Survival following resection for colorectal cancer

The crude overall five-year survival rate for New Zealand patients with colorectal cancer treated surgically was 42 percent. Less than 50 percent of patients with Stage I and Stage II tumors survived ten years. Women survived longer after surgery than men. It was not possible to determine a biologic cure rate because postmortem data were not available. Read at the joint meeting of the American Society of Colon and Rectal Surgeons with the Section of Colo-Proctology, Royal Society of Medicine, and the Section of Colonic and Rectal Surgery, Royal Australasian College of Surgeons, New Orleans, Louisiana, May 6 to 11, 1984.     

Diagnosis of disturbances of continence and defecation

Defecography was performed in 60 patients with disorders of continence or defecation in whom previous investigative procedures had not revealed any abnormality that could explain the disorder. A correct diagnosis was made in 47 patients (78%). Defecography appears to be a suitable procedure to detect functional disturbances of defecation. Since anterior rectal wall abnormalities such as colitis cystica profunda and solitary rectal ulcer were seen in eight patients, is in suggested that these abnormalities are a result of functional disorders of defecation. Furthermore, the function of the pelvic floor musculature can be assessed by defecography in order to determine the cause of fecal incontinence. Read at the joint meeting of the American Society of Colon and Rectal Surgeons, the Section of Colo-Proctology of the Royal Society of Medicine, and the Section of Colonic and Rectal Surgery of the Royal Australasian College of Surgeons, New Orleans, Louisiana, May 6 to 11, 1984.     

Reconstruction of rectovaginal fistula with sphincter disruption by combining rectal mucosal advancement flap and anal sphincteroplasty

PURPOSE: This study evaluated the effectiveness of combining advancement flap with sphincteroplasty in patients symptomatic with rectovaginal fistula and anal sphincter disruption. METHODS: Twenty patients with rectovaginal fistulas and anal sphincter disruptions after vaginal deliveries underwent combined rectal mucosal advancement flap and anal sphincteroplasty between July 1986 and July 1993. The mean age of the patients was 30 (range, 18–40) years and the mean duration of symptoms was 54.8 weeks (range, 7 weeks to 6 years). In addition to mucosal advancement flap repair, 13 patients underwent two-layer repair of anal sphincters (with reapproximation of the puborectalis in 8 of the patients); 6 patients underwent one-layer overlap repair of anal sphincters (with reapproximation of the puborectalis in 2 of the patients); and 1 patient underwent reapproximation of internal anal sphincter alone because squeeze pressures were adequate, as determined by anal manometry. RESULTS: Postoperatively, vaginal discharge of stool and flatus was eliminated entirely in all 20 patients. Perfect anal continence of stool and flatus was restored in 14 patients (70 percent). Incontinence was improved but not eliminated in six patients (4 incontinent to liquid stool and 2 to flatus), and two patients required perineal pads. Subjectively, 19 patients (95 percent) reported the result as excellent or good. There were no complications. CONCLUSION: The combination of mucosal advancement flap and anal sphincteroplasty is a safe and highly effective procedure for correcting rectovaginal fistula with sphincter disruption after obstetrical injuries.Poster presentation at the meeting of the American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994.     

The sialomucin content of colonic resection margins

In a prospective trial, the resection margins of 130 patients who underwent apparently curative resection for colorectal cancers were examined. Sialomucin was markedly increased in 17.0 percent of proximal resection margins and 17.3 percent in distal resection margins. Clinical follow-up has demonstrated four patients who have developed local recurrence of their disease. Three of these patients had increased sialomucin staining in the resection margins at the time of initial surgery. High iron diamine-alcian blue staining of resection margin may identify those patients at risk of developing local recurrence of colorectal cancer or metachronous tumor following apparently curative resection. Supported by the Cancer Research Council of the United Kingdom. Read at the joint meeting of the American Society of Colon and Rectal Surgeons with the Section of Colo-Proctology, Royal Society of Medicine, and the Section of Colonic and Rectal Surgery, Royal Australasian College of Surgeons, New Orleans, Louisiana, May 6 to 11, 1984.     

The fate of the rectal stump after subtotal colectomy for ulcerative colitis

In a retrospective review of 311 patients having subtotal colectomy for ulcerative colitis, information on the fate of the rectal stump was obtained in 288. Proctectomy was performed in 159 patients (55 percent); for persistent proctitis in 118 (41 percent), cancer prophylaxis in 37 (13 percent), and cancer in four (1.4 percent). One hundred twenty-two patients (42 percent) had ileorectal anastomoses. Eighty-four of these (69 percent) retained a functioning ileorectal anastomosis at the time of follow-up or death, one to 22 years later, and an additional six patients (5 percent) had a satisfactory ileorectal anastomosis for five to 14 years before proctectomy. Cancer developed in the rectal stump in nine patients (3.1 percent), underscoring the need for either proctectomy (total or mucosal) or long-term surveillance of the retained rectum. However, subtotal colectomy, by permitting ileorectal anastomosis or other sphincter-preserving surgery at a later date, does have a definite place in many patients requiring surgery for ulcerative colitis. Read at the joint meeting of the American Society of Colon and Rectal Surgeons with the Section of Colo-Proctology, Royal Society of Medicine, and the Section of Colonic and Rectal Surgery, Royal Australasian College of Surgeons, New Orleans, Louisiana, May 6 to 11, 1984.     

Parks' coloanal pull-through anastomosis for severe,complicated radiation proctitis

A variety of operations have been proposed for the treatment of radiation injuries of the rectum. In this study, the procedure advocated by the late Sir Alan Parks—resection of the diseased segment down to its points of fixation to the vagina, bladder or prostate; with perianal mucosal stripping of the anorectal segment and primary coloanal (pull-through) anastomosis—was performed in 11 patients. In two others, an attempt at colorectal anastomosis was abandoned because of extreme scarring in the pelvis. The procedures were done following definitive treatment of carcinoma of the rectum (seven patients), carcinoma of the cervix (two patients), carcinoma of the uterus (one patient), carcinoma of the ovary (one patient), seminoma (one patient), and carcinoma of the bladder (one patient). One patient died from a pulmonary embolus on the seventh postoperative day. Of the survivors with a coloanal anastomosis, all had successful closure of their temporary colostomies with follow-up from one to six years. In eight, continence was assessed as being good or excellent. Four patients required anastomotic dilatation and another required a surgical procedure for anastomotic stricture. There was one instance each of reoperation for small bowel obstruction and ileocolic fistula. There were no instances of recurrence of hemorrhage, fistulas, perineal pain or tenesmus. The Parks procedure obviates the need for a difficult dissection of the lower rectum and separation of tissues damaged by radiation and avoids the need for eversion techniques. Its selective use is advocated for patients suffering from severe radiation injuries of the rectum. Read at the Joint Meeting of the American Society of Colon and Rectal Surgeons with the Section of Colo-Proctology, Royal Society of Medicine, and the Section of Colonic and Rectal Surgery, Royal Australasian College of Surgeons, New Orleans, Louisiana, May 6 to 11, 1984. This paper received the Harry E. Bacon Foundation Award.     

Artificial anal sphincter

PURPOSE: This study was undertaken to evaluate the use of a fully implanted artificial anal sphincter for management of severe fecal incontinence. METHODS: An artificial anal sphincter was implanted in 12 patients who failed conventional management for severe fecal incontinence. Careful patient follow-up was recorded during a mean 58-month follow-up. Patients underwent preoperative and postoperative manometric assessment. Functional and patient satisfaction evaluations were obtained by mailed questionnaire. RESULTS: Three infections and three mechanical complications occurred in four patients (33 percent). A successful outcome was achieved in nine patients (75 percent). Postoperative manometric studies documented establishment of an elevated high-pressure zone compared with preoperative resting pressures. Seven patients returned a detailed functional assessment and patient satisfaction questionnaire at a mean of 40 months postsphincter activation. All seven patients reported continence to solid stool. Two patients had some problems with control of liquid stool, and three had occasional incontinence to flatus. Six of the seven patients rated their bowel control as good to excellent. All seven respondents were satisfied with their functional improvement. CONCLUSIONS: Early experience with an artificial anal sphincter has demonstrated that continence can be restored with acceptable morbidity in patients with severe fecal incontinence.Supported by American Medical Systems, Minneapolis, Minnesota.Presented in part at the meeting of The American Society of Colon and Rectal Surgeons, San Francisco, California, June 7 to 12, 1992.     

Anal manometry improves the outcome of surgery for fistula-in-ano

The aim of this prospective study is to investigate whether anal manometry is useful in orienting the surgical policy and improving the clinical and functional results following surgery for fistula-inano. Anal manometry was performed preoperatively and postoperatively in 96 patients. The results of surgery, in terms of both fecal soiling and recurrence rate, were analyzed and compared with those of another group of 36 subjects. Some operative maneuvers, such as internal sphincterotomy, laying open of the fistula with division of striated muscle, or use of a seton, were carried out according to the preoperative sphincter pattern as shown by anal manometry in the first group. A standard procedure was followed in the control group. The recurrence rate was 3 percent in the anal manometry group and 13 percent in the control group (P<0.01); postoperative soiling occurred in 14 percent of patients in the anal manometry group compared with 31 percent of patients in the control group (P<0.001). The functional results in transsphincteric and suprasphincteric fistulas, which are usually considered at higher risk for postoperative incontinence, were better in the anal manometry group, due to greater use of the seton. No increase in recurrence rate was observed in these complex fistulas after anal manometry. Internal sphincterotomy led to a disordered continence, mainly when associated with division of striated muscle; a significant decrease in resting tone from 56±22 to 47±50 and voluntary contraction from 114±30 to 85±28 mm Hg (mean ± S) was found after surgery in patients with soiling. In conclusion, the routine use of anal manometry may be recommended in the management of patients with fistula-in-ano as it improves the clinical and functional outcome of surgery. Read at the XIIth Biennial Congress of the International Society of University Colon and Rectal Surgeons, Glasgow, Scotland, July 10 to 14, 1988.     

Local recurrence of rectal carcinoma after hand-sewn and stapled anastomoses

A retrospective analysis was conducted of 119 consecutive patients in whom potentially curative anterior resection of invasive rectal carcinoma was performed between 1976 and 1982. Seventy-six anastomoses were stapled and 43 were hand-sewn. The distributions of tumor stage, location, histologic grade, size, and margins of resection were similar for both groups. The probability of local recurrence by two years for middle rectal tumors was 26±7 percent for the group with stapled anastomoses and 10±7 percent for those with hand-sewn anastomoses (P=0.07, log-rank test). Local recurrence probabilities did not differ for upper rectal tumors (P=0.14) or lower rectal tumors (P=0.20). Anatomic considerations that encourage use of the stapler may explain our findings. Read at the joint meeting of the American Society of Colon and Rectal Surgeons with the Section of Colo-Proctology, Royal Society of Medicine, and the Section of Colonic and Rectal Surgery, Royal Australasian College of Surgeons, New Orleans, Louisiana, May 6 to 11, 1984.     

Ileorectal anastomosis: A safe surgical technique

Conclusion We believe that by utilizing this technique for ileorectal anastomosis, the incidence of anastomotic leakage, with all its attendant mortality and morbidity, is minimized. Read at the joint meeting of the Section of Proctology, Royal Society of Medicine, the Section of Colonic and Rectal Surgery, Royal Australasian College of Surgeons, and the American Society of Colon and Rectal Surgeons, Washington, D.C., May 22 to 25, 1974.     

Surgical treatment of traumatic cloaca

PURPOSE: This study was designed to evaluate the repair of traumatic cloaca and determine the satisfactory outcome as determined by improvement in the continence mechanism of patients. METHODS: Forty-four patients were entered in this study during a 14-year period. The majority of traumatic cloaca occurred secondary to obstetric injury, most frequently during the first childbirth. No definite medical illnesses precipitated the occurrence of traumatic cloaca. Only two patients had diabetes mellitus, and one patient had prior radiation. All patients underwent surgical repair using puborectalis interposition and sphincteroplasty and perineal body repair, approximating the internal and external sphincter fused bundles and transversus perinei muscles in a vest-over-pants manner. Average stay in the hospital was less than three days, and postoperative morbidity was minimal. One patient had minor postoperative bleeding, which was corrected with cauterization. One patient had a superficial subcutaneous infection, which was drained on the 15th postoperative day. RESULTS: Majority of patients regained excellent control of continence to both flatus and feces. Four patients had unsatisfactory control to passage of flatus. One patient had unsatisfactory control to passage of liquid stool in addition to flatus. All five patients improved, with very satisfactory results, following an exercise program and biofeedback therapy. Six of 12 patients who had perineal discomfort before the surgical procedure, with associated dyspareunia, were the most dissatisfied subgroup in the series. Exact mechanism for perineal discomfort is unclear at this point.Read at the XVth Bienniel Congress of the International Society of University Colon and Rectal Surgeons, Singapore, Singapore, July 2 to 6, 1994.     

Fistula-in-ano in Crohn's disease

The outcome of aggressive surgical treatment of 64 symptomatic anal fistulas in 55 patients with Crohn's disease has been studied. Forty-one fistulas, in 33 patients, were treated by conventional fistulotomy (17 subcutaneous, 19 intersphincteric, 5 low transsphincteric fistulas). Thirty wounds (73 percent) healed within 3 months and eight more wounds (93 percent) healed within 6 months. Three wounds did not heal within 12–18 months. Two of these patients subsequently required proctocolectomy. Wound healing was not influenced by the presence of rectal Crohn's disease or granulomatous inflammation in the tract. No change in continence was experienced by 26 of the 33 patients who underwent fistulotomy. Three patients required proctocolectomy and the remaining four patients experienced minor degrees of incontinence postoperatively. Sixteen high transsphincteric, five suprasphincteric, and one extrasphincteric fistula in 22 patients were treated by laying open external tracts and placing a noncutting seton through the sphincter, which was left in place for prolonged periods to maintain drainage. During follow-up (6 months to 10 years, median 2.5 years), three fistulas healed and seven remained quiescent. Nine patients required further treatment by a new seton and three patients required proctocolectomy. Eight of the 22 patients who had a seton inserted had no change in continence, and six patients in this group developed minor changes in continence, mostly related to diarrhea associated with intestinal disease. Anal fistulas in Crohn's disease, which involve minimal sphincter muscle, can be successfully treated by fistulotomy. High fistulas should be treated with seton drainage to limit recurrent suppuration and preserve sphincter function.Read at the 89^th meeting of the American Society of Colon and Rectal Surgeons, St Louis, Missouri April 29–May 4 1990.     

Perianal abscess and fistula-in-ano in children

The authors present a retrospective review of 40 pediatric patients with perianal abscess and/or fistula-in-ano. The total patient population could be divided clinically into 2 broad groups. The first group consisted of 22 infants younger than 2 years of age, all of whom were males, and 10 of whom presented with recurrences after previous incision and drainage. Of the 14 infants presenting with an abscess, in 12 (85.7 percent), a fistula-in-ano was discovered at surgery. In contrast, in the group of 18 children older than 2 years of age, there were 7 females and 11 males, and fistulas were identified in only 7 of 13 patients (54.8 percent) who presented with abscesses. Surgical treatment consisted of examination under anesthesia and a diligent search for a fistulous tract. Abscesses were primarily saucerized and fistulotomy and cryptotomy of the confluent crypt was performed if a fistulous tract was identified. The only recurrences with this form of treatment occurred in the two immunocompromised patients.Read at the meeting of The American Society of Colon and Rectal Surgeons, Toronto, Canada, June 11 to 16, 1989.     

The role of preoperative colonoscopy in colorectal cancer

Routine preoperative colonoscopy has been recommended for those patients with the diagnosis of colorectal cancer to identify synchronous polyps and/or cancers which might otherwise be undetected on barium enema or at the time of operation. It has been suggested that this approach may alter surgical therapy or follow-up. The charts of 98 patients who underwent preoperative colonoscopy solely for the purpose of detecting additional polyps or cancers prior to open surgical resection for colorectal cancer were retrospectively reviewed. All patients had biopsy or barium-enema evidence of colorectal cancer. Patients with familial polyposis or chronic ulcerative colitis were excluded. Synchronous cancers were detected in 7.1 percent of patients, and synchronous neoplastic polyps in 29 percent. Forty-three percent of synchronous cancers and 73 percent of synchronous neoplastic polyps would not have been included in the standard surgical resection for the index cancer if the additional information provided by colonoscopy had not been available. Surgical treatment and/or follow-up were altered in 33 percent of patients as a consequence of the colonoscopic evaluation. Colonoscopy prior to surgery for colorectal carcinoma is highly desirable and may potentially improve long-term survival. Read at the joint meetings of The American Society of Colon and Rectal Surgeons with the Section of Coloproctology, Royal Society of Medicine, and the Section of Colonic and Rectal Surgery, Royal Australasian College of Surgeons, New Orleans, Louisiana, May 5 to 11, 1984.     

Lateral subcutaneous internal sphincterotomy for chronic anal fissure,an outpatient procedure

Summary We have adapted the lateral internal sphincterotomy technique for the repair of chronic anal fissure to a strictly office or outpatient procedure. The early cure rate in this review of our first 200 patients was very good—well in excess of 98 per cent. Complication were exceedingly minor, the considerable cost to the patient of hospitalization and time off from work has been saved, and patient acceptance has been excellent. Submitted to the joint meeting of the Section of Proctology, Royal Society of Medicine, the Section of Colonic and Rectal Surgery, Royal Australasian College of Surgeons, and the American Society of Colon and Rectal Surgeons, Washington, D.C., May 22 to 25, 1974.     

Anal fistula surgery

PURPOSE: This study was undertaken to assess results of surgery for fistula-in-ano and identify risk factors for fistula recurrence and impaired continence. METHODS: We reviewed the records of 624 patients who underwent surgery for fistula-in-ano between 1988 and 1992. Follow-up was by mailed questionnaire, with 375 patients (60 percent) responding. Mean follow-up was 29 months. Fistulas were intersphincteric in 180 patients, transsphincteric in 108, suprasphincteric in 6, extrasphincteric in 6, and unclassified in 75. Procedures included fistulotomy and marsupialization (n=300), seton placement (n=63), endorectal advancement flap (n=3), and other (n=9). Factors associated with recurrence and incontinence were analyzed by univariate and multivariate regression analysis. RESULTS: The fistula recurred in 31 patients (8 percent), and 45 percent complained of some degree of postoperative incontinence. Factors associated with recurrence included complex type of fistula, horseshoe extension, lack of identification or lateral location of the internal fistulous opening, previous fistula surgery, and the surgeon performing the procedure. Incontinence was associated with female sex, high anal fistula, type of surgery, and previous fistula surgery. CONCLUSIONS: Surgical treatment of fistula-in-ano is associated with a significant risk of recurrence and a high risk of impaired continence. Degree of risk varies with identifiable factors.Read at the meeting of The American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994.     

Is simple fistula-in-ano simple?

PURPOSE: A study of 523 fistulas of cryptoglandular origin operated on between January 1985 and December 1991 at the Lehigh Valley Hospital was undertaken for the purpose of establishing whether the so-called simple fistula-in-ano has a favorable outcome. High transsphincteric fistulas with or without high blind track, suprasphincteric, extrasphincteric, and horseshoe fistulas as well as fistulas associated with inflammatory bowel disease were excluded. METHODS: Four-hundred sixtyone patients with anal fistulas classified as simple fistulasin-ano (uncomplicated transsphincteric, low and high blind track intersphincteric) were studied retrospectively. There were 310 males and 151 females with an average age of 42 years and mean follow-up of 34 months. RESULTS: Thirty (6.5 percent) patients developed recurrent fistulas: 16 (53.3 percent) beacuse of missed internal openings at initial surgery, six (20 percent) attributed to missed secondary tracks, five (16.7 percent) because of premature fistulotomy wound closure, and three (10 percent) because of miscellaneous factors. CONCLUSION: All so-called simple fistulas-in-ano may not have readily detectable primary openings and may possess secondary tracks which preclude their behavior as simple fistulas.Read at the annual meeting of the Ohio Valley Society of Colon and Rectal Surgeons, Columbus, Ohio, April 17, 1993, and at the spring meeting of the New England Society of Colon and Rectal Surgeons, Brewster, Massachusetts, April 24, 1993.     

Electrophysiologic and manometric assessment of failed postanal repair for anorectal incontinence

The reason for failure to improve fecal incontinence after postanal repair in idiopathic (neurogenic) anorectal incontinence is unknown. The authors have studied 20 patients whose anorectal continence was not improved after Parks' postanal repair. Anorectal manometry, single fiber EMG of the external anal sphincter muscle, and measurements of the pudendal nerve terminal motor latency were studied before and nine months after postanal repair. All 20 patients had evidence of reinnervation within the external anal sphincter muscle before operation; 17 had a raised pudendal nerve terminal motor latency and all 20 had low resting voluntary contraction anal canal pressures. No significant differences were found between the resting, voluntary contraction anal canal pressures and single fiber EMG fiber density values before or after postanal repair. However, a significant increase in the pudendal nerve terminal motor latency was found after postanal repair (P<0.001) using a student's pairedt test. These results suggest that, in patients who are not rendered continent by postanal repair, a continuing neuropathic process takes place. Read at the joint meeting of the American Society of Colon and Rectal Surgeons with the Section of Colo-Proctology of the Royal Society of Medicine and the Section of Colonic and Rectal Surgery of the Royal Australasian College of Surgeons, New Orleans, Louisiana, May 6–11, 1984.     

Efficacy of a simplified lower gastrointestinal flexible endoscope cleaning method

Published guidelines from the Center for Disease Control (CDC) “strongly recommended” gas sterilization or 30 minutes of high-level disinfection with either 2 percent glutaradehyde or 6 percent hydrogen peroxide following each flexible endoscope cleansing for proper care. The guidelines were proposed on the basis of previous CDC studies performed on glutaraldehyde disinfection of respiratory equipment. A prospective study was performed culturing flexible endoscopes following cannulation of the lower gastroinstestinal tract and cleansing. A uniform endoscope cleansing method without gas sterilization or high-level disinfection was used between patients. Thirty aerobic and 30 anaerobic RODAC bacterial culturings revealed no obligate anaerobic organism growth and only sparse, aerobic, environmental and cutaneous organism growth. These were no instances of documented or suspected postendoscopy infectious complications. Our results indicate that high-level disinfection and gas sterilization of flexible endoscopes are not necessary to prevent bacterial disease transmission from patient to patient. Read at the joint meeting of the American Society of Colon and Rectal Surgeons with the Section of Colo-Proctology, Royal Society of Medicine, and the Section of Colonic and Rectal Surgery, Royal Australasian College of Surgeons, New Orleans, Louisiana, May 6 to 11, 1984.     

Is anterior resection of the rectosigmoid safe after preoperative radiation?

Forty patients with carcinoma of the rectum or rectosigmoid underwent preoperative irradiation, followed by anterior resection with anastomosis. The radiation dose was 4500 rads administered in 25 fractions over a period of five weeks. One to three weeks after the radiation was completed, anterior resection of the rectosigmoid with anastomosis was done. Of the 40 patients, 23 had hand-sewn anastomoses and 17 had EEA stapled anastomoses. Fourteen of the 40 had diverting loop colostomies, all colostomies were subsequently closed, and there were no clinical postoperative anastomotic leaks. Anterior resection and anastomosis are considered to be technically safe with the surgical and radiation techniques used. Read at the joint meeting of the American Society of Colon and Rectal Surgeons with the Section of Colo-Proctology, Royal Society of Medicine, and the Section of Colonic and Rectal Surgery, Royal Australasian College of Surgeons, New Orleans, Louisiana, May 6 to 11, 1984.