Experience with high-dose radiation therapy and the intestinal sling procedure in patients with rectal carcinoma.

BACKGROUND: Surgery for Dukes' Stage B2 or C rectal carcinoma has a locoregional recurrence rate of 15-67%; this rate is significantly reduced when postoperative radiation therapy (RT) is given. However, RT contributes to radiation-associated small bowel injury in a dose-dependent manner. METHODS: Polyglycolic acid mesh used as an intestinal sling is able to keep the small bowel out of the pelvis during RT, thereby preventing radiation-associated small bowel injury. RESULTS: The authors reviewed the perioperative experiences and acute toxic effects of RT in 53 patients in whom the polyglycolic sling was placed from May 1985 through May 1990 during laparotomy for rectal malignancies (47 primary and 6 recurrent). There were 26 men and 27 women whose ages ranged from 34 to 88 years (mean, 64.7 years). Mild postoperative ileus occurred in most patients, and one patient had an anastomotic leak with a pelvic abscess. Bowel displacement from RT portals was confirmed using radiologic contrast studies. Forty-three patients with primary tumors have completed postoperative RT, and a mean of 5174 cGy has been administered. CONCLUSIONS: After 1-6 years of follow-up (mean, 2.1 years), eight patients have died of systemic disease. There were no cases of radiation-associated small bowel injury and only two cases of pelvic recurrence from primary rectal adenocarcinoma (5%).

Pericardio-peritoneal window for malignant pericardial effusion.

Pericardio-peritoneostomy for malignant and non-hemorrhagic pericardial effusion is effective. This method relieves the patients of their symptoms and enables them to be discharged within 24 hours.

Cancer recurrent at stapled colon incision.

Recurrence of colon cancer at a stapled colotomy site separate from the anastomosis was discovered through a rising carcinoembryonic antigen (CEA). Resection resulted in cure. Exfoliation and implantation of cancer cells is discussed.

Papillary thyroid cancer in identical twins.

The cases of a set of 19-year old monozygotic twins are presented--the first report of thyroid cancer of follicular origin occurring in identical twins. This report includes a brief review of reports of cancer of various sites in twins. Several studies and reports emphasize genetic factors influencing the concurrence of cancer. Other reports downgrade the likelihood of genetic influence in cancer.

Efficacy of an absorbable mesh in keeping the small bowel out of the human pelvis following surgery.

Patients with pelvic malignancies frequently require postoperative radiation therapy either as adjunctive or palliative treatment. Tumoricidal doses, however, are frequently associated with small-bowel damage. Animal experiments demonstrated tolerance to high-dose radiation therapy and protection from radiation enteritis by use of an absorbable polymer polyglycolic acid (PGA) that is used as an intestinal sling to elevate the small bowel away from the operated site. Sixty patients (42 with rectal carcinomas and 18 with gynecologic malignancies) underwent surgical treatment that included the intestinal sling procedure. Postoperative radiation was begun within three weeks following surgery and patients received a mean approximating 5500 rads in fractionated doses. A mean follow-up time of 28 months has not revealed a single case of radiation enteritis (by either contrast studies or physiologic studies) or PGA mesh-related complications. The authors believe that this surgical technique should be employed in patients who may require postoperative radiation treatment for pelvic malignancy.

Early recognition and successful management of pelvic cellulitis following hemorrhoidal banding.

Reports have focused attention on a rare but potentially serious complication following rubber band ligation of internal hemorrhoids: pelvic cellulitis with progression to shock and death. This report documents the successful treatment of pelvic cellulitis. The timely use of broad-spectrum antibiotics at an early stage is critical. Emphasis is placed on early recognition and treatment of this potentially fatal complication.

Ruptured aneurysm of the internal iliac artery.

Our case and others reported in the literature illustrate that isolated aneurysms of the internal iliac artery are uncommon lesions with a highly lethal potential. The classic signs of ruptured abdominal aneurysm--pain, palpable mass, and shock--are usually altered with rupture of these aneurysms because of their deep location in the pelvis. Rectal examination will aid diagnosis. Surgical management of IIA aneurysms 4 cm or larger is indicated at the time of diagnosis, since rupture is usually fatal.

Unsuccessful control of abdominal aortic aneurysm by bypass and ligation.

Two patients developed abdominal aortic aneurysm rupture following bilateral iliac artery ligation and axillobifemoral bypass. The first patient developed his rupture several weeks after outflow ligation and apparent thrombosis of the aneurysm. At autopsy, the aneurysmal rupture occurred in the left posterior junction between the thrombosed aneurysm and the normal aorta. In the second case, the aneurysm was not completely thrombosed and plans were in progress for thrombosis of the aneurysm when the patient developed frank rupture, necessitating operative intervention. The authors await the published experience of others with bilateral common iliac artery ligation and extra-anatomic bypass for abdominal aortic aneurysm, but these authors do not currently recommend this management plan.

Who is my patient after my patient dies? Issues in organ procurement.

Organ donation, procurement, and transplantation have become commonplace events. When a person is dying, the attending physician's "patients" include not only the grieving family but also the many unknown persons awaiting an organ for transplantation. A regional transplant program can be immensely helpful to the attending physician, the hospital staff, and the family of the dying patient.