25
There are those who argue that the liveborn rate of is the only suitable counselling Down’s and those contend that women must be prewho figure10 sented with the real incidence of aneuploidy at the time of their amniocentesis." For mothers over 40 the distinction is perhaps not critical, since the risk of Down’s syndrome is greater than 1% whichever way it is calculated. But for those under 40 the different risk figures may lead to quite different responses to the suggestion of amniocentesis and prenatal diagnosis. The complexity and incompleteness of the data make counselling of the older mother a delicate matter. A key factor which has to be taken into consideration is the rate of fetal morbidity and mortality associated with the act of amniocentesis itself. Two surveys12,13 suggest that fetal mortality is less than 1%, but if amniocentesis becomes more widespread this may prove to be a conservative estimate. Though it is perhaps unwise to equate the rates of fetal loss from amniocentesis with the rates of expected fetal abnormality, these figures are undoubtedly highly influential when prenatal diagnosis is under consideration. Perhaps some genetic counsellors have been taking too much responsibility upon themselves and the correct course of action is to advise the older mother of the unresolved discrepancies between liveborn and amniocentesis rates of Down’s syndrome, to acquaint them with the possible complications of amniocentesis itself, and to allow them to use their own judgment of which risks pose the greater threat.
syndrome
,
OPERATIONS FOR DIVERTICULAR DISEASE SINCE the dietary-fibre boom, the number of operations done for uncomplicated diverticular disease has fallen impressively. A panel at the lst World Congress of Colo-Proctology, Madrid, agreed that surgery should now be reserved for complications. In the view of Loygue, of Paris, resection is mainly indicated for severe abdominal pain, subacute obstruction, abscess or a persistent mass, the possible existence of malignant disease, and persistent uncontrolled haemorrhage. Smith of Edinburgh contrasted resection and myotomy. He stressed the importance of the smooth muscle, seeing the diverticulum as a secondary extrusion of the mucosa. Fibre and fibre-like bulk agents reduced the intraluminal pressure mainly by adding to the bulk of the faeces, part of this action being due to increased adsorption of water. Myotomy likewise lowered the pressure, and the effect was maintained for two to three years; thereafter, the pressure rose gradually and symptoms tended to recur. Resection did not lower pressure in the distal sigmoid colon and upper rectum, but complications were less frequent after this operation. After either myotomy or resection, the patient ought to take bran postoperatively to keep the pressure down. Myotomy carries a risk of dehiscence or operative puncture with resultant pelvic abscess and even death, so the panel judged that the operation should be reserved for elderly patients who are 10. 11.
Wyatt, P. R. ibid. 1978, i, 1305. Kardon, N., Krauss, M., Silverberg, G., Davis, J. ibid. p. 1305. 12. N.I.C.H.D. National Registry for Amniocentesis Study Group. J. Am. med. Ass 1976, 236, 1471. 13. Simpson, N. E., Dallaire, L., Miller, J. R., Simonovich, L., Hamerton, J. L., Miller, J., McKeen, C. Can. med. Ass. J. 1976, 115, 739.
frail for more radical surgery, to people with especially thick muscle, and to people with localised disease in the pelvic colon. In most cases the correct operation is resection, often with a "covering" colostomy. Wide resection was not advocated. It was more important to resect bowel in the pelvis than towards the splenic flexure. The operation of transverse taeniamyotomy was discussed; this procedure, developed by Hodgson and extended by Pescatori of Rome might be safer than longitudinal myotomy. Rohner of Geneva discussed operative surprises. The commonest was more extensive obstruction or more diffuse inflammation than expected. Sometimes it was hard to say whether the affected diverticular segment contained a carcinoma, though bleeding due to a tumour was usually slight compared with that due to diverticular disease. Barium enema left a 20% group of doubtful cases. Colonoscopy was difficult and could be dangerous. too
The panel then turned to more complicated forms of diverticular disease. Puig La Calle discussed the management of abscess, fistula, and obstruction. Abscess "in the making" should be treated medically; riper abscesses should be drained, with or without a colostomy. Frank fistula of the communicating type, indicated by a faecal discharge, was preferably managed by an exteriorisation operation. Extension to the bladder could be treated in one stage, but more complicated fistulas, through an abscess cavity, for example, required the three stages of preliminary defunctioning colostomy, dismantling of the fistula, and colostomy closure. The differential diagnosis from a Crohn’s fistula had always to be kept in mind, and some patients had both conditions. Obstructions tended to settle spontaneously, the usual cause being ileus due to adjacent peritonitis. If it did not settle, some other diagnosis, such as carcinoma, had to be thought of. Perforation was perhaps the severest complication and here the general treatment, particularly resuscitation, was important. Puig La Calle maintained that suture and drainage with protective colostomy, although reckoned the least severe procedure for the patient, had a higher mortality than primary resection or Hartmann’s operation.
-
Slack, of the Middlesex Hospital, London, discussed the management of haemorrhage. In the minor form there was blood in the stool, often no pain, and the source was an inflammatory ulcer in the most involved segment, mainly the sigmoid colon. In major bleedingusually copious discharge of bright-red blood-sigmoidoscopy and colonoscopy were difficult and often fruitless, since the blood obscured everything. This sort of bleeding probably came from major vessels running over the diverticulum. With replacement of blood the bleeding usually stopped; but, if it did not, subtotal colectomy was a better course than attempting a transverse colostomy to see where the blood was coming from. Angiography might be useful, possibly with embolisation of the affected blood-vessel. Whether fibre deficiency is the cause of diverticular disease remains to be seen. If it is, we may expect to see a decline in its incidence and a further drop in the number of operations required. Meanwhile, the panel were at one in declaring that conservative management should continue as long as possible.
There are those who argue that the liveborn rate of is the only suitable counselling Down’s and those contend that women must be prewho figure10 sented with the real incidence of aneuploidy at the time of their amniocentesis." For mothers over 40 the distinction is perhaps not critical, since the risk of Down’s syndrome is greater than 1% whichever way it is calculated. But for those under 40 the different risk figures may lead to quite different responses to the suggestion of amniocentesis and prenatal diagnosis. The complexity and incompleteness of the data make counselling of the older mother a delicate matter. A key factor which has to be taken into consideration is the rate of fetal morbidity and mortality associated with the act of amniocentesis itself. Two surveys12,13 suggest that fetal mortality is less than 1%, but if amniocentesis becomes more widespread this may prove to be a conservative estimate. Though it is perhaps unwise to equate the rates of fetal loss from amniocentesis with the rates of expected fetal abnormality, these figures are undoubtedly highly influential when prenatal diagnosis is under consideration. Perhaps some genetic counsellors have been taking too much responsibility upon themselves and the correct course of action is to advise the older mother of the unresolved discrepancies between liveborn and amniocentesis rates of Down’s syndrome, to acquaint them with the possible complications of amniocentesis itself, and to allow them to use their own judgment of which risks pose the greater threat.
syndrome
,
OPERATIONS FOR DIVERTICULAR DISEASE SINCE the dietary-fibre boom, the number of operations done for uncomplicated diverticular disease has fallen impressively. A panel at the lst World Congress of Colo-Proctology, Madrid, agreed that surgery should now be reserved for complications. In the view of Loygue, of Paris, resection is mainly indicated for severe abdominal pain, subacute obstruction, abscess or a persistent mass, the possible existence of malignant disease, and persistent uncontrolled haemorrhage. Smith of Edinburgh contrasted resection and myotomy. He stressed the importance of the smooth muscle, seeing the diverticulum as a secondary extrusion of the mucosa. Fibre and fibre-like bulk agents reduced the intraluminal pressure mainly by adding to the bulk of the faeces, part of this action being due to increased adsorption of water. Myotomy likewise lowered the pressure, and the effect was maintained for two to three years; thereafter, the pressure rose gradually and symptoms tended to recur. Resection did not lower pressure in the distal sigmoid colon and upper rectum, but complications were less frequent after this operation. After either myotomy or resection, the patient ought to take bran postoperatively to keep the pressure down. Myotomy carries a risk of dehiscence or operative puncture with resultant pelvic abscess and even death, so the panel judged that the operation should be reserved for elderly patients who are 10. 11.
Wyatt, P. R. ibid. 1978, i, 1305. Kardon, N., Krauss, M., Silverberg, G., Davis, J. ibid. p. 1305. 12. N.I.C.H.D. National Registry for Amniocentesis Study Group. J. Am. med. Ass 1976, 236, 1471. 13. Simpson, N. E., Dallaire, L., Miller, J. R., Simonovich, L., Hamerton, J. L., Miller, J., McKeen, C. Can. med. Ass. J. 1976, 115, 739.
frail for more radical surgery, to people with especially thick muscle, and to people with localised disease in the pelvic colon. In most cases the correct operation is resection, often with a "covering" colostomy. Wide resection was not advocated. It was more important to resect bowel in the pelvis than towards the splenic flexure. The operation of transverse taeniamyotomy was discussed; this procedure, developed by Hodgson and extended by Pescatori of Rome might be safer than longitudinal myotomy. Rohner of Geneva discussed operative surprises. The commonest was more extensive obstruction or more diffuse inflammation than expected. Sometimes it was hard to say whether the affected diverticular segment contained a carcinoma, though bleeding due to a tumour was usually slight compared with that due to diverticular disease. Barium enema left a 20% group of doubtful cases. Colonoscopy was difficult and could be dangerous. too
The panel then turned to more complicated forms of diverticular disease. Puig La Calle discussed the management of abscess, fistula, and obstruction. Abscess "in the making" should be treated medically; riper abscesses should be drained, with or without a colostomy. Frank fistula of the communicating type, indicated by a faecal discharge, was preferably managed by an exteriorisation operation. Extension to the bladder could be treated in one stage, but more complicated fistulas, through an abscess cavity, for example, required the three stages of preliminary defunctioning colostomy, dismantling of the fistula, and colostomy closure. The differential diagnosis from a Crohn’s fistula had always to be kept in mind, and some patients had both conditions. Obstructions tended to settle spontaneously, the usual cause being ileus due to adjacent peritonitis. If it did not settle, some other diagnosis, such as carcinoma, had to be thought of. Perforation was perhaps the severest complication and here the general treatment, particularly resuscitation, was important. Puig La Calle maintained that suture and drainage with protective colostomy, although reckoned the least severe procedure for the patient, had a higher mortality than primary resection or Hartmann’s operation.
-
Slack, of the Middlesex Hospital, London, discussed the management of haemorrhage. In the minor form there was blood in the stool, often no pain, and the source was an inflammatory ulcer in the most involved segment, mainly the sigmoid colon. In major bleedingusually copious discharge of bright-red blood-sigmoidoscopy and colonoscopy were difficult and often fruitless, since the blood obscured everything. This sort of bleeding probably came from major vessels running over the diverticulum. With replacement of blood the bleeding usually stopped; but, if it did not, subtotal colectomy was a better course than attempting a transverse colostomy to see where the blood was coming from. Angiography might be useful, possibly with embolisation of the affected blood-vessel. Whether fibre deficiency is the cause of diverticular disease remains to be seen. If it is, we may expect to see a decline in its incidence and a further drop in the number of operations required. Meanwhile, the panel were at one in declaring that conservative management should continue as long as possible.
