Ileal pouch-anal anastomosis in patients with colorectal cancer: long-term functional and oncologic outcomes.
Radice E. Nelson H. Devine RM. Dozois RR. Nivatvongs S. Pemberton JH. Wolff BG. Fozard BJ. Ilstrup D.
Mayo Clinic and Mayo Foundation, Division of Colon and Rectal Surgery, Rochester, Minnesota 55905, USA.
When colorectal cancer complicates chronic ulcerative colitis or familial adenomatous polyposis, the role of ileal pouch-anal anastomosis is uncertain because of concerns that the procedure may compromise oncologic therapy and that oncologic therapy may compromise ileal pouch-anal anastomosis function. AIM: This study was undertaken to investigate the impact both of ileal pouch-anal anastomosis on cancer outcomes and of cancer treatments on ileal pouch-anal anastomosis function. PATIENTS AND METHODS: Of 1,616 patients undergoing ileal pouch-anal anastomosis for chronic ulcerative colitis or familial adenomatous polyposis (1981-1994), 77 patients were identified with adenocarcinoma of the colon (56), rectum (17), or both (4). Data were obtained from an ileal pouch-anal anastomosis registry, case notes, and postal and telephone surveys. RESULTS: Mean age of the 77 index patients was 37 (range, 13-60) years. Stage distribution was as follows: Stage 0, 9; Stage I, 31; Stage II, 15; Stage III, 22 patients. Twelve patients died with systemic disease (6 with a local component) after a mean follow-up of 6 (range, 2-15) years. Twenty-two patients received adjuvant therapy (chemotherapy, 16; radiotherapy, 2; both, 4 patients). Chemotherapy complications requiring dose reduction or interruption occurred in three (15 percent) patients. One patient developed radiation enteritis (17 percent). Pouch failure occurred in 16 percent of cancer patients, compared with 7 percent for the overall registry. There were no differences between cancer and non-cancer groups in operative complications, median stool frequency, incontinence, pad usage, or pouchitis. CONCLUSIONS: Although pouch failure is more common, ileal pouch-anal anastomosis can be performed in the setting of colorectal cancer without significant impact on oncologic outcome or long-term ileal pouch-anal anastomosis function.
Intraoperative colonic lavage in emergency surgical treatment of left-sided colonic obstruction.
Forloni B. Reduzzi R. Paludetti A. Colpani L. Cavallari G. Frosali D.
2nd Department of Surgery, Treviglio Hospital, Italy.
PURPOSE: The study contained herein was undertaken to verify if immediate resection with anastomosis with on-site lavage in emergency treatment of left colon obstruction is a safe alternative to the multistage procedure, to look for solutions to practical problems outlined by previous authors, and to check the hospital stay. METHOD: Between 1991 and 1995, all patients (61) admitted with left colon obstruction were treated with intraoperative colonic lavage and primary anastomosis. Personal development of Dudley's technique is reported. Complications and mortality are pointed out. Later, endoscopy was performed to check the status of all survivors. RESULT: Low mortality (2 percent) and major complication rates (3 percent) and short hospital stay (11 days, except for patients with major complications) are reported in our series. CONCLUSION: One-stage surgery with intraoperative lavage is a safe procedure. Patients have a better quality of life (no stoma occurred) with an effective cost-savings.
One-stage resection and anastomosis for acute obstruction of the left colon.
Department of Surgery, Mackay Memorial Hospital, and Taipei Medical College, Taiwan.
PURPOSE: The purpose of this study was to analyze a single surgeon's experience with one-stage resection with primary anastomosis in acute obstruction of the left colon, emphasizing intraoperative decompression before the anastomosis. METHOD: From January 1986 to September 1996, 91 patients received one-stage resection with primary anastomosis for acute obstruction of the left colon. Eighty-five of these 91 patients were operated on for carcinoma of the colon and rectum. Subtotal colectomies were performed in 20 patients, left hemicolectomies in 21 patients, sigmoid colectomies in 34 patients, and anterior resections in 16 patients. The preoperative serum albumin level was less than 3 gm/dl in 17 patients (less than 2.5 gm/dl in 10 patients). Four patients had associated abscesses, and one patient had colonic perforation with peritonitis before operative colonoscopy. Neither antegrade nor retrograde irrigation was performed. RESULTS: Operative mortality rate was 2.2 percent. There were two cases (2.2 percent) of anastomotic leakages. Other common complications included wound infection (11 cases), urinary tract infection (5 cases), intestinal obstruction (6 cases), and respiratory failure (3 cases). CONCLUSION: This experience suggests that an anastomosis can be performed more safely in patients with acute obstruction of the left colon than in those with an anastomosis in the nondiverted colon. Neither intraoperative irrigation nor routine subtotal colectomy was found to be necessary. Anastomosis below the peritoneal reflection is also not a contraindication.
High incidence of inflammatory bowel disease in The Netherlands: results of a prospective study. The South Limburg IBD Study Group.
Russel MG. Dorant E. Volovics A. Brummer RJ. Pop P. Muris JW. Bos LP. Limonard CB. Stockbrugger RW.
Department of Gastroenterology, University Hospital Maastricht, The Netherlands.
PURPOSE: To gain recent epidemiologic information about inflammatory bowel disease in The Netherlands, a prospective study over four years (1991-1995) was performed. METHODS: The incidence of inflammatory bowel disease and its subgroups was examined using standardized reports of newly diagnosed patients. A separate study compared the Inflammatory Bowel Disease Registration and computerized diagnostic files of a subgroup of general practitioners with the aim of estimating completeness of case ascertainment. RESULTS: The following mean incidence rates (per 100,000 inhabitants and year) were found: 6.9 (95 percent confidence interval, 5.9-7.9) for Crohn's disease, 10 (95 percent confidence interval, 8.7-11.2) for ulcerative colitis (23 percent of these with ulcerative proctitis), and 1.1 (95 percent confidence interval, 0.7-1.5) for indeterminate colitis. In the age category 20 to 29 years, the incidence rate of Crohn's disease with small-bowel involvement was higher in females than in males. In extended ulcerative colitis, a male preponderance was observed in the older age groups. Estimated case ascertainment was 78 percent. CONCLUSIONS: Compared with recent studies in neighboring countries, the observed age and gender standardized incidence rates are high in the south of The Netherlands. Completeness of case ascertainment might have contributed to this observation; however, case ascertainment was low in ulcerative proctitis. In the study area, differences in age and gender standardized incidence rates and in disease localizations could be compatible with an influence of environmental risk factors.
Is ileal pouch-anal anastomosis really the procedure of choice for patients with ulcerative colitis?
Jimmo B. Hyman NH.
Department of Surgery, University of Vermont College of Medicine, Burlington, USA.
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.
Laparoscopic-assisted resection-rectopexy for rectal prolapse: early and medium follow-up.
Stevenson AR. Stitz RW. Lumley JW.
Department of Surgery, Royal Brisbane Hospital, Australia.
PURPOSE: Objectives of this study were to describe the technique of laparoscopic-assisted resection rectopexy and audit the clinical outcomes, including review of functional results. METHODS: Data were prospectively collected for duration of operation, time to passage of flatus and feces postoperatively, hospital stay, morbidity, and mortality. Follow-up was performed by an independent assessor using a standardized questionnaire. Patients were also assessed by clinical review or telephone interview. RESULTS: During a four-year period, 34 patients underwent laparoscopic repair for rectal prolapse, of which 30 patients underwent laparoscopic-assisted resection rectopexy. Median duration of the operations was 185 minutes, median time for passage of flatus was two days postoperatively, and median length of hospital stay was five days. Morbidity was 13 percent and mortality rate was 3 percent. Comparison between the first ten patients who underwent laparoscopic-assisted resection rectopexy and the last ten revealed a significant reduction in both median duration of operating time (224 vs. 163 minutes; P < 0.005) and length of stay (6 vs. 4 days; P < 0.015). Follow-up study conducted at a median time of 18 months revealed that most patients (92 percent) felt that the operation had improved their symptoms, that incontinence was improved in 14 of 20 patients with impaired continence (70 percent), and that constipation was improved in 64 percent. Symptoms of incomplete emptying and the need to strain at stool were both improved in 62 and 59 percent of patients, respectively. No full-thickness recurrences have occurred, but two patients have had mucosal prolapse detected (7 percent) and treated. CONCLUSION: Laparoscopic-assisted resection rectopexy is feasible and safe, with acceptable recurrence rates and functional results compared with the open procedure in the surgical literature. There is rapid return of intestinal function associated with an early discharge from hospital.
Prognostic significance of extranodal microscopic foci discontinuous with primary lesion in rectal cancer.
Ueno H. Mochizuki H. Tamakuma S.
First Department of Surgery, National Defense Medical College, Saitama, Japan.
PURPOSE: The most common recurrence after curative resection of rectal carcinoma originates from tiny, undetectable residual foci within the pelvic cavity. The significance and methods used to predict the presence of extramural and extranodal microscopic cancer foci discontinuous with the main lesion of rectal cancers were investigated. METHODS: Four hundred twenty-seven patients who underwent resection of rectal carcinoma were studied. All resected specimens were examined for histologic evidence of extramural cancer separate from the main lesion. RESULTS: Extramural cancers not in continuity with the main rectal lesion were classified as follows: 1) extranodal microscopic cancers; 2) large tumor nodules; 3) lymph node metastases. Each classification was found to influence long-term prognosis. Among them, microscopic cancer was thought to be especially relevant because, by virtue of its microscopic nature, it may be left in the pelvic cavity, causing local recurrence. The existence of large tumor nodules and metastatic lymph nodes correlated closely with the presence of microscopic cancer. Because large tumor nodules and lymph node metastases are possibly detectable during the operation by palpation and may be analyzed by microscopic frozen sections, they might be useful predictors of the presence of microscopic cancers. CONCLUSIONS: In cases with extensive local rectal cancer spread, the nerve-sparing rectal resection that omits lateral dissection may be insufficient for local control because of incomplete removal of occult microscopic cancer, resulting in local recurrence. Presence of microscopic cancer correlates closely with large tumor nodules and metastatic lymph nodes. Intraoperative frozen section investigations may, thus, help in deciding on extent of location resection.
Changes in tumor proliferation of rectal cancer induced by preoperative 5-fluorouracil and irradiation.
Willett CG. Hagan M. Daley W. Warland G. Shellito PC. Compton CC.
Department of Radiation Oncology, Massachusetts General Hospital, Boston 02114, USA.
PURPOSE: This study examines the effect of 5-fluorouracil administration during preoperative irradiation on rectal cancer tumor proliferation. PATIENTS AND METHODS: One hundred and fifty-three patients with locally advanced rectal cancer received 45 to 50 Gy of preoperative irradiation with (103 patients) and without (50 patients) concurrent 5-fluorouracil, followed by surgery. Pretreatment tumor biopsies and postirradiation surgical specimens were scored for proliferative activity by assaying the extent of Ki-67 and proliferating cell nuclear antigen immunostaining and the number of mitoses per ten high-powered fields. Postirradiation specimens were also assessed for downstaging. RESULTS: Although 5-fluorouracil did not improve downstaging rates, marked decreases in the activity of all three markers of proliferation (mitotic counts, Ki-67, and proliferating cell nuclear antigen immunostaining) were seen in rectal cancers of patients receiving the drug. No significant decreases were noted in patients undergoing irradiation only. CONCLUSION: The addition of 5-fluorouracil to preoperative irradiation resulted in a more complete inactivation of the proliferating population. Frequency of downstaging, however, was unaffected. Thus, the quiescent cell population appears to represent a substantial barrier to further downstaging. New treatment strategies should be aimed at controlled recruitment of quiescent tumor cells at the time of irradiation.
Role of p53 and p21/WAF1 detection in patient selection for preoperative radiotherapy in rectal cancer patients.
Fu CG. Tominaga O. Nagawa H. Nita ME. Masaki T. Ishimaru G. Higuchi Y. Tsuruo T. Muto T.
Department of Colorectal Surgery, Changhai Hospital, Second Military Medical University, Shanghai, People's Republic of China.
BACKGROUND: Recent studies showed that p53 and p21 may play major roles in determining tumor radiosensitivity through the apoptosis pathway. The aim of this study was to investigate the predicting value of radiosensitivity in human rectal carcinoma. METHODS: p53 and p21/WAF1 expressions in formalin fixed, paraffin-embedded, preradiation biopsy samples from 49 patients with primary rectal carcinoma were analyzed immunohistochemically. p53 and p21 expressions and their relationships with histopathologic changes after radiation and other clinical features were evaluated. RESULTS: Expressions of p53 and p21/WAF1 were 49 and 28.6 percent, respectively. In 36.7 percent of total tumors, significant histopathologic effect can be observed. There was a significant inverse expression of p53 and p21. Most of the p53(+) or p21(-) tumors were radioresistant, and the majority of p53(-) or p21(+) tumors were radiosensitive. Tumors size in the radiosensitive, p53(-), or p21(+) group decreased more significantly than in radioresistant, p53(+), or p21(-) group (P < 0.01), and patients with radioresistant, p53(+), or p21(-) tumors had more local recurrence, more distant metastasis, and a shorter five-year survival rate than those with radiosensitive, p53(-), or p21(+) tumors, but without statistic significance. No statistically significant correlation can be observed between other tumor clinical features and radiosensitivity, p53, or p21 expressions. CONCLUSION: Immunohistochemistry detection of p53 and p21 expressions may be useful parameters for more radiosensitive patients selected for preoperative radiotherapy.
Appendiceal tumors: retrospective clinicopathologic analysis of appendiceal tumors from 7,970 appendectomies.
Connor SJ. Hanna GB. Frizelle FA.
Department of Surgery, Christchurch Hospital, New Zealand.
BACKGROUND: Appendiceal tumors are rare and often unexpectedly discovered in an acute situation, in which decision-making is difficult. To help define the most appropriate management, a retrospective analysis was undertaken to describe the clinicopathologic behavior of appendiceal tumors, and the literature was reviewed of the management of the different types of appendiceal tumors. METHOD: From a single center, a histopathologic database of 7,970 appendectomies, all appendiceal tumors, were identified and case notes reviewed. Analysis of clinical presentation, histopathology, operation, and outcome is presented. RESULTS: During a 16-year period (7,970 appendectomies), 74 patients (0.9 percent) with appendiceal tumors were identified: 42 carcinoid, 12 benign, and 20 malignant. Acute appendicitis was the most common presentation (49 percent), and 9.5 percent were incidental findings. Primary malignant tumors of the appendix were found in 0.1 percent of all appendectomies. Secondary malignant disease was identified in the appendix of 11 patients, most commonly (55 percent) from patients with primary colorectal disease. There was a high incidence of synchronous and metachronous colorectal cancer in all appendiceal tumors: carcinoids, 10 percent; benign tumors, 33 percent; secondary malignancies, 55 percent; primary malignancies, 89 percent. CONCLUSION: Appendiceal tumors are uncommon and most often present as appendicitis. Most are benign and can be managed by appendectomy, except adenocarcinomas and carcinoids larger than 2 cm, which are most appropriately managed by right hemicolectomy. A suggested management algorithm is provided. Controversy exists over the management of carcinoids 1 to 2 cm in size and adenocarcinoids. All types of appendiceal tumors have a high incidence of synchronous and metachronous colorectal cancer.
Perianal infections in patients with leukemia: importance of the course of neutrophil count.
Buyukasik Y. Ozcebe OI. Sayinalp N. Haznedaroglu IC. Altundag OO. Ozdemir O. Dundar S.
Department of Hematology, Hacettepe University Medical School, Ankara, Turkey.
PURPOSE: This study was performed to evaluate relations among neutrophil count (including its course), type of lesion, treatment, and prognosis in patients with leukemia and perianal infection. METHODS: Medical records of patients with acute and chronic leukemia who were followed during the last five years were reviewed retrospectively. RESULTS: The incidence of perianal infections was found to be 7.3 percent in 259 patients with acute leukemia. Only 1 of 108 patients with chronic leukemia suffered from this problem. Twenty percent of all patients with this complication died as a result of sepsis. Perianal abscess was the sole and obligatory indication for surgical treatment in our patients. There were ten patients in each treatment group. The operative group had better results (9 cures, 1 complication vs. 3 cures, 7 complications). However, median neutrophil count at diagnosis was notably higher in the operative group 1,280/mm3 vs. 96/mm3; P = 0.075). Also, significantly more frequent abscess formations and, consequently, operative treatments were performed in patients with a period of normal neutrophil counts during the infection compared with continuously neutropenic patients (9 operative, 4 nonoperative vs. 1 operative, 6 nonoperative; P = 0.057). Ten cures, three complications vs. two cures, five complications (3 mortalities) were present in patients with and without normal neutrophil counts, respectively (P = 0.062). When only severely neutropenic patients were considered, four patients in the surgery group had normal neutrophil counts before or shortly after surgery. However, only two of eight patients with perianal cellulitis had normal counts during full-course infection (P = 0.06). CONCLUSIONS: The course of the neutrophil count during infection was an important factor affecting the perianal lesion, and indirectly, choice of treatment and prognosis. A period of normal counts during infection usually led to well bordered and fluctuant lesions, and the prognosis was acceptable with operative treatment. However, continuously neutropenic patients developed nonfluctuating indurations. We found disappointing results with nonoperative treatment of such patients. In all studies, regarding treatment of perianal infections in neutropenic patients, the course of the neutrophil count and indications for surgery should be clarified to get reliable results.
Mucosal tenascin C content in inflammatory and neoplastic diseases of the large bowel.
Riedl S. Kadmon M. Tandara A. Hinz U. Moller P. Herfarth C. Faissner A.
Department of Surgery, University of Heidelberg, Germany.
PURPOSE: Tenascin C is a glycoprotein of the extracellular matrix. It is upregulated during embryologic development, wound healing, and under conditions of normal and neoplastic growth. Most available data on tenascin C expression in tissues is based on immunohistologic studies. The present study was designed to quantify tissue concentrations in patients with inflammatory and neoplastic diseases of the large bowel. METHODS: Fifty patients with ulcerative colitis, 19 patients suffering from familiar adenomatous polyposis without malignant transformation, and 69 patients with colorectal carcinoma were investigated. Tenascin C concentrations in tissue extracts were determined by semiquantitative Western blotting. RESULTS: The tenascin C tissue concentration of normal mucosa was 2.6 +/- 3.4 microg/mg (n = 55), 2.9 +/- 2.1 microg/mg in colorectal adenomas (n = 19), 7.5 +/- 4.7 microg/mg in ulcerative colitis (n = 50), and 18 +/- 15 microg/mg in colorectal carcinomas (n = 69; mean +/- standard deviation). In ulcerative colitis, the mucosal tenascin C content correlated with histopathologic disease activity. No differences were found between subgroups of adenomas or carcinomas. CONCLUSIONS: Tenascin C tissue concentrations were not altered in adenomas, slightly elevated in ulcerative colitis, and substantially increased in colorectal carcinomas. Although less useful as a diagnostic parameter, tenascin C tissue levels serve as an instrument for assessing the activity of stromal remodeling in large-bowel diseases generally. Specifically, they may reflect disease activity in ulcerative colitis.
Comparison of oral with rectal mesalazine in the treatment of ulcerative proctitis.
Gionchetti P. Rizzello F. Venturi A. Ferretti M. Brignola C. Miglioli M. Campieri M.
Dipartimento di Medicina Interna e Gastroenterologia, Universita di Bologna, Italy.
PURPOSE: The aim of our study was to compare the efficacy and safety of oral mesalazine with mesalazine suppositories in patients with active ulcerative proctitis. PATIENTS AND METHODS: A four-week, randomized, single-blind trial was performed in 58 patients with active, histologically confirmed ulcerative proctitis (< or = 15 cm) to evaluate the efficacy and safety of oral 800-mg mesalazine tablets taken three times per day (n = 29) compared with 400 mg of mesalazine suppositories administered three times per day (n = 29). Patients were evaluated at study entry and after two and four weeks. Efficacy evaluations included a disease activity index, which represents a score with four variables: stools frequency, rectal bleeding, mucosal appearance, and physician's assessment of disease severity. Histologic activity was also assessed at study entry and after two and four weeks in accordance with the criteria by Truelove and Richard. Safety assessment included clinical laboratory parameters and adverse event reports. RESULTS: There were no significant differences with regard to baseline comparisons of demographics and severity between the two treatment groups. Improvement in mean disease activity index score was significantly greater with suppositories compared with oral mesalazine, both at two-week and four-week visits (mean disease activity index scores at baseline, two, and four weeks: suppositories = 7.7, 2.59, and 1.48; tablets = 7.42, 5.72, and 3.48, respectively (P < 0.001)). The rate of histologic remission was significantly greater with suppositories compared with tablets both at two and four weeks (P < 0.01). There were no significant differences in adverse events or clinical laboratory results between treatment groups. CONCLUSIONS: Results of this study indicate that treatment with mesalazine suppositories produces earlier and significantly better results than oral mesalazine in the treatment of active ulcerative proctitis.
Treatment of therapy-resistant perineal metastatic Crohns disease after proctectomy using anti-tumor necrosis factor chimeric monoclonal antibody, cA2: report of two cases.
van Dullemen HM. de Jong E. Slors F. Tytgat GN. van Deventer SJ.
Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands.
PURPOSE: Two young females with well-documented Crohn's disease and nonhealing perineal wounds following proctectomy compatible with "metastatic Crohn's disease" are described. We hypothesized that metastatic Crohn's disease would be a tumor necrosis factor-dependent inflammatory reaction and have treated these two patients with the anti-tumor necrosis factor chimeric monoclonal antibody, cA2. MAIN FINDINGS: Administration of cA2 was followed by a rapid reduction of subjective and objective parameters of inflammation and caused a substantial reduction of the wound size. CONCLUSION: These preliminary data are consistent with a tumor necrosis factor-dependent inflammatory cause of Crohn's disease and its extraintestinal manifestations and provide support for targeting tumor necrosis factor in this condition.
Anal duct/gland cyst: report of a case and review of the literature.
Kulaylat MN. Doerr RJ. Neuwirth M. Satchidanand SK.
State University of New York at Buffalo, School of Medicine and Biomedical Sciences, Department of Surgery, and Buffalo General Hospital, 14203, USA.
PURPOSE: The purpose of this communication is to report a case of anal duct/gland cyst and review cases of perianal and presacrococcygeal mucus-secreting cysts reported in the literature with emphasis on their histopathologic features. METHOD: Our patient presented with coccydynia. An extraluminal retrorectal tumor was felt on rectal examination. A computerized tomographic scan demonstrated a presacrococcygeal mass closely related to the anorectal junction. The tumor and the coccyx were excised using a posterior approach. Cases of perianal and presacrococcygeal mucus-secreting cysts reported in the literature were reviewed. RESULTS: In our case, the tumor proved to be an anal duct/gland cyst. Some of the reported cases of presacrococcygeal glandular cysts had histopathologic features suggestive of anal duct/gland origin. CONCLUSION: Diagnosis of anal duct/gland cyst is based on routine histologic features, histochemical characteristics of mucus, and/or the presence of a communication with an anal duct or crypt. Based on these criteria, some of the reported cases of mucus-secreting cysts occurring around the anorectum may prove to be anal duct/gland in origin.
Squamous-cell carcinoma developing within anal lichen planus: report of a case.
Fundaro S. Spallanzani A. Ricchi E. Carriero A. Perrone S. Giusti G. Giannetti A. De Bernardinis G.
Department of Surgery, University of Modena, Italy.
AIM: We present a case of squamous-cell carcinoma developing within perianal lichen planus. This is a chronic or recurrent cutaneous and/or mucosal dermatosis affecting less than 1 percent of the population. Neoplastic degeneration of cutaneous lichen planus is rare; only one case of squamous-cell carcinoma developing within perianal lichen planus has been described up until now in the international literature. CASE REPORT: Our case involved a 68-year-old woman with chronic, long-term lichen planus spreading all over the vulva and perianal region and the mucosa of the anal canal, where squamous-cell carcinoma developed within the perianal lichen planus. Treatment consisted of wide, circular excision of the perianal skin and mucosectomy of the anal canal up to as far as 1 cm above the dentate line. Reconstruction was performed by means of two V-Y bilateral subcutaneous flaps. CONCLUSION: Wide excision was performed not only to remove the squamous-cell carcinoma but also the lichen planus to prevent recurrence of metachronous or synchronous squamous-cell carcinoma. Follow-up at one year after surgery showed no local recurrence of either lichen planus or squamous-cell carcinoma, which suggests that surgical removal should be the therapy of choice for long-term, chronic perianal lichen planus that has proved to be resistant to medical therapy.
Gluteus maximus flap for persistent fecal fistula following rectal resection via the posterior approach.
Yalti T. Krand O. Titiz MI.
Department of General Surgery, Haydarpasa Teaching Hospital, Uskudar, Istanbul, Turkey.
An alternative technique for the treatment of persistent anastomotic leak following resection of the rectum via combined celiotomy and posterior approach is described. Lower aspect of the gluteus muscle is advanced and sutured to cover the anastomotic gap.
Prophylactic oophorectomy in colorectal carcinoma: preliminary results of a randomized, prospective trial.
Young-Fadok TM. Wolff BG. Nivatvongs S. Metzger PP. Ilstrup DM.
Division of Colon and Rectal Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA.
Controversy exists regarding the role of prophylactic oophorectomy during resection for primary colorectal cancer. PURPOSE: A prospective, randomized trial was initiated to evaluate the influence of oophorectomy on recurrence and survival in patients with Dukes Stages B and C colorectal cancer. METHOD: Between November 1986 and March 1997, 155 patients were randomized to oophorectomy or no oophorectomy at laparotomy for resection of colorectal cancer. RESULTS: No incidence of gross or microscopic metastatic disease to the ovary was found among 77 patients randomized to oophorectomy, in contrast to previous reports. Preliminary crude survival curves suggested a survival benefit for oophorectomy between two and three years from surgery, but Kaplan-Meier survival analysis indicated that this was not statistically significant and the benefit does not appear to persist at five years. Kaplan-Meier curves of recurrence-free survival, however, suggest a more substantial separation of the curves, with 80 percent vs. 65 percent five-year disease-free survival for oophorectomy vs. nonoophorectomy, but further patient accrual is necessary to provide sufficient statistical power. CONCLUSIONS: Occult colorectal carcinoma metastatic to the ovaries has not been documented in this series of putative Dukes Stages B and C tumors. The possibility of a recurrence-free survival advantage emphasizes the need to continue this preliminary work.
DNA index as a significant predictor of recurrence in colorectal cancer.
Tomoda H. Baba H. Saito T. Wada S.
Department of Gastroenterological Surgery, National Kyusyu Cancer Center, Fukuoka, Japan.
PURPOSE: To clarify the prognostic significance of the DNA content in cases of colorectal cancer, we investigated the relationship between the DNA content, as determined by the DNA ploidy or DNA index, and disease-free survival. RESULTS: This study included 201 cases that were treated by curative surgery between 1989 and 1995 at our hospital. 68 were diploid and 133 were aneuploid. The mean DNA index of these tumors was 1.42. Recurrence occurred in 30 cases (14.9 percent). Tumor site, venous invasion, Dukes stage, DNA ploidy (diploid or aneuploid), and a DNA index (less than or greater than 1.4) correlated well with disease-free survival. A multivariable analysis suggested the DNA index to be a stronger predictor than DNA ploidy. Patients with aneuploid tumors had shorter disease-free survival than those with diploid tumors (P = 0.011), especially in Dukes Stage C cases (P = 0.0209). Patients with a DNA index greater than 1.4 also had a shorter disease-free survival than those with a DNA index less than 1.4 (P < 0.001), especially in Dukes Stage C cases (P = 0.0033). CONCLUSIONS: The DNA index value (less than or greater than 1.4) seems to be a stronger predictor than DNA ploidy (diploid or aneuploid), and the combination of Dukes stage, tumor site, and a DNA index is, therefore, considered to be clinically valuable in predicting recurrence in cases of colorectal cancer.
Curative surgery for colorectal cancer: long-term results and life expectancy in the elderly.
Violi V. Pietra N. Grattarola M. Sarli L. Choua O. Roncoroni L. Peracchia A.
Istituto di Clinica Chirurgica Generale e Terapia Chirurgica, University of Parma Medical School, Italy.
PURPOSE: The long-term prognosis after curative surgery for colorectal cancer was evaluated in relation to age and life expectancy as a possible basis for assessing the risk to benefit ratios in the elderly. METHODS: Data relating to 1,256 patients operated on from 1976 to 1994 were stored in a computer database prospectively from 1987. Patients were subdivided into four age groups (A = or =80). Distribution of general contraindications to curative surgery was examined. In the 869 patients who underwent curative treatment (A = 206; B = 256; C = 289; D = 118), distribution of tumor stage and elective/emergency surgery and the operative mortality rate were evaluated. Crude and age-corrected survival curves were calculated in 794 patients. The median crude survival of each group was related by gender and tumor stage to demographic life expectancy, assuming as "relative median survival index" the ratio between the two values. RESULTS: General contraindications to curative surgery increased significantly with age. The operative mortality rate was higher in Group D than in Groups A, B, plus C over the total series (P < 0.001) and in both elective (P < 0.001) and emergency surgery (P < 0.05). Intergroup analysis of long-term survival rates showed significant differences between "crude" (P = 0.0057) but not age-corrected (P = 0.66) curves. The relative median survival index increased with age, up to approximately 1 in the local stages of Groups C and D. CONCLUSIONS: To evaluate long-term results, elderly patients should be compared with unaffected, same-age subjects. Because the risks may be very high, the surgical policy in the elderly should be carefully weighed and related to life expectancy and actual results.
Use of guanylyl cyclase C for detecting micrometastases in lymph nodes of patients with colon cancer.
Waldman SA. Cagir B. Rakinic J. Fry RD. Goldstein SD. Isenberg G. Barber M. Biswas S. Minimo C. Palazzo J. Park PK. Weinberg D.
Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA.
INTRODUCTION: Guanylyl cyclase C appears to be expressed only in colorectal cancer cells in extraintestinal tissues. Thus, guanylyl cyclase C may be useful as a marker to detect colorectal cancer micrometastases not detectable by histopathology in lymph nodes of patients. METHODS: Twelve patients with colon adenocarcinoma, Dukes Stages A through C2, and one patient with a tubulovillous adenoma were included in this study. Forty-two lymph nodes were collected from fresh surgical specimens, and each was examined by histopathology and reverse transcription followed by polymerase chain reaction using guanylyl cyclase C-specific primers. Histopathology identified colon cancer cells in 6 of 16 lymph nodes from five Dukes Stage C patients but not in lymph nodes from the patient with a tubulovillous adenoma, the Dukes Stage A patient, or six Dukes Stage B patients. Reverse transcription followed by polymerase chain reaction using guanylyl cyclase C-specific primers was performed on all 42 lymph nodes. RESULTS: Guanylyl cyclase C messenger RNA was not detected by reverse transcription followed by polymerase chain reaction in lymph nodes from the patient with the tubulovillous adenoma or the patient with Dukes Stage A colon carcinoma. Seven lymph nodes from Dukes Stage C patients revealed guanylyl cyclase C messenger RNA including six lymph nodes containing histopathologically confirmed metastases. Of significance, guanylyl cyclase C messenger RNA was detected in 6 of 21 lymph nodes from Dukes Stage B patients. Indeed, clinical staging of two patients could be upgraded from B to C using reverse transcription followed by polymerase chain reaction and guanylyl cyclase C-specific primers. CONCLUSION: Reverse transcription followed by polymerase chain reaction using guanylyl cyclase C-specific primers might be useful to more accurately assess micrometastases in lymph nodes of colorectal cancer patients undergoing disease staging.
Fecal calprotectin concentration in patients with colorectal carcinoma.
Kristinsson J. Roseth A. Fagerhol MK. Aadland E. Schjonsby H. Bormer OP. Raknerud N. Nygaard K.
Department of Surgery, Aker University Hospital, Oslo, Norway.
PURPOSE: The study contained herein was undertaken to investigate fecal calprotectin excretion in a series of patients with colorectal carcinoma and to determine whether the excretion was influenced by localization or stage of the tumor. Furthermore, the effect of surgical treatment on the concentrations was studied. Fecal calprotectin was also compared with plasma concentrations of calprotectin, carcinoembryonic antigen, and C-reactive protein. METHODS: Fecal calprotectin was measured in 119 consecutive patients admitted for treatment of colorectal carcinoma. In 116 (97.5 percent) patients, resectional surgery was performed. Plasma calprotectin was measured in 90 (76 percent) patients, carcinoembryonic antigen in 88 (74 percent) patients, and C-reactive protein in 82 (69 percent) patients. RESULTS: Median fecal calprotectin concentration in the 119 patients was 50 (range, 2-950) mg/l, which was significantly (P < 0.0001) higher than in 125 control patients (median, 5.2 mg/l). In 23 patients studied also after resection, the excretion fell greatly. There were no significant differences in fecal calprotectin concentration among patients with different tumor stages. Elevated plasma calprotectin concentrations were found in 67 of 90 (73.3 percent) patients with colorectal carcinoma, compared with elevated fecal calprotectin in 111 of 119 (93.3 percent) patients, and there was no significant correlation between plasma and fecal calprotectin concentrations. Plasma calprotectin concentrations were significantly lower in patients with T1 or T2 tumors than in those with more advanced stages (P = 0.0025). CONCLUSION: Measurement of fecal calprotectin may become a diagnostic tool in detecting colorectal carcinoma. The specificity in relation to colorectal carcinoma has not, however, been completely investigated. Both neoplastic and inflammatory conditions may be associated with elevated values; therefore, it is unlikely that calprotectin can predict specific colonic disorders.
Differential diagnosis of dysplasia-associated lesion or mass and coincidental adenoma in ulcerative colitis.
Suzuki K. Muto T. Shinozaki M. Yokoyama T. Matsuda K. Masaki T.
Department of Surgery, Tokyo University Hospital, Japan.
PURPOSE: This study was undertaken to investigate factors that influenced differential diagnosis of dysplasia-associated lesion or mass and coincidental adenoma in patients with ulcerative colitis. METHODS: Among 346 patients with ulcerative colitis who underwent colonoscopy between 1979 and 1995, 27 patients had macroscopic neoplastic lesions and were divided into two groups: those with dysplasia-associated lesion or mass (16 patients) and those with adenoma (11 patients), each being categorized by the presence and absence of dysplasia in the flat mucosa adjacent to the elevated lesions, respectively. RESULTS: Thirteen of 27 patients had dysplasia-associated lesion or mass detected by colonoscopic biopsy; 10 of these patients underwent colectomy, and all had dysplasia-associated lesion or mass in the colectomy specimens. Two patients whose biopsy findings were adenoma had an unsuspected dysplasia-associated lesion or mass in the operative specimens. In the remaining 12 patients, the macroscopic lesions were excised during colonoscopy because of clinical and colonoscopic evidence of adenoma. One of them was proved to have dysplasia-associated lesion or mass, and the other 11 were confirmed as having adenoma in the polypectomy specimens. Patients with dysplasia-associated lesion or mass were significantly younger (P < 0.05), had longer duration of ulcerative colitis (P < 0.01), and had more extensive disease (P < 0.005) than those with adenoma. The colonoscopic appearance was plaque-like in 13, sessile in 13, and pedunculated in 2 of the 28 lesions with dysplasia-associated lesion or mass, whereas it was plaque-like in only 1 and sessile or pedunculated in 15 of the 16 lesions with adenoma (P < 0.001). The mean size of the lesions that were considered to be dysplasia-associated lesions or mass and adenoma was 1.8 and 0.5 cm, respectively (P < 0.0001). CONCLUSIONS: Colonoscopic biopsy for detection of dysplasia in the flat mucosa adjacent to macroscopic neoplastic lesions is an appropriate preoperative approach to distinguish dysplasia-associated lesions or mass from adenomas in patients with ulcerative colitis. The statistically significant variables that influenced the differential diagnosis were age, duration of disease, extent, tumor size, and tumor colonoscopic appearance.
Blood selenium and glutathione peroxidase status in patients with colorectal cancer.
Psathakis D. Wedemeyer N. Oevermann E. Krug F. Siegers CP. Bruch HP.
Department of Surgery, University of Lubeck, Germany.
PURPOSE: It is still controversial whether a low selenium level and a reduced activity of the selenium-dependent enzyme, glutathione peroxidase, in blood are associated with an increased risk and poor prognosis of cancer in humans. This study evaluates whether colorectal cancer patients have lower serum selenium and glutathione peroxidase levels than a gender-matched and age-matched control group and whether there is a correlation to clinical data and prognosis. METHODS: In a retrospective study, serum selenium and glutathione peroxidase activity of 106 patients with colorectal cancer were determined. Clinical data were provided by our long-term follow-up program for colorectal cancer patients. RESULTS: Patients with a selenium level 70 microg/l (P = 0.0009). When considering the different tumor stages, a decline of the mean selenium level in the T4 carcinoma group was found in the analysis of variance (P < 0.05). The lowest selenium level was found for patients with advanced tumor disease and in a preoperative situation, ie., high tumor burden. In comparison with the control group, the cancer group showed a significant reduction of serum glutathione peroxidase activity (P < 0.01) but no significant difference in selenium level. CONCLUSIONS: These results support the hypothesis of an association between low selenium level and advanced tumor disease. From our data, it cannot be decided whether this phenomenon is more likely to be a consequence or a causative factor for development and course of the disease.
Fatigue rate index as a new measurement of external sphincter function.
Marcello PW. Barrett RC. Coller JA. Schoetz DJ Jr. Roberts PL. Murray JJ. Rusin LC.
Department of Colon and Rectal Surgery, Lahey Hitchcock Medical Center, Burlington, Massachusetts 01805, USA.
PURPOSE: Assessment of sustained voluntary contraction of the external sphincter is helpful in evaluating the patient who has a defecation disorder on presentation. A new index of external sphincter function is described. METHOD: A prospective registry of patients referred for computerized anal manometry using standard protocols was reviewed. Patients were grouped by primary symptoms; those with overlapping complaints were excluded. The rate of fatigue, defined as the change in stationary squeeze over a 40-second period of voluntary contraction, was calculated by linear regression analysis. Fatigue rate index, a calculated measure of time necessary for the external sphincter to become completely fatigued, was determined to permit comparison of external sphincter fatigue in patients with different complaints. RESULTS: Twenty-six healthy volunteers (15 women; mean age, 45 years), 33 patients with a primary complaint of anal seepage (13 women; mean age, 53 years), 75 patients with gross incontinence (61 women; mean age, 53 years), and 49 patients with severe constipation (41 women; mean age, 45 years) were evaluated. Mean resting and squeeze pressures were 55 mmHg and 107 mmHg for volunteers, 37 mmHg and 97 mmHg for patients with seepage, 30 mmHg and 49 mmHg for incontinent patients, and 56 mmHg and 93 mmHg for constipated patients. Pudendal neuropathy, as evidenced by a prolonged pudendal nerve terminal motor latency (> 2.4 ms), was identified in 13 percent of volunteers, 32 percent of patients with seepage, 54 percent of incontinent patients, and 38 percent of constipated patients. Mean fatigue rate index was 3.3 minutes for volunteers, 2.3 minutes for seepage patients, 1.5 minutes for incontinent patients, and 2.8 minutes for constipated patients. Compared with volunteers and patients with seepage, the incontinent patients had a significantly shorter fatigue rate index (P < 0.05; Student's t-test), which was independent of the variations in resting pressure (P < 0.05; two-way analysis of variance). CONCLUSION: The external anal sphincter is normally subject to fatigue. Patients with worsening degrees of incontinence have a predictably lower fatigue rate index. Fatigue rate index is a simple measure of external sphincter integrity, which may be used in assessment of sphincter function and future treatment protocols.
Successful overlapping anal sphincter repair: relationship to patient age, neuropathy, and colostomy formation.
Young CJ. Mathur MN. Eyers AA. Solomon MJ.
University of Sydney and Central Sydney, Department of Colorectal Surgery, New South Wales, Australia.
BACKGROUND: Fecal incontinence from single anal sphincter defects are surgically remedial and commonly the result of obstetric injuries. Overlapping anal sphincter repair has previously been associated in small series with good results in 69 to 97 percent of patients. OBJECTIVES: The aims of this study were to assess the results of overlapping anal sphincter repair in one institution and to assess the effects of age, presence of a neuropathy, and addition of a temporary colostomy on the success of surgery. METHODS: A study of 57 overlapping anal sphincter repairs in 56 (54 females) patients at the Royal Prince Alfred Hospital during a six-year period was performed. All patients were investigated preoperatively with endoanal ultrasound and concentric needle electromyography. Patients have been assessed prospectively since 1994 with a questionnaire, including a four-point Likert scale of continence level, the St. Mark's incontinence scoring system (range, 0-13), the Pescatori incontinence scoring system (range, 0-6), and patient assessment of success or failure of the overlapping anal sphincter repair. A colostomy was selectively formed in conjunction with an overlapping anal sphincter repair in 21 patients (8 preoperatively, 13 simultaneously), and 18 patients had a concomitant neuropathy (3 unilateral, 15 bilateral). RESULTS: After a median follow-up of 18 months, median continence scores overall had improved from St. Mark's incontinence scoring 13 to 3 (P < 0.0001) and Pescatori incontinence scoring 6 to 2 (P < 0.0001). Forty-nine of 57 (86 percent) repairs have been successful, and 8 are considered to be failures. Twenty-one of 27 (78 percent) repairs in patients younger than 40 years of age were successful, as were 28 of 30 (93 percent) repairs in patients older than 40 years of age (P = 0.10). Four of 18 (22 percent) repairs associated with a neuropathy failed compared with 4 of 39 (10 percent) without a neuropathy (P = 0.21). Improved or normal continence was achieved in 17 of 21 (81 percent) patients with a stoma and overlapping anal sphincter repair and in 32 of 36 (89 percent) patients with an overlapping anal sphincter repair alone (P = 0.32). The presence of a stoma did not improve the rate of wound healing by primary intention (62 percent for stoma vs. 64 percent for overlapping anal sphincter repair alone; P = 0.55). CONCLUSIONS: Single anal sphincter defects can be successfully treated with an overlapping anal sphincter repair. There is no improvement in primary healing with selective stoma formation. Age of the patient and presence of a neuropathy should not detract from proceeding with overlapping anal sphincter repair when singular anal sphincter defects are detected on endoanal ultrasound in muscle that is still active.
Transanal approach to rectocele repair may compromise anal sphincter pressures.
Ho YH. Ang M. Nyam D. Tan M. Seow-Choen F.
Department of Colorectal Surgery, Singapore General Hospital, Singapore.
PURPOSE: This study prospectively assessed the functional results, particularly anal sphincter impairment, following transanal repair of rectocele for chronic intractable constipation. METHOD: Twenty-one consecutive women (mean age, 47.7 (standard error of the mean, 2.7) years) had the diagnosis of rectocele obstructing defecation made on synchronized anal manometry, electromyography, and cinedefecography. All underwent a standardized transanal repair with controlled anal stretching (maximum of 4 cm) from self-retaining anal retractors. The clinical function and anorectal manometry were assessed before surgery and were repeated six months later. RESULTS: All 21 patients were subjectively satisfied with the relief from constipation after surgery. There were significant improvements in the straining at defecation (before, n = 19; after, n = 3; P = 0.001), need to digitate per vagina (before, n = 16; after, n = 0; P = 0.001), stool frequency (before, 3.8 (0.7) times weekly; after, 8.6 (1.2); P = 0.004), and laxative requirements (before, n = 7; after, n = 0; P = 0.03). Although none were clinically incontinent, there was a mean 28 mmHg impairment in resting (P < 0.05) and 42.6 mmHg impairment in maximum squeeze anal pressures (P < 0.05) after operations. There was no other morbidity. CONCLUSION: Transanal rectocele repair effectively improves constipation problems, at the risk of impaired anal sphincter function. Although clinical incontinence was minimum, an alternative approach to rectocele repair should be considered when anal sphincters are lax.
Biofeedback training in patients with fecal incontinence.
Glia A. Gylin M. Akerlund JE. Lindfors U. Lindberg G.
Karolinska Institutet, Department of Surgery, Huddinge University Hospital, Sweden.
PURPOSE: This study was undertaken to assess the functional results of biofeedback training in patients with fecal incontinence in relation to clinical presentation and anorectal manometry results. METHODS: Twenty-six consecutive patients with fecal incontinence were treated with biofeedback training using anorectal manometry pressure for visual feedback. Ten patients had passive incontinence only, six patients had urge incontinence, and ten patients had combined passive and urge incontinence. RESULTS: Patients with urge incontinence had a lower maximum voluntary contraction pressure (92+/-12 mmHg) and a lower maximum tolerable volume (78+/-13 ml) than patients with passive incontinence (140+/-43 mmHg and 166+/-73 ml). Twenty-two patients completed the treatment, five patients (23 percent) showed excellent improvement, nine patients (41 percent) had good results, and eight (36 percent) patients showed no improvement. At follow-up on average of 21 months after therapy, 41 percent of our patients reported continued improvement. The maximum tolerable volume was higher in those with excellent (140.4+/-6.8 ml) or good (156.3+/-6.64 ml) results of therapy than it was in those with poor results (88.5+/-2.5 ml). Greater asymmetry of the anal sphincter also correlated to poor results. CONCLUSION: Biofeedback therapy improved continence immediately after training and at follow-up after 21 months, but the initial results were better. The urge fecal incontinence seems to be related to function of the external anal sphincter and to the maximum tolerable volume. Low maximum tolerable volume and anal sphincter asymmetry were associated with a poor outcome of therapy.
Pelvic floor procedures produce no consistent changes in anatomy or physiology.
van Tets WF. Kuijpers JH.
Department of Surgery, Lukas-Andreas Hospital, Amsterdam, The Netherlands.
PURPOSE: Postanal repair was designed to restore both anatomy and function of the anal canal in neurogenic fecal incontinence. In most series, the degree of continence is improved in fewer than 50 percent of patients. Adding anterior levatorplasty and sphincter plication (total pelvic floor repair) is claimed to improve functional results. We performed a randomized trial comparing postanal and total pelvic floor repair for neurogenic incontinence. METHOD: Twenty female patients were studied. All had Type D incontinence (Parks and Browning). Anal manometry, defecography, and grading of the degree of continence were repeated 12 weeks after surgery to assess changes in clinical, manometric, and radiologic parameters. Statistical analysis was done using Wilcoxon's signed-rank test and Wilcoxon's two-sample test. RESULTS: Continence improved in eight patients. Differences among clinical, manometric, and radiologic data were not statistically significant. CONCLUSION: Pelvic floor repair procedures produce no consistent changes in anatomy or physiology. Clinical improvement is caused by creation of a local stenosis or by the placebo effect rather than by improvement of muscle function.
Nifedipine and verapamil inhibit the sigmoid colon myoelectric response to eating in healthy volunteers.
Bassotti G. Calcara C. Annese V. Fiorella S. Roselli P. Morelli A.
Department of Clinical Medicine, University of Perugia Medical School, Italy.
BACKGROUND: Constipation is not an infrequent side effect complained of by patients taking calcium channel blockers. This effect may reduce patients' compliance and yield potentially serious consequences. However, the underlying mechanisms for constipation caused by such compounds are not known. AIMS: The purpose of the present study was to assess the effects of nifedipine and verapamil on the sigmoid myoelectric response to eating, a physiologic test of colonic motor function. SUBJECTS AND METHODS: Nine healthy male volunteers with no previous abdominal surgery were recruited for the study and underwent three paired studies at two-week intervals. Myoelectric sigmoid activity was recorded by means of two clip electrodes introduced within the viscus without preparation for 30 minutes basally and 90 minutes postprandially. Each study was preceded by placebo, nifedipine (20 mg), or verapamil (120 mg). RESULTS: Analysis of the tracings revealed that nifedipine strongly inhibited the sigmoid myoelectric response to the meal. This response was also significantly reduced in those taking verapamil compared with the placebo group, although to a much lesser extent than in those taking nifedipine. CONCLUSIONS: We conclude that constipation as a result of some calcium channel blockers may be caused by inhibition of colonic motor activity by nifedipine and, to a lesser extent, by verapamil. The latter compound probably displays other mechanisms (reduced colonic transit, increased water absorption) also responsible for this side effect.
Nonresective alternative for the cure of nongangrenous sigmoid volvulus.
Bhatnagar BN. Sharma CL.
Department of Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India.
PURPOSE: Recurrence in sigmoid colon volvulus is a very vexing problem, because it occurs after all types of treatment including a resection of the sigmoid. A nonresective procedure that prevents recurrence in the long term has been devised and tried during the period 1968 to 1992. METHODS: The procedure involves extraperitonealization of the whole sigmoid colon via a left paracolic gutter incision in a manner akin to an extraperitonealized colostomy and placing it in the left half of the infraumbilical abdominal wall. This article presents a study of 84 patients who underwent this operation and who were followed-up. Some very useful practical points for ensuring the success of the procedure are also presented. RESULTS: The subjects comprised 58 male and 26 female patients, aged 10 to 81 (median, 60) years. The operating time ranged from 40 to 70 (median, 50) min. The operative mortality (9 percent) and morbidity of the procedure including cardiopulmonary complications (7 percent), incidence of small-bowel obstruction (1 percent), and incisional hernia formation (2.3 percent), were reasonably low. The incidence of wound-healing problems was significantly (P < 0.02) reduced in the 1980s and 1990s. Seventy-six patients were available for follow-up ranging from 0.5 to 25 (mean+/-standard error, 6.671+/-0.573; median, 6) years. Forty-eight patients were followed-up for five or more years. No patients developed recurrence of volvulus during the entire follow-up period. CONCLUSIONS: This nonresective, recurrence-free procedure provides a cure for nongangrenous sigmoid volvulus. It may be performed safely, even in relatively poor-risk patients, with acceptably low morbidity and mortality rates.
Pelvic floor herniation after modified York-Mason approach to the rectum: report of a case.
Vorburger SA. Von Flue M. Harder F.
Department of Surgery, Kantonsspital Basel, Switzerland.
The York-Mason approach to the rectum with resection of the coccyx provides an excellent exposure for the treatment of large villous adenomas and low-risk rectal cancers. Morbidity related to this operation primarily arises as local infection (septic pelvis, fistulation), chronic coccygeal pain, and fecal incontinence. This is the first report to describe a pelvic floor herniation two years after a York-Mason approach to the rectum.
Computed tomographic angiography with three-dimensional reconstruction in patients with complex diverticular disease and portal hypertension: report of a case.
Armstrong N. Pozniak M. Helgerson R. Harms B.
Department of General Surgery, University of Wisconsin Hospital and Clinics, Madison 53792-7375, USA.
We report a case of a patient with portal hypertension secondary to alcoholic cirrhosis (Child's Class C) who initially presented with a colovaginal fistula secondary to acute sigmoid diverticulitis. The patient had a prior history of hepatic cirrhosis with ascites, coagulopathy, and portal hypertension. Computed tomography of the abdomen and pelvis demonstrated a large diverticular phlegmon and ascites. Computed tomographic angiography demonstrated a large left anterior abdominal wall varix in the region of the anticipated sigmoid resection. Three-dimensional reconstruction of the computed tomographic angiography further delineated the path of this large varix, confirming the increased risk from surgical intervention. Following initial conservative treatment with intravenous antibiotics, parenteral nutrition, and percutaneous abscess drainage, a transjugular intrahepatic portosystemic shunt procedure was performed to decompress the portal system varices. A repeat computed tomographic scan with three-dimensional reconstruction confirmed decompression of the varix. A successful sigmoid resection was subsequently performed. Preoperative computed tomographic angiography with three-dimensional reconstruction is a useful adjunct in planning the operative strategy in patients with complex intraabdominal pathology and collateral portovenous flow secondary to portal hypertension.
Pouch excision for recurrent serrated adenomas following restorative proctocolectomy for juvenile polyposis: report of a case.
Enriquez JM. Sanz JM. Tobaruela E. Diez M. Ratia T.
Department of Surgery, Hospital Universitario de Alcala de Henares, Madrid, Spain.
PURPOSE: The study contained herein was undertaken to report the case of a patient with juvenile polyposis in whom multiple and rapid recurrence of mixed polyps, with progressive predominance of the adenomatous component, developed in a diverted ileoanal pouch. METHODS: The case of this patient with juvenile polyposis was reviewed. Despite regular surveillance and polypectomies, extensive and multiple recurrences of serrated polyps developed. RESULTS: Because the pouch was never cleared of polyps, a compromise to remove the pouch was decided on. Such a case has not been reported previously. CONCLUSION: Mixed juvenile polyposis may affect any level of the gastrointestinal tract. The ileal pouch and any rectal remnant may incidentally need surgical excision.
Effects of pneumoperitoneum on tumor implantation with decreasing tumor inoculum.
Wu JS. Jones DB. Guo LW. Brasfield EB. Ruiz MB. Connett JM. Fleshman JW.
Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
INTRODUCTION: The aim of this study was to determine the effect of pneumoperitoneum on the rate of trocar-site implantation with decreasing inoculum of cancer cells. METHODS: A total of 0.5 ml of GW-39 human colon cancer cell suspensions at 1 percent (approximately 3.2 x 10(5) cells) and at 0.5 percent (approximately 1.6 x 10(5) cells; v/v) were injected into the abdomen of hamsters through a midline incision. Animals in each group were randomized to receive either pneumoperitoneum (1 percent = 33; 0.5 percent = 43) or not (1 percent = 32; 0.5 percent = 39). Gross and microscopic tumor implants were documented seven weeks later at four trocar sites. RESULTS: In the 1 percent group, pneumoperitoneum significantly increased trocar-site tumor implants from 50 to 71 percent (P < 0.001). Pneumoperitoneum also resulted in the following: 1) more frequent involvement of all four concurrent sites (38 vs. 10 percent; P < 0.02); 2) more frequent palpable tumors (13 vs. 5 percent; P < 0.01); 3) larger tumor mass (2.1 +/- 0.6 g vs. 0.2 +/- 0.1 g; P < 0.02). In the 0.5 percent group, pneumoperitoneum did not significantly increase trocar-site tumor implants, and it did not result in a larger tumor mass. The percent increase in trocar-site implants owing to pneumoperitoneum was influenced by the amount of tumor inoculum (21 percent in the 1 percent group; 10 percent in the 0.5 percent group). The mass of palpable tumor implants after pneumoperitoneum decreased with decreased inoculum: 1 percent = 2.1 +/- 0.6 g; 0.5 percent = 0.3 +/- 0.1 g (P < 0.0001). CONCLUSIONS: Pneumoperitoneum significantly increased both tumor implantation rate and mass when approximately 3.2 x 10(5) colon cancer cells were injected into the peritoneal cavity. These effects of pneumoperitoneum diminished with one-half as many tumor cells injected in the peritoneal cavity.
Decision-making in rectal cancer surgery: survey of North American colorectal residency programs.
Hool GR. Church JM. Fazio VW.
Department of Colorectal Surgery, Cleveland Clinic Foundation, Ohio 44195, USA.
PURPOSE: Although rectal cancer is common in the United States, there is significant variation in management and outcome of this disease. The aim of this study is to measure the amount of variability that exists in the way colorectal surgeons investigate and manage patients with rectal cancer. METHODS: A detailed questionnaire covering preoperative assessment, operative technique, and follow-up of primary rectal cancer was sent to all colorectal surgeons associated with colorectal residency programs throughout North America. RESULTS: One hundred ten responses were obtained (response rate, 71 percent). Surgeons were in broad agreement (>75 percent agree) on the routine preoperative use of endorectal ultrasound and carcinoembryonic antigen and the postoperative use of endorectal ultrasound. There was also broad agreement about the use of adjuvant therapy and radical resection for a poorly differentiated uT2,N0 cancer, the use of total mesorectal excision for a mid rectal cancer, and for the choice of loop ileostomy if diversion is necessary. Two-thirds of the surgeons used adjuvant therapy and radical resection for a uT3,N0 cancer and preferred a follow-up schedule of three monthly visits for two years with six monthly visits for the next three years. Opinion was divided (
Surgical treatment of piles: prospective, randomized study of Parks vs. Milligan-Morgan hemorrhoidectomy.
Hosch SB. Knoefel WT. Pichlmeier U. Schulze V. Busch C. Gawad KA. Broelsch CE. Izbicki JR.
Department of Surgery, University of Hamburg, Germany.
PURPOSE: The present prospective, randomized clinical trial compares the outcome of surgical hemorrhoidectomy according to Parks and Milligan-Morgan in terms of hospital stay, duration of incapacity to work, symptom relief, length of morbidity, and patient convenience. METHODS: Thirty-four consecutive patients with third or fourth degree internal hemorrhoids were randomly allocated to the two groups. Before surgery, all patients were interviewed using a standard questionnaire, followed by rectal examination. All patients underwent a follow-up interview and examinations 1, 2, 4, 8, and 12 weeks after the operation. RESULTS: No serious postoperative complications were seen. Length of hospital stay (3.2 days for Parks hemorrhoidectomy vs. 4.6 days for Milligan-Morgan hemorrhoidectomy; 95 percent confidence interval, 0.2 and 2.6, respectively; P = 0.02) and mean duration of incapacity to work (12.3 days for Parks hemorrhoidectomy vs. 20.2 days for Milligan-Morgan hemorrhoidectomy; 95 percent confidence interval, 5.7 and 10.2, respectively; P < 0.001) differed significantly between the Milligan-Morgan and Parks patients. Until two weeks after the operation, Milligan-Morgan hemorrhoidectomy patients experienced significantly more pain. CONCLUSIONS: Our study confirms that both operations are safe, easy to perform, and lead to satisfactory results. However, the Parks procedure is the preferred option, because it minimizes patients' postoperative discomfort, is more economic, has a significantly reduced hospital stay, and has a shorter time for return to work.
Results from pelvic exenteration for locally advanced colorectal cancer with lymph node metastases.
Hida J. Yasutomi M. Maruyama T. Nakajima A. Uchida T. Wakano T. Tokoro T. Fujimoto K.
The First Department of Surgery, Kinki University School of Medicine, Osaka-Sayama, Osaka, Japan.
PURPOSE: We examined the survival benefit of pelvic exenteration for locally advanced colorectal cancer with lymph node metastases, because this issue remains controversial. METHODS: Medical records of 50 patients who underwent curative pelvic exenteration for colorectal cancer were reviewed retrospectively. Nodal metastases were examined by the clearing method in 29 patients and by the conventional manual method in 21 patients. RESULTS: Invasion to contiguous pelvic organs was present in 40 patients (80 percent) and absent in 10 patients (20 percent). Node metastases were present in 33 patients (66 percent). Operative morbidity and mortality rates were 22 percent (11 patients) and 6 percent (3 patients), respectively. Respective five-year survival rates were 60 and 80 percent in the groups with and without organ invasion (no significant difference). Five-year survival rates in patients with nodal metastases was 54.6 percent but was significantly higher, 82.4 percent, in patients without nodal metastases. Five-year survival in 28 patients with both organ invasion and nodal metastases was 53.6 percent. CONCLUSIONS: Long-term survival was afforded by pelvic exenteration for locally advanced colorectal cancer with nodal metastases.
New method of radiotherapy for anal cancer with three-dimensional tumor reconstruction based on endoanal ultrasound and ultrasound-guided afterloading therapy.
Lohnert M. Doniec JM. Kovacs G. Schroder J. Dohrmann P.
Department of General Surgery, Christian-Albrechts-University, Kiel, Germany.
PURPOSE: Standard treatment of anal cancer is a protocol of combined chemotherapy and percutaneous radiotherapy. We developed a new endosonography-based radiation target simulation method, because endoanal sonography gives the best opportunity to stage the tumor accurately. Based on this method, an afterloading needle application procedure could be performed to optimize the radiation target geometry and to control the application of afterloading needles. In a prospective study, this new method was evaluated, with special regard for complications and tumor recurrence. METHODS: Anal cancer was restaged endosonographically six weeks after external beam radiation with 45 Gy. A computer-generated three-dimensional reconstruction of the tumor and radiation target simulation was performed based on endoanal sonographic imaging. By using a new type of applicator, which is permeable to ultrasound waves, the transperineal implantation procedure of afterloading needles could be controlled. Application needles were inserted into the target area according to the endoanal sonography-based dosimetry planing. The dose of the (high-dose rate) brachytherapy boost was started with two 6-Gy fractions, each within eight days. The fraction dose was reduced to 4 Gy to minimize side effects. Lymph node-positive tumors got additional chemotherapy (5-fluorouracil and mitomycin C). RESULTS: From January 1992 until August 1996, we performed 42 endosonography-guided afterloading procedures in 18 patients. One patient underwent percutaneous radiation two years before and was treated only by afterloading radiation. In every patient, we found complete tumor remission at the end of radiotherapy. Three patients with a high-dose rate of 2 x 6 Gy developed radiogenic proctitis, and two patients developed ulceration, which lead to reduction of the dose. After reduction to 4 Gy per fraction, no more side effects could be seen. In follow-up (median, 24 (range, 1-56) months), we detected two anal cancer recurrences (2/18 patients). CONCLUSION: The radiation target field can be optimized by individual endosonography-based three-dimensional tumor reconstruction and radiotherapy simulation. Endosonography-guided transperineal implantation of afterloading needles can be performed according to the computer-generated simulation by using a new type of applicator. We could achieve total primary tumor remission in every patient. After reduction of the afterloading dose to 2 x 4 Gy, no brachytherapy-related side effects could be seen.
Healing after anal fistulotomy: comparative study between HIV+ and HIV- patients.
Nadal SR. Manzione CR. Galvao VM. Salim VR. Speranzini MB.
Department of Proctology of the Emilio Ribas Infectious Diseases Institute, Sao Paulo, Brazil.
PURPOSE: The aim of this work was to compare wound-healing after anal fistulotomy in human immunodeficiency virus (HIV)+ and HIV- patients and to recognize healing parameters in HIV+ patients. METHODS: Sixty patients were treated with fistulotomy for intersphincteric anal fistula. For each patient, we evaluated white blood cell count values, T CD4 counts, Centers for Disease Control and Prevention classification, and healing duration. There were 31 HIV+ patients (7 A2; 1 A3; 7 C1; 6 C2; 10 C3). RESULTS: Seven C3 patients had incomplete healing. Statistically, there was no difference in the healing duration in HIV+ A2, C1, C2, and HIV-negative patients. C3 patients who did heal took longer than other HIV+ patients. T CD4 counts were similar to healed and not healed C3 patients, although healed C3 values of white blood cell counts were higher than not healed C3 values (4,450 and 2,380/mm3). CONCLUSION: After anal fistulotomy, HIV+ C3 patients either had retarded healing or no healing at all. Therefore, we feel that surgery should be done only in emergency cases of anorectal diseases or in patients with more than 3,000 white blood cells/mm3.
Defunctioning of the anorectum: historical controlled study of laparoscopic vs. open procedures.
Young CJ. Eyers AA. Solomon MJ.
University of Sydney and Central Sydney, Department of Colorectal Surgery, New South Wales, Australia.
BACKGROUND: Creating a defunctioning stoma for anorectal disease in patients in whom no resection or anastomosis is required appears eminently suited for laparoscopic techniques, with the intended advantages of early recovery, reduced pain, and avoidance of a laparotomy. OBJECTIVES: The study contained herein was undertaken to determine the feasibility of laparoscopic defunctioning stoma formation using a three-port technique (including one at the stoma site) and to compare initial results with a historical control group. METHODS: Duration of operation (anesthetic plus surgery), the time to tolerance of a liquid and then a solid diet, time to passage of flatus and feces, patient morphine requirements in the first 48 hours, and day of discharge were documented. RESULTS: Nineteen laparoscopic stomas were attempted (3 converted to open) and 23 open stomas were formed in the control group. The laparoscopic stoma group had lower morphine requirements (mean, 47.7 vs. 89.9 mg; P < 0.01), an earlier tolerance of both liquid (mean, 2.1 vs. 3.7 days; P < 0.01) and solid diets (mean, 3.6 vs. 5.5 days; P < 0.001), and an earlier time to passage of both flatus (mean, 2.2 vs. 3.6 days; P < 0.001) and feces (mean, 3.7 vs. 5.6 days; P < 0.001). Operating time was longer for the laparoscopic group (mean, 176 vs. 104 minutes; P < 0.001), whereas median time to discharge from hospital was shorter (median, 8 vs. 11 days; P = 0.014). Postoperative 30-day morbidity occurred in 1 of 19 laparoscopic group patients and 4 of 23 open group patients. CONCLUSIONS: In this select group of patients requiring defunctioning stoma only, laparoscopic surgery is feasible and safe and may have advantages over open procedures of less pain, earlier tolerance of diet, earlier return of bowel function, and a shorter median length of stay.
Role of Mycobacterium paratuberculosis in Crohns disease: a prospective, controlled study using polymerase chain reaction.
Clarkston WK. Presti ME. Petersen PF. Zachary PE Jr. Fan WX. Leonardi CL. Vernava AM 3rd. Longo WE. Kreeger JM.
University of Missouri-Kansas City School of Medicine, 64108, USA.
PURPOSE: Mycobacterium paratuberculosis has been proposed as a causative agent in patients with Crohn's disease. The purpose of this study was to determine whether M. paratuberculosis was present in tissue from patients with Crohn's disease in a defined geographic area. METHODS: We prospectively evaluated, using polymerase chain reaction and culture, whether M. paratuberculosis was present in 44 specimens (37 from intestinal mucosal biopsies and 7 from surgical resections) from patients with Crohn's disease, ulcerative colitis, or normal colonic mucosa. RESULTS: Of the 25 specimens tested from the 21 Crohn's patients, only 1 positive specimen was noted, whereas the 8 specimens from the 5 ulcerative colitis patients and the 11 specimens from the 11 control patients failed to demonstrate a positive result with polymerase chain reaction. Cultures of all specimens revealed no growth of M. paratuberculosis. CONCLUSION: M. paratuberculosis was only rarely detected in biopsy or surgical specimens from patients with Crohn's disease. These results do not support a common causative role of M. paratuberculosis in Crohn's disease.
Parameters of the rectoanal inhibitory reflex in patients with idiopathic fecal incontinence and chronic constipation.
Zbar AP. Aslam M. Gold DM. Gatzen C. Gosling A. Kmiot WA.
Academic Department of Colorectal Surgery, Hammersmith Hospital, London, United Kingdom.
PURPOSE: The rectoanal inhibitory reflex is a response of the internal anal sphincter to rectal distention, reflecting the functional nature of the anal sampling mechanism of rectal discrimination. The aim of this study was to assess the parameters of the rectoanal inhibitory reflex in healthy volunteers and incontinent and symptomatically constipated patients. METHODS: The rectoanal inhibitory reflex was recorded in 42 patients using reproducible threshold volumes. Excitatory and inhibitory latencies, maximum excitatory and inhibitory pressures, amplitude, and slope of inhibition, slope and time of pressure recovery, and area under the inhibitory curve were estimated. Pudendal nerve terminal motor latency and endoanal magnetic resonance imaging were performed in all incontinent patients. RESULTS: Significant linear trends were found for most parameters at each sphincter level when analyzed. Recovery time and area under the inhibitory curve differed between the sphincter levels and patient groups, with the most rapid recovery occurring in the distal sphincter of incontinent patients (P < 0.001). These pressure findings were not accounted for by differences in excitation between patient groups. CONCLUSION: A coordinated response by the internal anal sphincter to rectal distention with recovery of anal pressure from the distal to the proximal sphincter is suggested. Continence may rely on the character of internal anal sphincter inhibition, and recovery and preoperative assessment of rectoanal inhibitory reflex parameters may be important for predicting functional result following low anastomosis.
Clinical outcome of anterior overlapping external anal sphincter repair with internal anal sphincter imbrication.
Briel JW. de Boer LM. Hop WC. Schouten WR.
Department of Surgery, University Hospital Dijkzigt, Rotterdam, The Netherlands.
Fecal incontinence caused by overt anterior sphincter defects sustained during childbirth is usually treated by a delayed overlapping repair of the external anal sphincter. However, an obstetric trauma is frequently associated with disruption of the perineal body and loss of the distal rectovaginal septum. Data regarding a combined repair, consisting of restoration of the rectovaginal septum and perineal body, overlapping external anal sphincter repair, and imbrication of the internal anal sphincter, are scanty. PURPOSE: This prospective study was aimed at the following: 1) evaluating the clinical outcome of such an anterior anal repair in patients with fecal incontinence caused by obstetric trauma; 2) comparing the functional results with those obtained in a historical group of patients who underwent a conventional direct sphincter repair. METHODS: During the period between 1973 and 1989, 24 female patients (median age, 44 (range, 28-67) years) with fecal incontinence underwent direct sphincter repair (Group I). During the period between 1989 and 1994, a consecutive series of 31 female patients (median age, 46 (range, 23-78) years) with fecal incontinence underwent anterior anal repair (Group II). RESULTS: At two years of follow-up, continence had been restored in 15 patients (63 percent) in Group I, whereas restoration of continence was successful in 21 patients (68 percent) in Group II. CONCLUSION: The more complex anterior anal repair fails to confer clinical benefit compared with the rather simple direct sphincter repair.
Clinical outcome and bowel function following total abdominal colectomy and ileorectal anastomosis in the Oriental population.
Eu KW. Lim SL. Seow-Choen F. Leong AF. Ho YH.
Department of Colorectal Surgery, Singapore General Hospital, Singapore.
Total abdominal colectomy with ileorectal anastomosis is a commonly performed surgical procedure. The postoperative outcome of these patients, however, has not been studied in detail in the Asian population. AIM: The purpose of this study was to analyze the functional outcome of patients following total abdominal colectomy and ileorectal anastomosis. METHOD: All patients subjected to a total abdominal colectomy with ileorectal anastomosis during a six-year period from February 1989 to October 1995 were reviewed. RESULTS: Sixty-six patients (male:female, 40:26) with a mean age of 55.2 (range, 20-88) years underwent total abdominal colectomy with ileorectal anastomosis. Median follow-up after surgery was 26 (range, 4-78) months. Indications for surgery were synchronous or metachronous tumors (18), complicated pancolonic diverticular disease (15), obstructed tumors with impending perforation (13), familial adenomatous polyposis (7), slow-transit constipation (6), and others (7). Mean operative time was 137 +/- 48 minutes. Mean postoperative hospitalization was 13.3 +/- 11.9 days. Time to first bowel movement and commencement of solid diet were 4.7 +/- 1.8 and 7.2 +/- 2.4 days, respectively. Four patients had prolonged postoperative ileus. Average stool frequencies per day were 5.5 at one week, 4.3 at one month, 3.9 at six months, 3.2 at one year, and 2.9 at two years postoperatively. Thirty-three patients (50 percent) required antidiarrheal treatment for a transient period, but none required long-term therapy. Ninety-seven percent of all patients rated the functional outcome as good to excellent, and 3 percent said it was fair. There was two perioperative mortalities. Five cases required re-laparotomy, three for anastomotic complications and two for hemoperitoneum. Five patients had recurrent admissions for adhesion colic, which resolved with nonsurgical therapy. Ten patients succumbed on follow-up, six to tumor recurrence, two to unrelated cancers (stomach and bladder), and three to medical conditions. CONCLUSION: The functional outcome of ileorectal anastomosis is generally rated as good to excellent by patients. Acceptable bowel function and control is regained within six months of the operation and levels off at one year after surgery, and no patient requires long-term antidiarrheal medication.
Increased serum levels of transforming growth factor-alpha in patients with colorectal cancer.
Shim KS. Kim KH. Park BW. Yi SY. Choi JH. Han WS. Park EB.
Department of General Surgery, Ewha Medical Research Center, Ewha Womans University, College of Medicine, Seoul, Korea.
PURPOSE: This study was conducted to investigate the serum levels of transforming growth factor-alpha in patients with colorectal cancer and to investigate the clinical significance of these levels in association with tumor stage and histologic differentiation. Also, serum levels of transforming growth factor-alpha were measured after curative surgical resection. METHODS: Serum levels of transforming growth factor-alpha were measured in 42 consecutive patients with colorectal cancer before surgery, in 21 patients after surgical resection (part of the 42 preoperative patients), and in 20 healthy volunteers. We used TGF-alpha Assay. RESULTS: Serum levels of transforming growth factor-alpha in patients with colorectal cancer were significantly higher than in the healthy control group (P = 0.001). Significant elevations in serum levels of transforming growth factor-alpha were found in 50 percent (21/42) of patients with colorectal cancer when the mean + 2 standard deviations (80.4 pg/ml) of the control group were used as the upper limit of the normal range. Serum levels of transforming growth factor-alpha tended to decrease with increasing tumor size (n = 31; r = -0.52; P = 0.002). Serum levels of transforming growth factor-alpha before surgery (89.7 +/- 44.4 pg/ml; n = 21) significantly decreased to 60.3 +/- 19.8 pg/ml after surgical resections of tumors (P = 0.017). Serum levels of transforming growth factor-alpha completely decreased to the same serum levels of the control group after surgical resections in all patients who had serum levels of transforming growth factor-alpha greater than mean + 2 standard deviations (80.4 pg/ml) of the control group preoperatively (n = 11; P = 0.002). CONCLUSIONS: Levels of preoperative transforming growth factor-alpha in patients with colorectal cancer appeared to be higher than levels measured in control subjects. Serum levels of transforming growth factor-alpha before surgery significantly decreased after surgical resections of tumors. Additional studies are warranted to determine if serum levels of transforming growth factor-alpha may be useful as a potential biomarker in the management of patients with colorectal cancer.
Epidemiologic panorama of colorectal cancer in Mexico, 1980-1993.
Tovar-Guzman V. Flores-Aldana M. Salmeron-Castro J. Lazcano-Ponce EC.
Center for Public Health Research, National Institute of Public Health, Cuernavaca, Morelos, Mexico.
INTRODUCTION: Colorectal cancer is the third cause of cancer-related death in the world, with 468,000 estimated deaths in 1993. In some countries mortality rates have started to decline, and survival rates have increased. In this study performed in Mexico, information is presented on the increase in mortality from this form of cancer, especially in more economically developed areas. METHODS: The mortality trend for colorectal cancer was evaluated and standardized by five-year age groups in the period 1980 to 1993. Also, the standardized mortality ratio was calculated for Mexico's 32 states, as was the possible association between mortality and indicators of rurality level and fertility rates in the different regions of Mexico. RESULTS: In the period studied, 18,962 deaths were officially reported. The average age of death was 66 years. The mortality rate among women (1.8) was significantly higher than among men (1.55 per 100,000 inhabitants). Mortality from colorectal cancer grew by 100 percent in both genders (beta = 0.089; P < 0.001), especially in the age group 34 and younger, in the 45 to 49 age group, and in the older than 75 age group (P < 0.05). The standardized mortality ratio was greater in the states in the north of Mexico. Finally, an inverse correlation was observed throughout Mexico between the rurality index (r = -0.60; P < 0.001) and the fertility rates (r = -0.43; P < 0.05) and mortality from colorectal cancer. CONCLUSIONS: In this study, there is evidence that mortality from this cancer is higher in geographic areas with greater socioeconomic development, similar to regional patterns observed in other countries. In Mexico, the coming years will see a serious epidemic in mortality from this disease; therefore, immediate attention must be given to identifying the profile of high-risk subjects and implementing early cancer detection measures.
Diagnostic and therapeutic applications of monoclonal antibodies in colorectal cancer.
Stocchi L. Nelson H.
Division of Colon and Rectal Surgery, Mayo Clinic and Mayo Foundation, Mayo Medical School, Rochester, Minnesota 55905, USA.
PURPOSE: The study contained herein was undertaken to review and summarize the current literature on diagnostic and therapeutic applications of monoclonal antibodies in colorectal cancer. RESULTS: Limitations of traditional imaging techniques have encouraged development of targeted imaging strategies using radiolabeled monoclonal antibodies. Diagnostic immunoscintigraphy can detect lesions not identified by conventional imaging modalities, although it has not proven useful in the management of primary colorectal cancers and in hepatic metastases. Immunoscintigraphy shows promise in cases of local recurrence and rising carcinoembryonic antigen values; however, the impact of immunoscintigraphy on clinical outcomes and cost-effectiveness remains unproven. Radioimmunoguided surgery has been advocated as a method of more accurately detecting tumor extension and accomplishing radical resection. The technique remains controversial, and its use is not widespread. With respect to therapeutic applications, immunotherapy has most often been investigated in the setting of advanced stage disease. Results in this setting have been poor. In contrast, adjuvant immunotherapy after resection of Dukes C carcinoma has achieved convincing results, with improvements in survival comparable with that of adjuvant chemotherapy. Adjuvant trials are now under way to examine the effectiveness of monoclonal antibodies in the postoperative treatment of early-stage (II) tumors and the combination of monoclonal antibodies and chemotherapy in advanced-stage (III) tumors. Bispecific antibodies, or immunoconjugates with cytokines or toxins, represent additional areas of interest and future investigations. CONCLUSIONS: At present, immunoscintigraphy is not sufficient to determine, by itself, resectability of colorectal tumor and has limited usefulness in select cases of recurrent cancer and possibly in cases of rising carcinoembryonic antigen values. Immunotherapy with monoclonal antibodies as a postoperative adjuvant treatment shows promise and is currently being investigated in national trials.
Length measuring device for transrectal ultrasonography of anorectal lesions.
Yanagi H. Kusunoki M. Shoji Y. Ohtaki T. Yamamura T.
Second Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan.
We, herein, describe an attachable measuring device for transrectal ultrasonography. It is a useful piece of equipment for measuring the precise length of a lesion and for fixing the position of the transducer under examination for sphincteric dynamics.
Sacral insufficiency fractures--rare complication of pelvic radiation for rectal carcinoma: report of a case.
Parikh VA. Edlund JW.
Parkview Memorial Hospital, Fort Wayne, Indiana, USA.
PURPOSE: The report contained herein presents a patient who developed severe back pain because of bilateral sacral insufficiency fractures after pelvic radiation for rectal carcinoma. METHODS: This is a case report and review of the literature for a rare complication of pelvic radiation. RESULT: The patient was diagnosed by computerized tomography and radionuclide bone scans. Bed rest and analgesia followed by rehabilitation provided good relief of the symptoms. CONCLUSION: A rare complication of pelvic radiation is insufficiency fractures of the pelvis. Early detection is important, because significant morbidity may result from delaying treatment. Unawareness of this complication may lead to diagnostic difficulties and unnecessary work-up.
Involuntary contractions of the striated anal sphincters as a cause of constipation: report of a case.
Jost WH. Muller-Lobeck H. Merkle W.
Department of Neurology, German Diagnostic Clinic, Wiesbaden.
PATIENT HISTORY: We present a case of anismus in a 36-year-old patient. He complained of therapy refractory constipation that had been present for 15 years, with delayed micturition and voiding by stages. METHODS AND RESULTS: During digital examination of the anal canal, we found spontaneous contractions of the sphincters at rest. The urethral pressure profile showed irregular contractions during micturition. The electromyogram, which was performed with concentric needle electrodes from the external anal sphincter, puborectalis, and external vesical sphincter, revealed synchronous contractions of these muscles. Injections of botulinum toxin into the sphincters showed good effects and no incontinence. CONCLUSION: Focal dystonia of the striated anal and vesical sphincters is a very rare cause of constipation but should be included in the differential diagnosis.
Incontinence after lateral internal sphincterotomy: anatomic and functional evaluation.
Garcia-Aguilar J. Belmonte Montes C. Perez JJ. Jensen L. Madoff RD. Wong WD.
Department of Surgery, University of Minnesota, Minneapolis, USA.
PURPOSE: This study was designed to evaluate the anatomic and functional consequences of lateral internal sphincterotomy in patients who developed anal incontinence and in matched controls. METHODS: The study includes 13 patients with anal incontinence after lateral internal sphincterotomy and 13 controls who underwent the same operation and were continent and satisfied with the results of the procedure. Patients underwent clinical evaluation, anorectal manometry, pudendal nerve terminal motor latency testing, and endoanal ultrasonography. RESULTS: Sphincterotomies were longer in incontinent patients (75 vs. 57 percent), but the resting pressure and length of the high-pressure zone were not different between groups. Surprisingly, maximum voluntary contraction was higher in incontinent patients than in continent controls (136 vs. 100 mmHg). Rectal sensation and pudendal nerve terminal motor latency were similar in both groups. The defect in the internal sphincter was wider in incontinent patients than in continent controls (17.3 vs. 14.4 mm), but these differences were not statistically significant. The thickness of the internal sphincter measured by endoanal ultrasound was identical in both groups, but the external sphincter was thinner in incontinent patients both at the site of the sphincterotomy (6.8 vs. 8.1 mm) and in the posterior midline (7.1 vs. 8.6 mm). CONCLUSIONS: Anal incontinence after lateral internal sphincterotomy is directly related to the length of the sphincterotomy. Whether secondary to preoperative sphincter abnormality or the result of lateral internal sphincterotomy, the external sphincter is thinner in incontinent patients than in continent controls.
Colorectal and extracolonic cancer variations in MLH1/MSH2 hereditary nonpolyposis colorectal cancer kindreds and the general population.
Lin KM. Shashidharan M. Ternent CA. Thorson AG. Blatchford GJ. Christensen MA. Lanspa SJ. Lemon SJ. Watson P. Lynch HT.
Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska 68131-2197, USA.
PURPOSE: This clinical case review aimed to identify phenotypic variations in colorectal and extracolonic cancer expression between hereditary nonpolyposis colorectal cancer (HNPCC) families with MLH1 and MSH2 germline mutations and the general population. METHODS: Colorectal cancer onset and site distribution were compared among 67 members of MLH1 kindreds, 45 members of MSH2 kindreds, and 1,189 patients from the general population. Synchronous and metachronous cancer rates, tumor stage, extracolonic cancer incidence, and survival were also compared. RESULTS: Mean ages of colorectal cancer onset were 44, 46, and 69 years for MLH1, MSH2, and the general population, respectively (P < 0.001). More proximal and fewer distal colon cancers were noted in HNPCC than the general population (P < 0.001, P = 0.04). Site distribution showed disparity of rectal cancers (8 percent MLH1 vs. 28 percent MSH2; P = 0.01) based on genotypes. Overall, synchronous colorectal cancer rates were 7.4, 6.7, and 2.4 percent for MLH1, MSH2, and the general population, respectively (P = 0.016). Annual metachronous colorectal cancer rates were 2.1, 1.7, and 0.33 percent for MLH1, MSH2, and the general population, respectively (P = 0.041). Colorectal cancer stage presentation was lower in HNPCC than the general population (P = 0.0028). Extracolonic cancers were noted in 33 percent of MSH2 patients, compared with 12 percent of MLH1 patients and 7.3 percent of the general population with colorectal cancers (P < 0.001). Combined MLH1 and MSH2 ten-year survival was 68.7 percent compared with 47.8 percent for the general population (P = 0.009 stage stratified, hazard ratio 0.57). CONCLUSION: The presence of rectal cancer should not preclude the diagnosis of HNPCC, because the incidence of rectal cancer in MSH2 was comparable with that in the general population. Phenotypic variations, including the preponderance of extracolonic cancers in MSH2 patients, did not result in survival differences between genotypic subgroups. These phenotypic features of HNPCC genotypes may have clinical significance in the design of specific screening, surveillance, and follow-up for affected individuals.
Germline mutations of hMLH1 and hMSH2 genes in patients with suspected hereditary nonpolyposis colorectal cancer and sporadic early-onset colorectal cancer.
Yuan Y. Han HJ. Zheng S. Park JG.
Laboratory of Cell Biology, Cancer Research Center, Seoul National University College of Medicine, Korea.
PURPOSE: The present study was designed to determine the frequency of germline mutations in the hMLH1 and hMSH2 genes in 31 families suspected of having hereditary nonpolyposis colorectal cancer who do not fulfill the criteria of the International Collaborative Group on Hereditary Nonpolyposis Colorectal Cancer but in whom a genetic basis for colon cancer is strongly suspected and 45 patients with sporadic early-onset colorectal cancer who developed colorectal cancer before the age of 40 years without any family history of colorectal cancer. METHODS: Genomic DNAs were prepared from peripheral blood samples of patients who were tested. All coding exons and exon-intron borders of these two genes were screened, first with the polymerase chain reaction-single-strand conformation polymorphism method, followed by sequencing of the DNA fragments displaying an abnormal single-strand conformation polymorphism pattern. RESULTS: In 31 families with suspected hereditary nonpolyposis colorectal cancer, we found six different germline mutations in seven unrelated families, including one missense mutation and three frame-shift mutations in the hMLH1 gene and one missense mutation and one frame-shift mutation in the hMSH2 gene. Totally, frequency of mutation was 23 percent, 16 percent and 7 percent in the hMLH1 and hMSH2, respectively. Only one missense mutation of the hMSH2 gene was identified in 45 patients (2 percent) with sporadic early-onset colorectal cancer. The mutation detection rate in families with suspected hereditary nonpolyposis colorectal cancer was significantly higher than that of patients with sporadic early-onset colorectal cancer (P < 0.05). CONCLUSION: Our definition of suspected hereditary nonpolyposis colorectal cancer is useful in the diagnosis of hereditary nonpolyposis colorectal cancer and for identifying those families who need genetic presymptomatic diagnosis. Our results indicate that it may be important to perform DNA testing in families suspected of having hereditary nonpolyposis colorectal cancer. On the other hand, we only detected a low mutation rate (2 percent) in 45 patients with sporadic early-onset colorectal cancer.
Sphincter preservation with chemoradiation in anal canal carcinoma: abdominoperineal resection in selected cases?
Grabenbauer GG. Matzel KE. Schneider IH. Meyer M. Wittekind C. Matsche B. Hohenberger W. Sauer R.
Department of Radiation Oncology, University Hospitals of Erlangen-Nurnberg, Erlangen, Germany.
PURPOSE: This study contained herein assessed long-term results, toxicity, and prognostic variables following combined modality therapy of patients with International Union Against (Cancer Classification T1-4, N0-3, M0 squamous-cell carcinoma of the anal canal. PATIENTS AND METHODS: Between 1985 and 1996, 62 patients completed treatment with combined modality therapy. A median total dose of 50 Gy was given to the primary, perirectal, presacral, and inguinal nodes followed by a local boost in selected cases. 5-Fluorouracil was scheduled as a continuous infusion of 1,000 mg/m2 per 24 hours on days 1 to 5 and 29 to 33 and mitomycin C as a bolus of 10 mg/m2 on days 1 and 29. Routinely processed paraffin-embedded sections were stained using monoclonal antibodies for detection of proliferating cell nuclear antigen and MIB1 (Ki-67) antigen to determine the labeling index. In addition, DNA ploidy was assessed after Feulgen staining. RESULTS: Actuarial cancer-related survival, no evidence of disease survival, and colostomy-free survival rates at five years were 81, 76, and 86 percent, respectively. In univariate analysis, T category (T1/2 vs. T3/4) was predictive for no evidence of disease survival (87 vs. 59 percent; P = 0.03) and colostomy-free survival (94 vs. 73 percent; P = 0.05). N category (N0 vs. N1-3) influenced actuarial cancer-related survival (85 vs. 58 percent; P = 0.002) and no evidence of disease survival (80 vs. 53 percent; P = 0.02). A higher proliferative potential as measured by the MIB1 labeling index was associated with a better colostomy-free survival (90 vs. 50 percent; P = 0.04). In multivariate analysis, actuarial cancer-related survival was only influenced by the N category (P = 0.03) and no evidence of disease survival by N category (P = 0.03) and mitomycin C dose (P = 0.04). Salvage abdominoperineal resection achieved long-term control in only four of seven patients with local failures. CONCLUSION: Treatment with a combination of radiotherapy and chemotherapy is safe and effective for patients with anal canal carcinoma. Abdominoperineal resection is indicated as a salvage procedure in nonresponding and recurrent lesions and may be of benefit in a small subgroup of patients with poor prognostic factors.
Perioperative blood transfusions reduce long-term survival following surgery for colorectal cancer.
Edna TH. Bjerkeset T.
Department of Surgery, Innherred Hospital, Levanger, Norway.
PURPOSE: The aim of the study contained herein was to investigate the association between blood transfusion and long-term outcome for patients treated for colorectal cancer, controlling for the effect of other prognostic factors. We also wanted to study whether blood storage time influenced the prognosis. METHODS: Cox's proportional hazards regression analysis was used to analyze data from 336 patients who survived resection with curative intent. Median follow-up was 5.8 (2-16.8) years or until death. RESULTS: Local recurrences and distant metastases were significantly more frequent when more than two units of blood had been transfused. In the multivariate Cox's analysis, with backward elimination of nonsignificant factors at the 10 percent level, the following risk factors were significantly related to death by colorectal cancer: tumor stage (T stage and N stage), perforation of tumor, age, and the need for a blood transfusion. Transfusions of more than two units of blood were independently and significantly associated with death from colorectal cancer (relative hazard, 2.7; 95 percent confidence intervals, 1.4-5.2). Time of blood storage had no effect on the prognoses. In patients dying from diseases unrelated to colorectal cancer, age and American Society of Anesthesiologists group were significantly related to death, whereas blood transfusion was not. CONCLUSION: We found an independent and significant association between perioperative blood transfusion and poor prognosis in colorectal cancer patients. Blood storage time was not a prognostic factor.
Impaired interleukin-12 production is associated with a defective anti-tumor response in colorectal cancer.
O'Hara RJ. Greenman J. Drew PJ. McDonald AW. Duthie GS. Lee PW. Monson JR.
University of Hull, Academic Surgical Unit, Castle Hill Hospital, East Yorkshire, United Kingdom.
INTRODUCTION: Despite development of many chemotherapeutic regimens, colorectal cancer continues to have a high mortality. One of the major new potential therapies is interleukin-12, a heterodimeric cytokine produced by antigen presenting cells. In vitro and in vivo studies have demonstrated the role of interleukin-12 in stimulating a cell-mediated anti-tumor response against a number of colon adenocarcinoma tumor models. However, it is unknown whether patients with colorectal cancer have impaired interleukin-12 production. A study was performed to investigate production of interleukin-12 preoperatively and the relationship between these levels and disease stage at surgery. METHODS: Preoperative peripheral blood mononuclear cells from colorectal cancer patients and age-matched controls were stimulated by Staphylococcus aureus Cowan's Strain 1 (0.0075 percent wt/vol) in vitro for 24 hours. Expression of interleukin-12 was then assessed by enzyme-linked immunosorbent assay. A single pathologist assessed the tumors for stage according to TNM and Dukes classifications. RESULTS: Twenty-eight patients with colorectal cancer and 14 controls were recruited for the study. Interleukin-12 production was significantly impaired in patients with colorectal cancer compared with controls (P = 0.014), especially those with advanced disease: Dukes C, P = 0.001 and T4, P < 0.05. CONCLUSION: Interleukin-12 production is impaired in patients with colorectal cancer, especially those with advanced disease, suggesting a defective Thl-mediated anti-tumor response. These patients may well benefit from exogenous interleukin-12 treatment.
Metronidazole may inhibit intestinal colonization with Clostridium difficile.
Cleary RK. Grossmann R. Fernandez FB. Stull TS. Fowler JJ. Walters MR. Lampman RM.
Department of Surgery, St. Joseph Mercy Hospital, Ann Arbor, Michigan 48106, USA.
PURPOSE: Antibiotics suppress normal gut flora, allowing overgrowth of acquired or native Clostridium difficile, with release of toxins that cause mucosal inflammation. Oral metronidazole is used to treat antibiotic-associated colitis (pseudomembranous colitis). This study was designed to determine whether oral metronidazole, as part of preoperative bowel preparation, prevents or decreases incidence of antibiotic-associated colitis after elective colonic and rectal procedures. METHODS: Eighty-two patients (40 men) were prospectively, randomly assigned to receive one of two oral antibiotic regimens before colorectal surgery. All patients underwent mechanical bowel preparation with polyethylene glycol-electrolyte lavage solution before administration of oral antibiotics. Group 1 (n = 42) patients received three doses (1 g/dose) of neomycin and erythromycin. Group 2 (n = 40) patients received three doses (1 g/dose) of neomycin and metronidazole. Both groups received one preoperative and three postoperative doses of intravenous cefotetan (2 g/dose). Both groups had stool samples tested for C. difficile toxin in the preoperative and postoperative periods by enzyme-linked immunoabsorbent assay or by tissue culture cytotoxicity. Patients with preoperative stool studies positive for C. difficile were excluded from the study. RESULTS: Treatment groups were not different for age, gender, or surgical procedure. Mean age +/- 1 standard deviation was 67.6 +/- 13.6 (range, 34-94) years in Group 1 and 62.1 +/- 13.5 (range, 35-84) years in Group 2 (P = 0.069). Mean length of hospital stay +/- 1 standard deviation was 9.76 +/- 4.9 (range, 4-28) days for Group 1 and 8.05 +/- 2.6 (range, 3-14) days for Group 2 (P = 0.053). Five patients in Group 1 (neomycin and erythromycin) and one patient in Group 2 (neomycin and metronidazole) had positive stool studies for C. difficile. Relative risk of colonization with C. difficile in Group 1 was 4.76 times that in Group 2 (95 percent confidence interval, 0.581, 39). This difference was not statistically significant (P = 0.202). There were no significant differences in C. difficile colonization rates with respect to age, length of stay, or gender. CONCLUSIONS: This study suggests that there may be a clinical association between use of metronidazole preoperatively and inhibition of intestinal colonization by C. difficile in this patient population undergoing colonic and rectal surgery.
Rectal wall contractility in response to an evoked urge to defecate in patients with obstructed defecation.
Schouten WR. Gosselink MJ. Boerma MO. Ginai AZ.
Department of Surgery, University Hospital Dijkzigt, Rotterdam, The Netherlands.
PURPOSE: The aim of this study was to examine rectal sensory perception and rectal wall contractility in response to an evoked urge to defecate and to identify differences between control subjects and patients with obstructed defecation. METHODS: Twenty control patients (10 men; median age, 47 (range, 17-78) years) and 29 female patients with disabling obstructed defecation (median age, 48 (range, 18-70) years) entered the study. Under radiologic control, an infinitely compliant barostat balloon was inserted over a guide wire into the proximal part of the rectum. Additionally, a latex balloon was introduced into the distal part of the rectum. This latex balloon was inflated until an urge to defecate was experienced. Simultaneously, rectal wall contractility was assessed by measuring the variations in barostat balloon volume. These variations were expressed as percentage changes from baseline volume. RESULTS: By comparing controls and patients with obstructed defecation, a significant difference was found regarding mean distending volume required to elicit an urge to defecate (135 +/- 38 vs. 214 +/- 87 ml of air; P < 0.001, Mann-Whitney U-test). In all controls, the evocation of an urge to defecate induced a pronounced increase in rectal tone, proximal to the distal stimulating balloon. By comparing controls and patients, the increase in rectal tone was found to be significantly higher in control subjects (35 +/- 10 vs. 9 +/- 10 percent; P < 0.001). Twenty-five patients (86 percent) showed no or only minimum (20 percent) in rectal tone. However, their threshold for perception was greatly increased. CONCLUSION: The assembly used in this study provides a useful tool for investigation of rectal evacuation. In all of our patients, obstructed defecation was associated with abnormal rectal sensory perception and/or altered rectal wall contractility.
Patterns of colonic motility as recorded by a sham fecaloma reveal differences among patients with idiopathic chronic constipation.
Garcia-Olmo D. Sanchez PC.
Department of General Surgery, Digestive Motility Unit, Albacete General Hospital, Spain.
BACKGROUND: By using a technique designated sham fecaloma, we were able to identify two types of segmentary motor phenomenon: displacement motor phenomena and nondisplacement motor phenomena. The aim of the study contained herein was to evaluate for identification of patients with different types of slow-transit constipation. METHODS: Studies were performed in healthy subjects (n = 5; colonic transit time 125 hours; normal rectoanal manometry). A Foley-type recording probe with two perfused catheters (proximal and distal) was used. A rigid sigmoidoscope was used to place the probe at the sigmoid colon. Values recorded by the distal catheter were subtracted (point by point) from the values recorded by the proximal catheter. Subtraction curves were analyzed to quantify characteristics of displacement motor phenomena (an anally directed pressure gradient) and nondisplacement motor phenomena (an orally directed pressure gradient). RESULTS: All healthy subjects had contractions during the recording session. Displacement motor phenomena were predominant (displacement motor phenomena/30 minutes = 21.2 +/- 13.2; range, 3-39). Constipated patients yielded two different patterns: three patients had a very small number of contractions, and three patients had a prevalence of nondisplacement motor phenomena, with numbers similar to numbers of displacement motor phenomena in healthy subjects. A comparison of the patterns of constipated patients revealed a statistically significant difference (P = 0.039). CONCLUSION: Sham fecaloma is a simple and safe test. Constipated patients in this study had two different patterns of colonic motility: scarce activity without haustration and normal activity without displacement motor phenomena. This method might be useful as a diagnostic tool for clarification of the pathophysiology of severe colonic motor disorders.
Experimental models of colorectal cancer.
Banerjee A. Quirke P.
Department of Surgery, Royal Halifax Infirmary, and University of Leeds Medical School, United Kingdom.
PURPOSE: A review of in vivo and in vitro models of colorectal cancer is presented. METHODS: A retrospective literature review was performed with reference to CD-ROM Medline and Index Medicus. RESULTS: A comparison of the advantages and disadvantages of the models is presented in addition to a summary of individual model methodology and applications. CONCLUSIONS: Such models are a useful adjunct for surgical research in colorectal oncology.
Foley catheter-assisted endoscopic treatment of severe anastomotic stenosis following anterior resection of the rectum.
Changchien CR. Tang R. Wang JY.
Department of Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan.
Rectal stenosis following low anterior resection is common. Several methods of treatment have been described. We introduce a simple method for the treatment of anastomotic stenosis using a conventional proctoscope and an electric knife with a Foley catheter as an anvil. Under direct vision, this technique can afford accurate and safe incision of stenosis.
Peutz-Jeghers syndrome manifesting complete intussusception of the appendix and associated with a focal cancer of the duodenum and a cystadenocarcinoma of the pancreas: report of a case.
Yoshikawa A. Kuramoto S. Mimura T. Kobayashi K. Shimoyama S. Yasuda H. Kaminishi M. Yamakawa M. Oohara T. Murakami T.
Third Department of Surgery, University of Tokyo, Bunkyoku, Japan.
The unusual occurrence of an "inside-out" appendix reported here is a case of complete intussusception of the appendix of a 45-year-old woman with Peutz-Jeghers syndrome in whom the diagnosis of intussusception was made preoperatively. At laparotomy, the lead point of intussusceptum was revealed to be a Peutz-Jeghers syndrome polyp of the appendix. There was also a cystic lesion in the pancreas, and subsequent distal pancreatectomy revealed a cystadenocarcinoma of the pancreas. Two jejunal Peutz-Jeghers syndrome polyps and two duodenal Peutz-Jeghers syndrome polyps were found via intraoperative endoscopies. The duodenal polyps were endoscopically removed, whereas a jejunal wedge resection was performed for the adjoining jejunal polyps. One of the two duodenal polyps possessed an adenocarcinoma focus. To our knowledge, this is the first report of complete intussusception of the appendix caused by a Peutz-Jeghers syndrome polyp.
Preoperative irradiation affects functional results after surgery for rectal cancer: results from a randomized study.
Dahlberg M. Glimelius B. Graf W. Pahlman L.
Department of Surgery, Akademiska sjukhuset, Uppsala, Sweden.
PURPOSE: The Swedish Rectal Cancer Trial has unequivocally demonstrated that preoperative high-dose (5 x 5 Gy) radiotherapy reduces local failure rates and improves overall survival. This will have an impact on the primary treatment of rectal cancer. This study investigates the effect of preoperative high-dose radiotherapy on long-term bowel function in patients treated with anterior resection. METHODS: A questionnaire was answered by 92 percent (203/220) of patients who were included in the Swedish Rectal Cancer Trial and who were alive after a minimum of five years. Thirty-two patients were excluded, mainly because of postoperative stomas and dementia, which left 171 for analysis. RESULTS: Median bowel frequency per week was 20 in the irradiated group (n = 84) and 10 in the surgery-alone group (n = 87; P < 0.001). Incontinence for loose stools (P < 0.001), urgency (P < 0.001), and emptying difficulties (P < 0.05) were all more common after irradiation. Sensory functions such as "discrimination between gas and stool" and "ability to safely release flatus" did not, however, differ between groups. Thirty percent of the irradiated group stated that they had an impaired social life because of bowel dysfunction, compared with 10 percent of the surgery-alone group (P < 0.01). CONCLUSIONS: The study indicates that high-dose radiotherapy influences long-term bowel function, thus emphasizing the need for finding predictive factors for local recurrence to exclude patients with a very high probability for cure with surgery alone and to use optimized radiation techniques.
Incidence of neoplastic polyps in the ileal pouch of patients with familial adenomatous polyposis after restorative proctocolectomy.
Wu JS. McGannon EA. Church JM.
David G. Jagelman Center for Inherited Colorectal Cancer, Department of Colorectal Surgery, Cleveland Clinic Foundation, Ohio, USA.
PURPOSE: Although adenomatous polyps and even adenocarcinomas have been found in the terminal ileum of patients with familial adenomatous polyposis, the prevalence of neoplastic changes in the pouches of patients who have undergone restorative proctocolectomy is unknown. The objective of this study was to determine the frequency of pelvic pouch neoplasia in familial adenomatous polyposis patients after restorative proctocolectomy. METHODS: Patients in a polyposis registry who had undergone restorative proctocolectomy were recruited. Demographic, surgical, pathologic, and endoscopic data were obtained from patient records. Video pouchoscopy was done after two enemas and representative biopsies were taken. RESULTS: Of 102 eligible patients, 26 (17 males and 9 females) participated. Median age at ileal pouch-anal anastomosis was 31 (range, 12-58) years. Median follow-up period was 66 (11-156) months. Adenomas were found in the pouch of 11 (42 percent) patients, in the terminal ileum above the pouch in 1 patient, and in the anal canal of 4 patients. Among patients with pouch polyps, three patients had one lesion, three patients had two lesions, and five patients had more than ten lesions. The incidence of polyps increased steadily with time from restorative proctocolectomy. There was no relation between the incidence of pouch polyposis and the severity of colonic or duodenal disease. CONCLUSIONS: Proctocolectomy and ileal pouch-anal anastomosis is associated with a significant risk of pouch neoplasia in familial adenomatous polyposis patients. The severity of pouch adenomas was not related either to the severity of colonic or duodenal disease. The pelvic pouches of all patients with familial adenomatous polyposis who have undergone restorative proctocolectomy should be examined periodically.
Indications for colonic J-pouch reconstruction after anterior resection for rectal cancer: determining the optimum level of anastomosis.
Hida J. Yasutomi M. Maruyama T. Fujimoto K. Nakajima A. Uchida T. Wakano T. Tokoro T. Kubo R. Shindo K.
First Department of Surgery, Kinki University School of Medicine, Osaka-Sayama, Osaka, Japan.
PURPOSE: Functional outcome after anterior resection for rectal cancer is improved by colonic J-pouch reconstruction compared with straight anastomosis. The indications for colonic J-pouch reconstruction have yet to be determined. Therefore, we attempted to determine the level at which J-pouch reconstruction provides an advantage over straight anastomosis. METHODS: A total of 48 patients who underwent 5-cm colonic J-pouch reconstruction (J-pouch group) and 80 patients who underwent straight anastomosis (straight group) underwent functional assessment one year postoperatively. RESULTS: The functional outcome in the J-pouch group was significantly better than that in the straight group when the distance of the anastomosis from the anal verge was less than 8 cm. The difference was particularly obvious when the level of the anastomosis was below 4 cm. However, functional outcome in the straight group when the anastomosis was between 9 and 12 cm from the anal verge was also satisfactory and did not differ from that in the J-pouch group when the anastomosis was between 5 and 8 cm from the anal verge. CONCLUSIONS: Colonic J-pouch reconstruction is indicated when the distance of anastomosis from the anal verge is less than 8 cm, and it is essential when the distance is less than 4 cm.
Effect of perioperative blood transfusions on recurrence of colorectal cancer: meta-analysis stratified on risk factors.
Amato AC. Pescatori M.
Coloproctology Unit, Villa Flaminia, Rome, Italy.
PURPOSE: This study was undertaken to evaluate the influence of perioperative blood transfusions on colorectal cancer recurrence. METHODS: All articles published up to December 1996 in English (or with an English abstract) were retrieved, both using MEDLINE and scanning their references, to be considered for this meta-analysis. RESULTS: One hundred thirty-one articles were identified, and 99 of them were excluded because they analyzed survival or mortality, were repetitive publications, or were reviews or letters. Thirty-two original studies (9 were prospective) on 11,071 patients were included for further analysis; 20 showed a detrimental effect of perioperative blood transfusions. Nineteen articles used also multivariable techniques, and 11 found perioperative blood transfusions to be an independent prognostic factor. Pooled estimates of the effect of perioperative blood transfusions on colorectal cancer recurrence yielded an overall odds ratio of 1.68 (95 percent confidence interval, 1.54-1.83) and a rate difference of 0.13 (95 percent confidence interval, 0.09-0.17) against patients who received transfusions. Stratified meta-analyses also confirmed these findings when stratifying patients by site and stage of disease. The effect of perioperative blood transfusion was observed in a dose-related fashion, regardless of timing and type, although some heterogeneity was detected. Data on surgical techniques were not available for further analysis. CONCLUSIONS: A consistently detrimental association was discovered between the use of perioperative blood transfusion and colorectal cancer recurrence. Further studies are needed to confirm that blood transfusion has a causal association.
Postpartum fecal incontinence is more common in women with irritable bowel syndrome.
Donnelly VS. O'Herlihy C. Campbell DM. O'Connell PR.
Department of Obstetrics and Gynaecology, University College Dublin, National Maternity Hospital, Ireland.
PURPOSE: Anal sphincter damage can occur during vaginal delivery and may lead to impairment of fecal continence. The aim of this study was to determine the influence of irritable bowel syndrome on symptoms of fecal incontinence following first vaginal delivery. METHODS: A prospective, observational study was performed before delivery, six weeks, and six months following delivery in primiparous women. A bowel function questionnaire was completed, and anal vector manometry, mucosal electrosensitivity, pudendal nerve terminal motor latency, and anal endosonography were performed. A total of 208 women were assessed before and after delivery, and 104 primigravid women were studied after delivery only. A total of 34 of 312 (11 percent) had an existing diagnosis of irritable bowel syndrome. RESULTS: The prevalence of abnormal manometry or endosonography was similar in women with and without irritable bowel syndrome. However, six weeks after delivery, women with irritable bowel syndrome had a higher incidence of defecatory urgency (64 percent) and loss of control of flatus (35 percent) compared with those without (urgency, 10 percent, P < 0.001; flatus, 13 percent, P = 0.007). The incidence of frank fecal incontinence was similar in the two groups. Women with IBS had increased mucosal sensitivity to electrical stimulation of the upper anal canal both before and after delivery. CONCLUSION: Women with IBS are more likely to experience subjective alteration of fecal continence postpartum compared with the healthy primigravid population, but they are not at increased risk of anal sphincter injury.
Electrostimulation in fecal incontinence: relevance of the sphincteric compound muscle action potential.
Department of Neurology and Clinical Neurophysiology, Deutsche Klinik fur Diagnostik, Wiesbaden, Germany.
PURPOSE: Continence scores and anal manometry are commonly used to assess the effect of electrostimulation in fecal incontinence. This study determined the increase of muscular compound potentials in electroneurography of the pudendal nerve after three months of electrostimulation treatment. PATIENTS AND METHODS: Thirty women were tested; their average age was 46.8 (standard deviation, 9.82) years. Electrostimulation was applied twice daily for 15 minutes in each case. RESULTS: Before treatment, amplitudes were, on average, 0.54 mV (standard deviation, 0.2). After three months of electrostimulation, the amplitudes had increased to 0.84 mV (standard deviation, 0.2). The continence score was improved from 8.73 to 7.1 points. CONCLUSION: We believe that by electrostimulation the atrophic muscle can be trained to stabilize the pelvic floor, thus increasing anal pressure and, thereby, creating a basis for adequate voluntary contraction. Electrostimulation is, therefore, especially suitable for functional deficits of the external anal sphincter (insufficient voluntary contractions because of atrophic muscle) without identifiable muscular lesion.
Paradoxical high anal resting pressures in men with idiopathic fecal seepage.
Parellada CM. Miller AS. Williamson ME. Johnston D.
Academic Unit of Surgery and Centre for Digestive Diseases, The General Infirmary, Leeds, United Kingdom.
PURPOSE: Fecal incontinence has been a matter of concern for many years, but seepage is poorly understood, especially in men. METHODS: We compared the results of anorectal physiologic tests in a group of 16 male patients who complained of fecal soiling but had no previous history of anorectal surgery or disease and had normal clinical examinations with findings of 16 normal male controls. Physical examination and proctosigmoidoscopy were normal in each patient. RESULTS: Maximum anal resting pressure (median interquartile range) was 136 (120-145) cm H2O in the "seepage" group and 104 (83-112) cm H2O in controls (P < 0.01). Inflation volumes at which patients and controls experienced rectal sensation were 45 (35-80) and 90 (75-100) ml of air, respectively (P < 0.01). Maximum tolerated volumes in the rectum were 130 (85-180) ml of air in the seepage group and 190 (140-240) ml of air in controls (P < 0.01). Median length of the anal sphincter was 3.75 (3.5-4) cm in patients and 3 (3-3.5) cm in controls (P < 0.01). Maximum squeeze pressures, sensation in the anal canal, and sphincter relaxation in response to rectal distention were similar in the two groups. CONCLUSION: Male patients with "idiopathic" fecal seepage have a long anal sphincter with abnormally high resting tone.
Anal endosonographic evaluation after closed lateral subcutaneous sphincterotomy.
Garcia-Granero E. Sanahuja A. Garcia-Armengol J. Jimenez E. Esclapez P. Minguez M. Espi A. Lopez F. Lledo S.
Department of General Surgery, Hospital Clinico Universitario, University of Valencia, Spain.
PURPOSE: The present study was undertaken to evaluate anal endosonographic results of the transverse and longitudinal extent of internal anal sphincter division after closed lateral subcutaneous sphincterotomy and its relationship to outcome with respect to anal fissure recurrence and postoperative anal incontinence. METHODS: Ten patients selected for symptomatic anal fissure recurrence (mean follow-up, 10.9 months) and 41 asymptomatic control patients (mean follow-up, 15.5 months) were reviewed by anal endosonography after closed lateral subcutaneous sphincterotomy. Clinical evaluation was focused on anal fissure recurrence and postoperative anal incontinence. The anal endosonographic study involves serial radial images of the distal, proximal, and midanal canal. RESULTS: In 32 patients in whom a complete internal sphincter defect was identified, 31 (75.6 percent) were from the control group and only 1 patient (10 percent) was from the recurrence group (P < 0.001). In 19 patients, an incomplete internal sphincter defect was identified; 10 (24.4 percent) were from the control group (residual median size, 1.8 mm; contralateral, 2.5 mm) and 9 patients (90 percent) were from the recurrence group (P = 0.001; residual median size, 1.4 mm; contralateral, 2.2 mm). Ten patients (19.6 percent) were incontinent for gas and three patients (5.9 percent) for liquid feces, without significant differences between groups. CONCLUSIONS: Anal endosonography is a useful method for evaluating the anatomic effectiveness of closed lateral subcutaneous sphincterotomy. An incomplete sphincterotomy is associated with significant symptomatic anal fissure recurrence.
Is rectal intussusception a cause of idiopathic incontinence?
Lazorthes F. Gamagami R. Cabarrot P. Muhammad S.
Department of General and Digestive Surgery, University of Toulouse III, Purpan Hospital, France.
PURPOSE: The cause of rectal intussusception in patients primarily dominated by symptoms of anal incontinence has not been fully elucidated, especially for patients with idiopathic incontinence. METHODS: Between 1991 and 1996, 51 patients referred with a diagnosis of idiopathic incontinence were prospectively evaluated by standard questionnaire, clinical examination, defecography, and anal manometry. Fourteen female patients were identified with rectal intussusception and were treated by transabdominal rectopexy. Postoperatively, clinical assessment and anal manometry were performed at regular intervals. RESULTS: Continence was improved after rectopexy (P < 0.01). The postoperative increases in the anal resting pressure, maximum squeeze pressure, and maximum tolerated volume were not statistically significant. CONCLUSIONS: Rectopexy improved anal incontinence in patients with rectal intussusception. The cause of rectal intussusception in anal incontinence could not be explained by functional improvement of the internal anal sphincter tone or an increase in the maximum tolerated volume. Rectal intussusception may be a cause of idiopathic incontinence in patients; however, larger prospective studies are required to support this concept.
Perianal manifestations of human immunodeficiency virus infection: experience with 260 patients.
Barrett WL. Callahan TD. Orkin BA.
Department of Surgery, The George Washington University, Washington, DC, USA.
PURPOSE: Individuals infected with the human immunodeficiency virus often have disorders affecting the anorectum. These disorders may be complex and difficult to treat. We reported our early experience with 40 human immunodeficiency virus-positive patients with perianal disorders in 1990. We now present our series of 260 consecutive human immunodeficiency virus-positive patients with perianal disorders who underwent evaluation between 1989 and 1996 to examine the distribution of disorders, their treatments, and outcomes. METHOD: Patients were identified at initial presentation and followed prospectively. RESULTS: Two-hundred forty-nine (96 percent) of 260 patients were male, with an average age of 34.9 (range, 19-58) years. Average duration of human immunodeficiency virus positivity was 5 years, 5 months, with a maximum of 11 years, 5 months. Median CD4 count was 175 (range, 2-1,100) cells/mm3. Only 89 (34 percent) patients satisfied the criteria of the Centers for Disease Control and Prevention's for acquired immunodeficiency syndrome at presentation. The most frequent major presenting symptoms were anorectal pain (55 percent), a mass (19 percent), and blood in the stool (16 percent). Risk factors included homosexuality (75 percent) and a prior history of sexually transmitted disease (45 percent). Forty different perianal disorders were identified, which were categorized as benign noninfectious (18), infectious (14), neoplastic (6), and septic (2). The most common disorders were condyloma (42 percent), fistula (34 percent), fissure (32 percent), and abscess (25 percent). Neoplasms were present in 19 patients (7 percent). One hundred seventy-one patients (66 percent) had more than one disorder, with an average of 2.9 disorders among these patients. Four hundred eighty-five procedures were performed on 178 patients (2.7/patient), with no mortalities and a 2 percent complication rate. Thirty-one patients (12 percent) died during the course of follow-up, but anorectal disease was the cause of death in only two patients. CONCLUSIONS: Perianal manifestations of human immunodeficiency virus infection are common, often multiple, and varied. Patients with perianal disorders seek treatment throughout the course of the human immunodeficiency virus infection, and a perianal condition may be this disease's initial manifestation. Although recurrence is common and healing delayed, improved overall management of human immunodeficiency virus infection and a healthier human immunodeficiency virus-positive patient population have improved the outcome of surgical intervention in human immunodeficiency virus-infected patients with perianal disorders.
Cytomegalovirus enteritis: a highly lethal condition requiring early detection and intervention.
Page MJ. Dreese JC. Poritz LS. Koltun WA.
Department of Surgery, Milton S. Hershey Medical Center, Pennsylvania State University College of Medicine, Hershey 17033-0850, USA.
Cytomegalovirus infection causing symptomatic enteritis is most usually associated with immunosuppressed transplant patients or patients positive for human immunodeficiency virus. Most reports studying this illness are small and do not clearly define the risk factors or mortality rates. METHODS: The present study retrospectively reviewed the charts of 67 patients with biopsy-proven cytomegalovirus enteritis (esophageal, gastric, small bowel, and colonic) to define and to investigate factors that influence survival. Patients were classified into four groups based on underlying medical condition: 1) patients positive for human immunodeficiency virus; 2) transplant patients receiving immunosuppressive medications; 3) immunosuppressed nontransplant patients; and 4) otherwise healthy individuals. Mortality rates based on underlying medical condition, location of intestinal cytomegalovirus infection, cytomegalovirus therapy, age, and average days to institution of treatment were defined and statistically assessed. RESULTS: Mortality was significantly greater in the normal patient group (80 percent) than in the transplant (21 percent), other immunosuppressed (44 percent), or human immunodeficiency virus-positive (75 percent) groups (P = 0.0006, Cochran-Mantel-Haenszel statistics). There was no difference in mortality based on intestinal location of disease or treatment modality (surgery, medical therapy, or both). Cohorts of patients older than 65 years had a statistically higher mortality rate vs. those younger than 65 years old (68 vs. 38 percent; P = 0.05, Cochran-Mantel-Haenszel statistics). Statistically increased mortality was also associated with increased time from hospital admission to institution of cytomegalovirus treatment, whether therapy was medication alone or medication and surgery (P < 0.05, exact Wilcoxon's test). CONCLUSIONS: 1) Lethal cytomegalovirus enteritis can arise in patient populations not typically identified as being at risk for this disorder, including normal individuals. 2) Mortality in cytomegalovirus enteritis is adversely associated with age older than 65 years and increased time to institution of therapy but is not affected by anatomic site of infection or particular form of treatment. Paradoxically, in this study, normal patients had the highest mortality, which we attribute to a low index of suspicion and relatively late institution of therapy.
Small spot sign of rectal carcinoma by endorectal ultrasonography: histologic relation and clinical impact on postoperative recurrence.
Sunouchi K. Sakaguchi M. Higuchi Y. Namiki K. Muto T.
Department of Surgery, Kawakita General Hospital, Tokyo, Japan.
PURPOSE: We observed small spots at the margin of rectal carcinomas on endorectal ultrasonography. Our aim was to study the relationship between ultrasonographic evidence of these spots and histologic characteristics of disease and postoperative recurrence. PATIENTS AND METHODS: The study group comprised 55 patients, 36 men and 19 women, with rectal carcinoma as confirmed by biopsy. The patients were followed up at three-month intervals for six months to three years and six months after the operation. Endorectal ultrasonography was performed in the usual manner. Surgically resected specimens were stained with hematoxylin and eosin and histologically examined. Vessel invasion was graded from 0 (not invasive) to 3 (most invasive). RESULTS: Among the 55 patients studied, 3 had Stage T2,N0,M0 rectal carcinomas and 35 had Stage T3,N0,M0 carcinomas, 5 (14.3 percent) of whom had echographic evidence of small spots. Thirteen patients had Stage T3,N1/2,M0 carcinomas, comprising 12 (92.3 percent) with small spots, and four patients had T3,N1/2,M1 carcinomas, all with small spots. Vessel invasion of Grade 2 or higher was observed around the carcinomas in 20 of 21 patients who had small spots. Ten of 13 patients with many spots at the margin of the carcinoma (a spot grade of ++) histologically had marked venous or lymphatic invasion (an invasion Grade 3). The presence of small spots was closely associated with massive venous or lymphatic invasion (a vessel invasion grade of 2 or more). Four patients had synchronous liver metastases, and small spots were found in all four. Distant metastases and local recurrence were found in 11 of 21 patients with small spots. We found no recurrence in any patient without small spots on endorectal ultrasonography. CONCLUSIONS: Small spots indicate the presence of massive venous or lymphatic invasion and a high risk of postoperative recurrence.
Rectal neovagina: Simonsens technique for large rectovaginal fistula repair.
Simonsen OS. Sobrado CW. Bochinni SF. Habr-Gama A. Pinotti HW.
Colorectal Unit, Hospital das Clinicas, University of Sao Paulo Medical School, SP, Brazil.
Rectovaginal fistulas are difficult to manage and cause significant morbidity. A new technique for large rectovaginal fistula repair is presented; it is based on the creation of a neovagina associated with an established abdominal pull-through operation. This technique has been used since 1970 in selected cases, with very little morbidity and no operative mortality.
Mucosal ischemia caused by desmoid tumors in patients with familial adenomatous polyposis: report of four cases.
Department of Colorectal Surgery, Cleveland Clinic, Ohio, USA.
PURPOSE: The study contained herein was undertaken to demonstrate that mesenteric desmoid tumors can cause significant symptoms other than by a mass effect and that surgery can be effective in treating these symptoms. METHODS: The medical records of patients with intra-abdominal desmoid disease in the David G. Jagelman Inherited Colorectal Cancer Registry were reviewed. Four cases are described in which intramesenteric desmoid tumors adjacent to the bowel caused mucosal ischemia in patients with familial adenomatous polyposis. RESULTS: In one patient with an ileorectal anastomosis, this was manifest by multiple small-bowel strictures and treated by multiple strictureplasties. The other three patients had ileal pouches and presented with bleeding and pain from mucosal ulceration. All pouches needed to be removed. CONCLUSION: Intra-abdominal desmoid tumors may cause problems other than by mass effect. Patients with familial adenomatous polyposis and symptoms suggestive of desmoid disease but with no detectable mass should not be denied surgery.
Retroperitoneal fibrosis mimicking a rectal tumor: report of a case.
Haciyanli M. Erkan N. Elverdi B. Avci G. Fuzun M. Dicle O.
Department of General Surgery, Dokuz Eylul University Medical Faculty, Izmir, Turkey.
PURPOSE: The study contained herein was undertaken to report an original case of retroperitoneal fibrosis that resembled a rectal tumor both symptomatically and radiologically. METHOD: Reported is a case of retrorectal fibrosis with a brief literature review of the topic. RESULT: Although many forms of retroperitoneal fibrosis have been reported, extension below the pelvic rim is very unusual. Compression of the rectum and right ureter, with constipation as a chief complaint, made this case presentation unusual. Although computerized tomographic findings and needle biopsies supported the diagnosis of retroperitoneal fibrosis, an exploratory laparotomy was necessary to rule out a malignancy and to release the ureter. CONCLUSION: A fibrotic mass involving the retrorectal region may mimic a rectal tumor. To reach a final diagnosis, an exploratory laparotomy may be necessary, despite sophisticated evaluation techniques, because it is difficult to differentiate whether the mass is malignant.
Treatment of proctalgia fugax with topical nitroglycerin: report of a case.
Lowenstein B. Cataldo PA.
Department of Surgery, Fletcher Allen Health Care and the University of Vermont College of Medicine, Burlington, USA.
PURPOSE: We report a single case of proctalgia fugax that responded to 0.3 percent nitroglycerin ointment. METHODS: Case report. RESULTS: A single case of proctalgia fugax responded to topical application of 0.3 percent nitro glycerin ointment with no significant side effects. CONCLUSIONS: Nitroglycerin ointment is a newly described treatment for several painful anal conditions. We describe a single case of levator spasm or proctalgia fugax responding to topical application of nitroglycerin. This is only a single case report, and conclusive evidence awaits completion of a controlled clinical trial.
Subtotal colectomy vs. intraoperative colonic irrigation in the management of obstructed left colon carcinoma.
Torralba JA. Robles R. Parrilla P. Lujan JA. Liron R. Pinero A. Fernandez JA.
Virgen de la Arrixaca Hospital University, University of Murcia, Department of General Surgery, El Palmar, Spain.
PURPOSE: Whether primary anastomosis should be performed after segmental resection with intraoperative colonic irrigation or subtotal colectomy is not yet established in the surgical treatment of obstructive left colon carcinoma. In this prospective, nonrandomized study, we present the results of 66 patients undergoing one-stage surgery for obstructed left colon carcinoma. PATIENTS AND METHODS: We compared two techniques, subtotal colectomy (35 patients) and intraoperative colonic irrigation with segmental resection and immediate anastomosis (31 patients). RESULTS: The mortality rate was similar in both groups, 8.5 percent in the subtotal colectomy group and 3.2 percent in the intraoperative colonic irrigation group. The surgical complication rate was significantly higher in the intraoperative colonic irrigation group (41.9 percent) than in the subtotal colectomy group (14.2 percent; P < 0.05). Mean operating time was significantly lower in the subtotal colectomy group than in the intraoperative colonic irrigation group (P < 0.05). Both groups had a similar mean duration of hospital stay. Ten patients who underwent subtotal colectomy (31.2 percent) presented with diarrhea in the immediate postoperative period, which disappeared spontaneously or with antidiarrheal medication; a disabling diarrhea persisted in two patients only (6.2 percent). CONCLUSION: We believe that subtotal colectomy is the treatment of choice for obstructed left-sided colonic carcinoma. Segmental resection with intraoperative colonic irrigation is more appropriate than subtotal colectomy only in patients with carcinomas of the rectosigmoid junction or with previous anal incontinence to avoid the appearance of postoperative diarrhea.