Mortality rates after colectomy in Veterans Affairs hospitals are comparable with those reported in other large studies. Ascites, hypernatremia, do not resuscitate status before surgery, and American Society of Anesthesiologists classes III and IV OR V were strongly predictive of perioperative death. Clinical trials to decrease the complication rate after colectomy for colon cancer should focus on these risk factors.

It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Lower gastrointestinal hemorrhage is a complex clinical problem that requires disciplined and sophisticated evaluation for successful management. Diverticulosis is the most common cause. Colonoscopy is the diagnostic procedure of choice both for its accuracy in localization and its therapeutic capability. Selective mesenteric angiography should be reserved for those patients in whom colonoscopy is not practical. Precise identification of the bleeding source is crucial for a successful outcome. Specific directed therapy, such as segmental colonic resection for bleeding diverticulosis, is associated with the highest success rate and the lowest morbidity. A complete review of lower gastrointestinal bleeding is contained herein.

Ischemic colitis represents the most common form of gastrointestinal ischemia. The presumed etiologies are numerous; however, it typically develops "spontaneously," in the absence of major vasculature occlusion, and in the presence of viable intestine elsewhere. It is most usefully classified into gangrenous and nongangrenous forms, the latter of which may be subdivided into transient and chronic types. Ischemic colitis may develop in people who are otherwise healthy, although a variety of clinical settings, such as shock, predispose to its occurrence. It usually presents as an acute abdominal illness with bloody diarrhea. Diagnosis is confirmed by colonoscopy. Therapy and outcome are dependent on the severity of disease. Nongangrenous colonic ischemia usually requires only medical management and is associated with a good prognosis. The chronic subtype may lead to the sequelae of persistent segmental colitis or colonic strictures, occasionally requiring surgery. Urgent operative intervention and a high morbidity and mortality are the hallmarks of gangrenous colonic ischemia. Special considerations must be given to those patients in whom ischemic colitis develops in the context of colon carcinoma or obstructing colon lesions, after abdominal aortic surgery, and following cardiopulmonary bypass. This review will discuss the clinical spectrum of ischemic colitis.

Congenital and acquired diverticula of the jejunum and ileum in the adult are unusual and occur in approximately 1 percent to 2 percent of the population. They are pulsion diverticula thought to be the result of intestinal dyskinesia. These lesions can produce a significant diagnostic and therapeutic dilemma. They are multiple in the jejunum and solitary distally and are characteristically found in 60- or 70-year-old males. The diagnosis may be confirmed with contrast studies of the small intestine, arteriography, or nuclear scan. Consider these disorders in patients with 1) unexplained gastrointestinal bleeding, 2) unexplained intestinal obstruction, 3) an unexpected cause of acute abdomen, 4) chronic abdominal pain, 5) anemia, or 6) malabsorption. Medical therapy is helpful in controlling diarrhea and anemia, while surgical therapy is reserved for hemorrhage, obstruction, perforation, or failure of medical management. Asymptomatic diverticula discovered on routine contrast studies need not be resected. At surgery, incidental diverticula should be removed when evidence of dilated, hypertrophied loops of small bowel with large diverticula is found. Intraoperative air distention will aid in diagnosis. Resection and primary anastomosis is the preferred treatment for non-Meckelian diverticula. Diverticulectomy is reserved for a Meckel's diverticulum without evidence of ulceration. An incidental Meckel's diverticulum should be removed in the presence of mesodiverticular bands or ectopic tissue. Removal of a Meckel's diverticulum is not advised in the patient with Crohn's disease but may be performed in the patient undergoing restorative proctocolectomy for ulcerative colitis.