hemorrhage and, in one patient, by abscess formation. There was no delay in wound healing compared with a cohort group. The essentials of perioperative management are discussed with respect to timing of dialysis, methods of anesthesia and pain management, coagulation screening, and complications. Patients on well-managed chronic dialysis will tolerate anorectal surgery without undue jeopardy.
Dis Colon Rectum 1992 Jan
PMID:Is anorectal surgery on chronic dialysis patients risky? 173 84

Our aim was to analyze the predictive value of a variety of preoperative risk factors on operative outcomes. We reviewed all colorectal resections performed in a single hospital between January 1985 and May 1990. Nine hundred seventy-two resections were performed on 825 patients. We studied 17 preoperative risk factors generated from various medical risk categories. Using the multivariate discriminant function analysis, we calculated that 11 of the 17 risks were of significance in predicting outcomes (all with P less than or equal to 0.031). These factors included emergent operation, age greater than or equal to 75 years, congestive heart failure (CHF), prior abdominal or pelvic radiation therapy, corticosteroid use, albumin less than 2.7 g/dl, chronic obstructive pulmonary disease (COPD), previous myocardial infarction (MI), diabetes, cirrhosis, and renal insufficiency. The classification function generated by the discriminant analysis was used to categorize patients into one of four risk groups depending on their "risk score." The index used to develop each patient's "risk score" ranged from six points for an emergency operation to one point for diabetes. The mortality rates for the various risk groups were as follows: Group 1, zero to four points, 1 percent; Group 2, five to eight points, 10 percent; Group 3, 9 to 13 points, 19 percent; Group 4, greater than 13 points, 33 percent. In contrast to previous reports, we showed that age greater than or equal to 75 years alone is not a major preoperative risk factor but, rather, acts as a modifier for the other predictors of postoperative complications. We then assessed clinical questions concerning specific preoperative risks, such as steroid use, obesity, inflammatory bowel disease, COPD, and prior laparotomy, and their associated specific postoperative complications and have developed prevention strategies based on these findings. Through the use of the risk index, we also were able to assess an individual patient's operative risk more accurately.
Dis Colon Rectum 1992 Feb
PMID:Multifactorial index of preoperative risk factors in colon resections. 173 12

Perianal hidradenitis suppurativa, a chronic recurrent inflammatory disease of apocrine glands, adjacent anal canal skin, and soft tissues, is characteristically ignored and misdiagnosed. A retrospective analysis of 43 patients with perianal hidradenitis suppurativa was performed; 40 patients (93 percent) were male and 3 (7 percent) were female, with a median age at presentation of 29 years. Symptoms, including pain, swelling, purulent discharge, and pruritus, had been present for a median of six years. Diagnoses at the time of presentation included pilonidal disease (28 percent), anal fistula (37 percent), and perirectal abscess (16 percent). Associated medical conditions included diabetes (12 percent) and obesity (12 percent), and 70 percent of the patients were smokers. Once the correct diagnosis was established, 72 percent of patients had wide local excision with healing by secondary intention, and 28 percent of patients had incision and drainage or limited local excision. Although 67 percent of the patients had recurrence of disease after initial treatment, wide excision was more successful in preventing recurrence. Skin grafting failed uniformly, and colostomy was rarely necessary. Despite its relatively common occurrence, perianal hidradenitis suppurativa is infrequently diagnosed correctly and recurs in many patients despite appropriate surgical treatment, making the disease a source of frustration for surgeon and patient alike.
Dis Colon Rectum 1990 Sep
PMID:Perianal hidradenitis suppurativa. The Lahey Clinic experience. 239 Sep 7

This multicenter, prospective, randomized trial of short-term antimicrobial prophylaxis in colorectal surgery was designed to compare the efficacy of a single dose of cefotetan vs. multiple doses of cefoxitin. Of the 403 evaluable patients, 206 received cefoxitin (1 gm intravenously at the beginning of surgery and after 3, 6, and 12 hours, group A) and 197 cefotetan (2 gm intravenously at the beginning of surgery, group B). The two groups of patients were similar in respect to age, sex, obesity, preoperative weight loss, diabetes, type of disease, type, and mean duration of surgery. The abdominal wound infection rate was 11.2 percent in group A and 9.1 percent in group B (difference not significant). The number of patients with infections at nonsurgical sites (respiratory and urinary tract, phlebitis, and septicemia) was significantly greater in group A than in group B (17 vs. 9.1 percent, P less than .05). The mean postoperative hospital stay was similar in both the cefoxitin and cefotetan groups (15.1 vs. 15.9 days). Both regimens were inadequate in preventing infections in the presence of severe contamination of the operative field.
Dis Colon Rectum 1989 Feb
PMID:Single-dose cefotetan vs. multiple-dose cefoxitin--antimicrobial prophylaxis in colorectal surgery. Results of a prospective, multicenter, randomized study. 264 8

Although no absolute certainty exists about the role of nutrition in the etiology of cancer, many facts in favor of the relationship became available during the last decades. Correlation studies, experimental work and to a lesser extent case-control studies made it possible to clarify the role of certain nutrients and foods in carcinogenesis. The most important cancer sites where nutrition could play a role are esophagus, stomach, colon, rectum, prostate and breast. Esophageal cancer is of a very complex etiology, in which alcohol intake plays an important role, at least in western countries. The cancer-promoting properties of alcohol intake are enhanced by smoking. Three factors from nutrition are probably related to stomach cancer, namely salt, nitrate/nitrite and vitamin C. Salt is caustic to the stomach mucosa, resulting in atrophic gastritis. Salt is also co-carcinogenic and stomach cancer-promoting in experimental animals. Nitrate is probably important at the stage of atrophic gastritis, where bacterial overgrowth, due to the high pH, converts nitrates in nitrites, making the loco synthesis possible of potent nitrosocarcinogens. Vitamin C inhibits the latter step. The epidemiological evidence for the role of those factors is provided. The most important among them is the strong and consistent association of stomach cancer mortality with stroke. Rectum, colon, prostate and breast cancer are related in some way to fat intake. They all seem positively related to saturated fat intake, whereas breast cancer is probably also promoted by polyunsaturated fat intake. However, polyunsaturated fat seems to be without effect on rectum cancer. Colon and prostate cancer are probably also influenced by polyunsaturated fat but to a lesser degree than breast cancer. An important argument for this are the positive ecological correlations between changes in rectum, colon and breast cancer mortality from 1968 on, and changes occurring in coronary heart diseases, stroke and diabetes mortality. Those six types of mortality are decreasing, or only slightly increasing in the USA, Belgium, France, the Netherlands, etc. They are strongly increasing in East European countries. The intake of saturated fat has generally decreased in the first group of countries, and has markedly increased in the second group.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:Nutrition and cancer. 353 16

Nontraumatic Clostridium septicum infections may present as either septicemia or as metastatic myonecrosis. Most of these infections occur in debilitated patients with diabetes who are receiving cancer chemotherapy. The majority have a hematologic abnormality or a carcinoma of the colon. Usually there is an ulcerative lesion of the gastrointestinal tract that serves as the portal of entry. While most of these patients die from overwhelming sepsis, our patient was debrided early and treated promptly with high-dose penicillin therapy as well as hyperbaric oxygen therapy. He fully recovered from C. septicum gas gangrene and underwent resection of a recurrent colonic cancer.
Dis Colon Rectum 1983 Nov
PMID:Nontraumatic Clostridium septicum gangrenous myonecrosis. 662 41

Knowledge of the anorectum in health and in disease lags substantially behind that of other regions of the digestive tract. A paucity of fundable grant applications on anorectal research is reflected in a history of the National Institutes of Health (NIH) anorectal research support being disproportionately low. This history is of particular concern recognizing the relative national significance of anorectal diseases and disorders. The National Institute of Arthritis, Diabetes, and Digestive and Kidney Diseases (NIADDK) seeks to broaden research and research training support of: 1) anorectal diseases and disorders, 2) the basic sciences of the anorectum, and 3) the relationship of the anorectum to the more proximal gut. Applications for research and research training grants are encouraged. Potential grant applicants are encouraged to contact NIH staff for information on anorectal programs and on grant application procedures and policies.
Dis Colon Rectum 1984 May
PMID:The National Institutes of Health Grant mechanisms for anorectal and colonic biomedical research. 671 53

In a four-year period, 1,020 anorectal infections were treated. Twenty-four patients (2.3 per cent) developed massive tissue necrosis, leaving the anorectum devoid of its anatomic support unilaterally, bilaterally or circumferentially, thus resulting in a "floating or free-standing" anus. The most significant etiologic factors were diabetes and anorectal trauma. All patients had aggressive supportive therapy, appropriate use of antibiotics based on gram stains and confirmed by subsequent cultures, followed by early extensive debridement of all necrotic tissues. Colostomy was not utilized in any of the patients. There were no deaths in this series, and complete wound healing occurred in eight to 12 weeks with only one minor recurrent infection in the follow-up period that averaged 40 months.
Dis Colon Rectum 1983 Aug
PMID:Floating free-standing anus. A complication of massive anorectal infection. 687 78


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