Argon plasma coagulation is an effective treatment for refractory hemorrhagic radiation proctitis

INTRODUCTION: Chronic radiation proctitis complicating pelvic radiotherapy can be debilitating. It commonly presents with rectal bleeding, which can be difficult to control. Medical management of hemorrhagic radiation proctitis is not very successful, although surgery carries high risks. Thus, endoscopic treatments are preferred. The aim of this study is to assess the efficacy of argon plasma coagulation applied endoscopically to treat hemorrhagic radiation proctitis that has been refractory to topical formalin therapy. METHODS: Twelve patients who had ongoing bleeding from radiation proctitis, after previously failed formalin therapy, underwent endoscopic treatment using argon plasma coagulation. The efficacy of treatment was assessed by grading the frequency and severity of bleeding (0–4, 0 being no bleeding), hemoglobin level, and transfusion requirements. RESULTS: At a median follow-up of 11 months, ten patients (83 percent) had a significant reduction in the severity and frequency of bleeding, with complete cessation in six (50 percent). The presence of coexistent radiation-induced sigmoiditis in two patients was associated with reduced but persistent bleeding, because of difficulty in targeting the bleeding sites in the sigmoid colon. The median number of treatment sessions per patient was two (range, 1–3), with the number of sessions correlated with the extent of the proctitis. All patients had an improvement in their hemoglobin level, with the mean increasing from 11.2 to 12.3 g/dl. In the six months before starting therapy, all patients had been taking iron supplements, and four had required blood transfusions (median 3 units, range, 2–6). Iron supplements were ceased four weeks after the completion of therapy in all cases, and no further transfusions were required during the study period. None of the patients experienced any significant side effects or complications. CONCLUSIONS: Argon plasma coagulation is an effective and safe treatment for hemorrhagic radiation proctitis that has been refractory to topical formalin therapy.     

Formalin instillation for refractory radiation-induced hemorrhagic proctitis

PURPOSE: Our goal was to evaluate use of topical (4 percent) formalin in management of radiation-induced hemorrhagic proctitis, refractory to other methods of treatment. Specifically, we wished to determine its safely, ability to stop bleeding, and complications associated with therapy. METHODS: Sixteen patients with radiation-induced hemorrhagic proctitis were treated with topical (4 percent) formalin. All had been previously treated with conservative regimens such as cautery, topical steroids, or laser, but these had failed. Five-hundred milliliters (ml) of a 4 percent formalin solution was instilled into the rectum in 50-ml aliquots. Each aliquot was kept in contact with rectal mucosa for approximately 30 seconds. Treatments were performed under local anesthesia in nine patients, sedation only in four, spinal in two, and general in one patient. RESULTS: In 12 patients, bleeding stopped after a single formalin instillation; in 3, bleeding was considerably reduced but continued sporadically. One patient required three treatments before bleeding stopped. Four patients developed postoperative anal pain, of which one also had significant tenesmus and reduced capacity. Of these four patients, only two had significant anal pain and fissures that lasted longer than one month. CONCLUSIONS: Topical (4 percent) formalin is safe and effective in treatment of radiation-induced hemorrhagic proctitis. A single treatment will stop bleeding in 75 percent of patients.Supported in part by the Bowman Research Fund.Read at the meeting of The American Society of Colon and Rectal Surgeons, Montreal, Quebec, Canada, May 7 to 12, 1995.     

Long-term follow-up of local excision and radiation therapy for invasive rectal cancer

PURPOSE: Little is known regarding the long-term outcome of patients with rectal cancer treated by local excision and radiation therapy. We updated our institutional experience with this approach. METHODS: From January 1986 to December 1991, 23 patients (median age, 64 (range, 30–80) years) with mobile, moderately differentiated adenocarcinoma of the rectum were offered transanal excision. Two patients with large T3 tumors, who were judged intraoperatively to be unsuited for a local procedure, received radical resection and were excluded from analysis. Twenty-one patients underwent transanal excision en bloc (14) or piecemeal (7) through a resectoscope. Seventeen patients (74 percent) had either extensive medical problems or refused a colostomy. Patients received a median of 5,040 cGy postoperatively, and 15 also received 500 cGy preoperatively on protocol. Two patients received concomitant chemotherapy. Median follow-up is 56 months for all patients and 67 months for survivors (range, 27–92 months). RESULTS: There were 2 T1, 15 T2, and 4 T3 tumors. The distance from the anal verge was a median of 4 (range, 1–7) cm. The median tumor size was 3 (range, 2–7) cm. Sixteen patients had more than one-third of the wall involved. Four patients (19 percent) developed a local recurrence at 26, 30, 33, and 48 (median, 31.5) months. Three were salvaged (abdominoperineal resection = 2; low anterior resection = 1) and remain disease-free 18, 36, and 37 months postoperatively. Four patients (19 percent) developed metastases (lung = 3; liver = 1) at 3, 22, 25, and 44 months after initial treatment (median, 23.5 months). The actuarial five-year overall, disease-free and recurrence-free survival are 77, 75, and 58 percent, respectively. Twelve patients (57 percent) have no evidence of disease while retaining their rectum. There was one postoperative death. CONCLUSIONS: Long-term follow-up confirms that local excision and radiation therapy is of value in patients with mobile tumors of the rectum. It suggests that this treatment can be offered to those patients who refuse a colostomy or are medically compromised and may be an acceptable option for selected patients with T2 or T3, mobile adenocarcinomas of the rectum.     

Chronic radiation-induced proctitis: the 4 % formalin application as non-surgical treatment

Purpose

Radiation proctitis is a known complication following radiation therapy for pelvic malignancy. The majority of cases are treated nonsurgically. Rectal instillation of formalin solution has been described as a successful treatment for chronic radiation-induced hemorrhagic proctitis resistant to medical treatment. We present our results in patients undergoing treatment with application of 4 % formalin for radiation-induced injury to the rectum.

Methods

All patients were treated under anesthesia by direct application of 4 % formalin solution to the affected rectal areas. Patient gender, initial malignancy, grade of proctitis, need for blood transfusion, previous therapy, number of applications and response to treatment with formalin, complications, and length of follow-up were reviewed.

Results

A total of 15 patients with a mean age of 68.9 (range, 48–77) years were followed for 31.3 (range, 18–51) months. The mean interval from the conclusion of radiotherapy and the onset of symptoms was 6.9 months. The mean duration of hemorrhagic proctitis before formalin application was 7.9 months. Ten patients had only one formalin application and five patients required a second application because of the persistent bleeding. Thirteen patients (87 %) had complete cessation of bleeding. No complications related to the formalin treatment were observed.

Conclusions

According to a revision of the literature and our experience, despite the small number of patients in our trial, we can state that the application of 4 % formalin solution is an effective, safe, and well-tolerated treatment for chronic radiation-induced hemorrhagic proctitis with minimal discomfort and no severe complications.     

Morbidity and survival of liver resection for colorectal adenocarcinoma

Sixty-two patients underwent hepatic resection for isolated colorectal metastases from 1963 to 1988. The numbers of hepatic resections were: lobectomy, 24 (39 percent); wedge resection, 23 (37 percent); and segmentectomy, 15 (24 percent). The median number of intraoperative blood transfusions was 3 0 units (range, 0–16 units). The median number of days in the hospital following hepatic resection was 13 (range, 4–51 days). There were 19 patients (30 percent), who developed a total of 23 complications. Surgery was required for complications in nine patients. Surgical mortality occurred in 5 of 62 (8 percent) patients. The estimated median survival in 56 patients with one to three metastases was 26 months, with a 28 percent estimated 5-year survival. The median size of the metastases was 4.0 cm (range, 0.7–13 cm). The estimated median survival in 27 patients with metastases less than 4 cm in diameter was 26 months, with a 24 percent estimated 5-year survival. The estimated median overall survival from the time of hepatic resection was 25 months.     

Complications of absorbable pelvic mesh slings following surgery for rectal carcinoma

PURPOSE: To evaluate the intraoperative, postoperative, and long-term complications of an absorbable pelvic mesh sling after surgery for rectal carcinoma. METHODS: A retrospective review of medical records from April 8, 1991, through April 8, 1996. RESULTS: Twenty patients with a mean age of 57 (range, 37–79) years underwent pelvic mesh sling placement. The tumor stages were as follows: Stage I, 5; Stage II, 2; Stage III, 11; and Stage IV, 1. A recurrent perianal basal cell carcinoma was not included in the staging group. Surgery consisted of 18 abdominoperineal resections, 1 total proctocolectomy, and one Hartmann's procedure. Mean follow-up was 18 (range, 2–49) months. There were no intraoperative complications related to mesh placement. Twenty-nine complications occurred in 14 patients during the immediate postoperative period. Five were possibly mesh-related and included a pelvic abscess, perineal seroma, toxic perineal wound, pulmonary embolus, and lower extremity deep venous thrombosis, respectively. A mild postoperative ileus developed in 17 patients (85 percent), and a diet was initiated at a mean of seven (range, 4–24) days. Fourteen patients received postoperative radiotherapy with a mean dose of 5,339 (range, 2,500–7,020) cGy delivered in 180-cGy fractions. There were 14 immediate complications caused by radiotherapy in 11 patients, but only two patients required delays in treatment. Two patients had diarrhea alone, six developed perineal dermatitis alone, and three patients had both diarrhea and perineal dermatitis. All patients with diarrhea had received chemoradiation. One patient developed a partial small-bowel obstruction following radiation. CONCLUSIONS: Absorbable pelvic mesh sling placement can be performed with minimum morbidity and is recommended following surgery for rectal cancer when radiation is anticipated as part of multimodality therapy.     

福尔马林治疗出血性放射性直肠炎临床分析

目的评价经内镜下喷洒福尔马林液治疗出血性放射性直肠炎的效果及安全性。 方法回顾性分析2013年1月至2017年7月于民航总医院消化内科住院治疗的出血性放射性直肠炎10例患者的临床资料,并检索Pubmed、EMBASE数据库1996年~2017年的相关文献,结合文献复习进行治疗效果评价。 结果纳入出血性放射性直肠炎患者10例,平均年龄（71.1±6.9）岁,经过内镜下喷洒福尔马林治疗,总有效率100%。检索文献20篇,纳入病例数515,总体有效率为84.5%。经治疗后部分患者存在腹痛、腹泻、发热、里急后重、肛门疼痛、肛门溃疡、肛门狭窄、排便困难等不良反应。 结论经内镜下喷洒福尔马林液治疗出血性放射性直肠炎疗效确切,不良反应发生率低。     

Local excision of rectal carcinoma

PURPOSE: This study was undertaken to evaluate the treatment morbidity, functional outcome, and recurrence risk of patients undergoing local excision and combined chemoradiation therapy for rectal carcinoma. METHODS: Eighteen patients underwent local excision of their rectal carcinoma. Four patients underwent local excision alone (T1-2, N0-X, low risk), 10 patients underwent local excision with postoperative chemoradiation therapy using 5-fluorouracil and leucovorin (T1-2, N0-X, high risk), and 4 patients underwent local excision, chemoradiation therapy, and six months of additional 5-fluorouracil and leucovorin (T3 or N1). RESULTS: Of the four patients undergoing local excision alone, there was no treatment morbidity or alteration in functional outcome. Of the 14 patients receiving chemoradiation therapy, three reported early Grade 3–4 toxicity manifested by cystitis, proctitis, or perineal skin desquamation. At six months, two patients reported persistent rectal urgency and occasional fecal incontinence, and 11 patients reported increasing stool frequency (average, 3: range, 2–8). The six months of additional 5-fluorouracil and leucovorin were well tolerated and did not appear to further affect functional outcome. There were no local recurrences, although one patient developed distant mestastatic disease. CONCLUSION: This treatment regimen, while generally well tolerated, is associated with significant acute toxicity in certain patients. We have identified specific causative factors which can be modified to decrease acute morbidity, including the elimination of leucovorin during the combined chemoradiation therapy.Read at the meeting of the New England Colorectal Society, April 24, 1993.     

Squamous-cell carcinoma of the anal canal: Management with combined chemo-radiation therapy

Twenty patients with squamous-cell carcinoma of the anal canal received combined chemo-radiation therapy as their primary treatment. There were 18 women and two men with a mean age of 63 years (range, 34–91 years). The mean follow-up was 34 months (range, 6–62 months). Anal margin cancers and adenocarcinomas were excluded. Fourteen of 20 patients treated had a complete response. There were six local failures: three with residual disease at the end of treatment and three with recurrent disease at a later date. Of the three with residual disease, one underwent abdominoperineal resection and two received salvage therapy (one with chemo-radiation and one with radiation alone). All three patients with recurrent disease were treated with abdominoperineal resection. All six were disease free at the end of the study. Of the 14 patients with complete local response, one presented with liver metastases 19 months later. Sixteen patients (80 percent) were alive at the end of the study, and 19 patients (95 percent) had no evidence of disease. These data add support for salvage therapy in the treatment of patients with residual disease following initial chemo-radiation therapy. Salvage options for patients with squamous-cell carcinoma of the anus who fail the Nigro protocol will be discussed.Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990.     

Surgical treatment of cytomegalovirus enterocolitis in severe human immunodeficiency virus infection

PURPOSE: The aim of this study was to describe our experiences of surgical removal of inflamed bowel in cytomegalovirus enterocolitis. METHODS: Eight homosexual males with a mean age of 41 years (range, 29–59 years) and a mean CD4 count of 21×10 ⁶/1 (1–60× 10⁶/1)with advanced human immunodeficiency virus infection and severe cytomegalovirus enterocolitis were treated with ileocecal resection (4 patients) or right-sided hemicolectomy (4 patients). Symptoms were lower abdominal pain, severe diarrhea, fever, and weight loss, unrelieved by anticytomegalovirus therapy. Radiologic examination showed that ulcerative inflammation was limited to the right colon and terminal ileum. Microscopic examination confirmed the cytomegalovirus enterocolitis. Intermittent cytomegalovirus treatment, usually with foscarnet for 10 to 14 days every 4 to 6 weeks was given postoperatively. RESULTS: Two minor postoperative complications occurred: a lesser wound infection and a moderate bleeding from the abdominal wound edges. One patient died after three weeks because of gastrointestinal bleeding from an ulcerating Kaposi's sarcoma lesion and another patient died from unrelated causes three weeks after discharge from the hospital. The remaining 6 patients experienced complete or partial palliation of the abdominal symptoms for a mean of 14 months (range, 5–35 months) until death or the end of observation time. One patient is still alive two years after the operation. The overall mean survival was 12 months (range, 0.5–35 months). Recurrent or persistent symptoms and/or signs of cytomegalovirus enterocolitis occurred in four patients after a mean of seven months. CONCLUSION: Resection of inflamed bowel combined with postoperative anticytomegalovirus treatment leads to excellent palliation and a relatively favorable survival in AIDS patients with cytomegalovirus enterocolitis.     

Prospective study of biofeedback for treatment of constipation

PURPOSE: This study was designed to evaluate prospectively the results of pelvic floor physiotherapy with the aid of biofeedback in a heterogeneous group of patients with intractable constipation. METHODS: Biofeedback was used to treat 19 patients (age range, 16–78 (median, 63) years) with intractable constipation. Assessment, using visual linear analog scales of symptoms, was performed prospectively by an independent researcher. Biofeedback was performed by a physiotherapist, and patients were required to attend six sessions on an outpatient basis. The cause of constipation was heterogeneous, with no specific disorder being implicated on testing with anal manometry, defecating proctography, and colonic transit time. RESULTS: At six weeks, there was a median 27 percent (range, –8–93 percent) improvement in symptom scores. At six months, there was a median 23 percent (range, –54–64 percent) improvement in symptom scores. These were statistically significant compared with the scores at outset, six weeks ( P =0.0006), and six months ( P =0.012). However, only two (12.5 percent) patients at the six-month follow-up had an improvement of greater than 50 percent in their symptoms. CONCLUSION: Biofeedback is not recommended in the management of constipation.Presented at the Royal Australasian College of Surgeons Annual Scientific Congress, Melbourne, Australia, May 5 to 10, 1996.No reprints are available.     

Squamous cell carcinoma of the anus and HIV infection

We retrospectively reviewed six patients with squamous cell carcinoma of the anus (SCCA) and human immunodeficiency virus (HIV) infection treated between 1985 and 1988. All six patients were homosexual men. Five patients had AIDS and one was HIV-positive. The most common symptoms and signs were pain (n=5), mass (n =5), and bleeding (n=5). The average tumor size was 3.2 cm with a range of 1–10 cm. Five tumors were located in the anal canal and one at the anodermal junction. One patient was treated with biopsy alone, one with local excision, one with wide local excision and radiation therapy, and two with diverting colostomy. The average follow-up was 8 months. Of the five AIDS patients, two died, one was transferred to a hospice facility, one was lost to follow-up, and one remains alive 1 year following treatment. The HIV-positive patient died secondary to metastatic SCCA. This group of patients raises the question of a possible association between HIV and SCCA.     

Preliminary results of preoperative 5-fluorouracil, low-dose leucovorin, and concurrent radiation therapy for clinically resectable T3 rectal cancer

PURPOSE: We report the downstaging, sphincter preservation, acute toxicity, and preliminary local control and survival results of preoperative 5-fiuorouracil (5-FU), low-dose leucovorin (LV), and concurrent radiation therapy followed by postoperative LV/5-FU for treatment of patients with clinically resectable T3 rectal cancer. MATERIALS AND METHODS: A total of 32 patients received two monthly cycles of preoperative LV/5-FU (bolus daily×5). Radiation therapy (5,040 cGy) began concurrently on day 1. Postoperatively, patients received a median of two monthly cycles of LV/5-FU (range, 0–10). RESULTS: The complete response rate was 9 percent pathologic and 13 percent clinical, for a total of 22 percent. Total Grade 3+ acute toxicity during the preoperative combined modality segment was 25 percent (8/32). Of the 20 patients who were thought to initially require an abdominoperineal resection and for whom the intent of treatment was sphincter preservation, 17 (85 percent) were able to undergo sphincter-preserving surgery. With a median follow-up of 22 (3–59) months, none have developed local failure, and the three-year actuarial diseasefree survival rate was 60 percent. CONCLUSION: Our data reveal encouraging downstaging, sphincter preservation, and acute toxicity with this regimen. Additional follow-up is needed to assess the long-term local control and survival rates.Presented at the meeting of the American Society of Therapeutic Radiology and Oncology, Los Angeles, California, October 25 to 29, 1996.     

Aggressive surgical management of recurrent rectal cancer—Is it worthwhile?

OBJECTIVE: The purpose of this study was to determine whether radical surgery in appropriately selected patients who have recurrent rectal cancer can produce significant disease-free survival. PATIENTS AND METHODS: This is a retrospective review of the management of all patients presenting with recurrent local and metastatic rectal cancer at a single institution during an 11-year period. RESULTS: Of 489 patients who underwent curative surgery for primary rectal cancer during the period reviewed, 44 (9 percent) developed recurrent disease at a median interval of 18 (range, 3–60) months after curative surgery. Local pelvic recurrence alone was present in 28 (5.7 percent) patients. Overall survival after diagnosis of recurrent disease was 41 percent (18/44) at a median interval of 15 (range, 2–60) months. Curative resection was performed in 14 (32 percent) patients with a disease-free survival of 86 percent (12/14) at a median of 25 (range, 9–60) months after curative surgery. In comparison, survival in patients who underwent palliative treatment was significantly less (25 vs. 12 months;P <0.05; 95 percent confidence interval, 10, 23 (Mann-Whitney U test)); 20 percent survival at a median of 12 months ranged from 2 to 36 after diagnosis of recurrent disease. Of six patients in the curative group who developed second recurrences, four underwent further curative surgery and are disease-free at a median of 19.5 (range, 12–29) months after surgery. Palliative surgery provided good symptomatic relief and improved quality of life in 11 patients in the palliative group, although there was no survival advantage over those who underwent nonsurgical palliative treatment (n=19). CONCLUSION: In appropriately selected cases, aggressive surgical therapy produces significant disease-free survival in patients with recurrent rectal cancer.Dr. Ogunbiyi is supported in part by grants from the Ronald Raven Travelling Fellowship of the British Society of Surgical Oncology, The American Society of Colon and Rectal Surgeons Research Foundation International Travelling Fellowship, and the Royal College of Surgeons of England Ethicon Foundation Travelling Fellowship.Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996.     

Application of 10 Percent Formalin for the Treatment of Radiation-Induced Hemorrhagic Proctitis

Purpose Rectal instillation of 4 percent formalin solution has been described as a successful treatment for hemorrhagic radiation proctitis recalcitrant to medical treatment. We present our experience with a new method of treatment involving the topical application of 10 percent buffered formalin, which is well tolerated and suitable for office use. Methods Patients with marked or refractory rectal bleeding and clinical features consistent with radiation proctitis were reviewed. Treatment involved direct application of a 10 percent buffered formalin solution to the affected mucosa using a 16-inch cotton tip applicator applied through a proctoscope in the office setting. Results A total of 100 patients with a mean age of 75 (range, 49–91) years were followed for 18 (range, 1–79) months. The interval from radiation exposure to formalin treatment was 21 months. Overall, 93 percent of patients had cessation of bleeding after an average of 3.5 formalin applications at two-week to four-week intervals. Patients with severe (Grade 3) proctitis and those taking aspirin required an average of 1.5 additional treatments. A total of eight patients rebled at a mean of 24 months from treatment; however, all responded to further applications of formalin. Three patients complained of anal pain and one experienced dizziness postprocedure for a complication rate of 1.1 percent. Conclusions We present a simple, cost-effective, and well-tolerated method of controlling hemorrhagic radiation proctitis. It is performed by using materials readily available in the office of a colon and rectal surgeon, eliminating the need for bowel preparation, anesthesia, or a surgical suite. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.     

Chemotherapy for desmoid tumors in association with familial adenomatous polyposis

PURPOSE: This study was designed to assess the effect of chemotherapy on complex desmoid tumors associated with familial adenomatous polyposis. METHODS: Five patients (3 males, 2 females; age range, 29–45 years) had symptomatic, unresectable intra-abdominal desmoid tumors in association with familial adenomatous polyposis that were unresponsive to conventional medical therapy. Each patient was treated with a cytotoxic chemotherapeutic regimen consisting of doxorubicin and dacarbazine followed by carboplatin and dacarbazine. Response to treatment was assessed by measurement of tumor size using computerized tomography. Follow-up has been for a mean of 22 (range, 10–30) months. RESULTS: One patient has had a complete response, and three patients have had a partial response, with a reduction in tumor volume of at least 50 percent. One patient had a minimum response to treatment and developed a rapid increase in tumor size on cessation of therapy. Complications of treatment included febrile neutropenia, severe epistaxis, and subclavian vein thrombosis. CONCLUSIONS: The cytotoxic chemotherapeutic regimen described is effective in the treatment of selected unresectable desmoid tumors associated with familial adenomatous polyposis and should be considered in symptomatic patients who do not respond to conventional medical therapy.Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996. No reprints are available.     

Clinical,demographic, and follow-up characteristics of patients with two primary metachronous tumors,one of them being in the colon

The clinical characteristics of 152 patients diagnosed with two primary metachronous tumors—one or both of them in the colon—were studied. Nineteen patients had both primary tumors in the colon (Group I), 59 had the first primary tumor in the colon and the second tumor elsewhere (Group II), and 74 had the second primary tumor in the colon and the first primary tumor elsewhere (Group III). The group in which the second primary tumor was in the colon included significantly more female patients than did the other two groups, with a younger median age at diagnosis of first tumor. The median time interval between the two primary tumors was 44, 57, and 62 months in Groups I, II, and III, respectively. The number of clinic visits during the year before diagnosis of the second primary was similar in all groups, but only 60 percent of the patients kept their follow-up appointment. In most instances, the diagnosis was made after the patients' symptoms, although only a small percentage of the second primary tumors (15–30 percent) were diagnosed during routine follow-up. The second primary tumor occurred in the field of radiotherapy of the first primary tumor in 27 of 35 patients who received radiotherapy. To increase the number of patients diagnosed in an earlier stage of disease, they should be urged to keep their follow-up appointment, and physicians following patients with single tumors should be aware of the increased likelihood of a second tumor. To increase the cure rate of those tumors, efforts toward early diagnosis are warranted. This includes physical examination and mammography to detect breast cancer in women, annual occult blood tests and rectal examination, and sigmoidoscopy or colonoscopy at three-year intervals to detect colon cancer early     

Crohn's disease and carcinoma: Increasing justification for surveillance?

Carcinoma of the colon that arises in patients with Crohn's disease is being reported with increasing frequency. To help clarify the nature of this association, records of 25 patients with Crohn's disease and colorectal carcinoma seen from 1957 through 1989 were reviewed. One patient had leiomyosarcoma of the rectum, and two patients had the onset of Crohn's disease after the diagnosis and treatment of colorectal carcinoma. Therefore, 22 patients were available for complete retrospective analysis. The median age at diagnosis of Crohn's disease was 37 years (range, 15–67 years), and the median age at diagnosis of carcinoma was 54.5 years (range, 32–76 years). The median duration of symptoms preceding the discovery of colorectal carcinoma was 18.5 years (range, 0–32 years). Carcinoma arose in colonic segments with known Crohn's disease in 77 percent of patients, and six patients (27 percent) had associated colonic mucosal dysplasia. One lesion was classified as Dukes A, nine lesions were Dukes B, five lesions were Dukes C, and seven lesions were Dukes D. Patients with an onset of Crohn's disease before the age of 40 years had primarily Dukes C or D lesions and consequently poor survival. Most patients presented with nonspecific signs and symptoms, with nothing to distinguish the activity of the Crohn's disease from the presence of colorectal neoplasm. Younger patients with long-standing Crohn's disease should be considered for colonic surveillance to permit earlier diagnosis and treatment of potential colorectal carcinoma.Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to 17, 1991.     

Laparoscopic techniques for fecal diversion

Although the role of laparoscopic techniques in performing major colorectal resections is unclear, laparoscopy may be well suited for fecal diversion procedures because no resection and minimal tissue dissection is required. PURPOSE: This report reviews our initial experience with laparoscopic stoma procedures to assess safety and efficacy. METHODS: Using a simple two-cannula technique, 24 such procedures (16 loop ileostomies, 6 end sigmoid colostomies, 1 transverse, and 1 sigmoid loop colostomy) were attempted. Indications for diversion were rectovaginal fistula (7), perianal sepsis (7), incontinence (4), advanced rectal or colon carcinoma (4), and complicated pelvic infection (2). There were 15 females and 9 males with a median age of 44 (range, 25–88) years. RESULTS: Median operative time was 60 (range, 20–120) minutes, and median blood loss was 50 (range, 0–150) ml. There were no intraoperative complications. One case was converted to a laparotomy because of dense adhesions. Median time to passage of both flatus and stool was one (range, 1–3) day for ileostomy patients, two (range, 2–4) days for flatus, and 3 (range, 2–6) days for stool after colostomy. Median time to discharge was 6 (range, 2–28) days and was often delayed by the primary disease process or ostomy teaching. One major postoperative complication, a pulmonary embolism, occurred eight days after operation in a patient with near obstructing, widely metastatic colon carcinoma. This patient later died of pulmonary failure. All stomas have functioned well, with no revisions required. CONCLUSIONS: Laparoscopic fecal diversion procedures can be performed safely, simply, and effectively. Apparent advantages over standard techniques are avoidance of a laparotomy, while maintaining the ability to precisely identify and orient the pertinent bowel segment and rapid return of bowel function.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Montreal, Quebec, Canada, May 7 to 12, 1995.     

Ileocolic resection for acute presentation of Crohn's disease of the ileum

PURPOSE: Traditional therapy for patients with terminal ileitis found at laparotomy for appendicitis has been to perform appendectomy when the cecum is normal and to leave the diseased ileum in place. METHODS: To determine the role of ileocolic resection in the setting of acute ileitis, records of 1,421 patients with Crohn's disease seen from 1986 to 1994 were retrospectively reviewed. RESULTS: Crohn's disease was found at laparotomy for presumed appendicitis in 36 patients (2.5 percent). Ten patients underwent ileocolic resection, 23 had appendectomy, and 3 had exploratory laparotomy alone. One patient whose appendix was removed also had ileocecal bypass. Of the 36 patients, 20 were women and 16 were men. Mean age at operation was 24 (range, 11–61) years, and mean follow-up time was 14 (range, 0.1–49) years. After initial ileocolic resection, five patients (50 percent) required no further resection, with a mean follow-up time of 12.4 (range, 4–19) years. None required more than three ileocolic resections, with a mean follow-up time of 18.1 (range, 4–49) years. Of 26 patients treated traditionally, 24 (92 percent) required ileocolic resection for intractability or complications of Crohn's disease. Thirty-eight percent required resection within one year and 65 percent within three years (intractability, 8; obstruction, 3; fistula, 4; and perforation, 2). Of 24 patients who subsequently underwent resection, only 6 (25 percent) required further small-bowel resection for Crohn's disease, with a mean follow-up time of 13 (range, 0.1–34) years. CONCLUSION: The majority of patients found to have Crohn's disease at laparotomy for appendicitis required early ileocolic resection. Therefore, the traditional dictum of nonoperative therapy for these patients may not be in their best long-term interest and merits re-evaluation.Read at the meeting of The American Society of Colon and Rectal Surgeons, Montreal, Quebec, Canada, May 7 to 12, 1995.