Comparative evaluation of various methods of surgical correction in Hirschsprung's disease

An analysis of results of treatment of 46 patients with Hirschsprung's disease has shown that complications at the postoperative period were observed in 17 of 39 children subjected to radical operations by the methods of Duhamel, Swanson and others. A number of common and specific for each traditionally used method disadvantages responsible for the results of treatment were found out. The authors have developed a method of treatment of Hirschsprung's disease including ablation of the aganglionary zone and forming the termino-terminal colorectal anastomosis between the descended colon and the rectum mobilized and resected from the parasacral-perineal access. The new method was used in operations on 7 patients without complications.     

Current possibilities of the treatment of severe forms of nonspecific ulcerative colitis]

Treatment of patients with a severe form of nonspecific ulcer colitis with subtotal alteration of the colon is described. The disease was complicated by intestinal bleeding which could not be arrested by conservative therapy, so the Hartman operation was performed. Not traditional methods of treatment of ulcer colitis were used such as drainage of the thoracic lymph duct, lymphocytapheresis, lymphosorption, plasmapheresis which allowed to stabilize the patient's state and to perform radical proctectomy, subtotal colectomy with blind gut descended to the anal canal.     

Herniation of the small intestine through an incised rectal prolapse. Case report

Spontaneous rupture of protruding rectal wall with evisceration is a rare complication of rectal prolapse. We hereby present the case of a woman with a large prolapse of the rectum into which small intestine descended and strangulated. The evisceration became clear after incision of the prolapse taken for a large anal haematoma.     

Anastomotic suture incompetence after transperitoneal resection of the rectum

Sphincter saving operations were made in 68.1% of 276 radical operations on the rectum, 85.6% of them being transperitoneal resections. The advantages of this operation are: less traumaticity, blood loss and postoperative lethality as well as saved function of the sphincter apparatus. Incompetence of the sigmorectal anastomosis sutures developed in 29 (18.6%) patients. The dependence of frequency of this complication on the sex and age of the patients, on the character of the disease and localization of tumor, on using suturing apparatuses, radiation treatment and unloading colostomy was studied. The distinctions found proved to be unreliable. Direct causes of the development of the complication are thought by the author to be technical defects of the surgery, disturbed blood supply and regenerative abilities of the sutured end of the gut. Recommendations are given how to prevent the development of the complication and of its more severe consequences.     

Prospective evaluation of human chorionic gonadotropin in the differentiation of undescended testes from retractile testes

PURPOSE: We prospectively evaluated the efficacy of human chorionic gonadotropin (HCG) in the treatment of undescended testis and sought to determine whether HCG assists in the differentiation of undescended testis from retractile testis. MATERIALS AND METHODS: Patients with undescended testes were offered HCG. Testis position, laterality and the presence or absence of a hypoplastic scrotum were noted. The same physician (G. W. K.) recorded physical findings prospectively and stated clinical impression of descent. RESULTS: A total of 67 patients with 90 undescended or retractile testes were treated and evaluated with HCG. Of the 64 undescended testes 13 (20%) descended with HCG therapy, with none requiring subsequent surgery. Of the 26 retractile testes 15 (58%) descended with HCG (p <0.001). Based on physical examination, 100% of retractile testes descended if the testis was in the high scrotal position but only 40% descended if the testis was in the superficial pouch or inguinal area. In the undescended testes group no ectopic or nonpalpable testis descended with HCG. Evaluation of HCG with age demonstrated minimal response (15%) to HCG at less than 24 months, and a peak response between ages 2 and 6 years (75%) with response decreasing thereafter. CONCLUSIONS: HCG may have a limited role in the evaluation of undescended testis in patients younger than 2 years. HCG can serve as an adjunct in the clinical diagnosis of retractile testis in older children.     

Frontal resection as a means of decision for surgical treatment of rectum cancer

The work has been devoted to the improvement of methods of surgical treatment of cancer of the rectum. The possibilities to perform organ-saving operations in treatment of cancer of the rectum are discussed. An analysis of treatment of 351 patients with cancer of the rectum has shown that frontal resection of the rectum is possible in more than 40% of such patients since such interventions save the function of the rectum more completely. New methods of preoperative preparation of the patients are described as well as the application of the improved methods of surgical interventions.     

Results of therapy of rectal cancer following anterior resection and abdominoperineal rectum amputation

Since 1979, 174 patients with histopathologically proven adenocarcinoma of the rectum have undergone abdomino-perineal extirpation (Quenu) or anterior resection for cure. In 86% patients in Dukes stage B were undergone anterior resection and in 92.2% patients in Dukes stage C undergone extirpation. The recurrence rate was lower than 7%, 25% of them were local recurrences and 75% recurrence of the tumor in general. Anastomoic leak was not found after anterior resection. The three-years-survival rate was significantly higher in patients with adeno carcinoma of the rectum in the middle and upper part of the rectum. The three-years-survival rate was after anterior resection 87.6%. After abdominal extirpation, in most cases Dukes C, the three-years-survival time was 58.6%. For curative surgery a "curative" cancer resection involves resection of the cancer bearing rectal segment with its adjacent fat, blood vessels, nerves and lymph nodes. Specially in cases of mid rectal cancer involves resection of mesentery and utilizing high ligation of the inferior mesenteric artery and vein.     

Results of cryosurgery in the treatment of inoperable tumor stenoses of the anus and rectum]

Inoperable tumor stenosis of anus and rectum may be treated surgically only by implantation of artificial anus. Cryosurgery proves to be a feasible alternative in order to maintain free passage of the gut. The cryoprobe is introduced through a rectoscopy under direct view. Visible tumor is touched with the tip of the cryoprobe and subsequently temperature is lowered to approximately -19 degrees C. Usually anesthesia is not required. From 1976 to 1989, 213 patients had been treated by cryosurgery in our department. In 23 cases the use of an artificial anus became inevitable afterwards.     

结直肠损伤的手术治疗：附125例报告

目的:探讨结直肠损伤的手术治疗和围手术期处理。 方法:回顾性分析19年间收治的125例结直肠损伤患者的临床资料。结果:结肠和腹膜内直肠破裂69例中，初期缝合或切除吻合56例（81.16 %），行造口术11例，“损伤控制外科”术式2例。腹膜外直肠破裂18例中，14例行乙状结肠近端造口并骶前引流，4例一期修补未造口;其余38例非全层损伤患者，均做简单修补。全组死亡8例（6.40 %），6例术中、1例术后死于失血性休克，1例术后5 d死于胸腔感染。术后并发症包括局部感染6例、粘连性肠梗阻1例，均治愈。 结论:多数结肠和腹膜内直肠损伤可一期手术，应配合围手术期正确使用抗生素尤其甲硝唑。腹膜外直肠伤应分期手术，为阻断远端污染，应行乙状结肠近端造口而不选择襻式造口。     

The use of a dedicated rectosigmoidoscope for ultrasound staging of tumours of the upper and middle third of the rectum

OBJECTIVE: Tumours of the upper rectum, and many in the middle third, are not accessible to endorectal ultrasound staging because of the difficulty in reaching all sites of the rectum with a rigid probe. The aim of this prospective study was to assess whether using a dedicated rectosigmoidoscope, endorectal ultrasonography (ERUS) can accurately stage any rectal lesion irrespective of its distance from the anal verge. METHOD: A total of 173 consecutive patients with a primary rectal tumour were included. A rotating, high multifrequency (5.0-10 MHz) endoprobe was introduced through a dedicated rectosigmoidoscope and advanced above the lesion. A computer allowed for three-dimensional (3D) reconstruction of 2D images. Treatment was selected on the basis of 3D-ERUS findings. ERUS staging was correlated with pathological staging. RESULTS: The depth of invasion was correctly determined by 3D-ERUS in 78.2% of tumours of the lower rectum, 76.4% of tumours extending between the lower and middle third of the rectum, 80.9% of tumours of the middle third of the rectum, 78.5% of tumours extending between the middle and upper third of the rectum and 78.9% of tumours of the upper rectum. The accuracy for the absence of lymph node metastases was 81.2% for tumours of the lower rectum, 78.5% for tumours extending between the lower and middle third of the rectum, 85.7% for tumours of the middle third of the rectum, 83.3% for tumours extending between the middle and upper third of the rectum and 78.5% for tumours of the upper rectum. Analysis showed that there was no difference between the various tumour sites. CONCLUSION: Our findings indicate that using a dedicated proctosigmoidoscope, tumours of the upper and middle third of the rectum are equally accessible to ultrasonographic evaluation. The distance of the tumour from the anal verge does not influence the accuracy of examinations considered adequate by the operator.     

经直肠前列腺穿刺活检并发症分析及其防治

目的探讨经商肠前列腺穿刺活检并发症的发生率、相关因素和处理方法。方法对1995-2004年经直肠前列腺穿刺活检226例进行回顾性分析。由前列腺左右叶分别穿刺3点,中叶穿刺2点。干纱布置入直肠内压迫止血。穿刺前后各应用抗生素3d。结果穿刺后32例患者出现肉眼血尿(14．16％),12例患者直肠出血(5．31％),尿路刺激症状伴有／不伴有发热34例(15．04％),排尿困难29例(12．83％)。上述患者经相关处理后恢复。结论前列腺穿刺活检是诊断前列腺癌的一种安全、简便方法,但在应用中仍有可能发生各种并发症。使用细针穿刺和穿刺前充分的肠道准备是降低并发症发生率的有效手段。     

Postoperative morbidity and recurrence after local excision of rectal adenomas and rectal cancer by transanal endoscopic microsurgery

OBJECTIVE: Tumours in the middle and upper part of the rectum are not easy accessible to local excision. Transanal endoscopic microsurgery (TEM) has been recommended for excision of sessile adenomas in the middle and upper part of the rectum, and for small cancers in patients not fit for major surgery. The purpose of this study was to evaluate postoperative morbidity and local recurrence after TEM. MATERIAL AND METHODS: Seventy-nine patients were treated by TEM in the period 1994-2001. The median age was 74 years. The indications for TEM were rectal adenoma in 72 patients and rectal cancer in 7 patients. The tumours were located within 18 cm from the dentate line, median 10 cm. There were performed 69 transmural and 10 mucosal excisions. Mean follow up was 24 months (range 1-95 months). Twenty (25%) patients died during the follow up period, two because of metastases and 18 of other causes. RESULTS: Seven patients had complications. Two (2.5%) patients had peroperative perforation in the intra-abdominal part of the rectum treated by laparotomy. Five (6%) patients had postoperative cardiopulmonal or surgical complications. Eight patients with benign pre-operative histopathological examination had cancer. The local recurrence rate (13%) was similar for adenomas and for carcinomas. CONCLUSION: TEM is a safe technique well tolerated also by high-risk patients, and should be the preferred method in patients with benign tumours in the middle and upper part of the rectum, and in selected cases of early rectal cancer. Benign pre-operative histology does not preclude malignancy and some patients may need further treatment for unexpected malignancy.     

Preoperative preparation of the bowel for urological surgery: a review

The risk of postoperative complications following opening of the intestine can be reduced by lowering the intraluminal bacterial count. The latter is achieved principally by decreasing the mass of the gut content and by antibiotic prophylaxis. Macroscopically satisfactory decontamination of the gut can be attained with laxatives, enemas, elementary diet or orthograde lavage. We prefer oral lavage with Golytely solution since it allows rapid preparation of the gut and is well tolerated. The value of antibiotic prophylaxis in association with operations on the colon or rectum is undisputed and a number of regimes have been shown to be effective. In view of its effectiveness and lack of side effects. 24-hour perioperative parenteral prophylaxis with metronidazole can be recommended.     

Use of Surgical Procedures and Adjuvant Therapy in Rectal Cancer Treatment: A Population-Based Study

OBJECTIVE: To assess the use of surgical procedures by tumor location and compliance with adjuvant therapy recommendations by tumor stage. The study was conducted in a population-based setting to identify target patient groups for improved care. SUMMARY BACKGROUND DATA: Rectal cancer therapy potentially involves similar patients receiving different treatments. Low anterior resection (LAR), sparing the anal sphincter, and abdominoperineal resection (APR), ablating the anal sphincter, offer equivalent local recurrence and survival rates but may differ in quality of life measurements. The 1990 NIH Consensus Conference recommended that patients with stage II and III rectal cancer receive radiation and chemotherapy in conjunction with surgical resection, but this is not uniformly applied. To interpret the use of these therapies, information on tumor location in the rectum, which is rarely known in population-based studies, is necessary. Patient, hospital, or surgeon characteristics may influence which procedure is performed and whether adjuvant therapy is given. METHODS: Information about primary, invasive rectal adenocarcinomas diagnosed between 1994 to 1996 in 13 California counties was obtained from the regional cancer registry. Tumor location, determined from abstracted medical text, was divided into the upper, middle, and lower rectum. Hospitals were characterized by teaching status, number of beds, and cancer center designation. Surgeons were categorized as general or colorectal surgeons. Factors associated with a higher use of LAR versus APR in patients with middle and lower rectum tumors and factors associated with a higher use of NIH-recommended therapy in patients with stage II and III disease were separately analyzed. RESULTS: Among 637 eligible patients, APR was used in 22% of those with middle rectum tumors and 55% of those with lower rectum tumors. Factors significantly associated with a higher use of LAR included female gender, middle rectum location, and treatment in a major teaching hospital versus a nonteaching hospital. Recommended therapy was received by 44% of patients with stage II disease and 60% of those with stage III disease. Factors significantly associated with higher compliance with NIH recommendations included age younger than 60 versus older than 75, age 60 to 75 years versus older than 75, tumor location in the middle or lower rectum versus the upper rectum, stage III disease, and treatment at a teaching hospital versus a nonteaching hospital. CONCLUSIONS: Patients with similar rectal cancers receive different treatments independent of tumor stage or location. This may result in more APRs performed for middle and lower rectum tumors than necessary and less adequate treatment for stage II and III tumors than recommended.     

Prospective study of the effect of resection of the rectum on male sexual function

A prospective study to evaluate sexual dysfunction following resection of the rectum was performed in 21 male patients. Following proctocolectomy for inflammatory bowel disease (9 patients), the incidence of sexual dysfunction was 11%, and it was always partial. Following abdominoperineal excision of the rectum for carcinoma (7 patients), the incidence of sexual dysfunction was 50%, and it was total in 16%. After anterior resection with low colorectal anastomosis (5 patients), the incidence of sexual dysfunction was 40%. The risk of dysfunction following operations on the rectum increased with the age of the patient and was minimal below the age of 50 years. In patients with inflammatory bowel disease, careful dissection close to the rectum should avoid damage to the pelvic nerves, and the incidence of sexual dysfunction should be low.

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Résumé Dans une étude prospective, nous avons analysé chez 21 hommes les troubles de la fonction sexuelle après amputation du rectum. Leur fréquence est de 11% après proctocolectomie pour maladie inflammatoire de l'intestin (9 cas) et les troubles sont toujours partiels. Après abdominopérinéale pour cancer du rectum (7 cas), 50% des opérés ont des troubles, avec perte fonctionnelle totale dans 16%. La fréquence est de 40% après résection abdominale du rectum avec anastomose colorectale (5 cas). Le risque augmente avec l'age: il est minimal en-des-sous de 50 ans. Dans les maladies inflammatoires de l'intestin, une dissection attentive, qui reste au contact du rectum, doit éviter toute lésion des nerfs pelviens avec une fréquence faible de troubles de la fonction sexuelle.

     

Current problems of the surgical treatment of rectal cancer: analysis of the literature and personal experience

The surgical procedure is a crucial factor in preventing local recurrence in rectal cancer, and total mesorectal excision (TME) particularly is widely accepted as being associated with a decreased local recurrence rate. In this study, concerning 187 patients with rectal cancer, we compare conventional surgery, performed in 140 patients from 1979 to 1993, with a standardised TME procedure in 47 patients over the period from 1994 to 1998. The first group not treated by TME were operated on for 56 (40%) tumours of the upper rectum and 84 (60%) of the lower rectum; 35 (25%) were Dukes' A, 77 Dukes' B and 28 (20%) Dukes' C. 42 abdominoperineal amputations (30%) and 98 anterior resections (70%) were performed. The second group in which TME was performed comprised 17 (36%) tumours of the upper rectum and 30 (64%) of the lower rectum, 8 (17%) in stage I AJCC (Dukes' A), 16 (34%) in II (B) and 23 (49%) in III (C). 9 abdominoperineal amputations (19%) and 38 anterior resections (81%) were performed, 8 (21%) with an ultra-low anastomosis. In the first group of patients we observed 28 local recurrences (20%) and a 5-year disease-free survival in 50% of cases. In the second group we achieved a decreased rate of local recurrence (10.6%) which is about half that observed after conventional surgery, but there was no significant difference in survival. These data confirm the effectiveness of TME in reducing local recurrence rate, according to the literature; in future this procedure can get to reconsider the role of adjuvant therapy in the management of rectal cancer.     

Differential expression of androgen and estrogen receptor of appendix testis in patients with descended and undescended testes

Objectives:   The incidence of appendix testis has been shown to be 76% in descended and 24% in undescended testis in our previous intraoperative survey. To determine the possible role of the appendix testis in the process of testicular migration, we compared the androgen and estrogen receptor status of appendix testis in descended and undescended testes.
Methods:   Thirty-seven appendix testes were collected intraoperatively and the expression of androgen and estrogen receptors were examined with immunostaining and immunofluorescence labeling. Based on the diagnosis, the specimens were divided into three groups. Group H (groin hernia, n  = 11, as a group of descended testis), Group AU (acquired undescended testis, n  = 14), and Group CU (congenital undescended testis, n  = 12).
Results:   The testicular appendages were found to express both androgen and estrogen receptors in Group H and Group AU, but specimens in Group CU were only estrogen receptor positive, whereas androgen receptors were not present.
Conclusion:   The presence of the androgen receptor in the appendix testis of the descended testes and acquired undescended testes and its absence in patients with congenital undescended testis suggests that the appendix testis might play a role in the process of testicular descent.     

腔内水囊磁共振成像对直肠癌术前分期的诊断

目的评估腔内水囊磁共振成像（MRI）预测直肠癌术前分期的准确程度。方法回顾性分析19例直肠癌患者的临床资料，对照术前MRI和术后病理结果．评估MRI能否准确预测直肠癌T和系膜淋巴结转移（N）分期。结果MRI正确T分期15例（78．9％），错误4例，其中2例T1-2期报告为T3期，2例T3期报告为T1-2期；T1-2期的准确率为80％（8／10），B期的准确率为7／9。MRI正确N分期11例（57．9％），错误分期8例；其中高估2例，低估6例，灵敏度为3／9，特异度为80．0％（8／10）。结论术前腔内水囊MRI不能对直肠癌系膜淋巴结转移做出准确预测，可以对T分期进行一般预测。     

RECTAL CANCER FOLLOWING COLECTOMY AND ILEORECTAL ANASTOMOSIS FOR FAMILIAL ADENOMATOUS POLYPOSIS

Background : Familial adenomatous polyposis (FAP) has historically been treated by colectomy and ileorectal anastomosis (IRA). Preservation of the rectum allows the subsequent development of cancer in the rectum. The risk of rectal cancer following ileorectal anastomosis in the Australian population has not been published to date. Methods : An audit of the Familial Adenomatous Polyposis Registry of Western Australia was undertaken to assess patients who had undergone colectomy and ileorectal anastomosis. Fifty-five patients ranging in age from 13 to 65 years were studied. Results : Seven patients (13%) developed cancer of the rectum with a median follow-up of 10 years (range: 1–31 years). Median interval to diagnosis of carcinoma of the rectum following colectomy and IRA was 10 years. All patients who developed cancer in the retained rectum had rectal polyps. Colon cancer was present in the initial colectomy specimen in 13 patients (of these, five patients developed rectal cancer). Flat polyps were noted in five patients. Four patients with flat polyps developed cancer of the rectum. Conclusions : Total colectomy and IRA should be considered as part 1 of a staged procedure in the patient with FAP. With the exception of the patient with no evidence of rectal polyps, completion proctectomy should be undertaken within 10 years of the initial colectomy.     

Ultrasound diagnostics and preoperative staging of rectal cancer

Ultrasound (transrectal and transabdominal) examination was performed in 1991 patients. Rectal tumors were revealed in 117 (5,9%) patients, liver metastases were diagnosed in 31 (26,5%) patients. Transrectal ultrasound allowed to diagnose tumor in all examined 50 patients. Stage uT2 was diagnosed in 20 (40%) and uT3 stage of rectum cancer in 30 (60%) of patients. 10 (20%) patients revealed a pararectal lymph nodes tumor invasion. All patients were operated on. The sensitivity of the method for rectum cancer staging was 95,6%, specificity--40%, accuracy 85,7%. Sensitivity of ultrasound in pararectal lymph nodes invasion detection was 95,2%, specificity--95,0% and accuracy--92,3%.