Villous adenomas of the rectum: the accuracy of clinical assessment.

To avoid an unnecessary radical operation, it is important for surgeons to identify a clinically benign villous tumor of the rectum, especially in the middle third area, where a transanal approach may not be feasible. If the high accuracy of this clinical impression can be achieved, alternative methods such as piecemeal snare excision, or electrocoagulation, or both are justified. To evaluate the diagnostic accuracy of a benign rectal villous tumor, 151 patients with totally excised rectal tumors were reviewed. All of these patients had soft and nonulcerated lesions and were judged to be benign. Induration and ulceration of the lesions signified malignancy and were excluded. One hundred and fourteen patients (76%) had benign villous adenomas, 23 patients (15%) had superficial carcinomas, and 14 patients (9%) had invasive carcinomas. Hence the accuracy of detecting a clinically benign villous tumor of the rectum was 91%. This is high enough to avoid a more radical procedure when the clinical impression is that of a benign villous tumor of the rectum.

Restorative proctocolectomy with ileal reservoir and ileoanal anastomosis.

An initial experience with a technique of restorative proctocolectomy utilizing a rectal mucosectomy, total colectomy, and ileal reservoir (Parks S-pouch) with ileoanal anastomosis for patients with ulcerative colitis and familial polyposis is presented. Although there were no deaths, significant morbidity did occur and was attributed to the use of a temporary loop ileostomy which may not be necessary. Early functional results are promising and to date, patient satisfaction is very high.

Is subtotal colectomy a viable option in the management of chronic constipation?

To determine if subtotal colectomy constitutes a valuable alternative in the treatment of patients with chronic constipation, a retrospective review of 52 consecutive patients who underwent subtotal colectomy between January 1980 and August 1985 was undertaken. Forty-six patients underwent ileodistal sigmoidostomy while five patients underwent ileoproctostomy and five with concomitant rectal prolapse underwent simultaneous proctopexy. A mortality rate of 3.8 percent and morbidity rate of 60 percent were encountered. The most frequently occurring complication was small-bowel obstruction, which occurred in 36 percent, and necessitated laparotomy in 66 percent. Additional procedures were necessary in five patients because of newly discovered rectal prolapse (two patients), rectocele (one patient), unrelieved constipation (one patient), and incapacitating incontinence (one patient). Follow-up data available in 94 percent (mean, 46 months) disclosed that patients had an average of 2.8 bowel movements per day without the use of laxatives (89 percent) or enemas (80 percent). Overall, 79 percent were satisfied with the final outcome. It is concluded that subtotal colectomy constitutes a viable option in the treatment of chronic constipation. However, the significant morbidity and mortality associated with the procedure dictate the need for careful patient selection on the basis of appropriate physiologic testing.

Colocolostomy and coloproctostomy utilizing the circular intraluminal stapling devices.

Coloproctostomy or colocolostomy by peranal insertion of a circular stapling device was performed on 265 patients between January 1978, and June 1981. A low anterior resection was performed in 174 patients. Stapler-related technical complications occurred in 52 patients (20 per cent). Complementary transverse colostomies were performed in 11 patients, of which seven were performed on the first 30 patients. Intraoperative complications occurred in 18 patients (7 per cent). Twenty-six major postoperative complications occurred (10 per cent), and clinical anastomotic leaks occurred in eight patients (3 per cent). Four postoperative deaths occurred (1.5 per cent). This study concludes that (1) coloproctostomy or colocolostomy can be safely performed by transanal insertion of a circular stapling device, (2) these instruments allow a sphincter-preserving procedure to be performed for lesions in the low and midrectum (5 to 10 cm from the anal verge) with an acceptable early morbidity and mortality, and (3) the majority of stapler-related technical complications can be managed without protecting colostomy.

Endorectal advancement flap for treatment of simple rectovaginal fistula.

An endorectal advancement flap technique has been utilized in 35 women for repair of "simple" rectovaginal fistulas, i.e., those of low or midseptal location, less than 2.5 cm in diameter, and of traumatic or infectious etiology. Colostomy is unnecessary. Concomitant sphincteroplasty for correction of associated anal incontinence is readily accomplished. Results are excellent with healing ultimately achieved in 32 of 35 women (91 per cent).

Abdominoperineal resection for recurrent cancer following anterior resection.

Cases are reviewed of 12 patients who had abdominoperineal resections for cancer recurrence subsequent to anterior resection. Although this procedure is technically more difficult, we experienced no mortality or significant morbidity, and the postoperative hospital stay was similar to that of patients who received an abdominoperineal resection as a primary procedure. Although we have no long-term cures, at least significant palliation can be achieved in selected patients who have no evidence of distant metastases.

Recurrence following stapled coloproctostomy for carcinomas of the mid portion of the rectum.

A retrospective analysis of 90 patients who underwent a curative surgical resection for a carcinoma of the middle third of the rectum was carried out to determine the preliminary recurrence rates associated with stapled coloproctostomy. Acknowledging the obvious limitations of this preliminary report, the liberal use of restorative resections for these lesions does not appear to be resulting in an obvious increase in tumor recurrence, and the use of the circular intraliminal staplers has significantly decreased the number of abdominoperineal resections required to treat these lesions. We will continue to use stapled coloproctostomy for the majority of these lesions; however, definitive statements regarding the over-all effect of this approach upon survival time await further studies incorporating larger numbers and longer follow-up studies.