The Turnbull-Cutait pullthrough procedure for certain cancers of the rectum and Hirschsprung disease.

The technique of the Turnbull-Cutait pullthrough procedure as performed at the Cleveland Clinic for carcinoma of the rectum and other conditions is described. The results in 127 patients are reported. Eighty-four patients were operated upon for cancer of the rectum and 47 for miscellaneous benign conditions. The average distance of tumors from the anal margin was 7.6 cm. The average margin of resection was 4.1 cm. The overall operative mortality was 1.2% in the cancer group. Ischemic necrosis occurred in 1.2% of the cancer patients, and minor pelvic sepsis occurred in 7.1%. The five-year survival in Dukes' A, B and C carcinoma of the rectum was 100%, 57% and 53%, respectively. The incidence of pelvic recurrence of the tumor at 6% was within acceptable limits. The quality of bowel function following the pullthrough procedure is discussed. It is concluded that this pullthrough procedure has a significant role in the management of carcinoma of the rectum and other conditions.

The risk of cancer following colectomy and ileorectal anastomosis for extensive mucosal ulcerative colitis.

A retrospective study was performed on 89 patients who underwent total colectomy and ileorectal anastomosis for extensive mucosal ulcerative colitis between the years 1957 and 1977 in order to determine the risk of developing cancer of the rectum. The 30-day operative mortality rate was 0%. Of the 84 patients available for follow-up study, four patients, (4.8%) developed a carcinoma of the rectum. The risk of cancer per patient-year was zero in the first decade, 1/206 in the second decade, and 1/116 in the third decade. The cumulative risk of developing cancer was 0% at 10 years, 2.1% +/- 2.1% at 15 years, 5.0% +/- 3.5% at 20 years, and 12.9% +/- 8.3% after 25 years of disease. Patients with cancer or precancer in the colon at the time of colectomy appear to be at high risk for the later development of rectal cancer.

Late development of colorectal cancer subsequent to pelvic irradiation.

Two cases of irradiation-associated carcinoma of the colon are reported and the literature reviewed. The clinical courses and operative difficulties in treating these patients are emphasized. The necessity for life-long follow-up examinations with proctoscopic and barium-enema evaluations in high-risk patients is stressed. Irradiation-associated carcinoma of the colon occurs almost exclusively in women, but should be investigated in patients of either sex who live for long periods after pelvic irradiation.

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.

Pullthrough operation with delayed anastomosis for rectal cancer.

The technique of pullthrough resection with delayed anastomosis for carcinoma of the rectum as performed at the Cleveland Clinic is described. A series of 84 cases of rectal cancer treated in this way is reported. The average tumour diameter was 4.5 cm, the average margin of resection was 4.1 cm and the average distance of the tumour from the anus was 7.6 cm. The incidence of necrosis of the pullthrough was 1.2 per cent. The overall 5-year survival was 63 per cent with 100 per cent, 57 per cent and 53 per cent for Dukes' A, B and C tumours respectively. The quality of bowel function following surgery is described in detail. It is felt that this procedure has an important place in sphincter conservation in carcinoma of the middle third of the rectum.

Left-sided colectomy with retroileal colorectal anastomosis.

Following resection of the sigmoid and descending colon for cancer or extensive diverticular disease, it may be impossible to make a colorectal anastomosis due to inadequate length of the residual transverse colon. To correct this problem, the remaining transverse colon may be pulled into the pelvis by making a "window" in the terminal part of the ileal mesentery. From January 1966 to January 1975, 302 resections of the descending colon with colorectal anastomoses were performed by one of the authors (R.B.T.) for upper sigmoid cancer and extensive diverticulitis at the Cleveland Clinic. Eleven patients (4%) had retroileal colorectal anastomoses. The retroileal apprach is a technical aid when performing an extensive left-sided colectomy and/or when there is insufficient length of residual transverse colon to make a tension-free colorectal anastomosis.

Transperitoneal relocation of the ileal stoma without formal laparotomy.

A method of transperitoneal ileal stoma relocation without formal laparotomy is described. Twenty of these procedures were performed during a ten year period. There was one postoperative failure. The barium stomal injection is a valuable aid in the peroperative diagnosis of possible underlying Crohn's disease. Transperitoneal relocation of an ileal stoma without formal laparotomy is a safe and useful method in selected patients.

Total fecal diversion by the temporary skin-level loop transverse colostomy.

The temporary skin-level loop transverse colostomy has been described. Proof of its ability to divert the fecal stream totally is illustrated by complete diversion in 25 patients ingesting a postcolostomy barium meal. There was no postoperative complication.

The dilemma of Crohn's disease: ileosigmoidal fistula complicating Crohn's disease.

Between 1965 and 1975, 27 patients underwent surgical treatment for ileosigmoidal fistulas complicating Crohn's disease at the Cleveland Clinic. There was no death and no anastomotic leak. The preferred procedure is resection of the ileocecal area involved by Crohn's disease with ileocolic anastomosis and a separate segmental resection of the sigmoid colon with colocolic anastomosis. A covering temporary loop ileostomy is used when there is associated pelvic sepsis or small-bowel obstruction.

The dilemma of Crohn's disease: ileoduodenal fistula complicating Crohn's disease.

Nine cases of duodenal fistula complicating Crohn's disease are reported. All nine patients were male. Four patients had Crohn's disease of the ileum and five had ileocolitis. No patient had primary duodenal Crohn's disease. Because attempt at primary closure of the duodenal defect may fail, our treatment of choice has been formal cross cut two-layered duodenojejunal anastomostis with extensive drainage of the area postoperatively. This treatment has been associated with no mortality and little morbidity, and no late recurrence of duodenal fistula.

Fibrous inflammatory polyps of the ileum and cecum: review of five cases with emphasis on differentiation from mesenchymal neoplasm.

Five case histories of patients with fibrous inflammatory polyps of the ileocecum are reported. Clinical impression in all five cases was that these tumefactions represented gastrointestinal malignancies. Gross pathologic examination revealed polypoid intramural growths ranging from 2.5 to 7.0 cm in greatest dimension. Transmural desmoplasia through the bowel wall into subserosal fat was initially thought to be indicative of neoplastic invasion. Microscopic evaluation revealed a fibroblastic and vascular proliferative process. Pseudosarcomatous changes were identified in cellular fibroblastic areas with plemorphism and mitotic activity. The manner of dissection among bundles of muscularis mucosae and muscularis propria suggests an inflammatory process as opposed to the pushing aside of whole large muscle bundles as seen in mesenchymal neoplasms arising in bowel wall. All five patients experienced survival of 6 to 17 years following surgery. These lesions are thought by us to represent localized exuberant polypoid granulation tissue proliferations which simulate mesenchymal neoplasm.

Indications for surgery in Crohn's disease: analysis of 500 cases.

Data for 500 patients with Crohn's disease who underwent operations were analyzed (316 patients, 1966 to 1969; 184 patients, 1972 to 1973) by comparison of various anatomic disease locations (clinical pattern): (1) ileocolic, 225 patients; (2) small intestinal, 130 patients; (3) colonic, 127 patients; (4) anorectal, 18 patients. Indications for surgery were tabulated and compared using statistical analysis for the three large patterns. For patients with ileocolic Crohn's disease, the primary surgical indications were internal fistula and abscess, 44%, intestinal obstruction, 35%, and perianal disease, 12%. For patients with Crohn's disease of the small intestine, the primary surgical indications were intestinal obstruction, 55%, and intestinal fistula and abscess, 32%. Patients with colonic Crohn's disease had a significantly more diverse surgical indication, with poor response to medical therapy, 26%, internal fistula and abscess, 23%, toxic megacolon, 20%, and perianal disease, 19%. These values were highly statistically significant (P less than 0.0001) in all instances but one. This study demonstrates that statistically significant differences occur in the surgical indication depending on the location of Crohn's disease. Patients with ileocolic, small intestinal, and colonic involvement have striking differences in clinical course. It is concluded that Crohn's disease is not a homogeneous entity, but should be recognized as having a varying course depending on clinical pattern.

Grafting the unhealed perineal wound after coloproctectomy for Crohn disease.

The unhealed perineal wound following proctectomy for Crohn disease is a most unfortunate and disabling complication; treatment has been generally unsuccessful and disappointing. Since 1967, we have managed these wounds by skin-grafting the raw surface of the saucerized wound, rather than by attempting to obliterate the cavity. The graft is applied to the defect two or three days after wide debridement and saucerization. No attempt is made to cover more than the readily accessible raw surface. The graft is first dressed on the third postoperative day, and daily thereafter. The patient receives 40 units of corticotropin (ACTH) daily during his hospital stay; the drug therapy is continued in smaller dosage for several months. Results to date have been satisfactory, with seven wounds totally dry, and 37 resurfaced sufficiently so as to make the amount of drainage negligible. Four patients had results classified as poor.