A defunctioning stoma in the treatment of lower third rectal carcinoma.

INTRODUCTION: Total mesorectal excision (TME) is the accepted standard for rectal cancer treatment. However, there is an increased risk of symptomatic anastomotic leakage associated with TME as TME potentially endangers the blood supply of the remaining rectum. On top of this, many patients will receive neo-adjuvant radio-chemotherapy. A defunctioning stoma helps in avoiding severe complications of anastomotic failure. MATERIAL AND METHODS: We prospectively collected data of all patients with a rectal carcinoma within reach of the palpating finger, operated on in our department between December 2000 and January 2005. There were 70 patients (42 men and 28 women, median age 70 (range 32-95)). RESULTS: In 40 patients (40/70 = 57%) a sphincter-saving procedure was performed. Eleven patients were diagnosed with anastomotic leakage or failure. Seven patients had neo-adjuvant radio-chemotherapy, 4 had no neo-adjuvant therapy. In 4 patients signs of anastomotic leakage were seen on the barium-enema that is routinely performed before closing the defunctioning stoma. Seven patients (7/40 = 17,5%) had clinical signs of anastomotic leakage. Three of them could be treated conservatively with antibiotics and parenteral nutrition. Two of these patients did not have a defunctioning stoma. Four patients needed re-intervention and were treated in intensive care for several days. Three of these patients did not have a defunctioning stoma. CONCLUSION: Neo-adjuvant radio-chemotherapy and TME resection are two factors in the treatment of rectal cancer that might interfere with anastomotic healing in the case of a sphincter-saving procedure. The construction of a defunctioning stoma helps in limiting the complications of anastomotic leakage or failure.

Surgical treatment of acute, massive lung embolism. Results and follow-up.

Between 1970 and 1984 the diagnosis of acute, massive lung embolism was made 30 times in our department. In 29 patients the clinical diagnosis was correct and a Trendelenburg operation under extra-corporeal circulation was performed. In 18 cases there was an operation in the immediate preoperative course. In 1 case there was a combination of operation and the use of contraceptives. 3 cases were immobilized by a plaster of Paris cast. In 4 cases the use of oral contraceptives and in 3 patients the history of chronic recurrent lung embolism were evident. The mean immobilisation time was 15 days. In 24 cases the diagnosis was made only on the base of the clinical anamnesis, and examination, E.C.G. and chest radiography. In 4 cases angiography and in 1 patient the scintigraphy confirmed the diagnosis. Preoperatively 28 patients were in severe shock. One patient was operated electively. 14 patients needed external cardiac massage. In all cases clots were found in the left pulmonary artery, 28 in the right pulmonary artery, in 3 cases clots in the right atrium, 3 in the right ventricle and three in the inferior caval vein. Nine De Weese caval vein clips were inserted and one Mobin-Uddin filter. Postoperatively 18 patients were alive and well without sequelae. Two patients developed a cerebro-vascular accident (CVA) with one complete recovery. Ten patients died. Postoperative treatment consisted of I.V. heparin administration immediately after surgery and 6 months of oral anticoagulants. Except for chronic recurrent lung embolism the pulmonary function tests were excellent postoperatively without recurrence of the disease.