Colorectal cancer in patients over 70 years old. A prospective study of operative results.

All patients (284, mean age 70.8 years) admitted with a diagnosis of primary colorectal cancer to our surgical department during the years 1984-87 were evaluated prospectively. We compare 170 (59.9%) patients > 70 years old and 114 (40.1%) patients < or = 70 years. The overall operability rate was 97.3% and the resectability rate 92.8%. The overall operative mortality rate was 2.1%, four patients in the older group and two patients in the younger group (NS). Among patients who underwent emergency surgery, the operative mortality was 6.1% (4 patients). The overall morbidity rate was 26.7% without significant differences between the two age-groups. A separate subset analysis was done to compare the very old patients (age > or = 80) to the old patients (age 70-79). There were no significant differences between these groups in tumor location, presentation and staging, as well as in operability rate and operative morbidity and mortality. The operative mortality in those over the age of 80 was 3.5%. We concluded that age should not be a determinant in consideration of operation for primary colorectal cancer, since operative mortality and morbidity are similar in both the elderly and their younger counterparts.

Prostaglandin E2 in duodenal ulcer complications.

Prostaglandins are presumed to have cytoprotective properties and may play a role in the pathogenesis of duodenal ulcer and its complications. To evaluate this hypothesis, 35 patients with either duodenal ulcer bleeding (18 patients) or gastric outlet obstruction (17 patients) were investigated. Biopsies were taken from gastroduodenal tissues and secretions for prostaglandin E2 (PGE2) levels. These levels were compared to those taken from the same areas during a later endoscopy. A correlation was found between the severity of the clinical endoscopic findings and PGE2 levels. Increased levels of PGE2 were found in the quiescent phase and decreased levels found during the deteriorated phase. These differences of PGE2 levels were found to be of significant value (P less than 0.002). Furthermore, the patients in which the PGE2 levels were decreased at second endoscopy needed surgery. PGE2 may, thus, be a factor in duodenal ulcer pathogenesis and its complications, and be used as a prognostic marker and guide.

Perforated duodenal ulcer in the elderly patient.

Acute perforation of a duodenal ulcer in a patient over of 70 years of age is associated with a high death rate. During a 10-year period, 35 such patients were operated on; in all omentopexy was performed. Two courses of the disease were observed: the first (19 patients) was defined by acute disease of less than 24 hours' duration preceding surgery; the second (16 patients) was of longer duration, starting with various abdominal complaints and presenting more severely only after the first 24 hours. Postoperative death rates were 0% in the first group and 50% in the second. Other factors that were studied, including diabetes mellitus, presence of concomitant malignant diseases and intake of ulcerogenic drugs, had no significant effect on the outcome in these patients.

Methane production in patients with colorectal carcinoma.

In searching for a screening test to identify a population at high risk for large bowel cancer, methane production was measured in 45 patients with colorectal carcinoma compared with 67 individuals who served as a control group. There was no significant difference in methane production between the colorectal cancer patients and the control group (37.8 and 25.4% respectively). Within the colorectal cancer group 54% of the males were methane producers compared with 19% of the females (P = 0.03). There were no differences according to disease stage. In view of these results, we see little value in using expired air methane concentration as a screening test for large bowel cancer.

Prostaglandin E2 in pyloric stenosis.

Prostaglandins are presumed to have many cytoprotective properties that play a role in the pathogenesis of duodenal ulcer and its complications where decreased levels of prostaglandin E2 (PGE2) impair gastric motility, oppose ionic membrane influx, and enhance obstructive changes. These are just some of the mechanisms that may cause pyloric obstruction and may result from decreased PGE2 levels. To evaluate this hypothesis, 17 patients with duodenal ulcer complicated by pyloric stenosis were examined. Biopsy specimens were obtained from the duodenal bulb, ulcer margins, gastric antrum, fundus, and gastric secretions. Prostaglandin E2 levels were measured and compared with those taken from the same areas during a second endoscopy in a later quiescent or exacerbated phase. During the active phase of pyloric stenosis, decreased levels of PGE2 were found in the gastroduodenal tissues and secretions were compared with levels found during convalescence. These level differences were statistically significant. A correlation between the severity of the clinical and endoscopic findings and the PGE2 levels was found. A further decrease in PGE2 levels in the second endoscopy were indicative of the presence of scar tissue, representing an irreversible obstructive peptic disease.

Biliary colic treatment and acute cholecystitis prevention by prostaglandin inhibitor.

Sixty patients were treated in the emergency ward for biliary colic. Cholelithiasis was proven by ultrasonography. Twenty patients (group I) were treated by placebo. Twenty patients (group II) were treated by papaverine, and 20 patients were treated by diclofenac sodium (Voltaren) (group III). Twenty more patients (group IV) with low back pain (LBP) were treated with diclofenac sodium (Voltaren) as a control to assess the analgesic effect of Voltaren. Two interesting observations were made: Voltaren was proven more efficient for pain relief (P less than 0.002), and none of the patients treated with Voltaren were in need of hospitalization and immediate surgery. In comparison, nine patients of the other two groups progressed to acute cholecystitis and needed surgical intervention. The possible anticolic and anti-biliary inflammation properties and the indications for use of Voltaren are discussed.

Plasmacytoma of the stomach.

A case of plasmacytoma of the stomach is described. The clinical presentation, diagnostic pitfalls and the treatment of this rare entity are discussed.

Leukergy in inflammatory bowel disease.

In the phenomenon of leukergy, white blood cells agglomerate in peripheral blood slides. This agglomeration has been described in inflammatory infections of various causes. This study assesses this phenomenon in inflammatory bowel disease. A correlation was found between the severity of inflammatory bowel disease activity and the percentage of leukergy. Leukergy was found to parallel the clinical and endoscopic findings of inflammatory bowel disease. Furthermore, leukergy was found to be more accurate than white blood count and erythrocyte sedimentation rate. It is also found to accurately assess the course of the disease when clinical and other laboratory tests were masked by steroid and antibiotic administrations. Leukergy is a quick, inexpensive test that can easily be performed at the patient's bedside.

Colonic bleeding due to rupture of an isolated iliac artery aneurysm into a caecal carcinoma.

We describe a case of a fistula between an atherosclerotic aneurysm of the right common iliac artery and a caecal carcinoma, causing massive colonic bleeding. A fistula between a true aneurysm and a carcinoma of the colon has not to our knowledge been previously reported. Various aspects of this case are discussed from a pathogenetic point of view.

Prevention and treatment of urinary retention and infection after surgical treatment of the colon and rectum with alpha adrenergic blockers.

In a retrospective study, 153 male patients who underwent surgical treatment of the colon and rectum presented with complaints indicating obstruction of the prostate gland and clear indications for preoperative administration of alpha-blockers. Between the years 1982 and 1984, the alpha-blocker phenoxybenzamine hydrochloride (PB-HCl) was prohibited from use by the Ministry of Health because of suspicions of its carcinogenic properties. This enabled a comparative study between two groups of patients. Seventy-five patients (group 2a1) were prohibited from receiving PB-HCl. Urinary retention occurred in 54.7 per cent and urinary tract infection in 65.3 per cent. Seventy-eight patients (group 2a2) were administered PB-HCl. In this group of patients, urinary retention occurred in 19.2 per cent and urinary tract infection in 15.4 per cent. Forty-one patients with urinary retention of group 2a1 who were not administered PB-HCl were compared with 50 patients with urinary retention (group 3) who received PB-HCl. Spontaneous relief was observed in 21.9 and 76.0 per cent, respectively. PB-HCl was shown to be extremely effective, both as a preventative and therapeutic agent, when complaints indicating the prostate gland are present in patients undergoing surgical treatment of the colon and rectum.

Low-energy CO2 laser intestinal anastomosis: an experimental study.

Intestinal anastomosis was performed in 17 Wistar rats via tissue welding by the low-energy CO2 laser. The postoperative course in the animals studied was uneventful. The integrity of the anastomosis was investigated manometrically, immediately upon completion of the anastomosis as well as 20 days later. Ten additional Wistar rats served as controls in which conventional interrupted one-layer anastomosis was performed. The results show a significant superiority of the intestinal anastomoses that were constructed by means of laser tissue welding. The time to complete the anastomosis was also significantly shorter when laser rather than manual suturing was used. Serial histological examinations for up to 90 days following surgery revealed complete healing and epithelization of the anastomotic site.

Alpha-adrenergic blocker for posthernioplasty urinary retention. Prevention and treatment.

In a prospective, randomized study, 102 patients over the age of 60 years underwent inguinal hernioplasty. We compared a group of 58 patients who received phenoxybenzamine hydrochloride with a control group of 44 patients. The phenolsulfonphthalein test was performed in all patients. Twenty-six (25.5%) of the 102 patients developed acute urinary retention after the hernioplasty; all of them were in the control group. All of these 26 patients had pathological phenolsulfonphthalein test. In 21 of these 26 patients, urinary retention disappeared within 48 hours following phenoxybenzamine administration.

Intrarectal bypass graft in low anterior resection and sigmoid obstruction--an experimental study.

The most common causes for morbidity and mortality in colorectal resections are anastomotic leaks. In low anterior resection, the incidence of anastomotic leakage ranges from 17 to 50%. With the use of the stapler technique, leakage incidence rate remains high and ranges from 10 to 25%. Colostomy formation and closures are associated with considerable morbidity and mortality. Due to the high incidence of anastomotic leakage rate in low anterior resection, and the additional complications of diverting colostomy formation and closure, the use of a rectal stent-intrarectal bypass graft has been instituted. This is carried out by means of a silastic graft, which prevents the fecal stream and gas pressure from coming into contact with the anastomotic site at the low rectum. The efficacy of intrarectal bypass graft was examined in two high-risk surgical situations, the first in very low anterior resection and the other, after early sigmoid obstruction. In both situations the intrarectal bypass graft provided for a safe anastomosis. Even when dehiscence and early obstructions occur, the tube may prevent leakage. This procedure presents effective practical implications which obviate the need for a proximal colostomy formation, thereby eliminating the physical and psychological stress that accompanies colostomies.

Hidden loop jejunostomy--an experimental model.

A hidden loop jejunostomy, the placement of a proximal small bowel loop under the skin of dogs, is described. A feeding tube was inserted in the loop at a later date, which enabled feeding for at least 6 weeks. This procedure was well tolerated by the 10 dogs involved in this experimental model. It should be considered as a possible surgical procedure at initial explorative laparotomy in patients with advanced cancer originating at the gastric cardia or esophagogastric junction.

Right and left colon carcinoma: a retrospective comparative study.

We studied 347 patients with primary colorectal carcinoma treated by surgery during 1973-1983: 64 (18.2%) with right colon carcinoma, 158 (45.7%) with left colon carcinoma, 14 (4.2%) with transverse colon carcinoma, and 110 (31.9%) with rectal carcinoma. We compared the right-sided carcinoma (RSC) and left-sided carcinoma (LSC) groups. Obstruction was found in 17.2% of RSC compared with 20.3% LSC patients (P greater than 0.05). Advanced disease (Dukes stages C and D) was found in 34.4% on the right and 47.8% on the left side (P = 0.01). Crude 5-year survival rate, by life table method, was 71% on the right and 66% on the left side (P greater than 0.05); this difference became significant (P = 0.03) when Dukes stage B patients were compared. We conclude that patients with RSC are not diagnosed, as is commonly believed, at advanced stages of the disease. We found that the 5-year survival rate of RSC patients was the same or, occasionally, better than that of LSC patients.

Recurrent spontaneous perforation of the colon.

A 58-year-old man with recurrent spontaneous perforations of the colon is reported. The first two events were of the sigmoid colon, and a sigmoidectomy was performed after the second perforation. The third spontaneous perforation had occurred in the transverse colon, however, although a patent sigmoid colostomy was present. Neither primary colonic pathology nor elevated intraluminal pressure were found, which means that the cause and pathogenesis of these perforations are unknown. Six months later, a subtotal colectomy with ileo-sigmoid anastomosis was performed with an apparent satisfactory result.

Common bile duct stone caused by a foreign body.

Foreign bodies are very rare in the common bile duct. We report a patient with incomplete obstruction of the common duct, due to stone formation around an ingested fish bone.

Operative cholangiography with an antiseptic contrast solution. An experimental study in dogs.

A new antiseptic contrast material, composed of sodium diatrizoate-meglumine diatrizoate and PVP-iodine solutions, was prepared and tested for operative cholangiography. It was tested in vitro, and in vivo in dogs and displayed satisfactory contrast radiologic features, and strong and rapid bactericidal action without detectable side effects. It seems to be promising in reducing the risk of bacterial spread during cholangiography.