A Diverting Stoma Is Not Necessary when Performing a Handsewn Coloanal Anastomosis for Lower Rectal Cancer

Purpose Although a temporary diverting stoma is a frequent surgical procedure for the protection of anastomosis in a sphincter-preserving operation for lower rectal cancer, its impact on anastomotic leakage is not conclusive. This study was designed to evaluate anastomotic complications after ultralow anterior resection and handsewn coloanal anastomosis without a diverting stoma for lower rectal cancer patients. Methods Between January 1995 and December 2005, 96 patients were treated by ultralow anterior resection and handsewn coloanal anastomosis for lower rectal cancer. Fifty-one patients received preoperative concurrent chemoradiation, whereas 45 had no preoperative treatment. No diverting stoma was created in any of these cases. The anastomotic complications were evaluated between the groups. Results Six of 96 patients (6.1 percent) developed anastomotic complications: three anastomotic stenoses, one partial anastomotic dehiscence, one retrorectal abscess, and one rectovaginal fistula. All of the complications occurred in the preoperative radiation group, whereas none from the nonradiation group had an anastomotic complication (P = 0.017). The patients with stenosis and partial dehiscence were managed conservatively. The patient with retrorectal abscess was treated with debridement, irrigation and drainage, and seton procedure with a transanal approach. The patient with rectovaginal fistula underwent a second coloanal anastomosis. Conclusions The anastomotic complication rate was low even without a diverting stoma. This study suggests that a diverting stoma is not necessary when performing a handsewn coloanal anastomosis for lower rectal cancer however, an effort should be made for healthy anastomotic healing in patients with rectal cancer who are preoperatively radiated. Presented at the Congress of the International Society of University Colon and Rectal Surgeons, Istanbul, Turkey, June 25 to 28, 2006. Reprints are not available.     

Functional and quality-of-life outcomes in patients with rectal cancer after combined modality therapy, intraoperative radiation therapy, and sphincter preservation

PURPOSE: Locally advanced primary and recurrent rectal cancers treated with external beam radiation therapy, intraoperative radiation therapy, and chemotherapy represent a complex group of patients in the setting of extensive pelvic surgery and sphincter preservation. We sought to define functional outcome and quality of life in this subset of patients. METHODS: We retrospectively reviewed our experience with locally advanced primary and recurrent rectal cancer patients who underwent intraoperative radiation therapy with either low anterior resection (n = 12) or coloanal anastomosis (n = 6) between 1991 and 1998. Current functional outcome and quality of life were evaluated by a detailed questionnaire. RESULTS: Median time from operation to assessment was 24 (range, 6-93) months. Using a standardized Sphincter Function Scale, incorporating the number of bowel movements per day and degree of incontinence, patients were graded as poor, fair, good, or excellent function. Of all patients, 56 percent reported unfavorable (poor or fair) function. Of the subset of patients with coloanal anastomosis or very low low anterior resection, 88 percent had unfavorable function as compared with 30 percent with standard low anterior resection. (P = 0.02; Fisher's exact probability test). A quality-of-life satisfaction score based on social, professional, and recreational restrictions demonstrated 56 percent of patients to be dissatisfied with their bowel function. CONCLUSIONS: The majority of patients with advanced rectal cancers who require external beam radiation therapy, extensive pelvic surgery, and intraoperative radiation therapy report unfavorable functional and quality-of-life outcomes after sphincter preservation. In this setting patients being considered for coloanal anastomosis or very low anterior resection may be better served by permanent diversion.     

Long-term functional evaluation of straight coloanal anastomosis and colonic J-pouch

AIM: This study was designed to analyze the functional and clinical outcomes of straight coloanal anastomosis compared with colonic J-pouch performed after low anterior resection. MATERIALS AND METHODS: Between September 1989 and June 1996, all patients who underwent low anterior resection with anastomosis less than 4 cm from the dentate line were classified into two groups based on the restoration of intestinal continuity: “straight” coloanal anastomosis (n=39) or colonic J-pouch (n=44). Both groups were assessed according to the level of anastomosis, anastomotic complications (stricture, leak, pelvic abscess), age, and gender. For comparison of functional outcome, daily bowel movements, tenesmus, urgency, incontinence score (range, 0–20), and anorectal manometric findings were evaluated preoperatively and at six months, and one and two years after surgery. RESULTS: There were no significant differences between the groups relative to age: (coloanal anastomosis, 66.3±10.1 (range, 46–86),vs. colonic J-pouch, 64.9±13.2 (range, 39–88) years); gender (females): (coloanal anastomosis, 46.2 percentvs. colonic J-pouch; 38.6 percent); diagnosis: (rectal carcinoma: coloanal anastomosis, 84.6 percent,vs. colonic J-pouch, 77.3 percent); preoperative incontinence score (coloanal anastomosis, 1.5±4.6,vs. colonic J-pouch, 1.1±4); bowel movements: (coloanal anastomosis, 2.1±2.3,vs. colonic J-pouch, 2.1±1.9/day); level of anastomosis: (coloanal anastomosis, 1.8±1.3,vs. colonic J-pouch, 1.5±1.3 cm from the dentate line); history of perioperative radiation therapy: (coloanal anastomosis, 15.4 percent,vs. colonic J-pouch, 20.5 percent); or manometric findings. There was also no significant difference in postoperative mortality: (coloanal anastomosis, 5.1 percent,vs. colonic J-pouch, 2.3 percent); or anastomotic complications: (coloanal anastomosis, 7/39 (17.9 percent),vs. colonic J-pouch, 2/44 (4.5 percent)P=0.08); strictures: (10.3vs. 0 percent); leaks: (5.1vs. 2.3 percent); bleeding: (2.6vs. 0 percent); rectovaginal fistula: (0vs. 2.3 percent). Also, in the colonic J-pouch group, two patients developed pouchitis, and one patient experienced difficult evacuation one year after surgery. There was a statistically significant better function judged by less frequent bowel movements (4±2vs. 2.4±1.3/day;P<0.005) and urgency (36.7vs. 7.7 percent;P<0.05), incontinence score (2.2±3.7vs. 0.8±1.6;P<0.05) up to one year after surgery. At two years, the coloanal anastomosis group did not show statistical improvement in functional results compared with one year postoperatively. Rectal compliance in manometric findings was significantly increased in the coloanal anastomosis group at one year after surgery (12.4±12.6vs. 4.2±1.5 ml/mmHg;P<0.05). However, these differences were less profound after two years. CONCLUSION: The functional superiority of the colonic J-pouch was greatest at one year after surgery. By two years, adaptation of the “straight” coloanal anastomosis yielded similar functional results. However, the almost fourfold reduction in anastomotic complications in the colonic J-pouch group reveals a second potential advantage of this technique.     

The Development of a Validated Instrument to Evaluate Bowel Function After Sphincter-Preserving Surgery for Rectal Cancer

PURPOSE Sphincter-preserving surgery is technically feasible for many rectal cancers, but functional results are not well understood. Therefore, the purpose of this study was to develop an instrument to evaluate bowel function after sphincter-preserving surgery.METHODS A 41-item bowel function survey was developed from a literature review, expert opinions, and 59 patient interviews. An additional 184 patients who underwent sphincter-preserving surgery between 1997 and 2001 were asked to complete the survey and quality-of-life instruments (Fecal Incontinence Quality of Life, European Organization for Research and Treatment of Cancer QLQ 30/Colorectal Cancer 38). A factor analysis of variance was performed. Test–retest reliability was evaluated, with 20 patients completing two surveys within a mean of 11 days. Validity testing was done with clinical variables (gender, age, radiation, length of time from surgery), surgical variables (procedure: local excision, low anterior resection, coloanal anastomosis), reconstruction (J-pouch, straight), anastomosis (handsewn, stapled), and quality-of-life instruments.RESULTS The survey response rate was 70.1 percent (129/184). Among the 127 patients with usable data, 67 percent were male, the median age was 64 (range, 38–87) years, and the mean time for restoration of bowel continuity after sphincter-preserving surgery was 22.9 months. Patients had a median of 3.5 stools/day (range, 0–30), and 37 percent were dissatisfied with their bowel function. Patients experienced a median of 22 symptoms (range, 7–32), with 27 percent reported as severe, 37 percent as moderate, and 36 percent as mild. The five most common symptoms were incomplete evacuation (96.8 percent), clustering (94.4 percent), food affecting frequency (93.2 percent), unformed stool (92.8 percent), and gas incontinence (91.8 percent). The factor analysis identified 14 items that collapsed into three subscales: FREQUENCY (α = 0.75), DIETARY (α = 0.78), and SOILAGE (α = 0.79), with acceptable test–retest reliability for the three subscales and total score (0.62–0.87). The instrument detected differences between patients with preoperative radiation (n = 67) vs. postoperative radiation (n = 15) vs. no radiation (n = 45) (P = 0.02); local excision (n = 10) vs. low anterior resection (n = 55) vs. coloanal anastomosis (n = 62) (P = 0.002); and handsewn (n = 18) vs. stapled anastomosis (n = 99) (P = 0.006). The total score correlated with 4 of 4 Fecal Incontinence Quality of Life (P < 0.01) and 9 of 17 European Organization for Research and Treatment of Cancer subscales (all P < 0.01).CONCLUSIONS Patients undergoing sphincter-preserving surgery for rectal cancer have impaired bowel function, and those treated with radiation, coloanal anastomoses, or handsewn anastomoses have significantly worse function. This reliable and valid instrument should be used to prospectively evaluate bowel function after sphincter-preserving surgery in patients undergoing rectal cancer therapy.Supported in part by a Limited Project Grant from The American Society of Colon and Rectal Surgeons Research Foundation, 2002.Presented at the meeting of The American Society of Colon and Rectal Surgeons in Dallas, Texas, May 8 to 13, 2004.     

Parks' coloanal sleeve anastomosis for treatment of postirradiation rectovaginal fistula

Postirradiation rectovaginal fistula is a complex problem in colorectal surgery. The modified Parks procedure curettage of rectal mucosa heavily damaged by radiation is introduced. Fifteen cases of coloanal sleeve anastomosis for the repair of rectovaginal postirradiation fistula are described. All patients previously were irradiated heavily because of carcinoma of the uterine cervix. Three patients had simultaneous repair of vesicovaginal fistula. One postoperative death was observed. Of the surviving patients, functional results have been good in 11. In the seven patients with difficult stripping of the rectal mucosa, surgical curettage was performed. The latter procedure is suggested as the method of choice in relevant cases.     

Ultralow anterior resection and coloanal anastomosis for distal rectal cancer: functional and oncological results

We evaluated the functional and oncological outcome of ultralow anterior resection and coloanal anastomosis (CAA), which is a popular technique for preserving anal sphincter in patients with distal rectal cancer. Forty-eight patients were followed up for 6-100 months regarding fecal or gas incontinence, frequency of bowel movement, and local or systemic recurrence. The main operative techniques were total mesorectal excision with autonomic nerve preservation; the type of anastomosis was straight CAA, performed by the perianal hand sewn method in 38 cases and by the double-stapled method in 10. Postoperative complications included transient urinary retention (n=7), anastomotic stenosis (n=3), anastomotic leakage (n=3), rectovaginal fistula (n=2), and cancer positive margin (n=1; patient refused reoperation). Overall there were recurrences in seven patients (14.5%): one local and one systemic recurrence in stage B2; and one local, two systemic, and two combined local and systemic in C2. The mean frequency of bowel movements was 6.1 per day after 3 months, 4.4 after 1 year, and 3.1 after 2 years. The Kirwan grade for fecal incontinence was 2.7 after 3 months, 1.8 after 1 year, and 1.5 after 2 years. With careful selection of patients and good operative technique, CAA can be performed safely in distal rectal cancer. Normal continence and acceptable frequency of bowel movements can be obtained within 1 year after operation without compromising the rate of local recurrence.     

Laparoscopic-assisted bowel resection with construction of a colonic reservoir for cavernous hemangioma of the rectum: report of two cases

Diffuse cavernous hemangioma of the rectum is an unusual benign vascular lesion, marked by delayed diagnosis and often presenting recurrent rectal bleeding and anemia. Colorectal resection with coloanal anastomosis and construction of a colonic reservoir is the preferred surgical treatment. We report two cases of patients, a 23-year-old man and a 27-year-old woman, with cavernous hemangioma of the rectum, diagnosed by colonoscopy and confirmed by magnetic resonance imaging. Arteriography demonstrated vascular tumors in the rectal wall. Use of the embolization technique was not successful, since no large caliber vessel was available for this procedure. The patients underwent anterior abdominal excision of the rectum with a laparoscopic approach+ colonic reservoir and hand sewn coloanal anastomosis. Ileostomy closure was performed in both patients at 3 months after surgery, and they demonstrated good early and late postoperative outcomes. In summary, laparoscopic-assisted bowel resection may be a good option for surgical management of diffuse cavernous hemangioma of the rectum.     

Radiation-induced proctitis

Opinion Statement The incidence of chronic, radiation-induced proctitis is between 2% and 5 %. There is not a direct relationship between the incidence of acute radiation proctitis and the subsequent development of chronic proctitis. The treatment for this condition should proceed in a step-wise fashion from conservative therapy such as antidiarrhea medication, topical steroids, sucralfate enemas, and iron replacement to more aggressive treatment in those who do not respond. In the case of persistent rectal bleeding, laser therapy and formalin instillation should be tried prior to surgical intervention. If surgery is necessary, a transverse or descending colostomy should be tried. Aggressive surgery such as rectal resection and colo-anal anastomosis is associated with significant morbidity and mortality and should be reserved as a last resort measure.     

Evaluation of preoperative and postoperative radiotherapy on long-term functional results of straight coloanal anastomosis

PURPOSE: Preoperative radiotherapy for rectal cancer avoids radiation to the reconstructed rectum and may circumvent the detrimental effects on bowel function associated with postoperative radiotherapy. We compared the long-term functional results of patients who received preoperative radiotherapy, postoperative radiotherapy, or no radiotherapy in conjunction with low anterior resection and coloanal anastomosis to assess the impact of pelvic radiation on anorectal function. METHODS: One hundred nine patients treated by low anterior resection and straight coloanal anastomosis for rectal cancer between 1986 and 1997 were assessed with a standardized questionnaire at two to eight years after resection. All radiotherapy was given to a total dose of 4,500 to 5,400 cGy with conventional doses and techniques. Most patients received concurrent 5-fluorouracil–based chemotherapy. RESULTS: There were 39 patients in the preoperative radiotherapy group, 11 patients in the postoperative radiotherapy group, and 59 patients in the no radiotherapy group. The postoperative radiotherapy group reported a significantly greater number of bowel movements per 24-hour period (P < 0.01) and significantly more episodes of clustered bowel movements (P < 0.02) than either the preoperative radiotherapy group or the no radiotherapy group. No significant difference in anal continence or satisfaction with bowel function was found among the three groups. CONCLUSION: In this study of straight (nonreservoir) coloanal anastomoses, postoperative pelvic radiotherapy had significant adverse effects on anorectal function, with higher rates of clustering and frequency of defecation than with preoperative radiotherapy. No differences in continence rates were demonstrated, perhaps because of the sample size of the compared groups. We attribute the adverse effects of postoperative radiotherapy to irradiation of the neorectum, which is spared when treatment is given preoperatively. The deleterious effects of adjuvant radiation on long-term anorectal function can be reduced by preoperative treatment.     

The Strictured Anastomosis: Successful Treatment by Corticosteroid Injections—Report of Three Cases and Review of the Literature

Abstract Clinically significant anastomotic strictures usually only occur with very low colorectal anastomoses below the level of the peritoneal reflection. The reported rate averages 8 percent and has been attributed to tissue ischemia, localized sepsis, anastomotic leak, proximal fecal diversion, radiation injury, inflammatory bowel disease, and recurrent rectal cancer. Most patients will have symptoms of obstipation, frequent small bowel movements, and bloating. Symptomatic strictures are often approached by dilation (balloon or Hegar) or less often repeat resection. Many of these patients have anastomoses that are too low to consider repeat resection. Strictureplasty with linear stapling devices, stricture resection by use of the circular stapling device, and repeat dilations have all been described. Steroid injections into the stricture have been described in strictured esophagogastric anastomoses but have not been commonly used for strictured coloproctostomies. We describe three cases of coloanal stricture following resections that were complicated by postoperative pelvic abcesses, anastomatic leaks, and pelvic fibrosis. Two cases had undergone low coloanal anastomosis that was protected by a loop ileostomy and developed as significant stricture in the early postoperative period. The third case was managed without a protective loop ileostomy. These were initially managed by repeated dilation of the anastomosis. Each episode was followed by rapid recurrence of the stricture. All patients underwent subsequent dilation with injection of 40 mg of triamcinolone acetate (divided dose in four quadrants) into the stricture and subsequent complete resolution of the stricture. Those patients with loop ileostomies had them taken down and all have been followed for up to 12 months without clinical or endoscopic evidence of recurrent stricture.The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.     

慢传输型便秘结肠次全切除术后盲肠直肠吻合方式的探讨

目的探讨慢传输型便秘行结肠次全切除术后更合理的盲肠直肠吻合方式。 方法对兰州军区兰州总医院连续收治并进行手术治疗的34例STC患者的临床资料进行回顾性分析,男性3例,女性31例;年龄36～75岁,平均60.5岁。所有患者均选择行结肠次全切除盲肠直肠吻合,手术在常规开腹或是腹腔镜辅助下进行,盲肠直肠吻合方式采用回盲瓣对侧的盲肠侧壁与直肠残端进行端侧吻合。 结果传统开腹施行手术18例,腹腔镜辅助手术16例。术后1～3天开始排便,6～20次/d,术后第5-6天时排便次数逐渐减少。22例患者在术后10天时大便次数减少至8次/d以内;10例患者术后出现稀水样便伴肛门疼痛,经口服易蒙停、思密达等对症处理后好转。术后发生吻合口瘘1例、切口感染5例、尿潴留2例、炎性肠梗阻2例。30例患者得到随访2月至8年,大便次数保持在1-6次/d。2例患者7年后诉肛门坠胀,排便不净感。1例患者于术后4.5年时出现不完全性肠梗阻,经保守治疗后痊愈。27例患者术后立即感觉治疗效果满意,占80%;随访过程中,所有患者自觉症状均较术前改善明显,对手术治疗满意。无围手术期死亡。 结论对于确实需要手术治疗的STC患者,结肠次全切除盲直端侧吻合可以作为术式选择之一。     

A late colon pouch vaginal fistula after low anterior resection – case report and discussion of aetiology

Spontaneous stercoral perforation resulting in rectovaginal fistula is uncommon. A patient is reported who developed a colon pouch vaginal fistula during an episode of severe constipation more than 3 years after successful surgery for rectal cancer. Patients with colon pouch to anus anastomosis may have an incresed lifelong risk of this complication and faecal impaction should be treated urgently. Colon pouch to anus anastomosis has become the standard reconstruction technique following low anterior resection and total mesorectal exision. Early vaginal fistula remains a well recognised complication whether a straight coloanal or a colon pouch to anal anastomosis is performed. No previous report has been found of a late colon pouch vaginal fistula in the absence of radiotherapy or recurrent disease. Received: 12 January 1999 / Accepted in revised form: 15 February 1999     

Haemorrhagic radiation proctitis: endoscopic severity may be useful to guide therapy

Background and aims Management of haemorrhagic radiation proctitis remains controversial. Both endoscopically delivered argon plasma coagulation and rectal administration of formalin have been recommended. We evaluated the efficacy of argon plasma coagulation according to endoscopic severity of radiation proctitis.Patients and methods Fourteen patients treated with argon plasma coagulation for rectal bleeding due to radiation proctitis were reviewed. Patients were classified with a new endoscopic score for haemorrhagic radiation proctitis, comprising three factors: telangiectasia distribution, surface area involved, and presence of fresh blood. Seven patients were categorised as having grade A (mild), four grade B (moderate), and three grade C (severe) radiation proctitis. Rectal bleeding was assessed pre- and post-treatment using a five-point bleeding scale.Results All patients with grade A and B radiation proctitis were treated successfully by argon plasma coagulation (mean 1.5 sessions). In one patient with grade C radiation proctitis argon plasma coagulation was successful after four sessions, but in the other two patients bleeding could not be controlled; a subsequent single formalin administration was successful in both. Overall in 12 patients (85.7%) bleeding ceased or improved significantly. The mean rectal bleeding scale reduced significantly from 2.6 to 0.9. One patient treated with argon plasma coagulation developed an asymptomatic rectosigmoid stenosis.Conclusion Argon plasma coagulation is a simple, safe and efficacious therapy for mild/moderate radiation proctitis. In patients with severe radiation proctitis several sessions are usually necessary, and success is not certain; in these cases, topical formalin administration may be more effective. Endoscopic severity of haemorrhagic radiation proctitis may be useful to guide appropriate therapy.An erratum to this article can be found at     

Quality of life after surgery for rectal cancer

INTRODUCTION: A permanent colostomy is a serious limitation of the quality of life. Besides cure of cancer, preservation of sphincter function is an important goal of surgery for rectal cancer. METHODS: In a prospective study a concept offering every patient with rectal cancer either sphincter salvage or a "neosphincter" was investigated, and the impact of this strategy on oncologic results, sphincter function, and quality of life was analyzed. RESULTS: From 1992 to 1997, 276 patients were accepted for the study. Two hundred sixty-one patients had elective surgery, and 15 patients had emergency surgery for their rectal tumors. The postoperative mortality rate was 4 percent. A radical resection (R0) was possible in 197 patients (75 percent). Anterior resection was the most common procedure (n = 87), and intersphincteric resection with coloanal anastomosis was the preferred method for low tumors (n = 65). Abdominoperineal resection was necessary in 15 cases. Thirteen patients had an immediate restoration of sphincter function by means of a dynamic graciloplasty, and 2 patients needed emergency abdominoperineal resection for bleeding. The follow-up was relatively short (median, 36.4 months) at the time of data analysis and showed a local recurrence rate of 8 percent. Although postoperative continence according to the Williams score revealed satisfactory results, subjective quality of life and the scale for specific symptoms showed a significantly worse outcome in patients with ultralow (coloanal) anastomoses compared with those with anterior resection. CONCLUSIONS: We conclude that for elective curative surgery of rectal cancer, a permanent colostomy is not necessary provided all presently available techniques of sphincter salvage and restoration are applied. However, the patient has to be informed about possible side effects associated with surgical procedures such as coloanal anastomosis or neosphincter reconstruction, to avoid severe psychological difficulties.     

Restorative resection: Coloanal anastomosis for benign and malignant disease

Sixteen patients underwent anterior resection and coloanal anastomosis between October 1984 and September 1987. Indications included adenocarcinoma of the low rectum in 9, villous tumor in 2, carcinoid tumor in 1, radiation proctitis in 1, adult onset Hirschprung's disease in 1, rectourethral fistula in 1, and megarectum in 1. There was no in-hospital mortality and no anastomotic dehiscence. The Kirwan classification was used to evaluate functional results. Ninety-three percent of patients expressed satisfaction with their surgical results. Eighty-seven percent of patients are normally continent. A single patient is grossly incontinent. Eight of nine patients with carcinoma were resected for cure. A single patient has died of an unrelated disorder and the remaining seven are free of disease at an average follow-up of 24 months. The authors conclude that coloanal anastomosis is a safe procedure accompanied by minimal morbidity, or risk of local recurrence. Excellent, or at least acceptable, continence can be anticipated in the majority of carefully selected patients. The coloanal anastomosis should be strongly considered in any patient with a low-lying rectal lesion in whom body habitus precludes the possibility of conventional low anterior resection.     

Preliminary results of coloanal anastomosis

Coloanal anastomosis after resection of the rectum is the ultimate procedure to preserve the patient's sphincter and avoid a permanent colostomy. Carcinoma of the midrectum, and sometimes of the lower third of the rectum, may not require excision of the pelvic floor and anus for cure. A colonal anastomosis was achieved in 38 patients in whom the indications for surgery were carcinoma in 29, recurrent or extensive adenomas in four, radiation proctitis in two, rectal fistula following radical cystectomy in one, secondary low Hartmann reconstruction after a failed attempt in one, and stenosis of a very low colorectal anastomosis in one. Twenty-six patients were men and 12 women, with a mean age of 62. Dukes' staging for carcinoma were A: 9, B: 7, C: 11, and two had a palliative resection. The mean distance from the anus was 6.0 cm. All had a temporary defunctioning colostomy. There were no postoperative deaths and 17 (45 percent) had postoperative complications, major in 7 (18 percent), minor in 10 (26 percent). Mean follow-up is now 40 months (range, 12 to 64 months). Among patients who underwent curative resection, three have had pelvic recurrences. Two of these patients died of widespread distant disease and one underwent abdominoperineal resection and is now free of disease. All others are alive with no evidence of disease. The colostomy was closed in all but six (16 percent). Two (palliative) died within the colostomy and the other four are awaiting closure. Anastomotic stricture was the most common long-term problem, occurring in 16 and requiring more than one dilatation in eight. Six months after closing the colostomy, the mean daily number of bowel movements is 3.8. Twenty-six (87 percent) are continent to solid stools, two are incontinent to solid stools, and 16 have to wear a pad to prevent soiling. All but one prefer their present status to having their colostomy. In selected cases of rectal carcinoma with little or no extramural spread, the authors estimate that resection and colonal anastomosis is a good alternative with acceptable function and a low rate of recurrent disease, which is comparable to complete rectal excision but avoids a permanent colostomy. However, it should not be a substitute for standard abdominoperineal resection for extensive lower rectal carcinoma or for a colorectal anastomosis when the latter is technically feasible.     

Acute Ischemic Proctitis: Report of Four Cases

Acute ischemic proctitis is an extremely rare clinical entity. It is mainly described in patients with significant atherosclerotic and cardiac risk factors who present with lower gastrointestinal symptoms in the setting of hemodynamic instability. Previous reports of ischemic proctitis suggest that rectal resection is not necessary in the treatment of this disease. We present four cases of acute ischemic proctitis that required complete proctectomy. All patients had large vessel atherosclerosis with rectal bleeding and sepsis as the presenting signs and symptoms. Three of four patients underwent complete proctectomy as the initial procedure. The fourth patient underwent complete proctectomy five days after the initial intervention. Two of four patients survived and were ultimately discharged from the hospital. A third patient recovered from surgery but ultimately died of respiratory complications. Only the patient who was initially treated by subtotal proctectomy died as the result of the disease. Although ischemic necrosis of the rectum is rare, complete proctectomy may be necessary to save the patient’s life.     

Efficacy of hyperbaric oxygen therapy in patients with radiation‐induced rectal ulcers: Report of five cases

For decades, hyperbaric oxygen therapy has been considered a treatment option in patients with chronic radiation‐induced proctitis after pelvic radiation therapy. Refractory cases of chronic radiation‐induced proctitis include ulceration, stenosis, and intestinal fistulas with perforation. Appropriate treatment needs to be given. In the present study, we assessed the efficacy of hyperbaric oxygen therapy in five patients with radiation‐induced rectal ulcers. Significant improvement and complete ulcer resolution were observed in all treated patients; no side‐effects were reported. Hyperbaric oxygen therapy has a low toxicity profile and appears to be highly effective in patients with radiation‐induced rectal ulcers. However, hyperbaric oxygen therapy alone failed to improve telangiectasia and easy bleeding in four of the five patients; these patients were further treated with argon plasma coagulation (APC). Although hyperbaric oxygen therapy may be effective in healing patients with ulcers, it seems inadequate in cases with easy bleeding. Altogether, these data suggest that combination therapy with hyperbaric oxygen therapy and APC may be an effective and safe treatment strategy in patients with radiation‐induced rectal ulcers.     

Preoperative and postoperative evaluation by manometric study of the anal sphincter after coloanal anastomosis for carcinoma

The purpose of the present study was to pre- and postoperatively evaluate the anal sphincter after coloanal anastomosis in 20 patients with carcinoma of the rectum at 5.5 to 8 cm from the anal verge. The 20 patients matched age and sex with the controlled subjects. Of the 20 patients, 17 with normal preoperative manometric studies when compared with control subjects underwent a coloanal anastomosis as described by Castrini, and three patients with preoperative incontinence underwent abdominoperineal resection. Manometric studies preoperatively, and postoperatively at three and 12 months, indicated a statistically significant decrease in squeezing pressure, and rectal compliance at three months that almost normalized by 12 months. The rectal compliance correlated with the number of bowel movements per day at three months (four to five per day) and at 12 months (two to three per day). The rectoanal reflex and length of pressure zone have remained unchanged. Results seem to indicate that anal continence can be preserved after coloanal anastomosis.     

Rectal Ulceration as a Result of Prostatic Brachytherapy: A New Clinical Problem

INTRODUCTION: Prostate cancer is the most common cancer of males in the United States. One treatment modality for localized prostate cancer is brachytherapy, the implantation of radioactive seeds directly into the prostate. Although this is an effective treatment option, significant complications can result. More commonly these complications involve the genitourinary tract, but radiation proctitis is a well-recognized, less common complication. A specific complication of brachytherapy, the development of a rectal ulcer is not well recognized. The clinical course of this complication and results of treatment options are unknown. METHODS: Three cases of rectal ulceration as a consequence of prostatic brachyradiotherapy are presented, and the presumed course of disease and treatment options is discussed. RESULTS: Two patients were initially treated with local advancement flaps that both failed. These patients developed rectourethral fistulas. One patient was treated with diverting colostomy and suprapubic urinary diversion. The second underwent proctectomy and coloanal anastomosis. This also failed after multiple attempts to treat perianastomotic fistulas. The third patient was treated endoscopically for bleeding and has had no further interventions. CONCLUSION: In the small percentage of patients who develop rectal ulcerations from prostatic brachyradiotherapy, local medical or surgical treatments will often result in failure. They also may contribute to the eventual development of rectourethral fistulas, the likely natural progression of this disease. These fistulas should be treated with both urinary and fecal diversion. Earlier stages of ulceration may be treated with rectal resection and reconstruction, but selection criteria for these procedures have yet to be determined.