Sleeve advancement anorectoplasty for complicated anorectal/vaginal fistula

Transanal flap-advancement procedures for complicated anorectal or rectovaginal fistula may include vertically incised flaps, horizontal flaps, and tubal flaps. Anatomic and pathologic considerations affecting choice of the three major techniques are examined in the context of their historical development over the last century. Application of the tubal (or sleeve) advancement principle is described in a woman whose combined rectovaginal and cryptogenic fistulas encompassed more than one-third of her anal circumference, necessitating surgical modifications beyond those afforded by previously documented techniques. Obliteration of disease and preservation of sphincteric competence were the achieved objectives of the procedure. Rationale for the procedure and technical details of the sleeve advancement anorectoplasty are described, mindful of the surgical antecedents of this therapeutic option.     

The use of transanal rectal advancement flaps in the management of fistulas involving the anorectum

Between 1981 and 1986, transanal rectal advancement flaps were employed in the surgical management of 39 anorectal fistulas at the Cleveland Clinic. Included were 23 low rectovaginal, 12 fistulas-in-ano and, four rectourethral fistulas. Nineteen fistulas occurred in patients with Crohn's disease while the other 20 included 11 due to obstetric or surgical injury. This technique has become the Clinic's standard management for low rectovaginal fistulas but is reserved for complex fistulas-in-ano. Active proctitis or malignancy are contraindications to the procedure. Surgery requires elevation of a broad-based rectal flap, curettage of the tract, and advancement and primary suture of the flap over the internal opening. Fistulas were eradicated in 27 cases (69.2 percent) including 11 of 19 due to Crohn's disease (57.9 percent) and 16 of the 20 (80.0 percent) from other causes (mean follow-up 25 months). Rectovaginal fistulas healed in 60.0 percent of those with Crohn's disease compared with 76.9 percent of those due to other causes. Complex fistulas-in-ano in Crohn's disease did less well. Only two of six of these fistulas healed. Temporary stomal diversion was used on nine occasions and a successful outcome was achieved in only four, indicative of the greater complexity of these cases. It is concluded that the transanal rectal advancement flap can be an effective method of repair for fistulas of the anorectal region including selected cases due to Crohn's disease Read at the meeting of the American Society of Colon and Rectal Surgeons, Washington, D.C., April 5 to 10, 1987.     

Surgical treatment of enterovesical fistulas in Crohn's disease

A review of the surgical treatment of enterovesical fistula in Crohn's disease was undertaken to evaluate its effectiveness and long-term results. Sixty-three patients, 39 men and 24 women, with a mean age of 34.4 years were identified with enterovesical fistula. They had documented Crohn's disease for a mean period of 7.0 years. Distribution of anatomic pattern was 34.9 percent ileal, 7.9 percent colonic, and 57.2 percent ileocolic. Nineteen (30.1 percent) had previous abdominal surgery for Crohn's disease. Presenting symptoms included frequency and dysuria in 93.6 percent, pneumaturia in 79.3 percent, and fecaluria in 63.4 percent; 60.3 percent of patients had all three features. Enterovesical fistula was confirmed preoperatively in 43 patients, suspected clinically in 15 patients, and diagnosed intraoperatively in 5 patients. Sixty-one of 63 patients underwent surgery with resection of the phlegmon or abscess with the diseased bowel and curettage or resection of the fistula. After curettage of the bladder defect, pelvic and bladder drainage was instituted. Coexistent fistulas, most commonly ileosigmoid, occurred in 31 patients. Intra-abdominal abscesses were found in 21 patients, of whom 15 required two-stage procedures. One patient died (mortality 1.6 percent), urine leak occurred in 3.2 percent, and wound infection occurred in 1.6 percent. Follow-up (mean, 106 months) has identified one recurrence of enterovesical fistula due to Crohn's disease, and a further recurrence from concomitant sigmoid diverticulitis. Enterocutaneous fistulas developed in 6.4 percent and 11 patients (17.4 percent) have required further resections for Crohn's disease. Surgical treatment of enterovesical fistula in Crohn's disease is a safe and effective treatment.Study performed at The Cleveland Clinic Foundation.Read at the meeting of The American Society of Colon and Rectal Surgeons, Toronto, Canada, June 11 to 16, 1989.     

New option for recurrent rectovaginal fistulas

PURPOSE: To describe an operative technique for repair of recurrent rectovaginal fistulas. METHODS: A diamondshaped cutaneous flap advancement into the vagina and a standard endoanal advancement flap are described for use as an alternative option in treatment of recurrent rectovaginal fistulas. RESULTS: Complete healing of fistula was achieved with no impairment of continence. CONCLUSION: This technique is suitable in treatment of recurrent rectovaginal fistulas especially in frail and elderly patients.     

Surgical repair of rectovaginal fistulas in patients with Crohn's disease: Transvaginal approach

The surgical management of rectovaginal fistulas complicating Crohn's disease has been associated with unacceptably high failure rates. We sought to modify the available surgical techniques to provide a solution to this challenging problem. Between December 1983 and January 1990, 14 patients with Crohn's disease underwent repair of a rectovaginal fistula. A modified transvaginal approach was employed by the authors. A diverting loop ileostomy was performed on all patients, either as the initial step in the staged management of intractable perianal disease or concurrent with the repair of the rectovaginal fistula. The fistula was completely eradicated in 13 of the 14 women and did not recur during the mean follow-up period of 55.0 months (range, 3–77 months). Intestinal continuity was reestablished in these 13 patients within 6 months after the initial fistula repair. One patient with a very low-lying fistula constituted our only failure. We have found the transvaginal method preferable to the transanal approach because of the relative ease in raising the vaginal flap as compared with a flap of fibrotic and inflamed anorectal mucosa. On the basis of this study, we conclude that a modified transvaginal approach is an effective method for repair of rectovaginal fistulas secondary to Crohn's disease.Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990.     

Surgical management of ileosigmoid fistulas in Crohn's disease

Ileosigmoid fistulas are found in Crohn's disease and may present a surgical dilemma. PURPOSE: This study was designed to examine surgical practice to determine types of intervention, enumerate complications, and elicit guidelines for surgical management. METHOD: The medical records of patients with ileosigmoid fistula and Crohn's disease from 1975 to 1995 were reviewed. RESULTS: Ninety patients (44 men) were studied. A preoperative diagnosis of ileosigmoid fistula was made in 77 percent of patients. Sigmoid repair was performed in 43 patients (47.8 percent), sigmoid resection in 32 patients (35.6 percent), 12 patients (13.3 percent) underwent more extensive procedures, and 3 patients (3.3 percent) either had surgery elsewhere or were observed. The fistula was never directly responsible for a stoma. The repair and resection groups were similar with respect to age, length of Crohn's disease, and preoperative symptoms. There was no significant difference between groups in the incidence of postoperative complications; there were no postoperative deaths. Average length of stay was 8.3 days following repair and 9.9 days after resection. Reasons for resection included significant purulence or inflammation, a large fistula defect, a defect on the mesenteric border of the sigmoid, and active sigmoid Crohn's disease. Surgeon's assessment of the presence of Crohn's disease in the sigmoid correlated with pathologic examination and was aided by knowledge of recent endoscopic appearance and biopsy results; intraoperative frozen section and colonoscopy were helpful in distinguishing serosal inflammation from active Crohn's disease. CONCLUSION: Contrast studies identified 77 percent of ileosigmoid fistulas preoperatively. Performing repair rather than resection does not increase the risk of complications, if standard surgical principles are followed. Preoperative or intraoperative endoscopy assists the surgical evaluation of the sigmoid.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996.     

Evaluation of surgery for perianal Crohn's fistulas

PURPOSE: This study was designed to evaluate the operative treatments performed on patients with perianal Crohn's disease at a tertiary referral colorectal university hospital and to determine the efficacy of management by assessing patient satisfaction. METHODS: A retrospective survey included 59 patients with perianal Crohn's disease who had undergone surgery during the period of 1991 to 1993, inclusive. RESULTS: Twenty-seven patients were treated by laying the fistula open (81 percent successful), and another 27 cases were treated with a loose seton (85 percent successful). Five cases were complicated fistulas and underwent diversionary stomas as part of a primary procedure. Overall success rate, as judged by patient satisfaction, was 83 percent. CONCLUSION: Conservative surgery has a role in management of perianal Crohn's disease. Patient satisfaction can be achieved without complete healing. Better preoperative assessment may improve results further.     

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

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

Surgical management of ileosigmoid fistulas in Crohn's disease: Role of preoperative colonoscopy

PURPOSE: Surgical treatment of ileosigmoid fistulas in Crohn's disease remains controversial and can be radical (resection of both segments) or conservative (ileal resection with suture or wedge resection of the sigmoid). At our institution, the sigmoid defect is sutured if the sigmoid is not affected by primary Crohn's disease or by important stricture; otherwise, the sigmoid is resected. We reviewed our experience to evaluate our results with this procedure. METHODS: Thirty patients with ileosigmoid fistulas underwent operation. Among them, 15 had a preoperative colonoscopy, whereas others had no Endoscopic work-up. In nine patients, the sigmoid was thought to be affected by Crohn's disease (n = 7) or stricture (n = 2) and was resected. In 21 patients, the sigmoid was thought to be affected by proximity, and a simple suture (n = 15) or wedge resection (n = 6) was performed. Eleven patients had a temporary stoma (37 percent). One had coloproctectomy. RESULTS: One patient died postoperatively. One patient had postoperative sigmoidocutaneous fistula after conservative treatment. Histology of the sigmoid specimen showed Crohn's disease in 8 patients (27 percent), including 5 of 9 resected specimens, and 3 of 21 conservative procedures. All patients with Crohn's misdiagnosis did not have preoperative colonoscopy. Nine of 11 stomas were closed in a median delay of four months. With a median delay of nine years, four patients have again undergone surgery for recurrent colonic Crohn's disease, all of whom underwent surgery initially without preoperative colonoscopy. CONCLUSION: Preoperative Endoscopic assessment of the colon is a reliable guide to use when choosing between sigmoid resection or a conservative approach and can result in reduced morbidity and improved long-term results.     

Factors related to frequency,type, and outcome of anal fistulas in Crohn's disease

PURPOSE: Relation of clinical factors to frequency, type, and, in particular, outcome of anal fistulas in Crohn's disease was studied. METHODS: One hundred twelve patients seen in this hospital between January 1972 and June 1993 who suffered from Crohn's disease were included in the study. Those 35 (31 percent) with anal fistulas were reexamined or interviewed and asked about their perianal symptoms and anal control. RESULTS: Rectal involvement of Crohn's disease was associated with an increased incidence of anal fistula (49 vs. 17 percent;P <0.01), especially high ones (82 vs. 17 percent;P <0.01). Ten of 18 patients with low fistulas underwent fistulotomy; all 10 fistulas healed, but slowly (mean healing time, 7.5 months), and 4 of them recurred. Of eight low fistulas managed by drainage alone, four healed. Finally, 11 of 18 patients with low fistulas had their fistulas healed. Fourteen of 17 patients with high fistulas were primarily treated by drainage and 3 by local surgery. Finally, only three patients had healed fistulas—two after simple drainage and one after local surgery, and seven patients had to undergo proctectomy. Only two patients with low fistulas required proctectomy. Eight patients (33 percent) of those 24 with fistulas in whom anal continence could be assessed, 5 with local surgery and 3 with drainage alone, reported minor defects in anal control. CONCLUSIONS: Fistulotomy is a justifiable option with satisfactory results for low symptomatic anal fistulas associated with Crohn's disease, although healing may be delayed and some fistulas will recur. Outcome of high fistulas is less satisfactory, and proctectomy is ultimately required in a number of patients; therefore, for high fistulas a conservative approach is primarily recommended.     

Treatment of rectovaginal fistulas that has failed previous repair attempts

PURPOSE: The purpose of this study was to assess results of treatment of rectovaginal fistulas (excluding pouch vaginal fistulas) that have failed previous attempts at repair. METHOD: A retrospective chart review of all patients presenting with nonhealing rectovaginal fistula was performed. RESULTS: Twenty eight patients with persistent fistulas were identified. In 18 patients the fistula was classified as simple, and in 10 the fistula was complex. Fourteen fistulas were secondary to obstetric injury, five were caused by Crohn's disease, and nine patients had miscellaneous etiologies for their fistulas. Of patients with persistent simple fistulas, 13 (72 percent) of the fistulas healed, 5 after advancement flaps, 5 following sphincteroplasty, and 3 after coloanal anastomoses. Of persistent complex fistulas, only four of ten (40 percent) healed, one following sphincteroplasty, one with coloanal anastomosis, and two after gracilis transposition. A total of 23 advancement flaps were done in 17 patients with five fistulas healing (29 percent). Sphincteroplasty and fistulectomy was successful in six of seven patients (86 percent). Coloanal anastomosis resulted in healing of four of six patients (67 percent) in whom it was attempted. Gracilis muscle transfer was successful in two of two patients (100 percent). CONCLUSION: Persistent rectovaginal fistula presents a difficult management problem. Choice of operation must be tailored to the underlying pathology and type of repair previously done. Advancement flap repair is generally not recommended for persistent complex fistulas or for simple fistulas that have failed a previous advancement flap repair.Dr. MacRae was supported in part by the Wigston Foundation, Toronto, Ontario, Canada.Read at the meeting of The American Society of Colon and Rectal Surgeons, in Montreal, Quebec, Canada, May 7 to 12, 1995.     

Surgical treatment of low rectovaginal fistulas

Forty women with low rectovaginal fistulas were operated upon over a 9-year period. The etiology of the fistula in the majority was obstetric. Nine women had prior attempts to repair the fistula. All 40 women were managed with endorectal advancement flap with the addition of sphincteroplasty or perineal body reconstruction in 15 patients and rectocele repair in six patients. Postoperative complications included urinary difficulties (two patients) and wound complications (three patients). There were two recurrences. All women treated with sphincteroplasty or perineal body reconstruction were continent. Seven women complained of varying degrees of incontinence postoperatively; none had undergone sphincter or perineal body reconstruction. Endorectal advancement flap is a safe and effective operation for women with rectovaginal fistulas. Concomitant sphincteroplasty or perineal body reconstruction should be performed in women with historical, physical, or manometric evidence of incontinence.     

The value of the rectus abdominis myocutaneous flap in the treatment of complex perineal fistula

Complex perineal fistula and persistent perineal sinus are difficult to treat. We describe our experience with wide excision of the diseased perineum using a combined abdominoperineal approach. Ten patients were reconstructed by a rectus abdominis myocutaneous flap (n=7), rectus abdominis muscle flap (n=2), and omental graft (n=1). Primary healing was achieved in all cases. A median follow-up of 18 months (range 6–54 months) has shown no recurrence of perineal disease or associated abdominal incisional hernia. There were no perioperative deaths. We propose that the rectus abdominis myocutaneous flap is indicated if large amounts of perineal skin has to be sacrificed. When less skin is removed a repair with greater omentum or rectus muscle alone is adequate. The abdominoperineal approach together with filling the residual pelvic cavity with well-vascularized tissue allows definitive treatment to be carried out in one stage.Based on an oral presentation at the Tripartite Meeting, Birmingham, United Kingdom, June 19–22, 1989.     

Autologous fibrin glue in the treatment of rectovaginal and complex fistulas

This nonrandomized series reports the use of autologous fibrin glue to treat complex rectovaginal and anorectal fistulas. The use of an autologous source to prepare fibrin glue eliminates the risk of disease transmission. Ten patients, six women and four men, with complex fistulas were treated with autologous fibrin glue application. Five patients had rectovaginal fistulas; one of them had Crohn's disease. Five patients had complex anal fistulas; two of them had Crohn's disease, and one had a large postanal ulcer associated with HIV disease. All patients had outpatient preoperative mechanical bowel preparation and prophylactic parenteral antibiotics. Six of the ten patients (60 percent) reported complete healing of the fistulas. Follow-up ranged from three months to one year. Four of five rectovaginal fistulas healed. The two patients with Crohn's disease and complex anal fistulas and the patient with HIV disease did not heal, but all three reported significantly less drainage. Autologous fibrin glue is a viable alternative for the treatment of recurrent rectovaginal and complex abscess/fistulas.     

Consequences of ileal pouch-anal anastomosis for Crohn's colitis

Patients with Crohn's colitis are generally not considered candidates for the ileal pouch-anal anastomosis (IPAA). procedure. We reviewed 362 consecutive patients undergoing IPAA and analyzed the outcome of this procedure on 25 patients with a preoperative diagnosis of mucosal ulcerative colitis who were subsequently proven to have Crohn's disease. The mean follow-up was 38.1 months. Sixteen patients have a functioning pouch, seven have required pouch excision, one is diverted, and one has died. Only one of nine patients in whom there was a preoperative clinical feature suggestive of Crohn's disease has a functioning pouch, with complications uniformly occurring within months of ileostomy closure. In contrast, 15 of 16 patients without preoperative features of Crohn's disease have maintained their pouch, generally with good results. These data suggest that patients in whom there is clinical and pathologic evidence of Crohn's disease do very poorly without meaningful symptom-free intervals. However, patients without any clinical features of Crohn's disease, despite a histopathologic diagnosis of Crohn's colitis, have had a good outcome with IPAA thus far.Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990.     

Absorption of glycine irrigating solution during endoscopic transanal resection of rectal tumors

Purpose: This study was undertaken to evaluate the potential metabolic complications of 1.5 percent glycine irrigating solution during endoscopic transanal resection (ETAR) of rectal tumors. METHODS: Thirteen consecutive frail patients (mean age, 81 (range, 57–91) years) undergoing 18 ETAR were prospectively studied from July 1993 to January 1995. Indications for ETAR included palliation of advanced rectal cancer (12 patients) and an extensive villous tumor (1 patient). A 27-French two-way Iglesias resectoscope was used. Packed cell volume, blood glucose, and serum concentrations of sodium, potassium, and creatinine were measured before, during (at 45 minutes), and after (at 6 and 24 hours) ETAR. Plasma concentration of glycine and hemoglobin levels were both measured preoperatively and at 45 minutes and 24 hours, respectively. Variables studied included resection time, volume and rate of irrigating fluid, height of irrigating fluid bag above operating table, resectate weight, occurrence of intraperitoneal and extraperitoneal perforation, blood loss, and clinical symptoms. RESULTS: Two patients were excluded. Mean operating time was 456 minutes. A mean of 192.3 liters of irrigant was infused into the rectum. Mean irrigation rate was 43,330 ml/minutes. Mean height of irrigating fluid bag was 692 cm. Extraperitoneal perforation occurred in two patients. Blood loss exceeded 200 ml in four patients, one of whom complained of nausea (operating time, 110 minutes). Mean rise in p-glycine at 45 minutes (10,028 mol/l; 387 percent of preoperative values) was significant (P =0.006). Changes in packed cell volume, b-hemoglobin, b-glucose, s-sodium, and s-creatinine levels were not significant. There was significant correlation between p-glycine and s-creatinine levels at six hours (P =0.033), between p-glycine levels and fall in s-sodium at 24 hours (P =0.037), and between levels of b-hemoglobin and packed cell volume at 24 hours (P =0.0004). There was a positive linear correlation between p-glycine and operating time (r =0.7; P =0.0026) and between p-glycine and volume of irrigating fluid (r =0.5; P =0.0386). CONCLUSIONS: Operating time best predicts increase of p-glycine in ETAR.     

Role of the seton in the management of anorectal fistulas

PURPOSE: To identify the incidence of major fecal incontinence and recurrence after staged fistulotomy using a seton. METHODS: A five-year retrospective chart review of 116 patients (70 males and 46 females) ranging in age from 18 to 81 years (mean, 42 years), in whom setons were placed as part of a surgical procedure for anorectal fistulas, was carried out. Follow-up ranged from 2 to 61 months (mean, 23 months). RESULTS: Setons were employed to identify and promote fibrosis around a complex anorectal fistula as part of a staged fistulotomy in 65 patients (56 percent). Other indications for seton placement included 24 women with anteriorly situated high transsphincteric fistulas (21 percent) and three patients with massive anorectal sepsis (floating, freestanding anus) (2.5 percent). In addition, setons were used to preclude premature skin closure and promote controlled long-term fistula drainage in 21 patients with severe anorectal Crohn's disease (18 percent) and in three patients with AIDS (2.5 percent). Major fecal incontinence (requiring the use of a perineal pad) occurred in five patients (5 percent), and recurrent fistulas were noted in three (3 percent). CONCLUSIONS: Staged fistulotomy using a seton is a safe and effective method of treating high or complicated anorectal fistulas.     

Total anorectal reconstruction with a double dynamic graciloplasty after abdominoperineal reconstruction for low rectal cancer

PURPOSE: Total anorectal reconstruction with a double dynamic graciloplasty was performed after abdominoperineal reconstruction (APR) for low rectal cancer. In four patients an additional pouch was constructed to improve neorectal motility and capacity. The aim of this study was to evaluate the results in the first 20 patients and to report on the preliminary results of patients with an additional pouch. METHODS: Twenty patients with a mean age of 52 (range, 25–71) years and a rectal tumor at a mean of 3 (range, 0–5) cm from the anal verge were treated. In 14 patients the Miles resection, colon pull-through, and construction of a neosphincter were performed in one session. Six patients had the double graciloplasty at an average of 4.1 (range, 1.1–8.8) years after APR. In four patients a pouch was constructed with an isolated segment of distal ileum. RESULTS: After a mean follow-up of 24 (range, 1–60) months after APR, none of the patients developed local recurrence, whereas four patients developed distant metastasis. Fifteen of 20 patients were available for evaluation, and 5 patients were still in training. Of these 15 patients, 8 patients were continent (53 percent), 2 patients were incontinent, and in 5 patients the perineal stoma was converted to an abdominal stoma. Failures were attributable to necrosis of the colon stump (n=2) and incontinence (n=3). At 26 weeks mean resting pressure was 44 (standard deviation (SD), 28) mmHg, and mean pressure during stimulation was 90 (SD, 46) mmHg at a mean of 35 (SD, 1.2) volts at 52 weeks. Mean defecation frequency was three times per day (range, 1–5). Of the eight patients who were continent, six used daily enemas. Mean time to postpone defecation was 11 (range, 0–30) minutes. CONCLUSION: In experienced hands, the double dynamic graciloplasty is an oncologically safe procedure that can have an acceptable functional outcome in a well-selected group of patients. However, to improve the outcome, further modifications will be necessary. So far, the addition of a pouch has not resulted in improved outcome. Supported by the Profileringsfonds of the Maastricht University Hospital, The Netherlands, and by the Stichting Fondsenwervingsactie Volksgezondheid, Amsterdam, The Netherlands. Read in part at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 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.     

Experience with the use of the circular stapler in rectal surgery

This report provides our personal experience along with a general overview of the use of the circular stapler in rectal surgery. To determine the results of our experience with the use of the circular stapler for construction of anastomoses following resection, a series of 215 anastomoses performed in 214 patients was reviewed. The patients ranged in age from 33 to 88 years. There were 116 men and 98 women. Indications for operation included malignancy, diverticular disease, villous adenoma, Crohn's disease, and rectal procidentia. The types of operation performed included removal of varying portions of the large bowel. The anastomosis was performed in a uniform manner with the EEA ^® (United States Surgical Corp., Norwalk, CT) and more recently the CEEA (United States Surgical Corp., Norwalk, CT). The operative mortality was 0.47 percent, with the death being unrelated to the anastomosis. Intraoperative complications encountered included bleeding, difficult extraction, instrument failure, incomplete doughnuts, deficient anastomoses, and miscellaneous problems. Early postoperative complications included one leak and a number of complications unrelated to the anastomoses. Anastomotic stenosis developed in 27 patients, but only 8 were permanent and only 3 of these were symptomatic. Two of these patients were treated with balloon dilatation. Anastomotic recurrences developed in 131 percent of patients. Our experience gained with the circular stapling device and that reported in the literature have shown it to be a reliable method of performing anastomoses to the rectum in a safe and expeditious manner.This study was conducted with support from The Sir Mortimer B. Davis Jewish General Hospital Foundation and The American Physician Fellowship.