Use of epidural anesthesia and spontaneous ventilation during transabdominal colon and rectal procedures in selected high-risk patient groups.

PURPOSE: Patients with cardiopulmonary compromise who require transabdominal colon and rectal procedures are at increased risk for postoperative cardiac and pulmonary complications and prolonged hospital stays. Because epidural anesthesia has been shown to minimize reductions in functional residual capacity and consequently improve pulmonary function, we sought to determine its impact on patients undergoing colon and rectal procedures who were at high risk for postoperative cardiopulmonary morbidity. METHODS: We prospectively studied 31 patients undergoing colon and rectal procedures in whom epidural anesthesia with spontaneous ventilation were used. The criteria for entry included histories of respiratory insufficiency, atherosclerotic heart disease, and extremes of age. Patients who received general endotracheal anesthesia were excluded from consideration. Cardiac and pulmonary morbidity, mortality, and length of stay were analyzed. The data obtained were compared with those of a similar group of 50 patients who during the same time interval had undergone transabdominal colon and rectal operations with general anesthesia in the absence of epidural anesthesia. RESULTS: There were 19 males and 12 females in the epidural study group. Mean age was 71 (range, 35-92) years. There were no cases of pulmonary morbidity. Cardiac morbidity was 6 percent (2/31), with a mortality rate of 3 percent (1/31). Average length of postoperative hospital stay was 10.5 (range, 7-19) days. There were 29 males and 21 females with a mean age of 67 (range, 51-92) years in the general anesthesia group. Pulmonary morbidity was 18 percent (9/50). Incidence of cardiac complications was 4 percent (2/50). There were no mortalities. Average length of stay in the general anesthesia group was 13.6 (range, 6-24) days. CONCLUSION: Use of epidural anesthesia with spontaneous ventilation in elective transabdominal colon and rectal procedures may decrease the incidence of pulmonary complications and length of postoperative hospital stay in a select group of high-risk patients.

Avoidance of anastomotic complications in low anterior resection of the rectum.

PURPOSE: This retrospective study was designed to evaluate the efficacy of suction-irrigation drainage systems in reducing anastomotic complications. The current trend for lesions of the upper and middle rectum emphasizes maintaining an intact anal sphincter mechanism as long as limits of resection are not compromised. Removal of the rectosigmoid colon with an anastomosis below the peritoneal reflection accomplishes this goal but with appreciable morbidity and mortality, which is in great part related to subsequent anastomotic breakdown and resultant pelvic abscess and fecal fistula formation. The presence of collections of blood, serum, and cellular debris contribute significantly to anastomotic disruption by serving as a culture medium in which bacteria may thrive, leading to abscess formation with subsequent deleterious effects on the integrity of the adjacent low lying anastomosis. Many surgeons accepted this risk and routinely performed diverting colostomies to minimize the consequences of anastomotic disruption below the peritoneal reflection. The authors felt that if this risk could be sufficiently reduced, it would obviate the need for a protecting stoma. METHODS: From 1980 to 1988, 60 consecutive patients were subjected to anterior or low anterior resections in which a closed Shirley sump irrigation system was used to facilitate postoperative drainage of the pelvis and thus avoid hematoma formation. Since this original study group of 60 patients, another 100 consecutive patients have been entered into this study. This cohort group again consisted of patients with lesions of the upper, middle, and lower rectum who underwent anterior or low anterior resections of the rectum. RESULTS: Fifty-three of the original 60 patients did not have protecting stomas. Clinical leak rate for this series was 1.67 percent. Clinical leak rate for this updated series of 100 patients was 1 percent, with overall clinical leak rate of 1.25 percent in 160 consecutive patients. There were no deaths in the series, and overall morbidity was 7.5 percent. CONCLUSIONS: The authors felt that removing blood, serum, and cellular debris from the pelvis following resections of all or part of the rectum minimizes the risk of anastomotic disruption. With this routine, covering colostomies are no longer required for most patients undergoing anterior or low anterior resections of all or part of the mesorectum.

Ligation device assisting low anterior anastomosis.

UNLABELLED: The use of the circular stapler has enabled surgeons to perform very low anterior resections where previously abdominoperineal proctectomy would be performed for carcinoma of the rectum. The use of the roticulator or other linear stapler devices has facilitated these anastomoses and precluded the necessity for pursestring sutures, thereby reducing the incidence of incomplete tissue rings, which should reduce the risk of anastomotic leaks. One significant drawback to the roticulator, especially in the narrow male pelvis, is its application for very low lesions. In many cases the stapler cannot be forced deeply enough into the pelvis to allow for a sufficient margin below the tumor. PURPOSE: The purpose of this article is to report results of a prototype that applies a gasket that automatically fixes the rectum to the rod of the circular stapler. METHOD: To date the device has been used 22 times in 14 patients (8 patients had both limbs attached using the device, whereas 6 patients had only the rectal stump attached in this manner). RESULTS: All anastomoses healed without complication, all patients had complete donuts of tissue, and only two anastomoses had to be reinforced. CONCLUSION: The use of this device may facilitate stapling of very low anastomoses for carcinoma of the rectum.

Simple in-office sphincterotomy with partial fissurectomy for chronic anal fissure.

Chronic anal fissure is an extremely common problem of the anorectum. It is often confused with symptomatic hemorrhoids and is frequently missed by the examining physician. Symptoms are most commonly pain and bleeding after defecation. A simple office procedure involving partial lateral internal sphincterotomy with or without excision of a sentinel tag has been used over the past five years with extremely satisfactory results. This procedure was used upon 86 patients. Anatomic and symptomatic relief was obtained in 96.4 per cent of the patients. Due to diagnostic related groups and attempts at cutting medical costs by avoiding hospitalization, sphincterotomy performed as an office procedure is the method of choice for treating chronic anal fissures unresponsive to medical management. Hospitalization is rarely required.

Abdominal pain in patients with acquired immune deficiency syndrome.

The patient with acquired immune deficiency syndrome (AIDS) and abdominal pain presents the surgeon with a difficult challenge. The pain may be due to an opportunistic infection, ileus, organomegaly, or a true surgical emergency. The hospital records of 235 patients with AIDS were reviewed. Of the 29 patients with abdominal pain, 12 had infectious diarrhea, eight were diagnosed as having ileus or organomegaly, and nine had miscellaneous causes for their pain. Only five patients underwent laparotomy. Two patients were operated on for pain associated with bleeding (Meckel's diverticulum and intestinal Kaposi's sarcoma); one had a perforated duodenal ulcer and one had severe ileitis. One patient was electively operated on for Burkitt's lymphoma. Laparotomy for abdominal pain is not usually necessary in patients with AIDS. Specific recommendations for evaluation and management of these patients are offered.

Y-V anoplasty for treatment of anal stricture.

Anal stricture, a most distressing anorectal condition is frequently of either a previous perirectal infection or as a result of previous rectal operation, most commonly hemorrhoidectomy or fistulectomy. Anal dilation offers only transient relief from this condition, the stricture recurring extremely quickly after cessation of treatment. We have used a Y-V advancement flap technique in 14 patients with this condition. All patients were classified as either "complete satisfaction" or "significant improvement," after a minimum of six month follow-up study. The technique and several alternate methods are presented and described herein.

Reducing the risk of wound infection in operations upon the colon.

One hundred and forty-seven patients undergoing elective colonic operations during a 30 month period were studied. The over-all wound infection rate was 6.8 per cent. Thirty-seven patients had subcutaneous drains used and, in none, did a wound infection develop. The incidence of wound sepsis in the remaining patients was 9.1 per cent. Wicks appear to be of benefit in reducing the incidence of wound infections in elective colonic operations.

Reducing the recurrence risk of fistula in ano.

A method of reducing the risk of recurrence of fistula in ano is described. The technique involves injecting saline solution into the external opening of the tract and identifying the internal opening by the egress of liquid. The procedure has been used in 74 patients over the last two years with a recurrence rate of 1.38 per cent.

Importance of patient selection in local treatment of carcinoma of the rectum.

Fifty-eight patients with potentially curative adenocarcinomas of the rectum underwent fulguration of their tumors without regard to size of the lesion. The overall 5 year survival rate was 48.3 percent. However, if patients with adenocarcinomas that arose in villous adenomas were excluded, the 5 year survival rate dropped to 31.7 percent. Of the six patients with a carcinoma less than 3 cm in diameter, the 5 year survival rate was 83 percent. Of the 30 patients with lesions 3 cm or larger, the 5 year survival rate was 23.3 percent. No patient with a lesion larger than 4 cm was cured. It is believed that patients with small adenocarcinomas (less than 3 cm) have a better chance of cure with fulguration than with radical surgery. Cancers between 3 and 4 cm may be treated successfully by local means. Fulguration of rectal carcinomas should not be performed in patients with lesions larger than 4 cm in diameter, except for palliation or in those who refuse permanent colostomy.

Value of pelvic suction-irrigation in reducing morbidity of low anterior resection of the rectum--a ten-year experience.

Resection of the rectosigmoid colon with anastomosis below the peritoneal reflection carries appreciable mortality and morbidity rates particularly because of leakage and resulting sepsis, Protecting the anastomosis with a transverse colostomy does not prevent this complication although it does reduce the catastrophic sequelae that often occur. Anastomotic leakage rates have been reported to be as high as 69% and fecal fistula rates as high as 27% following this type of surgery. A pelvic. A pelvic hematoma may act as a culture medium should sepsis occur and may interfere with anastomotic healing. A method of removing accumulated blood and serum from the pelvis following low anterior resection has been employed with the aim of reducing anastomotic leakage, and a 10-year experience has been compiled. Sixty consecutive patients were studied from July 1970 to June 1980. All underwent barium enema examination and/or proctosigmoidoscopy following low anterior resection with concomitant or previous transverse colostomy. There were four subclinical leaks seen at 6 weeks for an incidence of 6.8%. All resolved spontaneously within 6 additional weeks. No fecal fistulas or pelvic abscesses were encountered. Contaminated blood and serum are significant contributing factors to low anterior anastomotic breakdown. By removing such material before it can become infected, this complication can be significantly reduced.

Sparing the rectum in familial polyposis: causes for failure.

Familial polyposis is a hereditary premalignant condition that culminates in the development of large-bowel cancer in the untreated patient. Controversy exists about the most appropriate prophylactic treatment; the alternatives are proctocolectomy and ileostomy versus colectomy and ileorectal anastomosis. There is discrepancy in the surgical literature about the exact incidence of subsequent rectal cancer in patients who undergo colectomy and ileorectal anastomosis. On the basis of our own experience and the reported work of others, we have identified five factors that may influence the development of rectal cancer in the retained rectum in familial polyposis: the patient's age at the time of colectomy; the length of retained colon; the tendency of spontaneous regression of polyps in the retained rectum; the presence of carcinoma in the excised colon; and the adequacy of postoperative follow-up. An analysis of these factors as they pertain to the major reported series on the incidence of rectal cancer may shed some light on the apparent discrepancies in results.

Local treatment (electrocoagulation) for carcinoma of the rectum in the elderly.

For more than 70 years, surgical excision with permanent colostomy has been the most common operation for adenocarcinoma of the rectum. Local treatment has been advocated by some surgeons, but most prefer radical surgery. Abdominoperitoneal resection often diminishes the risk of local recurrence, but mortality and morbidity rates are very high, especially in the elderly. Although local treatment for rectal cancer remains controversial, the author believes that the elderly constitute a separate category of patients because their mortality and morbidity rates are high and because they usually are unable to care for a colostomy. Local treatment seems a much more desirable form of therapy. A series of 6 elderly patients (average age, 77) were treated by local electrocoagulation followed by radiation therapy, for biopsy-proven adenocarcinoma of the rectum; one died after nine months from liver metastases (present at the time of diagnosis), and one had to undergo a colostomy after 19 months. For the 4 remaining patients, follow-up has ranged from three years to nine months. To date there has been no recurrence, no evidence of metastases, and no mortality or morbidity. In the author's opinion, the results of electrocoagulation-radiation treatment of small rectal adenocarcinomas are superior to the results of radical surgery in elderly patients.

Reanastomosis of end stoma and mucous fistula without formal laparotomy.

I describe a method of reestablishing bowel continuity by anastomosis of an end stoma and mucous fistula without formal laparotomy. Both the end colostomy or ileostomy and mucous fistula are mobilized and a tunnel is created by blunt dissection along the anterior parietal peritoneum between the two sites. The more easily mobilized stoma is then drawn through the tunnel and out the other site and the anastomosis is performed. Advantages of the procedure include zero mortality in the present series, very minimal morbidity, early ambulation, feeding, and discharge from the hospital as well as minimal postoperative discomfort. Six patients underwent this procedure during the past three years. All results were considered satisfactory. The use of the intraperitoneal tunnel is an effective and safe method of restoring bowel continuity that precludes many of the complications associated with long laparotomy incisions.

Surgical management of familial polyposis and Gardner's syndrome.

Twenty-six patients with documented familial polyposis or Gardner's syndrome were followed up to twenty-eight years after total colectomy with ileorectal anastomosis. All patients were followed a minimum of five years. Patients were subjected to periodic proctosigmoidoscopies, and rectal polyps were electrocoagulated when found. In no patient in this series did an adenocarcinoma of the rectum develop during the follow-up period. Total abdominal colectomy with ileorectal anastomosis is the treatment of choice in patients with familial polyposis and Gardner's syndrome, provided adequate follow-up is assured and polyps are destroyed when encountered.

Abdominal actinomycosis: A complication of colonic perforation.

Actinomycosis is a chronic, suppurative, mycotic infection, which tends to form abscesses and fistulas. The organism is a saprophyte of the human mouth. When a break in the normal contiguity of the gastrointestinal tract occurs, the organism may gain access to the surrounding tissues and become almost impossible to eradicate without surgical extirpation and administration of a long course of antibiotics. The diagnosis of actinomycosis should be considered for any patient in whom persistent or unusual enterocutaneous fistulas develop, when there is a recent history of perforated viscus or surgical intervention involving the gastrointestinal tract, such as appendectomy. The diagnosis is confirmed by the presence of "sulfur granules" in the fistulous tracts.