Electrocoagulation as primary therapy for rectal carcinoma.

The survival of forty-seven patients with cancer of the rectum treated by electrocoagulation is compared with thirty-seven patients treated by abdominoperineal resection. The one to ten year survival for the electrocoagulationgroup was 48 per cent and the one to eight year survival for the abdominoperineal resection group was 46 per cent. We believe that electrocoagulation when selectively applied has a place in the management of cancer of the rectum.

Five year survival in patients with carcinoma of the rectum treated by electrocoagulation.

Sixty-eight patients with rectal cancer treated by electrocoagulation are reviewed. All were followed up for a minimum of 5 years. The survival rate in patients with small exophytic cancers is greater than 70 percent. However, the recurrence rate after electrocoagulation is 40 percent. Electrocoagulation offers an alternative for the primary treatment of rectal cancer, particularly in older patients with small lesions.

Is preoperative colonoscopy necessary in carcinoma of the colon and rectum?

The incidence of synchronous polyps of the colon has been shown to be 25 to 40 per cent and the incidence of synchronous carcinomas to be two to eight per cent. Because of this, many surgical groups now advocate routine preoperative colonoscopy on all patients with colon carcinoma. The possibility of spreading and implanting tumor cells with the colonoscope has prompted the authors to purposely avoid preoperative colonoscopy and then clear the colon of any missed lesions with an early postoperative colonoscopy. This study is a retrospective review of 104 patients who have undergone a partial colectomy for colon and rectal carcinoma followed by a postoperative colonoscopy between June 1982 and June 1986. The purpose is to determine the adequacy of intraoperative palpation to detect synchronous neoplasms, and to further define the role of perioperative colonoscopy. The results of 34 per cent synchronous polyps and 5.8 per cent synchronous carcinomas parallels previous studies. The six patients with synchronous carcinomas were discovered by intraoperative palpation and the operation was modified in four of the six patients. Postoperative colonoscopy revealed polyps in 20 per cent of the patients, but all of these were amenable to snare polypectomy or electrocoagulation. No carcinomas were overlooked by palpation. It is our conclusion that intraoperative palpation is adequate for detection of synchronous carcinomas and therefore the risk and expense of preoperative colonoscopy can be avoided. Early postoperative colonoscopy, however, is imperative to clear the colon of small polyps which have the potential to progress to carcinoma.

Presacral cysts: transrectal excision in select patients.

Fourteen patients presenting with presacral cystic lesions were managed over a 20-year period. Retrospective review identified 12 females and 2 males. Fifty-seven per cent were symptomatic at diagnosis. Forty-three per cent presented with pain; half of these patients had infected cysts. All lesions were palpable on digital rectal exam. Computed tomography identified the cyst in all seven patients in which it was performed. The transrectal approach was used for cyst excision in ten patients. One patient had transrectal drainage and wall biopsy only. Three patients underwent posterior parasacral excision. Pathologic review demonstrated four dermoid cysts, four epidermoid cysts, four cyst hamartomas, and two benign teratomas. One cyst hamartoma had a focus of invasive adenocarcinoma. Two complications occurred. There were no deaths. Follow-up averaged 39 months, at which time there were no recurrences. Developmental cysts are the most common presacral tumors. Excision is recommended, and the transrectal approach may be used in select patients with low morbidity and minimal recurrence.

Symposium on outpatient anorectal procedures. Pilonidal disease.

Many procedures have been advocated to treat pilonidal disease, suggesting that no one method is highly efficacious. In the office, the surgical approach is directed towards three aspects of the condition: pilonidal abscess, recurrent pilonidal disease following surgery and chronic pilonidal disease following spontaneous rupture of an abscess or secondary to incision and drainage. In managing the acute pilonidal abscess, an intradermal injection is given over the indurated, fluctuant area as well as the midline orifice which can almost always be identified. The midline orifice is incised and the incision carried into the abscess cavity. The edges of the cavity are excised. Healing takes place secondarily. A second procedure is rarely needed.

The levator syndrome and its variant.

The levator syndrome is an entity characterized by pain high in the rectal area that can be elicited by pressure applied to the levator ani. The etiology, diagnosis, and treatment of this disorder are described. Its importance lies in its misdiagnosis or in the failure to diagnose.

Surgical management of diverticulitis. The role of the Hartmann procedure.

Presented is the authors' experience with 182 patients treated primarily by the one-stage primary resection or two-stage resection. (Hartmann operation). One hundred thirty five patients undergoing primary resection had an associated mortality rate of 2.2 per cent. Of 44 patients operated upon using the Hartmann operation for complicated diverticulitis (obstruction, perforation, abscess formation, or fistula formation) the mortality rate was 4.5 per cent. Primary resection in an elective setting is associated with the lowest mortality and morbidity; however, marked inflammation, obstruction and/or peritonitis preclude primary anastomosis. In the urgent setting the staged operation is associated with acceptable morbidity and mortality.

Suture-line recurrence in carcinoma of the colon and rectum.

Seventy-three patients with adenocarcinoma of the sigmoid, rectosigmoid and rectum were reviewed to determine the incidence of suture-line recurrence. Four patients (5.5 per cent) developed suture-line recurrence despite the use of a number of techniques to reduce this problem. All four recurrences were in patients who had Dukes' C lesions of the rectum. It would appear that such recurrences are not related to implantation factors alone.

Lateral internal sphincterotomy.

Lateral internal sphincterotomy proved to be effective in 99 per cent of the 418 procedures in which it was performed. The complication rate of 5 per cent was an improvement over most of the rates reported in the medical literature and over our previous experience with posterior sphincterotomy and anoplasty. Anal wounds and fissures healed faster than with previous procedures. It is encouraging that this simple and rapid procedure has such great efficacy with a minimum of complications.

Conservative treatment of anal fissure: an unselected, retrospective and continuous study.

Three hundred and ninety-three patients who had anal fissures were followed continuously for approximately five years. More than 44 per cent of them were cured nonsurgically within a four-to-eight-week period. There was an 8 per cent complication rate, consisting of abscesses and fistulas, necessitating surgical treatment. The recurrence rate following healing was 27 per cent, but a third of these patients had recurrent fistulas that healed in response to further conservative treatment. The authors feel that conservative treatment of anal fissure is justified unless there is advanced anal stenosis.

Bupivacaine, a long-acting local anesthetic, in anorectal surgery.

The long-acting local anesthetic, bupivacaine, was used in a series of 467 anorectal patients, both inpatients and outpatients. Bupivacaine was found to be safe and effective. Like other local anesthetics, it has none of the operative and postoperative complications frequently associated with general or spinal anesthetics. Its longer duration of action makes it extremely useful in anorectal operations on hospatilized and non-hospitalized patients. The potential hypertensive effects of using epinephrine in the local anesthetic solution appears to be negated by the calming, hypotensive effects of the intravenously administered sedatives in hospitalized patients.

The dilemma of pilonidal disease: pilonidal cystotomy, reappraisal of an old technique.

A series of 126 patients treated by inhospital pilonidal cystotomy is reviewed. One hundred twenty-four were treated using local anesthesia with supplemental diazepam or Innovar. Most patients spent only three days in the hospital, with healing occurring in less than two months. Recurrences occurred in 20.9 per cent of the patients. The recurrences were treated by office procedures in all but one instance. Most patients were pain-free and back to work within two weeks after operation.

Detachment of the continent ileostomy poucn from the anterior abdominal wall: report of two unusual cases.

The cases of two patients with continent ileostomies are presented. These illustrate the problems encountered with detachment of the pouch from the abdominal wall resulting in angulation of the efferent loop of the pouch in relation to the nipple valve and difficulty intubating the pouch. Both patients required operative correction of the separation. Several suggestions are made in order to prevent or decrease the incidence of the complications. Removal of a peritoneal strip around the efferent loop of the pouch appears to facilitate adequate fixation of the pouch to the anterior abdominal wall.

The outpatient management of acute hemorrhoidal disease.

A procedure for the outpatient management of acute hemorrhoidal disease is presented. Treatment, using local anesthesia with hyaluronidase, is directed to (1) relieve pain, (2) decrease edema, (3) treat appropriately the internal hemorrhoidal disease, and (4) treat the external thrombosis if present. Adequate treatment of the acute disease will, in a significant proportion of patients, avoid further surgical intervention. Eperience with results of this modality of treatment in patients is presented.

Surgical treatment of complete rectal prolapse.

The Ripstein procedure was used to effect a cure of rectal procidentia in 30 patients. There was no operative mortality, and morbidity was confined to problems related to two patients with intestinal obstruction, one with fecal impaction, and one with wound infection. We believe the operation to be the treatment of choice in patients to control the anatomic and clinical abnormalities related to rectal procidentia. Associated colonic abnormalities, such as an extremely redundant sigmoid or associated diverticulitis, may dictate the choice of a different procedure that does not require introduction of a foreign material.

Tube cecostomy with cecal extraperitonealization in the management of obstructing left sided carcinoma of the large intestine.

The technique of tube cecostomy has enabled us to manage safely and expeditiously patients with obstruction of the large intestine secondary to left sided carcinoma. Extraperitonealization of the cecum and insertion of a large bore catheter are each critical to the success of this modality.

Complications of colostomies.

One hundred twenty-six patients underwent 130 end colostomies, 44 for benign and 86 for malignant disease, and were followed for an average of 35 months. The left or sigmoid colon was used in 99 and the transverse colon in 31. Stomas were made electively in 98 patients and urgently in 32. Seventy-six stomas were brought out through the incision and 54 from separate sites. There were 69 complications in 55 patients (44 percent) including 11 strictures, 9 wound infections, 14 hernias, 9 small-bowel obstructions, 4 prolapses, 2 abscesses, 1 peristomal fistula, 17 skin erosions, and 2 poor stoma locations. Fifteen complications required reoperation. Five of these procedures included stoma revision. Total numbers of complications were not related to the stoma site, the disease process, the urgency of the procedure, or the segment of colon used. Wound infections, however, were increased in urgently made stomas. The incidence of hernia was equivalent in stomas brought out through the incision or at a separate site. Forty-one patients (30 percent) had 43 colostomies closed an average of 3.5 months after creation. Thirteen patients had 14 complications--5 wound infections, 6 hernias, 2 small-bowel obstructions, and 1 rectovaginal fistula. One patient died. Four patients required reoperation. There were no anastomotic leaks. Complications were equivalent in Hartmann closures and transverse colostomy closures. Complications were similar in stomas created for cancer and those created for diverticular disease.

Seton management of complex anorectal fistulas in patients with Crohn's disease.

Anorectal fistulas associated with Crohn's disease are difficult to manage, particularly when the rectum is diseased. Significant morbidity has been associated with both medical and surgical therapy. Although conventional therapy is acceptable in the management of simple fistulas in Crohn's disease, these approaches often exacerbate rather than ameliorate problems in patients with complex fistulas. The authors report ten cases of complex fistulas in patients with Crohn's disease managed with their technique of long-term, indwelling setons. These setons are placed through the fistula tract and tied loosely to maintain the patency of the fistula without cutting through the sphincters. At the time of insertion, although abscesses are incised and drained, no attempt is made to divide the superficial tissues or sphincter overlying the fistulous tract. The patients ranged in age from 23 to 81 years and had a history of Crohn's disease for 1 to 20 years. All cases resulted in excellent palliation. No patient required a proximal colostomy. These patient have been followed for four months to seven years. Despite severe proctitis in six of these patients at the initial operation, no patient has required a proctectomy. The authors believe this technique achieves adequate palliation and should be employed as the procedure of choice in patients with complex anal fistulas associated with Crohn's disease.