Showing papers in "Diseases of The Colon & Rectum in 1985"
TL;DR: Thirty-three small “flat adenomas,” not more than 1 cm in diameter, were collected from surgically and colonoscopically removed specimens, and their colonoscopic and histologic characteristics were described.
Abstract: Thirty-three small "flat adenomas," not more than 1 cm in diameter, were collected from surgically and colonoscopically removed specimens, and their colonoscopic and histologic characteristics were described. There were 14 adenomas with mild atypia, five with moderate atypia, 14 with severe atypia (or focal carcinoma limited to the mucosa). The grade of atypia seems to increase with the size of lesions, and these lesions were assumed to play an important role in the adenoma-carcinoma sequence. The importance of recognizing the presence of these small "flat adenomas" in everyday practice is stressed.
416 citations
TL;DR: An analogous to the TNM classification for postoperative pathologic tumor staging, a preoperative tumor staging based on ultrasonic determination of the infiltrative depth of tumor is proposed, which is called u TNM.
Abstract: Digital examination and computed tomography are the current modalities employed to assess the depth of invasion of rectal cancer. Each technique has limitations in that high rectal tumors cannot be examined digitally and CT is unable to detect small tumors. However, preoperative diagnostic capability can be improved with the use of intrarectal ultrasound. We have examined 25 patients with rectal cancer preoperatively with digital examination and intrarectal ultrasound. In order to determine the accuracy of the ultrasonic method, we compared the results to the histopathologic findings of the excised specimen. Digital examination was essentially impossible in eight of the 25 rectal tumors because the tumors were either unreachable or could not be palpated in their full longitudinal extent. Of the remaining 17, digital examination corresponded with pathologic findings in 15, while tumor spread was overestimated in two patients. Sonography corresponded with pathologic findings in 23 of the 25 tumors. Two had been overstaged. Analogous to the TNM classification for postoperative pathologic tumor staging, we propose a preoperative tumor staging based on ultrasonic determination of the infiltrative depth of tumor, which we call u TNM.
378 citations
TL;DR: One hundred twenty patients with primary retrorectal tumors (79 congenital, 14 neurogenic, 13 osseous, and 14 miscellaneous) had their initial treatment at the Mayo Clinic from 1960 to 1979, with a mean age of 43 years.
Abstract: One hundred twenty patients with primary retrorectal tumors (79 congenital, 14 neurogenic, 13 osseous, and 14 miscellaneous) had their initial treatment at the Mayo Clinic from 1960 to 1979. The mean age was 43 years (100 patients were adults). Female predominance was associated with congenital cysts (15:1) and male predominance with chordomas (5:1). Forty-three percent of the patients had malignant lesions. No dermoid cysts were found in this series. Diagnosis was made by digital examination or sacral radiographs in all patients. Computed tomography scan was the most important diagnostic method; the rate of positive findings was 100 percent in 20 patients. Approach to the tumor was posterior in 79 of 102 patients in whom resection was possible. Ten of 66 patients with benign tumors had recurrence. The five-year survival rate for patients with chordomas was 75 percent and for patients with other malignant lesions was 17 percent. Because preoperative biopsy can cause tumor spread, abscess, fecal fistula, or meningitis, it should not be performed if tumors are potentially resectable. Whenever possible, total resection should be done.
294 citations
TL;DR: In order to assess fistulography for anal fistula, 25 fistulograms were reviewed and the results as for extensions and internal openings were compared with the surgical findings.
Abstract: In order to assess fistulography for anal fistula, 25 fistulograms were reviewed. The results as for extensions and internal openings were compared with the surgical findings. Fistulograms were correct in only 16 percent. False-positive results occurred in 10 percent. Fistulography is inaccurate and unreliable.
213 citations
TL;DR: A biofragmentable bowel anastomosis ring (BAR) for sutureless intestinal anastomasosis is described in this paper, with the laboratory results comparing the BAR to sutured and stapled anastomsoses.
Abstract: A biofragmentable bowel anastomosis ring (BAR) for sutureless intestinal anastomosis is described with the laboratory results comparing the BAR to sutured and stapled anastomoses. There was equivalent healing with all three methods of anastomosis. However, “burst” pressure was highest at day zero and overall necrosis was least with the BAR. By virtue of these findings and being sutureless, it is hoped that the limits of safe bowel anastomosis can be extended.
212 citations
TL;DR: Persistent contraction of the pelvic floor muscles, for which the name “spastic pelvic floor syndrome” is proposed, represents a functional disorder of normal pelvicfloor muscles, causing a functional outlet obstruction.
Abstract: In 12 patients with constipation, it was detected by defecography that, during straining, the anorectal angle did not increase, but remained at 90 degrees. These patients were unable to excrete barium. since the anorectal angle is a measure of activity of the pelvic floor musculature, a dysfunction of this muscle was suspected. In order to determine whether this abnormality represented a true functional disorder or just a voluntary contraction of the pelvic floor muscles due to embarrassment, we performed electromyographic, manometric, and transit time studies in these patients. The electromyographic studies confirmed the persistent contraction during defecation straining. Both manometry and electromyography revealed normal muscle function at rest and during squeezing. Colonic transit time studies demonstrated rectal retention in nine of 12 patients, indicating outlet obstruction. Persistent contraction of the pelvic floor muscles, for which we propose the name “spastic pelvic floor syndrome,” represents a functional disorder of normal pelvic floor muscles, causing a functional outlet obstruction.
211 citations
TL;DR: A study evaluating 179 patients with complete rectal prolapse operated on at the University of Minnesota affiliated hospitals from 1953 to 1983 finds that abdominal proctopexy and sigmoid resection was more likely to result in improvement of continence than was perineal rectosigmoidectomy.
Abstract: This is a retrospective study evaluating 179 patients with complete rectal prolapse operated on at the University of Minnesota affiliated hospitals from 1953 to 1983 with no mortality. One hundred and two of 138 patients who underwent abdominal proctopexy and sigmoid resection were followed from six months to 30 years with a recurrence rate of 1.9 percent. Twenty-two of the 33 patients who underwent perineal rectosigmoidectomy were followed from six months to three years with no recurrence. Nine patients who underwent abdominal proctopexy and subtotal colectomy because of colonic inertia associated with procidentia were followed from one to six years with no recurrence. Patient interviews revealed that 72 to 80 percent considered their results as excellent or good. Incontinence or persistent constipation caused the remaining patients to consider their results fair or poor, despite anatomic correction of the prolapse. Abdominal proctopexy and sigmoid resection was more likely to result in improvement of continence than was perineal rectosigmoidectomy.
166 citations
TL;DR: Patients with anal fistula treated within an eight-month to seven-year period by anal fistulectomy and rectal mucosal advancement and an 80 percent follow-up revealed a 90 percent asymptomatic group and a ten percent group who had minor symptoms.
Abstract: One hundred eighty-nine patients with anal fistula treated within an eight-month to seven-year period by anal fistulectomy and rectal mucosal advancement are presented. An 80 percent follow-up revealed a 90 percent asymptomatic group and a ten percent group who had minor symptoms. Eight percent of the symptomatic patients had minor soiling; 7 percent were incontinent for gas, and 6 percent were incontinent for loose stools. No patient was incontinent for solid feces. There was a 1.5 percent rate of recurrent anal fistula comparable to other techniques.
156 citations
TL;DR: Four clinical factors were found to be predictive of mortality: persistent postoperative sepsis, fecal peritonitis, preoperative hypotension, and prolonged duration of symptoms, which identified a subgroup of patients who, because of an increased risk of death, would be likely to benefit from the more complete eradication of the septic focus achieved by colostomy and resection.
Abstract: Sigmoid diverticulitis with perforation and generalized peritonitis is a grave complication of diverticular disease. To compare accurately the results of two operative approaches—proximal colostomy with drainage and proximal colostomy with resection or exteriorization—the authors assessed the clinical and pathologic features of 121 consecutive patients with perforating sigmoid diverticulitis. There were no differences between treatment groups in age, sex, mean duration of symptoms, clinical presentation, number of coexistent diseases, type of peritonitis or chronic corticosteroid use. Overall mortality for emergency operation was 12 percent. Mortality was significantly greater (P<0.05) among the 31 patients treated by colostomy and drainage (26 percent) than among the 90 patients treated by colostomy and resection or exteriorization (7 percent). Seven of the nine patients who died from persistent sepsis had undergone colostomy and drainage. Four clinical factors were found to be predictive of mortality (P<0.05): persistent postoperative sepsis, fecal peritonitis, preoperative hypotension, and prolonged duration of symptoms. These factors identified a subgroup of patients who, because of an increased risk of death, would be likely to benefit from the more complete eradication of the septic focus that is achieved by colostomy and resection.
146 citations
TL;DR: In this paper, a group of 86 patients with anorectal Crohn's disease were followed up from ten to 40 years to determine the course of the disease and the number of patients who later required proctectomy.
Abstract: A group of 86 patients with anorectal Crohn's disease were followed up from ten to 40 years to determine the course of the disease and the number of patients who later required proctectomy. The overall cumulative probability of avoiding proctectomy was 91.6 percent at ten years and 82.5 percent at 20 years. Resection of all proximal Crohn's disease did not ameliorate the anorectal disease, except in patients who had all proximal disease removed and had no recurrence.
139 citations
TL;DR: The results suggest that there may be a somewhat weaker association than previously reported between colonic cancer and dysplasia at a distance from the Colonic cancer.
Abstract: To assess the association of mucosal dysplasia and colonic cancer in patients with ulcerative colitis and to avoid bias in biopsy interpretation that may have affected results of previous studies, the authors examined coded histology slides from colectomy specimens of 22 patients who had ulcerative colitis and colonic cancer and 22 patients who had ulcerative colitis but no colonic cancer. As expected, it was found that dysplasia occurred contiguous to each cancer. However, at a distance from the cancer (i.e., in histology blocks not containing cancer), some dysplasia was found (low or high grade) in 16/22 cases (73 percent), and high grade dysplasia in 11/22 cases (50 percent). These results suggest that there may be a somewhat weaker association than previously reported between colonic cancer and dysplasia at a distance from the colonic cancer. Further, these results suggest that, in studies of dysplasia, it is important to avoid bias in biopsy interpretation and to describe sampling methods.
TL;DR: This report does not condemn banding but focuses on problems associated with a procedure perceived by many to be risk free.
Abstract: Band ligation of symptomatic internal hemorrhoids is a well-established and accepted outpatient procedure. The purpose of this paper is to alert the medical profession to potential complications and death following this procedure. Each of the four patients described in this report experienced pain and inability to urinate following banding. This report does not condemn banding but, rather, focuses on problems associated with a procedure perceived by many to be risk free.
TL;DR: From 1962 to 1982, 27 patients with pulmonary metastases as the only site of recurrent colorectal carcinoma underwent pulmonary resection at Roswell Park Memorial Institute, with a median survival of 27 months.
Abstract: From 1962 to 1982, 27 patients with pulmonary metastases as the only site of recurrent colorectal carcinoma underwent pulmonary resection at Roswell Park Memorial Institute. Only five of these patients had symptomatic pulmonary lesions. No postoperative mortality occurred. The median survival after pulmonary resection was 27 months. Five patients are alive presently without recurrent colorectal cancer and two patients are alive with recurrent pulmonary metastases. Patients with solitary lesions had a better survival than patients with multiple lesions. The major sites of recurrence following thoracotomy were the lungs and liver.
TL;DR: In this article, a new technique of transrectal repair of rectocele operating through a standard Fansler operating speculum was developed, which is based on the technique of Sullivan, as described elsewhere.
Abstract: Colorectal surgeons are frequently faced with rectocele patients who have distressing bowel difficulty and anorectal complaints. In 1977, a new technique of transrectal repair of rectocele operating through a standard Fansler operating speculum was developed. The principle of the repair is based on the technique of Sullivan, as described elsewhere. The main difference is in dealing with the mucosal prolapse. A total of 355 cases of transrectal repair of rectocele was compiled for study covering a period from 1977 to 1982. Ninety-eight percent of patients have improved. Only 2 percent reported no improvement after surgery. There was a 5.6 percent overall infection rate. With refinement of the technique, no infection has been observed in the last 96 cases of the series.
TL;DR: Antimicrobials have little therapeutic potential for relapse of intestinal Crohn's disease and had no effect on fecal flora or hematologic parameters.
Abstract: We have undertaken a prospective randomized trial of one month's antimicrobial therapy for patients with symptomatic relapse of Crohn's disease. Criteria for entry included two major symptoms: fever, abdominal pain, diarrhea, weight loss, abdominal mass or complications (excluding perianal disease); and two hematologic abnormalities: hemoglobin, ESR, albumin, C reactive protein, iron, or total iron binding capacity. Patients were monitored for the aforementioned clinical and hematologic (hemoglobin, albumin, CRP) parameters over six weeks and for changes in fecal flora. Randomization was to four groups: metronidazole alone (M), cotrimoxazole alone (C), metronidazole and cotrimoxazole (C plus M), or double placebo (P). Seventy-two patients entered the study (18=M, 16=C 21=C plus M, 17=P). After two weeks, improvement was reported as follows: M=67 percent, C=17 percent, C plus M=71 percent, P=35 percent. In the metronidazole group, two patients required surgery and one had trouble-some side effects. In the cotrimoxazole group, two had side effects. In the combined group (C plus M), four had troublesome side effects and two of the placebo group (P) required operation. By four weeks, there was no difference in response among the groups: (M=44 percent, C=62 percent, C plus M=57 percent, P=41 percent). Antimicrobials had no effect on fecal flora or hematologic parameters. These results indicate that antimicrobials have little therapeutic potential for relapse of intestinal Crohn's disease.
Journal Article•
TL;DR: Article historique de L.R. Dragstedt concernant le traitement chirurgical de la rectocolite ulcerohemorragique.
Abstract: Article historique de L.R. Dragstedt concernant le traitement chirurgical de la rectocolite ulcerohemorragique
TL;DR: Patients with complicated diverticular disease identified in a retrospective review at the Lahey Clinic between 1967 and 1982 underwent resection with primary anastomosis, associated with acceptable morbidity and mortality rates under appropriate circumstances.
Abstract: One hundred forty patients who had complicated diverticular disease were identified in a retrospective review at the Lahey Clinic between 1967 and 1982. Of these patients, 86 underwent resection with primary anastomosis with a 1 percent mortality rate and an 18 percent morbidity rate; 13 had resection with anastomosis and creation of a proximal colostomy with no death and a 22 percent morbidity rate; 19 had the Hartmann operation or colostomy with mucous fistula with a 16 percent mortality rate and a 23 percent morbidity rate; and 22 underwent a traditional three-stage operation with 14 percent mortality and 24 percent morbidity rates. The average duration of hospitalization was 21 days for patients who underwent the one-stage operation, and 52 days for patients who underwent the three-stage procedure. Primary resection for complicated disease is associated with acceptable morbidity and mortality rates under appropriate circumstances.
TL;DR: Minor complications occur frequently after internal sphincterotomy for anal fissure and stenosis and long-term minor defects in continence occur in a significant number of patients.
Abstract: Internal sphincterotomy is thought by most surgeons to have minimal complications. We retrospectively reviewed 306 patients following internal sphincterotomy to determine the incidence of any complications. Major complications (requiring reoperation) caused by fistula, bleeding, abscess, or unhealed wounds occurred in ten patients (3 percent). Minor complications caused by pruritus, persistent wound, pain, bleeding, abscess, discharge, urgency, impaction, or defects of continence occurred in 110 patients (36 percent). Complications were lowest for closed sphincterotomy (20 percent) and highest for open sphincterotomy alone (55 percent). All patients were cured of anal fissure or stenosis. Long-term follow-up (average 4.3 years) revealed a 22 percent incidence of persistent minor complications. Defects in continence caused 15 percent of total long-term morbidity. Minor complications occur frequently after internal sphincterotomy for anal fissure and stenosis. Closed sphincterotomy has the lowest complication rate. Long-term minor defects in continence occur in a significant number of patients.
TL;DR: Classifcation was found to be a useful guide in the operative management of patients with fistula-in-ano, especially with respect to the recurrence rate and alteration of continence.
Abstract: To evaluate the application of Parks' classification in the management of patients with fistula-in-ano, a study was undertaken to assess the outcome of surgery, especially with respect to the recurrence rate and alteration of continence. A retrospective analysis of 160 consecutive patients who were classified at the time of operation was conducted. The distribution of fistulas was as follows: intersphincteric, 41.9 percent, transsphincteric, 52.1 percent, suprasphincteric, 1.3 percent, extrasphincteric, 0. A horseshoe extension occurred in 8.8 percent of the fistulas and 3.8 percent did not exactly conform to the classification as they were either complex or combinations of more than one type of fistula. The sole immediate postoperative complication was bleeding, which occurred one week postoperatively and ceased spontaneously (0.7 percent). Alteration in continence occurred in 6 percent of patients with 2.6 percent experiencing temporary incontinence to flatus, 1.3 percent to liquid stool, and 0.7 percent to solid stool. Permanent loss of control for flatus occurred in one patient (0.7 percent) and for liquid stool in one patient (0.7 percent). No patients suffered loss of control for solid stool. Recurrence developed in 6.3 percent of patients, all between five and 25 months postoperatively. Classification was found to be a useful guide in the operative management of patients with fistula-in-ano.
TL;DR: It is believed that intussusception of therectum is a relatively common cause of difficult emptying of the rectum and, when the correct diagnosis is established, operation presents a fair chance for improvement.
Abstract: Anorectal disorders that disturb normal defecation are described, especially intussusception of the rectum (internal procidentia). A review of 190 patients, half of whom were treated operatively and the other half conservatively, is presented. Diagnostic procedures, symptoms, and indications for operations are evaluated. We believe that intussusception of the rectum is a relatively common cause of difficult emptying of the rectum and, when the correct diagnosis is established, operation presents a fair chance for improvement.
TL;DR: The data suggest that sialomucin properties of the normal-appearing flat mucosa in FPC are different from those of thenormal colon, and that this simple technique may be useful for the early detection of high-risk individuals in the FPC family.
Abstract: Colonic mucosa in 62 patients with familial polyposis coli (FPC) was stained by a Periodic Acid-Thionin Schiff/Potassium Hydroxide/Periodic Acid-Schiff® method in which the normal colonic mucosa usually stained red and carcinoma stained blue or purple. In FPC, 82.2 percent stained blue or purple, whereas 38.8 percent stained blue or purple in normal controls. The data suggest that sialomucin properties of the normal-appearing flat mucosa in FPC are different from those of the normal colon, and that this simple technique may be useful for the early detection of high-risk individuals in the FPC family.
TL;DR: Low anterior resectioin, with anastomosis in the deperitonealized portion of the colon, was found to increase morbidity without significantly decreasing recurrence when compared with high anterior resection, and offers results comparable to those of other repairs currently being performed.
Abstract: One hundred thirteen patients underwent anterior resection for complete rectal prolapse betwen 1968 and 1980. These patients were followed for an average of seven years; recurrence developed in eight patients (9 percent). Recurrences were found to occur at three months to eight years postoperatively, and the probability of a recurrence at two, five, and ten years was 3 percent, 6 percent, and 12 percent, respectively. Operative mortality was 1 percent and morbidity was 29 percent. Low anterior resectioin, with anastomosis in the deperitonealized portion of the colon, was found to increase morbidity without significantly decreasing recurrence when compared with high anterior resection. The effects of repair on patient continence were unpredictable. High anterior resection is preferable to low anterior resection in the treatment of rectal prolapse and offers results comparable to those of other repairs currently being performed.
TL;DR: The long-term prognosis as regards recurrence after colectomy and ileorectal anastomosis must be rated as mediocre, but the prognosis after ileostomy and co-lectomy or proctocolectomy seems to be more favorable than was often previously believed.
Abstract: Two-hundred and seven survivors of excisional surgery for primary Crohn's disease of the large intestine have been followed for a mean period of 15 years (range, 7 to 25 years). Of the 45 patients who were treated by colectomy and ileorectal anastomosis, 32 (71 percent) developed recurrence in the terminal ileum, rectum, or ileum and rectum, (and in the duodenum in one). Most recurrences appeared during the first few years, but there appeared to be some continuing predisposition to recurrence indefinitely. Nineteen of the patients with recurrences proceeded to rectal excision and ileostomy. A total of 17 patients (3 percent) with or without recurrence had good functional results with a retained ileorectal anastomosis. Of the 162 patients who were treated by ileostomy and colectomy or proctocolectomy (rarely rectal excision and iliac colostomy), 24 (14.8 percent) had recurrences, usually in the bowel immediately above the stoma and, occasionally, more extensively else-where. Most recurrences manifested themselves in the first eight to ten years after operation, and the continuing predisposition thereafter was relatively slight. The inconvenience occasioned by the stoma in these 162 patients was rated as nil in 36.4 percent, negligible in 33.3 percent, moderate or severe in 25.3 percent, and ileostomy refashioning was performed in 5.0 percent with improvement in most instances. The overall condition of the 162 patients was considered to be excellent in 71 percent, fair in 22.8 percent, and poor in 6.2 percent. Most of those placed in the second two categories were so graded because of intercurrent conditions which, if discounted, would have resulted in the general condition of 89 percent of patients being rated as excellent. In 141 patients who finished with a complete proctocolectomy, healing of the perineal wound was straightforward and complete in 61.7 percent, delayed but eventually complete in 28.4 percent, and perineal sinuses formed in 9.9 percent, but many of these healed after further operations. Forty-one of 207 patients treated for primary disease came to reoperation by ileectomy and ilcostomy for recurrent disease. At this writing, only four of the 40 patients followed for a mean period of over 12 years (range, one to 25 years) have developed further recurrences, but yet a third recurrence has appeared in two of those four. Gallstones developed in 5.3 percent and urinary stones in 2.4 percent of the 207 patients studied. The long-term prognosis as regards recurrence after colectomy and ileorectal anastomosis must be rated as mediocre, but the prognosis after ileostomy and colectomy or proctocolectomy seems to be more favorable than was often previously believed.
TL;DR: Results of this study seem to indicate that intestinal stasis is not a cause of melanosis of the colon and rectum and confirm that melanosis may well be due only to the consumption of anthracene laxatives; melanosis coli does not appear to be a sensitive marker of impairment of motor function in the “cathartic colon.”
Abstract: In patients with constipation the prevalence of melanosis in rectal biopsies was evaluated in an attempt to correlate its occurrence with laxative consumption and intestinal stasis. Melanosis was present in 58 percent of the patients and in none of a control group. Melanosis was present in 73.4 percent of patients consuming anthracene laxatives and in 26.6 percent of those not consuming anthracene laxatives (P<0.01). No correlation was found between the occurrence (and grading) of melanosis and pattern of transit through the large bowel, bowel movements, and duration of symptoms. Results of this study seem to indicate that intestinal stasis is not a cause of melanosis of the colon and rectum and confirm that melanosis may well be due only to the consumption of anthracene laxatives; melanosis coli does not appear to be a sensitive marker of impairment of motor function in the “cathartic colon.”
TL;DR: An experimental study using fresh specimen revealed that the middle low echoic layer of the rectal wall corresponded to the muscularis propria, and future studies, using a sonographic probe with higher frequency and better resolution, are expected to produce valuable benefits in deciding indications for local excision of rectal carcinomas.
Abstract: To make objective and accurate assessment of depth of invasion in rectal carcinoma, transrectal ultrasonography, was performed on 49 patients with rectal carcinoma. Two types of scanners were available for use;i.e., 5.0 MHz linear array scanner and 3.5 MHz radial scanner. An experimental study using fresh specimen revealed that the middle low echoic layer of the rectal wall corresponded to the muscularis propria. Depth of cancer invasion was assessed as to whether or not invasion had reached the muscularis propria, or whether invasion had gone through the muscularis propria. The result of 5.0 MHz linear array scan was superior to 3.5 MHz radial scan, and was fairly satisfactory. Future studies, using a sonographic probe with higher frequency and better resolution, are expected to produce valuable benefits in deciding indications for local excision of rectal carcinomas.
TL;DR: It is illustrated that the optimal time for colostomy closure must be determined on an individual basis and the morbidity can be minimized by delaying closure in specific groups of patients for one to two months.
Abstract: A series of 126 colostomy closures was analyzed to evaluate factors contributing to morbidity. There were no deaths, but there was a 33 percent complication rate. Patients with penetrating abdominal trauma and foreign-body rectal perforations had fewer serious complications following colostomy closures than patients with diverticulitis or cancer. No significant difference was found in the anastomotic leak rate, length of surgery or length of hospitalization in patients with sutured or stapled anastomoses. Most patients in this series had end colostomies that required limited resection and anastomoses. Complication rates were comparable with previous series, which consisted predominantly of loop colostomy closures. The incidence of surgical complications was not related to the time interval between colostomy formation and closure. Timing of closure, however, significantly influenced the complication rate in two specific patient groups: patients with intraperitoneal colon perforation at the initial procedure when closure was performed within four weeks, and patients with surgical complications at the time of colostomy creation if they underwent closure within eight weeks. Early closures in patients still recovering from colostomy complications were associated with the highest incidence of anastomotic leak. Wound infections at stoma sites were decreased by leaving the skin open. The average hospitalization was 11.1 days for patients without complications, 15.5 days for those with wound infection, 18.5 days for patients with ileus, and 20.4 days for patients with anastomotic leaks. This study illustrates that the optimal time for colostomy closure must be determined on an individual basis. The morbidity can be minimized by delaying closure in specific groups of patients for one to two months. Delaying closure for an arbitrary time interval in all patients, however, is not warranted.
TL;DR: This study suggests that the presence of an internal fistula, even if it involves the bladder, is not an absolute indication for immediate surgery and that the severity of the symptoms should dictate the treatment policy.
Abstract: There is doubt about the timing of surgery for patients with internal fistulas in Crohn's disease Although immediate operative intervention for all patients has been advocated, such a policy has not always been followed at St Mark's Hospital Between 1971 and 1982, 83 internal fistulas were identified in 59 patients with Crohn's disease Fifty-nine fistulas arose primarily from the small intestine and involved another segment of the bowel, five were between large bowel and duodenum, and three between areas of large bowel Sixteen fistulas (ten from ileum and six from large bowel) involved the bladder Thirty-six patients with 54 fistulas underwent immediate surgical treatment Fifteen patients with 20 fistulas required surgery later There was one postoperative death among the 51 patients treated surgically and one late death unrelated to the treatment of the fistula Of the remaining 49 surgically treated patients, 46 were traced and remain well, six after further surgery Eight patients with nine fistulas (four involving the bladder) were treated at St Mark's without operation One later required surgery elsewhere for an enterocutaneous fistula, but the remaining seven patients are well This study suggests that the presence of an internal fistula, even if it involves the bladder, is not an absolute indication for immediate surgery and that the severity of the symptoms should dictate the treatment policy
TL;DR: It is concluded that the incidence of gastroduodenal polyps is independent of the clinical presence of other extracolonic manifestations and it is advisable that polyposis patients should be followed with gastroduODenoscopy and biopsy of polyps.
Abstract: A total of 26 patients with familial polyposis coli without extracolonic manifestations were examined by gastroduodenoscopy. Histologically verified polyps were found in 18 patients (69 percent, 95 percent confidence limits 48–86). Gastric adenoma was diagnosed in one patient, fundic gland polyposis in six patients, and duodenal adenomas in 12 patients. It is concluded that the incidence of gastroduodenal polyps is independent of the clinical presence of other extracolonic manifestations. It is advisable that polyposis patients should be followed with gastroduodenoscopy and biopsy of polyps.
TL;DR: Five adult patients, two men and three women, with congenital developmental cysts were operated on via a posterolateral approach through a parasacrococcygeal incision, believing this to be the procedure of choice for excision of retrorectal cystic lesions.
Abstract: Congenital developmental cysts are the most common retrorectal tumors. Five adult patients, two men and three women, with congenital developmental cysts were operated on via a posterolateral approach through a parasacrococcygeal incision. All wounds healed primarily with no infection or other complications. Recurrent perianal infections and repeated anorectal operations suggest the possibility of retrorectal growths; thus diagnosis requires physician awareness. Computerized tomography is the best preoperative diagnostic test to delineate anatomy and to rule out bony involvement. Because of an infection rate of approximately 30 percent, as well as the presence of symptoms and malignancy in 8 percent of the patients, surgical excision is the treatment of choice. The authors use a posterolateral approach that provides excellent exposure and obviates the need for removal of the coccyx or transection of the sphincter muscle. The authors believe this to be the procedure of choice for excision of retrorectal cystic lesions.
TL;DR: The strategy for careful follow-up of patients at risk of cancer after “curative” operation for rectal cancers is outlined and a plea is made for a controlled trial of postoperative radiotherapy.
Abstract: Pelvic and perineal recurrences of cancer after rectal amputation are frequent, often isolated, and thus directly responsible for a fatal outcome by local decompression accidents or infection. This study explores the patterns of recurrence after “curative” operation for rectal cancers. One hundred thirteen patients who underwent abdominoperineal resection are reviewed: there were 36 local recurrences,i.e., an incidence of 31.8 percent. About 70 percent of these recurrences occurred within two years after surgical treatment. Low level of tumor in the rectum, local spread into perirectal fat or serosa, lymph node involvement, and histologic grade of malignancy were the only factors that were statistically related to local recurrence. The strategy for careful follow-up of patients at risk is outlined and a plea is made for a controlled trial of postoperative radiotherapy.