90th annual convention poster presentations and abstracts

American Society of Colon and Rectal Surgeons

American Society of Colon and Rectal Surgeons

90th Annual Convention Poster Presentations

and Abstracts

May 12-17, 1991 Boston, Massachusetts

ABSTRACTS

Abstracts appear in the order of presentation. Their number corresponds to the title listed in the scientific program.

Clinical Significance of Diminutive Polyps of the Rectosigmoid

(1) C.N. Ellis, D. J. Coyle . . . . . . . . . . . . . . Birmingham, AL H. W. Boggs, G. W. Slagle, P. A. Cole .. Shreveport, LA

Diminutive colon polyps are a common finding during examination of the rectosigmoid. To determine the clinical significance of these, 637 consecutive complete colonoscopies on 526 patients were reviewed. In 430 patients, only adenomatous or hyperplastic polyps 5 mm or smaller were identified in the rectosigmoid colon and removed for pathologic examination. In 156 patients (36.3 percent), additional polyps were identified in the proximal colon. Proximal colon polyps were found in 123 of 382 patients (32.2 percent) with one, 28 of 42 (66.7 percent) patients with two, and five of six patients with three or more rectosigmoid polyps (P < 0.05). Pathologic review revealed 211 patients with only hyperplastic, 179 with adenomatous polyps, and 40 patients with both hyperplastic and adenomatous rectosigmoid polyps. Of these patients, 70 (33.2 percent), 71 (39.7 percent), and 15 (38.0 percent), respectively, had additional proximal colon polyps (P = NS). These data suggest that diminutive rectosigmoid polyps, whether hyperplastic or adenomatous, are associated with proximal colonic neoplasia, with the incidence increasing as the number of rectosigmoid polyps increases. It is suggested that total colonoscopy is indicated for all patients with small polyps of the rectosigmoid colon.

Minute Depressed Carcinomas of the Large Intestine (2)

S. Kuramoto, O. Ihara, T. Oohara . . . . . . . . Tokyo, Japan

Until recently, colonic cancer in humans has been believed to develop from raised adenomas; therefore, depressed lesions of the large intestine have been ig- nored. However, the development of the videoimage endoscope improved the ability to distinguish endoscopic images. There are many small depressed lesions in the colon and rectum. We looked for them to analyze their characteristics.

From January 1988 to March 1990, 1,208 colonoscopic examinations were carried out in the Third Department of Surgery, University of Tokyo, using videoimage colon- oscope (Olympus CF type V10 I). 739 patients were men and 469 were women; 59 depressed lesions were endo- scopically picked out and biopsies were performed. Three lesions were diagnosed as minute depressed-type early cancers (IIc; under 5 mm), and 17 lesions were confirmed as adenomas. The other 39 lesions included 12 lymphoid follicle hyperplasias and 9 artefacts. Thir- teen of 20 carcinomas and adenomas were proximal to the sigmoid-descending colon junction.

P2

There are many more depressed minute carcinomas than expected. They are considered to be the origin of some advanced colorectal cancers that were missed when small. Over half of the depressed lesions were in the proximal colon. To prevent advanced colorectal cancers, total colonoscopy is necessary.

Malignant Polyps: The Ochsner Experience (3)

J. Nichols, F. Opelka, J. B. Gathright, J. B. Green New Orleans, LA

The proper therapy for polyps containing invasive carcinoma has been evolving since endoscopic polypectomy was first introduced. A review of the 16-year experience with endoscopic re'moral of malignant polyps at the Ochsner Medical Foundation was performed to assess the adequacy of treatment and prognosis for these patients.

During the study period, 11,800 colonoscopies and 6,200 polypectomies were performed, with 53 malignant polyps removed. Ten patients were excluded due to fragmentation of the specimen and inability to assess depth of invasion (8), unavailability of the histologic slides, or the patient being lost to follow-up before treatment (one each). The remaining patients' records, histologic studies, and outcomes were evaluated according to Haggitt Level of invasion in the polyp.

Follow-up for a mean of 65 months (range 24-196 months) showed no evidence of recurrence in 26 patients treated by endoscopic polypectomy and surveillance (4 Level 1, 13 Level 2, 5 Level 3, 4 Level 4). Residual disease without nodal disease was found in only 3 of 17 patients undergoing resection (1 of 10 Level 3, 2 of 9 Level 4).

Colon cancer amenable to primary endoscopic therapy is rare. When present, endoscopic polypectomy appears to be adequate therapy for most patients. Further study may reveal reliable histologic criteria for primary endoscopic therapy of even Level III and Level IV polyps.

Long Term Follow-Up After Endoscopic Polypectomy (4)

J. B. Poulard, A. Ott, S. Bank, I. B. Margolis Jamaica, NY

In order to determine the yield of long term follow- up colonoscopy after endoscopic polypectomy, the records of 134 patients who had undergone at least one repeat colonoscopy were reviewed; 67 (50 percent) had polyps on the first reexamination (interval 1-9 years). Recurrent polyps were found in 36 percent on a second examination, 36 percent on a third examination, 29 percent on a fourth, and 25 percent on a fifth examination. When the first follow-up examination was negative, 8 of the 39 (21 percent) subsequent examinations revealed polyps. Following two negative examinations, 3 of 14 (21 percent) showed polyps, one patient had a polyp

Vol. 34, No. 4 MEETING ABSTRACTS P3

found on an examination 12 years after index polypectomy subsequent to three negative intervening examinations. It thus appears that al though the risk of new polyps is initially approximately 50 percent; this does diminish following a negative examinat ion to a plateau at the 20-25 percent level and continues throughout the length of t ime encompassed by this study.

Colonoscopy in Patients with a Family History of Large Bowel Cancer

(5) A. Meagher, M. Stuart . . . . . . . . . . . . . . Sydney, Australia

The management of the relatives of a patient with colorectal cancer remains controversial. Since 1982, it has been the coauthor 's pol icy to advise all patients who have a positive family history of bowel cancer and who are over the age of 30 years to undergo colonoscopy. Up until August 1990, 600 such patients have had at least one colonoscopy. Colorectal neoplasia has been detected in 270 patients (45 percent) . The incidence was essential ly the same for the 171 patients with only second degree relatives affected (43 percent) , for the 194 patients with more than one affected relative (45 percent) , and for the 429 patients with an affected first degree relative (46 percent) . Only the 55 patients with more than one affected first degree relative had a higher incidence (67 percent) . The incidence in 136 totally asymptomatic patients was 36 percent but was 48 percent in the 464 with symptoms (37 with carcinoma). Even in the 30-39 year age group, there were over 20 percent with neoplasia. It is currently advised that all patients over the age of 30 years with a family history of colorectal cancer undergo colonoscopy on presentat ion and, if clear, every 4 years thereafter unless two first degree relatives are affected when it should be every 3 years.

Extended Low Anterior Resection of the Rectum (6)

J. A. Heine, D. A. Rothenberger, F. D. Nemer, C. E. Christenson . . . . . . . . . . . . . . . . . Minneapolis, MN

Ninety-seven patients (59 females, 38 males) with a mean age of 64 years underwent ex tended low anterior resections of the rectum for lesions (91 malignant) 7 cm or less from the anal verge. Nine of 12 patients with a covering stoma had restoration of continuity. There were three early deaths. Anastomotic dehiscence resul ted in pelvic abscess in 6 patients and rectovaginal fistula in five, all of whom required fecal diversion. Other significant complicat ions occurred in 11 patients. There were no septic complicat ions in patients with a covering stoma. More distal lesions (2-5 cm) had a lower rate of anastomotic dehiscence than lesions at 6 and 7 cm (chi- square, P < 0.05), Preoperative radiotherapy significantly increased the risk of anastomotic dehiscence (chi- square, P < 0.01). Functional outcome was assessed in 41 patients at a mean of 46 months (3-130). Average number of bowel movements per 24 hours was 3.2 --- 2.2.

Nineteen patients (47 percent) had perfect or near perfect continence; 20 (49 percent) and two patients noted occasional minor and major incontinence, respectively. There was no correlat ion be tween functional outcome and the level of the lesion, sex, preoperat ive radiotherapy (chi-square, P > 0.1), or patient age (Student 's two tai led t, P > 0.2). Ninety-five percent of patients were very satisfied with the outcome. Extended low anterior resect ion for very low rectal lesions was per formed with 3 percent mortali ty and 22 percent significant complication rate. Functional outcome is acceptable to most patients but difficult to predict. Covering stomas should be considered for patients who have received preoperat ive radiotherapy.

Functional Results of Proctectomy and Colo-Anal Anastomosis in Patients with Rectal Cancer

(7) R. C. Saad, J. M. Church, V. W. Fazio, I. C. Lavery, J. R. Oakley, J. W. Milsom, T. K. Schroeder

Cleveland, OH

Proctectomy and coloanal anastomosis offers preservation of per-anal defecat ion for patients with low rectal cancer, but carries a risk of impaired anorectal function. This study reviewed the postoperat ive functional status of patients undergoing proctec tomy and CAA for rectal cancer, to de te rmine its suitability as a treatment option. Methods: A review of 49 patients undergoing proctectomy and CAA for rectal cancer was performed. Patients were classified as continent, or with minor ( l iquid stool, <2 t imes per week) or major incont inence (solid stool, or >2 t imes per week, or constant usage of pads); 36 patients underwent postoperat ive anorectal manometry. Results: Follow-up was available in 42 patients (mean duration 26 months) ; 29 were continent (69 percent) , 10 had minor (24 percent) and 3 had major incont inence (7 percent) . Mean stool f requency was 3.2/day (range 0.3-12). There was no difference in anal resting pressure, squeeze pressure, or anal canal length be tween continent and incontinent patients. Neither the use of perioperative radiotherapy, the choice of hand sewn or s tapled anastomosis, nor t ime since CAA affected the incidence of incontinence. Incont inent patients had twice as many stools per day as continent patients (2.2 vs . 4.4); 11 of 38 (29 percent) patients used pads and 5 of 32 (16 percent) patients were unable to defer defecation. Con- clusion: Patients undergoing proctec tomy and CAA achieve acceptable functional results. The need for perioperative radiotherapy or hand sutured anastomosis are not contra-indications to its use.

Perioperative Irradiation in Resectable Rectal Carcinoma: An Evaluation of late Secondary Effects

(8) L. P~hlman, G. Frykholm, B. Glimelius

Uppsala, Sweden

Between 1980 and 1985, 471 patients with a resectable rectal carcinoma were randomly al located to receive

P4 MEETING ABSTRACTS

ei ther preoperat ive irradiation (25 Gy in 1 week) or postoperat ive irradiation (60 Gy in 8 weeks) to a high risk group of patients, i.e., Dukes' stage B and C cases. After a minimum follow-up of 4 years, a statistically significantly reduced local recurrence rate was found in the preoperat ively irradiated group. No difference in survival was noted. After a p ro longed follow-up (>5 years), 324 patients were evaluated in order to find possible late side effects from the bowel, urinary tract or skin; 170 patients had a survival exceeding 5 years. Totally 16 (5 percent) of the 324 patients were reoper- ated because of late small bowel obstruction: 7 of 187 (4 percent) had preoperat ive irradiation, 6 of 80 (8 percent) had postoperative irradiation, and 3 of 57 (5 percent) had no radiotherapy. Significant morbidi ty from the urinary bladder occurred in two patients who received preoperat ive irradiation and in two after postoperat ive irradiation. Perineal pain and fibrosis were not iced in three patients treated with postoperat ive irradiation.

Conclusion: Since the treatment results after preoperative irradiation was superior to postoperat ive irradiation and the incidence of significant morbidi ty was not higher, preoperat ive irradiation seems to be preferred as adjuvant treatment in patients with rectal carcinoma.

The Use of Photodynamic Therapy in the Palliation of Massive Advanced Rectal Cancer: A Phase I/II Study

(9) H. Kashtan, M. Papa, B. Wilson, H. Stern

Toronto, Ontario

Photodynamic therapy is a relatively new form of cancer therapy util izing a photosensi t izer such as He- matoporphyrin Derivative (HpD). We conducted a pi lot study to de termine the efficacy of its use in pall iat ing advanced rectal cancer, to de termine toxicity, and to establish objective outcome criteria. Six patients with very advanced, usually recurrent rectal cancer were treated with PDT after being photosensi t ized with Pho- tofrin II. A protocol was establ ished to measure clinical and radiologic response to therapy. A new intraluminal del ivery system was incorporated. Five patients had both clinical and radiological responses to therapy. In two patients we observed such significant responses that they cannot be accounted for on a photobio logic basis alone. One patient deve loped a significant sunburn, post discharge. There was no major toxicity of b leed ing or sepsis even at maximum doses (200 joules/cm2). We are con- fident that PDT has a role to play in rectal cancer and speculate as to future applications.

The Results of Abdomino-Perineal Resections for Failures After Combination Chemotherapy and Radiation Therapy for Anal Canal Cancers

(10)

R. Zelnick, P. Haas, M. Ajlouni, T. Fox, E. Szilagy Detroit, MI

Thirty patients treated with combinat ion chemotherapy (CT) and radiation therapy (RT) for anal canal car-

Dis Colon Rectum, April 1991

cinoma were reviewed retrospectively to analyze the results of abdominoper inea l resect ion (APR) for treatment failures. Mean fol low up was 34.9 months. Pathol- ogy was 24 squamous and six cloacogenic cancers. Twenty-five had negative nodes and five had positive nodes. The group received 5FU, mitomycin-C, and RT 30-50 Gy plus 20 Gy boost for positive nodes. Biopsy was obtained at 6 weeks post therapy; 17 of 22 (77 percent) with primary tumor less than 5 cm and negative nodes are disease free at 37 months post CT-RT. None of the patients (n = 7) with primary tumor greater than 5 cm or positive nodes were free of disease. APR was done for positive biopsy in eight patients and for local recurrence (19 months post CT-RT) in one patient. Eight of nine who had APR died of disease (mean 20 months) and one of nine d ied of other causes. A review of pub- l ished series, including our data, reveals 24 cases of APR post CT-RT for positive b iopsywi th 17 of 24 (71 percent) dead of disease within 3 years. APR for CT-RT failures has a poor prognosis. Future protocols may de termine if further CT-RT will improve survival. APR for pall iat ion should always remain an option.

Preservation of Anorectal Function in Advanced Epidermoid Anal Cancer

(11)

B. J. Cummings . . . . . . . . . . . . . . . . . . Toronto, Ontario

Although the treatment of ep ide rmoid anal cancer with radiation (RT) or combined 5FU, mitomycin, and RT (FUMIR) is widely accepted, some authors have repor ted that it is difficult to preserve anorectal function if the cancer is bulky, or deep ly invasive, or circumferential. Sixty-one patients with one or more of these characteristics were treated with RT or FUMIR (48-50 Gy uninterrupted or split course radiation plus one or two courses concurrent 5FU 1,000 mg/m2/24 hours for 96 hours, and mitomycin 10 mg/m2).

Control of Anal Cancer

RT (%) FUMIR (%)

Size > 5 cm 9/17 (53) 27/34 (79) Invading adjacent organ 6/14 (43) 13/17 (76) >-3/4 anal circumference 2/10 (20) 12/14 (86)

Anorectal function was preserved in 8 of 23 (35 percent) treated by RT, and in 28 of 38 (74 percent) treated by FUMIR. Function was lost due to fibrosis or necrosis in one patient treated by RT and in three treated by FUMIR. Mild anorectal fibrosis caused increased frequency and urgency of defecation, without incontinence, in 10 percent treated by FUMIR.

Radiation plus concurrent 5FU and mitomycin is effective against advanced anal cancers. The finding of a bulky, invasive, or circumferential cancer is not a contraindication to treatment in tended to conserve anorectal function.


Early Radiation Effect on the Anal Sphincter Function (12)

J. W. Fleshman, Z. Dreznick, R. D. Fry, I. J. Kodner St. Louis, MO

The early effect of pelvic irradiation on the anal sphincter mechanism has not been previously investigated. The purpose of this study was to evaluate pro- spectively the acute effect of preoperat ive irradiation on anal function. Methods: A group of 20 patients with rectal carcinoma, mean age of 60.9 years (range 43-83), were subjected to 45 Gy of external beam irradiation. The field of irradiation included the sphincter mechanism in 10 patients and was del ivered above the anorectal ring in 10 patients. Anal manometry was per formed in all patients before and 4 weeks after radiotherapy using a 4- channel perfused catheter. Results: No significant difference of sensory threshold (SENS), maximal resting pressure (RP), or squeeze pressure (SP) was found before and after radiotherapy (Table 1).

Table 1 (Mean).

Irradiation SENS (cc) RP (mm Hg) SP (mm Hg)

Fine Wire Need le EMG (n) EMG

EAS PR CG EAS PR

Overall 45 43 34 16 14 Activation 19 18 10 9 7 No change 14 i8 22 4 3 Inhibition 12 7 2 3 4

Activation of the pelvic floor muscles occurred during straining in nearly half of the subjects. Most of the remainder showed no measurable change; inhibit ion of the EAS and PR occurred in only 26 and 16 percent, respectively. Fine wire e lect rodes and a bolus in the anus y ie lded similar results. We concluded that activation of the pelvic floor muscles during straining in the laboratory was a normal finding. Although the finding of pelvic floor inhibi t ion during straining may be useful to exclude the diagnosis of NRP, the finding of paradoxical activation of PR or EAS during straining is of no diagnostic significance.

PFC Above 23 59 158 Include 20 78 152 Combined 22 73 155

Post Above 24 60 141 Include 27 71 149 Combined 26 66 145

Rectoanal reflex and bal loon expuls ion test were normal in all patients before and after irradiation. Conclu- sions: External pelvic irradiation for rectal cancer was not associated with early dysfunction of the anal sphincter. Sensory threshold was sl ightly increased after irradiation. Inclusion of the anal sphincter in the field of irradiation had no impact on function.

Is There a Role for Electromyography in the Diagnosis of the "Non-Relaxing Puborectalis Syndrome?

(13)

R. E. Perry, J. H. Pemberton, W. L. Litchy Rochester, MN

The "non-relaxing puberoctalis" syndrome (NRP) is d iagnosed with e lect romyography (EMG) by failure of the pelvic floor muscles to relax during straining. To determine the frequency with which this occurs in normal subjects, concentric needle EMG of the external anal sphincter (EAS), puborectal is (PR), and coccygeus (CG) muscles was performed on 45 asymptomatic female volunteers aged 18-35, during rest, squeeze, and rehearsed straining. Sixteen subjects had, in addition, fine wire e lect rode EAS and PR EMG, with a 3-cc bal loon in the anal canal to simulate a fecal bolus. Findings: There was an increase in EMG activity in all three muscles in all subjects during squeezing. The response during straining was less predictable.

Relationship Between Anal Canal Tone and Rectal Motor Activity

(14)

A. Ferrara, J. H. Pemberton, K. E. Levin, R. B. Hanson . . . . . . . . . . . . . . . . . . . . . . . Rochester, MN

The anal canal sphincters maintain fecal cont inence partly by tonic contraction, but little is known about the influence of rectal motili ty upon this tonic activity. Aim: To evaluate the relat ionship be tween anal canal tone and rectal motor activity. Methods: A fully ambulatory system for p ro longed pressure recording was developed. In eight healthy subjects (5 males, 3 female, mean age 35 years, range 22-43), a f lexible transducer catheter (OD 4.5 mm) was introduced endoscopical ly such that sen- sors were at 1, 2, 8, 12, 16, and 24 cm from the anal orifice; 24 hour spontaneous motor activity was stored in a 2 MB portable recorder for later transfer to a Microvax II for computer ized analysis and display. Mean anal canal tone was calculated and rectal motor complexes (RMCs) characterized. Results: During sleep, anal canal tone showed cyclic depress ions (mean per iodici ty 1.6 hours, range 1-4) during which the mean pressure was 15 + 4 mm Hg (8 21/mm Hg). RMCs were identif ied in all subjects occurring a mean of 16 times in 24 hours (range 12-22). RMCs had a mean duration of 15.3 minutes (range 8-35), contractile frequency of 2-3/minutes , mean peak ampli tudes of 50 60 mm Hg, and a periodic- ity of 78 + 24 minutes (35-265 minutes) . Importantly, a RMC was invariably accompanied by a rise in anal canal tone and contractile activity (frequency: 2-3 minutes ampli tude; 15-20 mm Hg) so that a recto-anal canal pressure gradient was always preserved. Conclusion: Anal canal tone varied greatly, particularly during sleep, when there was a significant decrease in pressure. How- ever, this never occurred during a RMC. This temporal relat ionship be tween cyclic variations of anal canal tone

P6

and rectal motor activity represents a new and important mechanism preserving fecal continence.

Normal Variation in Anorectal Manometry 05)

R. L. Cali, G. J. Blatchford, A. G. Thorson, M. A. Christenson, R. M. Pitsch . . . . . . . . . . . Omaha, NE

Interest in and use of anorectal manometry as a diagnostic tool has increased in recent years. Debate and uncertainty persist what constitutes normal variations. In an effort to define these variations, 60 volunteers were recruited to undergo anorectal manometry. No volunteers had any anorectal symptoms or pathology. Patients were divided into three groups (male, null iparous females, and mult iparous females). Anorectal manometry using an 8-port perfused catheter was performed. Values for maximum mean pressures and sphincter length were obtained at rest and squeeze and the vector symmetry index (VSI) was calculated.

Ranges for each value were establ ished (Fig. 1). The Student 's t-test was used to calculate statistical significance. Significant variation was found be tween males and multiparous females for VSI (P < 0.05), mean maximum squeeze pressure (P < 0.001), and calculated sphincter length at rest (P < .05).

These results help to establish a range of normal variation that can be expected in manometr ic data. Asymptomatic mult iparous females tend to have lower pressures, shorter sphincter length, and less symmetry than males or null iparous females. These variations should be taken into account when evaluating these various subgroups.

Biofeedback: A Viable Treatment Option for Anal Incontinence

(16) L. L. Jensen, A. C. Lowry . . . . . . . . . . . Minneapolis, MN

More and more frequently patients are seen in the office with complaints of anal incontinence. We offer b iofeedback to se lec ted patients. We have enrol led 44

NORMAL SQUEEZE PRESSURE

cm w a t e r 300 27S L 1

250 > 228 F 200 t 175 I 150 H 125 100

75

25

6.0 5.0 4.0 3.0 2.0 1.0

c m f rom ana l v e r g e

MEETING ABSTRACTS Dis Colon Rectum, April 1991

patients in our program. Forty-three of these are female. Average age is 50 (range 11-77). Twenty-one patients had idiopathic incontinence. Nine patients were incontinent fol lowing sphincter repair or other rectal surgery. The remaining 14 patients were incontinent because of other miscel laneous problems. Twenty-six patients used a pad. Thirty-one patients have comple ted treatment. Our results show that the mean change in the number of acc idents /week was 3.5 (0-7) . Using a previously publ i shed incont inence scoring system (max. score 30), scoring decreased from 16 (12-30) pretreatment to 2 (0-30) posttreatment. EMG pressures increased from 1.4 **V and 2.3 ~V at rest (R) and squeeze (S) prior to treatment to 2.0 #V (R) and 5.8 #V (S) following treatment. Treatment was considered successful in 28 of 31 patients as def ined by at least a 90 percent decrease in f requency of incontinence. Of the three failures, two required permanent diversion and one required subsequent sphincteroplasty. Twenty-four improved patients are at least 6 months posttreatment. Twenty-one of those report that their cont inence level is the same or has cont inued to improve. The other three returned for a single refresher session and can now maintain continence. We bel ieve b iofeedback has a role in the management of select patients. With anal incont inence to improve their quality of life.

What is the Optimum Pelvic Floor Repair for Neuropathic Fecal Incontinence?

(17) M. R. B. Keighley, M. Oya, J. Oritz, M. Pinho, J. Asperer, G. Chattaphaday . . . . . . . . . Birmingham, UK

The results of postanal repair (posterior repair) for neuropathic fecal incont inence are disappointing. Ante- rior levatoplasty and external sphincter plication (anterior repair) is c la imed to provide improved results. A pilot study from this unit suggested that a combined anterior and poster ior repair (total repair) might be superior to postanal repair.

Twenty-nine women with postobstetr ic neuropathic incont inence have been randomized to treatment by anterior (n = 8), poster ior (n = 10), or total repair (n = 11). All patients have been s tudied by anal manometry, mucosal electrosensitivity, and videoproctography. Pre- l iminary clinical results indicate that comple te continence to flatus and feces was achieved in 3/8 after anterior repair, 2/10 after posterior repair, and 8/11 after total repair. These data support that total pelvic floor repair is the op t imum operat ion for women with postob- stetric fecal incontinence.

Dynamic Graciloplasty for Fecal Incontinence (18)

C. Baeten} J. Konsten, F. Spaans, P. Soeters, A. Habets . . . . . . . . . . . . . . . Maastricht, The Netherlands

Complete fecal incont inence is a debil i tat ing and dis- tressing disorder, which can often not be treated suc-


cessfully. In the past, plastic operat ions have been developed. The gracilis muscle transportation was rarely successful due to its fatiguability and contraction on volition. In exper imental cardiac surgery it has been demonstra ted that a skeletal muscle can be repro- grammed by continuous neurost imulat ion to become infatiguable by a change in fiber pattern and to become independen t of volition. In this study we investigated the effect of neurost imulat ion of a t ransposed gracilis muscle in nine patients on their otherwise untreatable incontinence. Leads were implanted in the transposed gracilis and connected to a neurost imulator that was implanted in the abdominal wall. All patients underwent the same training program with the neurostimulator. In the follow-up (mean 32 weeks, range 20-200 weeks) seven patients became comple te ly continent. One patient had bad results due to nondis tent ion of the rectum in a frozen pelvis, and one patient had an infection leading to removal of neurost imulator and leads. This last patient had promising results after recent reimplan- tation. All patients were evaluated with anal manometry (74 percent pressure rise) and with an enema test (increase of retention t ime from 27 to 312 seconds) . Defe- cography showed perfect cont inence and voluntary defecation when stimulation was d isconnected with the help of a magnet. Dynamic graciloplasty gives a continuous contraction independen t of volit ion and leads to satisfactory fecal continence.

Ileal Bacteriology and Pouchitis: An Experimental Study (19)

W. R. Schouten, J. G. H. Ruseler van Embden, J. J. A. Auwerda . . . . . . . . . Rotterdam, The Netherlands

To investigate the role of bacteria and their metabo- lites in the pathogenesis of pouchitis, an exper imental study was conducted in 15 beagle dogs. After subtotal colec tomy an i leostomy was constructed with (n = 5) and without (n = 10) prestomal reservoir. Before and after a 6-week per iod of progressive, intermittent stoma occlusion in five dogs with conventional i leostomy (Group II) and in five dogs with reservoir (Group III) , ileal effluent, bacterial flora, and mucosal morpho logy were analyzed. Group I (n = 5, no reservoir, no occlusion) served as control group. I leos tomy occlusion in Group II did not alter bacterial flora, whereas in Group III an increasing numbers of anaerobes were found. After the occlusion period, mucosal morphology in Group II did not differ from that in Group I. In contrast, all reservoirs showed chronic inflammation with slight mucosal atrophy. In Group II, i leostomy occlusion did not alter blood-group antigenicity of intestinal glycoproteins, whereas in Group III this antigenicity comple te ly disappeared, indicating breakdown of the glycoprotein layer. This phenomenon was associated with a significant increase in glycosidase activity in Group III. Six weeks after i leostomy construction proteolytic activity (trypsin, chymotrypsin, elastase) was reduced in Group I and II. In Group I l l , however, this activity did not alter.

Based on these findings we conclude that chronic inflammation of ileal reservoirs is caused by overgrowth of anaerobes. These organisms produce an increased amount of glycosidase-enzymes, resulting in breakdown of protect ing mucosal glycoproteins. Further damage is caused by persistent activity of proteolytic enzymes.

Ileal Ecology After Ileoanal Anastomosis with Myectomy (20)

P. M. Sagar, P. Goodwin, P. J. Holdsworth, D. Johnston . . . . . . . . . . . . . . . . . . . . . . . . . . . . Leeds, UK

Ileoanal anastomosis with myectomy has been advocated as an alternative form of restorative proctocolectomy that el iminates the need to construct an ileal pouch. We have investigated the effect of this procedure on fecal bacteriology, fecal volatile fatty acids, ileal mucosal morphology, and the efficiency of emptying of the "neorec- rum." Thirty female adult beagles underwent proctocolec tomy with one of four operative p rocedures - - s t ra igh t i leoanal anastomosis (IAA) (n = 7), IAA with myectomy (m) (n = 8), IAA + M + ileal valve (V) (n -- 7), or IAA with J-pouch (P) (n = 8). IAA was associated with a lower ratio of anaerobes to aerobes ( P < 0.01) and lower levels of fecal volatile fatty acids, particularly acetic and propionic acids (P < 0.05), compared with each of the other operative groups. Mucosal inflammation and the degree of villous atrophy ( P < 0.01) were more marked in the J-pouch group compared with the other procedures. The percentage of stool re tained after defecation was greater in the J-pouch group (P < 0.05). These findings suggest important differences in the ecology of ileal pouches compared with single lumen i leum with and without myectomy. This study lends further support to the concept of i leoanal anastomosis with myectomy.

Comparison of Colorectal Anastomotic Bursting Pressures (ABP) Using Sutured, Stapled, and Biodegradable Auastomotic Ring (BAR) Technique

(21) C. A. Bundy, D. M. Jacobs, M. P. Bubrick

Minneapolis, MN

Previous comparative studies of sutured, stapled, and BAR colorectal anastomoses have failed to show consistent differences in healing. Although ABP of colorectal anastomoses may be an important determinant of healing, comparative studies of the three techniques have not been performed. The fol lowing study was undertaken to compare ABP of colorectal canine anastomoses. Methods: BAR, stapled, and sutured colon anastomoses were sequent ia l ly p laced in each of the 48 dogs following division of the colon at three equal ly spaced sites. Four groups of 12 dogs were sacrificed either on day 0, 3, 7, or 28. ABP was measured using a waterbath with colored saline infused into the bowel segment and ABP was recorded when colored saline leaked from the bowel. From previous studies, normal canine colonic burst pressure is 434 --+ 89 (range 323-520).

P8 MEETING ABSTRACTS Dis Colon Rectum, April 1991

Mean ABP (mm Hg) Day BAR Stapled (ST)

Suture (SU)

0 233 • 63"t 167 + 43# 69 -4- 26 3 135 + 88* 273 +- 118# 181 + 61 7 346 • 58 340 • 75 298 + 82

28 310 • 87*4 446 -4- 83# 373 +-- 105

* P< 0.05 BAR vs. SU; + P< 0.05 BAR vs. ST; # P< 0.05 SU vs. ST.

Conclusion: BAR anastomoses have the greatest strength on the day of surgery, sutured anastomoses are strongest on the third day, and all are comparable by the seventh day. Bursting pressures for all groups by day 28 approach normal colonic burst pressure, with differences likely reflecting variance in anastomotic fibrosis and luminal area.

Lower Limit of Tissue Blood Flow for Safe Colonic Anastomos is~An Experimental Study Using Laser Doppler Flowmetry

(22)

H. Kashiwagi, F. Konishi, K. Kanazawa Tochigiken, Japan

Laser doppler flowmetry was used to clarify the lower limit of colonic tissue blood flow for safe anastomosis of the colon in an experimental study. A preliminary study showed a good correlation between laser doppler flow- merry and hydrogen gas clearance method with the r value of 0.91; 22 dogs were divided into three groups according to the length of devascularization at the co- Ionic end for anastomosis; i . e . , Group A, 2 cm; Group B, 4 cm; and Group C, 6 cm. The mean laser doppler values at the devascularized end of the colon measured from the serosal side in the three groups were, 1.0, 0.8, 0.6. The leakage rate in the three groups were 0 percent (0/ 7), 15 percent (1/6), and 78 percent (7/9). There was a significant difference in laser doppler value between the dogs with leakage and those without. The dogs with leakage showed the laser doppler value lower than 0.8. It is concluded that the lower limit of colonic blood flow for safe anastomosis measured from the serosal side is considered to be slightly higher than 0.8 in laser doppler value. Based on this result the application of this method for the intraoperative measurement of colonic tissue blood flow in colorectal surgery will become possible.

Fibrin Glue Improves Healing of Irradiated Bowel Anastomoses

(23) D. O. Woodland, T. J. Saclarides, M, S. Bapna

Chicago, IL

Many surgeons have concern when dealing with irradiated bowel anastomoses. Previous studies have demonstrated diminished tensile strength of small bowel anastomoses which have been irradiated intraopera-

tively. Sixty-nine Sprague-Dawley rats were studied to determine whether fibrin glue improves healing of small intestine anastomoses irradiated intraoperatively with a single dose of 2,000 rads. These rats were divided into three study groups. Group I; ileal anastomosis without radiation, without fibrin glue; Group 2: ileal anastomosis with radiation, without fibrin glue; Group 3: ileal anastomosis with radiation, with fibrin glue. Seven days postoperatively, the rats were sacrificed and the anastomotic segment was tested for breaking (tensile) strength. Anas- tomotic collagen content was evaluated using a hydroxyproline assay. Tensile strength results demonstrated that Group 2 was significantly weaker than Groups t and 3 and that the hydroxyproline content of Group 3 was significantly greater than Group 2. The results show that the addition of fibrin glue to an intraoperatively irradiated small bowel anastomosis improves healing, demonstrated by both tensile strength and collagen content studies.

Tens. Streng. Hydroxyproline Cont. Group N mg (SD) t~g/mg dry wt. (SD)

1 23 60.6 (23.7) 13.3 (4.7) 2 23 38.2 (21.3) 11.4 (4,0) 3 23 60.7 (23.7) 15.6 (6.7)

1 vs. 3 tensile str. not significant. Hydroxyproline content Group

Groups 1, 2. 3 significantly greater than

Local Immunity and Metastasis of Colorectal Carcinoma (24)

Y. Kubota, K. Sunouchi, M. Ono, T. Muto Tokyo, Japan

The spread of tumor cells from a primary neoplasm to distant organs and the production of metastasis is the most devastating aspect of cancer. The outcome of the process has been shown to depend on host defense mechanism. Therefore, we investigated the local immunity in metastasis of colorectal carcinoma. The subsets of tumor infiltrating lymphocytes (TIL) and prostaglan- din (PG) E2 was measured in the resected tissues of 20 colorectal cancers without metastases and 11 with metastases. Subsets of TIL (Leu 1, Leu 2a, Leu 3a, Leu 10, Leu 11; Becton-Dickinson Co.) were detected by immu- nohistochemical staining of frozen tissues. The number of positive cells were counted and expressed as number positive per 250 x 250/~m 2. The number of T cells (Leu 1) and natural killer cells (Leu 11) were larger in early (mucosal and submucosal) cancers and decreased in parallel with the presence of metastasis (control n = 9: 89 + 28, 6 -+ 4; early cancers n = 9 :269 + 112,* 76 + 56*; advanced cancers without metastases n = 11:182 --- 80,* 56 + 59*; advanced cancers with metastases n = 11: 76 +__ 42,* 26 -4- 21,* P < 0.05 ANOVA). The level of PGE2 from the draining vein was higher than those from both feeding artery and the periphery vein. The V/A ratio of cancers with metastases was significantly higher than those of cancers without metastases. (13.2 +-- 2.4 vs. 5.6


-4- 0.8). TIL was decreased in parallel with the increase of PGE2 V/A ratio. We conclude that TIL and PGE2 may play an important role in metastasis of colorectal carcinoma and that PGE2 have adverse effect in suppressing local immunity.

DNA Ploidy Pattern of Colonic Flat Adenoma (25)

T. Muto, T. Masaki, K, Suzuki, M. Adachi Tokyo, Japan

In an attempt to clarify the nature of "fiat adenoma," DNA content was measured by means of microspectro- photometry. Thirty-nine fiat adenomas (FA). 13 with mild, 22 with moderate, and 4 with severe atypia were col lected for this study. In FA, diploidy, polyploidy, and aneuplo idy was found 100, 0, 0 percent in mild atypia, 41.9, 4.5, 54.5 percent in moderate atypia, and 0, 0, and 100 percent in severe atypia, respectively. FA seems to have much higher malignant potential than previously expected, because in particular FA with moderate atypia more than 5 mm showed aneuplo idy in 93 percent. These data suggest that flat adenomas with moderate atypia play an important role in the pathogenesis of small colonic carcinomas.

Assessment of Anorectal Physiology Prior to Subtotal Colectomy for Chronic Constipation

(26)

J. A. Heine, W. D. Wong, S. M. Goldberg Minneapolis, MN

Anorectal physiologic assessment was carried out on 18 patients (16 females, mean age 44.4 years) with chronic constipation prior to subtotal co lec tomy in an attempt to define the role of these studies in the select ion of patients for surgical management. Preoperative stool frequency ranged from every 7 to 30 days. Six patients strained at stool for longer than 30 minutes. Eight patients had abnormali t ies of anorectal physiology including high resting anal pressure (2), d iminished rectal sensation (2), and non-relaxation of the puborectal is (5). There was no mortality. Small bowel obstruction occurred in five patients (28 percent) and two required laparotomy. Functional outcome was assessed at a mean of 29 months (8-54). Sixteen patients (89 percent) had at least one bowel movement daily. Two patients with intractable constipation required i leostomies and difficult defecation persis ted in four. Three of these six patients with suboptimal outcome had a rion-relaxing puborectal is although this abnormali ty was not predictive of poor outcome at a statistically significant level (chbsquare, P > 0.05). We conclude that subtotal colectomy for constipation results in an acceptable outcome for most patients. Caution should be observed before submitt ing patients with abnormal pelvic floor physiology to surgical treatment, even though some will benefit.

Preoperative studies of pelvic floor physiology should be considered investigational at this time.

Colectomy for Constipation: Preoperative Physiologic Investigation Is the Key to Success

(27)

S. D. Wexner, N. Daniel, D. G. Jagelman Ft. Lauderdale, FL

The results of total abdominal colec tomy with ileorectal anastomosis (TAC) as a t reatment for colonic inertia (CI) were prospect ively assessed. 112 patients were evaluated for chronic constipation be tween July 1988 and March 1990. Patients underwent pancolonic transit times, anorectal manometry, c inedefecography (CD), and elec- t romyography (EMG). CI was def ined as diffuse marker delay on transit study without evidence for paradoxical puborectal is contraction on CD or EMG. 13 patients (10.7 percent; 12 females and 1 male) of a mean age of 49 (range 24-75) years with CI underwent TAC. Preopera- tive bowel f requency ranged from three per week to one per month; all 13 patients evacuated only with high doses of laxatives, enemas, or both. TAC was per formed with no postoperat ive mortali ty or major morbidity; two patients were readmit ted 3 and 4 weeks after surgery, respectively, and both underwent successful conservative treatment for partial small bowel obstruction. At a mean follow-up of 14 (range 5-26) months, these 13 patients repor ted a mean frequency of spontaneous daily bowel evacuation of 3.0 (range 1-7). No patients contin- ued to use laxatives or enemas, and patient satisfaction with the operat ion was "excellent" or "good" in 12 patients (92 percent) and satisfactory in one patient. No patient repor ted worsening of symptoms. Thorough preoperative physiologic evaluation permits the selection of a small group of patients with colonic inertia who may benefit t remendous ly from total abdominal colec tomy with i leorectal anastomosis.

Internal Rectal Intussusception--Cause or Effect of Obstructed Defecation: Results of Surgical Treatment

(28) J. Christiansen, O. Rasmussen, B.-W. Zhu

Copenhagen, Denmark

Twenty-one patients with obstructed defecation and defecography demonstrat ing internal rectal intussusception were treated surgically. None were incontinent, and anorectal manometry and e lec t romyography studies were normal. Median rectal compliance were lower although not significantly so than in an age- and sex- matched control group. The patients were treated by abdomino-rectopexy, 14 by Ivalon sponge technique, and seven by Orr 's fascia sling method. Follow-up after 6 months to 4 years showed that 19 patients were cured of the rectal intussusception as demonstra ted by defecography. Only 10 were improved and nine were un- changed. These results suggest that internal rectal intus-

PIO MEETING ABSTRACTS

susception may not be the cause, but rather an effect of obstructed defecation of otherwise unknown etiology. The intussusception may aggravate defecat ion disorders as shown by the improvement obtained in half of the patients, but defecographical ly demonst rable intussus- cept ion should not necessari ly be an indication for surgical treatment.

Treatment of Rectal Prolapse in the Elderly by Perineal Rectosigmoidectomy

(29)

J. G. Williams, D. A. Rothenberger, J. L. Schottler, S. M. Goldberg . . . . . . . . . . . . . . . . . . . Minneapolis, MN

Many patients with rectal prolapse are not suitable candidates for abdominal repair, and a variety of per ineal approaches have been described. Of these, we favor per ineal rectosigmoidectomy, which we per formed on 114 patients during the last 10 years. Their ages ranged from 21-100 years; 80 percent were aged over 70 years. Preexisting medical problems were present in 81 patients (71 percent) , Cardiac disease was present in 68 (60 percent) and 21 (18 percent) suffered with demen- tia. Median hospital stay was 4 days (range 2-25 days). There were no deaths and complicat ions deve loped in only 14 patients (12 percent) . Bleeding from the suture line occurred in three patients and there were no anastomotic leaks. Ten patients were lost to follow-up. Me- dian follow up of the remaining patients was 12 months (interquarti le range 4-36). Eleven patients (10 percent) deve loped a recurrent rectal prolapse 3-48 months after surgery. Six patients underwent repeat rectosigmoidectomy. Sixty-six patients (64 percent) had varying degrees of incont inence prior to surgery. Sixteen (24 percent) regained full cont inence and a further 19 (29 percent) improved. Twenty-six patients (39 percent) remained the same, and in five patients (8 percent) the degree of incont inence deter iorated further. These results show that per ineal rec tos igmoidectomy is an effective opera- t ion for rectal prolapse in the e lder ly high risk patient. Morbidity, length of hospital stay, and recurrence rates are low. Improvement in cont inence is less than following an abdominal procedure.

A Prospective Assessment of Biofeedback for the Treatment of Paradoxical Puborectalis Contraction

(30) S. D. Wexner, S. Heyman, F. Marchetti, D. G. Jagelman . . . . . . . . . . . . . . . . . Fort Lauderdale, FL

One hundred consecutive patients were prospect ively evaluated for chronic constipation. All patients underwent colonic transit study, anal manometry, cinedefecog- raphy (CD), and concentric needle e lec t romyography (EMG). Fourteen patients (11 females and 3 males) of a mean a g e o f 62 (range 10-84) years who had paradoxical puborectal is contraction (PPC) identif ied as the e t io logy for the constipation were referred for biofeedback. Prior

t o biofeedback, none of these 14 patients had any unassisted bowel movements (BMs). Twelve patients had


laxative-assisted BMs a mean of 4.3 (range 1 7) t imes weekly. Seven patients had enema-assis ted BMs a mean of 2.0 (range 1-3) t imes weekly. Patient underwent a mean of 9.8 (range 5-19) 1-hour computer assisted biofeedback sessions using an intra-anal EMG sensor. After b iofeedback retraining, these 14 patients had a mean of 8.2 (range 1-21) unassisted weekly BMs. Two patients cont inued to take laxatives less than once each week, and two patients took one and three weekly enemas, respectively. These latter two patients considered the treatment to have been a failure. The other 12 patients rated their improvement as "excellent" for an overall success rate of 86 percent at a mean length of follow-up of 8.2 (range 1 to 15) months. No biofeedback-associated complicat ions were identified. EMG-based anal biofeedback is a valuable and relatively noninvasive technique associated with an 86 percent success rate in the treatment of PPC.

Mucinous Carcinoma: Just Another Colon Cancer? (3i)

J. B. Green, A. E. Timmcke, T. C. Hicks, J. E. Ray, J. B. Gathright . . . . . . . . . . . . . . . . . . . New Orleans, LA

The significance of mucinous carcinoma has been controversial since first descr ibed by Parham in 1923. Previous reports have suggested mucinous tumors affect younger patients, involve more proximal colon, are more advanced at the t ime of diagnosis, and have a poorer prognosis than non-mucinous colon carcinoma. More recent reports have refuted these results. In an effort to clarify the significance of mucinous histology, a retrospective review of patients with invasive colon cancer treated at the Ochsner Clinic be tween 1982 and 1985 was undertaken. Mucinous adenocarcinoma, as def ined by _> 50 percent mucin, was found in 57 patients. During the same t ime period, 407 non-mucinous adenocarcino- mas were resected. The mean age, distr ibution within the colon, stage at diagnosis, and survival of mucinous carcinoma patients were compared with those with non- mucinous tumors. Mucinous tumors presented at a statistically significant more advanced stage (38 percent vs .

21 percent Dukes' C lesions, P < 0.01). No significant differences were seen in age at presentation, distr ibution within the colon, or stage for stage survival. In our experience, mucinous adenocarcinoma presents at more advanced stage, but otherwise acts similarly to nonmu- cinous adenocarcinoma.

Colorectal Cancer and Pregnancy (32)

M. A. Bernstein, R. D. Madoff, P. F. Caushaj Worcester, MA

Colorectal cancer present ing in pregnancy is an uncommon disease that is repor ted to be associated with an ext remely poor prognosis. Because of the rarity of this condit ion, only small series have been repor ted in the literature. In order to better characterize this disease, we mailed 1,529 quest ionnaires to the membersh ip of

Vol. 34, No. 4 MEETING ABSTRACTS

the ASCRS. Thirty-four women with large bowel cancer who presented during pregnancy or in the immedia te postpartum per iod were identified.

The mean age at presentat ion was 30.4 years. Tumor distr ibution was as follows: right colon 3, transverse colon 1, descending colon 2, s igmoid 4, rec tos igmoid 3, and rectum 21. Dukes' stage at presentat ion was A- -0 , B--11 , C--15. Eight patients presented with hepatic metastases. Mean survival was 41 months. Patient status was: alive, no evidence of disease, 13 (mean follow-up 72 months); alive with disease, 5 (mean follow-up 26 months); d ied of disease, 16 (mean survival 17 months) .

Our data demonstrate that large bowel cancer associated with pregnancy presents in a distal distr ibution with 24 of 34 (71 percent) lesions located in the rectum or rectosigmoid. The disease presents an advanced stage with 22 of 34 (65 percent) patients having nodal and /o r hepatic metasases at the t ime of diagnosis. Our data confirm the poor prognosis associated with this lesion.

(33)

DNA Flow Cytometry in Colorectal Cancer: Clinicopathologic Correlations with Ploidy Status in 100 Patients

R. Zelnick, R. J. Zarbo, C. K. Ma, T. Fox Jr. Detroit, MI

DNA flow cytometry was per formed using a 2-color mult iparametric technique, deve loped at our institution, on 100 fresh mechanical ly dissociated tumors from patients undergoing colon and rectal cancer resect ions be tween 1988 to 1989. Thirty-five tumors were d iploid and 65 were aneuploid, with mean age at resect ion of 67 years (range 33-90 years). There was no statistical correlation (Student t-test) be tween p lo idy status and clinicopathologic parameters such as age ( P > 0.85), sex (P > 0.63), size ( P > 0.15), depth of invasion ( P > 0.62), grade (P > 0.2), lymph node status ( P > 0.79, vascular invasion ( P > 0.46), lymphocytic infiltrate (P > 0.66), fibrosis ( P > 0.76), and tumor per ipheral border (P > 0.62). The Dukes' stage distr ibution of this series was comparable to historical colorectal controls. Ploidy status did not correlate with individual Dukes ' stages or com- b ined Dukes' A + B vs . Dukes' C + D stages. The incidence of aneuplo idy was Dukes' A- -79 percent , Dukes' B- -57 percent , Dukes' C - -66 percent , and Dukes' D - - 6 8 percent. Ploidy status appears to be unrelated to the other numerous cl inicopathologic parameters tradit ionally considered in the assessment of colon and rectal cancers.

The True Incidence of Metachronous Colorectal Cancer (34)

R. L. Cali, G. J. Blatchford, A. G. Thorson, M. A. Christenson, R. M. Pitsch . . . . . . . . . . . Omaha, NE

The benefit of l ifelong colonic surveillance to detect metachronous lesions has been well established. The crude rate of developing a metachronous lesion has been variably est imated from 0.6 to 3.6%. This figure undoubt-

P l l

edly falls short of the true risk of developing a metachronous lesion over t ime because it does not account for patient death due to other causes.

To de termine a more accurate estimate of the true risk of metachronous lesions, 2,118 patients with colorectal cancer were studied. To minimize the influence of synchronous lesions, metachronous lesions were def ined as those occurring greater than 2 years after the primary colon cancer.

Metachronous cancers were identif ied in 33 patients, for a crude rate of 1.5 percent . The cumulative risk for developing a metachronous lesion was calculated by summing the rates for the populat ion at risk each year after the diagnosis of the primary lesion. At the end of 15 years, the cumulative risk was five t imes that of the crude rate (7.5 percent) . Therefore, the true, cumulative risk of metachronous colorectal cancers is higher than that commonly reported. This emphasizes the increased risk that patients with colorectal primaries have for developing a metachronous lesion.

The Prognostic Significance of Location of Lymph Node Metastases in Colorectal Cancer

(35) H. Shida, T. Yamamoto, T. Machida, T. Imanari

Tokyo, Japan

The prognost ic value of stage of nodal metastases was evaluated for 357 patients who underwent curative resection for colorectal cancer. Cumulative 5-year disease-free survival rate (5DFSR) was 63 percent in Dukes' C patients. Subdivision of Dukes' C patients according to number of positive nodes revealed that 5DFSR was 66 percent for patients with 1-3 nodes and 53 percent in those with 4 or more nodes. Division according to location revealed that 5DFSR was 72 percent in those who had only local node metastases, compared with 39 percent in those who had distant nodal metastases along the major vessels.

Although the number and location were correlated, there were 12 patients who had only one positive distant node with no local node involvement. Their 5DFSR was lower than those who had 4 or more positive local nodes (27 vs . 59 percent) .

Lymph node dissection had been performed with ei ther high or low ligation of the major vessel. In the case of distant node metastases, higher 5DFSR was noted in patients with high ligation than in those with low ligation (45 vs . 28 percent) . We conclude that the location, rather than the number, of nodal metastases has a higher impact on prognosis in colorectal cancer.

Postoperative Adjuvant Radiotherapy in Astler-Coller B2 and C Rectal Cancer

(36)

J. Y. Wang, Y. T. You, R. P. Tang, J. S. Chen, C. R. Chang-Chien . . . . . . . . . . . . . . . . . . Taipei, Taiwan

Between 1979 and 1983, 127 patients (RT-group) with and 122 (S~group) without postoperat ive and adjuvant

P12

radiotherapy were compared to de termine the effect of postoperative radiotherapy on the survival and disease failure. Each group was stratified into subgroups according to substage and tumor differentiation: subgroup BW (stage B2 and well differentiated tumor), BM (stage B2 and moderate ly differentiated), CW (stage C and well differentiated), CM (stage C and modera te ly differen- t iated), and P (all poor ly differentiated). About 95 percent of living patients were fol lowed for a min imum of 5 years. Postoperative radiotherapy led to a reduced 5- year survival rate in subgroup BW (87 vs. 67 percent , P = 0.02). In the remaining subgroups, there was a t rend the RT-group had worse survival rate (65 vs. 56 percent , 64 vs. 47 percent , and 46 vs. 41 percent for subgroup BM, CW, and CM respectively). The local failure rates were 10 vs. 23 percent , P = 0.15 in subgroup BW; 32 vs.

21 percent, P = 0.4 in subgroup BM, for S-group and RT- group, respectively. Nine percent had severe or life- threatening radiat ion-related complications. Postopera- tive adjuvant radiotherapy alone did not improve the survivals of patients with stage B2 or C rectal cancers. It even led to worse prognosis in those patients with well differentiated and stage B2 rectal cancer.

Recurrence Pattern After Hepatic Resection for Colorectal Metastases.

(37)

K. Sugihara, K. Hojo, Y. Moriya, H. Hasegawa Tokyo, Japan

A total of 159 patients with hepatic metastases from colorectal cancers underwent hepatic resect ion be tween 1978 and 1989 at National Cancer Center Hospital in Japan. Of them, 109 had curative hepatic resection, excluding 6 with non-curative resect ion of primary tumors, 19 with extrahepatic metastases, 7 with residual tumors in the liver, and 18 with cancer positive surgical margin. All 107 except 2 hospital deaths were fol lowed by period- ical examinations including CEA assay, abdominal ultrasound, computed tomography, and chest x-ray. The 3- year and 5-year survival rate was 56.6 and 37.2 percent , respectively (by Kaplan-Meier test). Patients with metachronous metastases showed the bet ter survival rate than those with synchronous ones with statistical signiL icance (by general ized Wilcoxson test). Other possible determinants of prognosis failed to show the differences in a survival rate among the subgroups. During the average follow-up of 30.6 months, 58 were found to have recurrent diseases; hepatic recurrence in 33, pulmonary in 17 and local in 9. Hepatic recurrent tumors were deve loped at the initial resect ion region in 10, the other segment of the same hepatic lobe in 9, the other hepatic lobe in 6, and the both lobes with mult iple tumors in 8. Of 10 developing recurrent tumors at the resect ion region, two could not have deve loped them if initial resec- t ion was more extensive. They were only 2.5 percent of 81 who had l imited partial hepatic resection.


Thoracotomy for Colorectal Cancer Metastases (38)

B. Krueger, T. J. Saclarides, W. Warren, L. P. Faber Chicago, IL

We reviewed the charts of 91 patients with colorectal metastases to the lung. Since 1978, 23 patients underwent a total of 35 thoracotomies to eradicate metastases, which were synchronous in two cases and metachronous in 21. The synchronous metastases were resected 1 and 30 months after bowel resection. Identif ication and resection of the metachronous metastases fol lowed colorectal resection by an average of 33 months. Sex distribution was equal; average patient age was 57 (22-69) years at the initial diagnosis of cancer. The primary site was colonic in 65 percent , rectal in 35 percent. Available pathology revealed that 13 percent were Duke's A (mod- ified), 25 percent were Duke 's B, 44 percent were Duke's C, and 19 percent were Duke's D. Adjuvant therapy was given to 35 percent prior to thoracotomy and to 26 percent fol lowing pulmonary resection. Average survival following initial diagnosis of the colorectal primary was 47 (9-197) months in the thoracotomy patients vs. 33 months for those with nonresec ted thoracic metastatic disease. Forty-one percent of patients with resected pulmonary disease survived 5 years from the initial diagnosis of colorectal cancer. Comparisons will be presented in patient demographics and survival data for groups with and without thoracotomy for metastatic disease. We conclude that, for se lec ted patients with thoracic colorectal metastases, thoracotomy should be per formed even if mult iple procedures are required.

Physician Performance Profiles: Utilization and Quali ty Monitoring

(39)

M. E. Abel, Y. S. Y. Chiu, T. R. Russell, P. A. Volpe San Francisco, CA

During the 1980s physicians and hospitals were pres- sured to reduce length of stay by government as well as private insurers. The end of the decade brought a shift from intensive util ization review to quality care monitoring. The approach for the 1990s has become outcome assessment and establ ishment of practice parameters. In the select ion of providers, outcome is be ing assessed more critically by employers and third party payors.

An institutional exper ience in the establ ishment of depar tmental and physician performance profiles is presented. Data were derived from quality and utilization monitor ing in caring for surgical patients. Colorectal procedures were per formed on 483 patients over a 2- year period. Large bowel resect ion was done on 197 of these patients. The average length of stay for patients undergoing colorectal resect ion was 12.34 days in 1988 and decreased to 11.7 days in 1989. Utilization of ancil- lary services demonstra ted the fol lowing patterns, expressed as percent of charges, from 1988 to 1989 respectively: imaging 3 and 2 percent , pharmacy 15 and 14 percent, and laboratory 13 and 12 percent.


Quality assurance depar tment review revealed a mortality of 1.3 percent (1988) and 0 percent (1989). The morbidi ty was 7.2 percent in 1988 and 4.0 percent in 1989.

Departmental and physician performance profiles have been establ ished at our institution and will be presented in substance. Such information will a l low for comparative outcome analysis of surgical specialists.

A Prospective Randomized Trial of Impatient v s .

Outpatient Bowel Preparation for Elective Colorectal Surgery

(4O)

R. C. Frazee, J. Roberts, S. Symmonds, S. Snyder, J. Hendricks, R. Smith . . . . . . . . . . . . . . . . . Temple, TX

A prospective randomized trial of inpatient vs . outpatient bowel preparat ion for elective colorectal surgery was performed in 100 consecutive patients. Bowel preparation was standardized for both groups and consisted of 4 liters of Colyte and oral neomycin and flagyl the day before surgery. The patients were randomized within four subcategories: i leocolostomy, colocolostomy, abdominal per ineal resection, and other. Tap water enemas were adminis tered on the morning of surgery to assure an adequate mechanical prep. Ninety-six percent of the inpatient group and 97 percent of the outpatient group were able to drink 3/4 or more of the oral lavage prep ( P - - 0.789, Fischer 's exact test). A mean of 2.26 tap water enemas was required to achieve clear returns for the inpatient group compared with 2.28 tap water enemas for the outpatient group (P = 0.221, Fischer 's exact test). The adequacy of the bowel prep as graded by the primary surgeon was good 93 percent, fair 4 percent , and poor 4 percent for the inpatient group and good 84 percent , fair 13 percent, and poor 3 percent in the outpat ient group (p -- 0.673, Fischer 's exact test). Wound infection developed in 4 percent of the inpatient group and 4 percent of the outpatient group (P = 1.0, Fischer 's exact test). Anastomotic leak or intra-abdominal abscess was seen in one patient in each group (P = 1.0, Fischer 's exact test). We conclude that outpat ient bowel preparat ion is equal ly effective to inpatient for elective colorectal surgery and offers the advantage of cost savings and shorter hospitalization.

The Safety of Primary Closure in the Management of Penetrating Colon Trauma

(41) N. Merchant, H. Hashmi, T. Scalea, R. Whelan

Brooklyn, NY

A retrospective review of 157 consecutive patients who sustained penetrat ing colon injuries was undertaken. Eighty-seven percent of the patients had gun shot wounds and 13 percent had stab wounds. Operative treatment included: 1) primary closure in 89 patients (56 percent) , 2) colostomy and mucus fistula or Hartmann's

pouch in 60 patients (38 percent) , 3) exter ior ized repair in 4 (3 percent) , 4) pr imary repair with proximal diversion in 3 (3 percent) . The severity of injury was assessed by determining the presence of hypotension (BP <80 systolic), the transfusion requirements , and the number of associated injuries. For the primary closure group (n = 89), 20 percent were hypotensive, 14 percent required 3 or more units of blood, and 50 percent of patients had 2 or more associated visceral injuries. For those requiring colostomy, 45 percent presented with hypotension, 55 percent received 3 or more units of blood, and 59 percent had two or more associated injuries.

Intra-abdominal infections, including abscesses, anastomotic leaks, and fistulas, occurred in three patients (3 percent) of the primary closure group and in 13 (22 percent) of those who had colostomies. Seventy-seven percent of those patients with colostomies who developed intra-abdominal infections required 7 or more units of b lood and had two or more associated injuries. The overall mortali ty was 4 percent (6 patients). All six patients had colostomies, four received greater than 20 units of blood, and five had three or more associated injuries.

These results suggest that the deve lopment of intra- abdominal infections in patients with penetrat ing colon trauma is related more to the overall severity of injury than to the method of colon wound management. Fur- thermore, primary closure is a safe alternative and appears to be the procedure of choice in the majority of patients with colon injuries. The precise criteria for patient select ion for primary closure have yet to be identified.

Small Bowel Obstruction (SBO) After Colon Resection (42)

C. N. Ellis, H. W. Boggs, G. W. Slagle, P. A. Cole Shreveport, LA

To de te rmine the e t io logy and outcome of patients with SBO following a colon resect ion for benign and malignant diseases, the medical records of 118 patients who underwent 120 laparotomies for small bowel obstruction occurring over 30 days after a colon resection were reviewed. Contrary to other reports, benign adhesions were the most common etiology, causing the obstruction in all patients with a history of benign colon disease, 82.6 percent of patients with a history of adenocarcinoma of the colon, and 30.1 percent of patients with known recurrent malignancy. The morbidi ty and mortali ty was 36.9 and 0 percent for those with a benign obstruction, and 53.8 and 23.1 percent , respectively, for those with a malignant e t io logy ( P < 0.008). Gangrenous bowel was not found in any patient with a malignant obstruction but was present in 6.5 percent of patients with adhesive SBO ( P < 0.008). In patients with SBO the outcome is more related to the e t io logy of the obstruction. Considering the high l ike l ihood of adhesive obstruction in patients with a history of, or known, metastatic colorectal carcinoma, and the increased risk of


intestinal gangrene with adhesive SBO, it is suggested that a history of colorectal malignancy not deter surgeons from aggressive early surgical intervention in these patients who develop SBO.

Ischemic Colitis: Patients and Prognosis (43)

W. E. Longo, B. J. Gusberg, G. H. Ballantyne New Haven, CT

Although segmental ischemic injury to the large intestine is often a self-l imited event, it can lead to fulminant necrosis and death. We reviewed 47 patients from 1978- 1985. The mean age at presentat ion was 56.2 years with a 2.2:1 male predominance. In 32, symptoms occurred without a prior hemodynamic event. Ten deve loped ischemic colitis in the hospital and an addit ional six after aortic surgery. Associated diseases were: diabetes (17 percent) , renal failure (5 percent) , and hematological disorders (5 percent) . Sixty-one percent were d iagnosed at the time of exploratory laparotomy. The mean delay in diagnosis was 1.8 days (range 3 hours to 23 days). In 21 patients the right colon was ischemic, and 19 had rectos igmoid involvement; 15/16 patients were successfully treated nonoperat ively with antibiotics and bowel rest. Among the 31 requiring intestinal resection, enteric continuity was reestabl ished in 14; second- look laparotomy (8 patients) revealed further ischemia in two (20 percent) . Overall, operative mortali ty was 29 percent (9/ 31). No patient has deve loped recurrent ischemia (mean follow-up 5.3 years). Ischemic colitis often occurs without an obvious predisposing event, it can involve all segments of the large intestine, and frequently requires surgery. Although its course may be self-limited, e lder ly and diabetic patients and those developing ischemia fol lowing aortic surgery or hypotension, continue to have a poor prognosis.


one case where laparotomy was normal and in the other the patient was in the agonal stage of AIDS. Survival was 89 percent at 1 month and 48 percent at 6 months from laparotomy.

Carefully se lected AIDS patients can survive surgery for major intra-abdominal sepsis and necrosis. The perioperative mortali ty of emergency laparotomy is lower than previously suggested.

The Clinical Conundrum of Solitary Rectal Ulcer (45)

J. Tjandra, V. W. Fazio, I. C. Lavery, J. M. Church, J. R. Oakley, J. W. Milsom . . . . . . . . . . . . Cleveland, OH

A retrospective study of 80 patients with biopsy-proven SRU was conducted to review its clinical spectrum. The median follow-up was 25 months. The F:M ratio was 1.4:1 and the mean age was 48.7 years. Principal symptoms were rectal b leed ing (56 percent) , constipation (35 percent) , and excessive straining at defecation (28 percent). Twenty-one patients (26 percent) were asymptomatic and required no treatment. A previous "wrong" diagnosis was made in 25 percent . Rectal prolapse was identif ied in 26 percent (overt 15 percent , occult 11 percent) . Proctoscopy revealed ulcerated lesion in 29 percent (always symptomatic) , a polypoid mass in 44 percent (which predomina ted in the asymptomatic group), and edematous hyperemic mucosa in 27 percent. Management by bulk laxatives and bowel retraining led to symptomatic improvement in 19 percent of cases (Table 1). In 30 percent of cases, symptOms persis ted despi te healing of the lesion. Intractability led to surgery in 27 (34 percent) patients.

Conclusions: The macroscopic appearance of SRU has a significant bearing on the clinical course. The polypoid variety tends to be asymptomatic and when symptomatic, tends to respond to therapy more favorably than non-

Emergency Laparotomy in AIDS (44)

T. Davidson, T. G. Allen-Mersh, B. Gazzard, A . J . G . Miles, C. Wastell, M. Viponde, A. Stotter, R. F. Miller, N. Fieldman, W. W. Slack

London, UK

We have reviewed exper ience with emergency laparotomy in AIDS (Centers for Disease Control Grade 4) patients over a 3-year per iod from three inner city hospitals whose HIV units treat >2,000 AIDS patients/year.

Twenty-eight patients underwent emergency laparotomy. The commonest indication was acute colitis (seven patients) complicated by toxic megacolon in five and colonic perforation in two patients. Treatment was by total colectomy and ileostomy. Intestinal lymphoma pro- ducing perforation or obstruction occurred in five patients, appendici t is in five patients, and mycobacterial (MAI) infection in four patients.

Overall, 22 patients were treated by resection or perforation closure, and four underwent lymph node biopsy for MAI. Surgery was inappropriate in two patients, in

Table 1. Treatment in Symptomatic Patients

Macroscopic Lesion

Symptomatic Improvement

Nonoperative (%) Surgery (%)*

Ulcer 2/24 (8) 7/13 (54) Polypoid 6/18 (33) 10/12 (83) Hyperemic 3/17 (18) 3/6 (50)

* Thirty-one procedures in 27 patients: local excision (n = 6), rectopexy (n = 10). resection (n = 10), diversion (n = 2), and miscellaneous (n = 3).

polypoid varieties. Most cases do not require surgery and the optimal surgical procedure remains unclear.

Colonic Carcinoids in Connecticut: Incidence, Distribution, and Survival

(46)

P. E. Savoca, G. H. Ballantyne, J. T. Flannery, I. M. Modlin . . . . . . . . . . . . . . . . . . . . . . New Haven, CT

Population based studies of colonic carcinoids have not previously been reported. Consequently, the aims of


this study were threefold: first to de te rmine the true incidence of colonic carcinoids in Connecticut from 1975-1986, second to compare the site distr ibution of these lesions with that of ordinary colon cancer in the same populat ion, and finally to examine survival and cause of death in these patients. Age-specific incidence and percent distribution were calculated based on 1970 census data, while survival was calculated using the Kap- plan-Meyer method. Carcinoids of the appendix were excluded. Complete follow-up was accompl ished in 96 percent of cases. A total of 54 cases of ei ther benign or malignant carcinoids of the colon were reported: 23 males and 31 females. Average age was 64.1 ___ 8.7 years (mean + SEM) with a range of 12-83 years. This is nearly identical to that of adenocarcinoma. The age adjusted incidence of carcinoids was 1.21/100,000 popula t ion / year about 1/33 that of colonic adenocarcinoma. Al- though adenocarc inoma of the colon is still predomi- nantly left-sided (67 percent) , 50 percent of carcinoids were located in the cecum, and only 27 percent occurred in the left colon. The number of carcinoids occurring in the ascending colon (16 percent) , transverse colon (6 percent) , and left colon (10 percent) were comparable to adenocarcinoma. Two-year survival of all patients with colonic carcinoids was 63 percent as compared with 80 percent of adenocarcinoma, whereas five-year survival was 37 percent. Almost 20 percent of patients survived more than 5 years, and death due to carcinoids was observed in this populat ion up to 7 years after the t ime of diagnosis. In addition, there was a high incidence of metachronous gastrointestinal malignancies (19 percent). These data indicate that colonic carcinoids result in a high mortality and are associated with a high rate of metachronous gastrointestinal malignancies. We therefore r ecommend that these patients should undergo an ex tended per iod of follow-up and that vigorous surveillance of the entire GI tract should be init iated seeking evidence of synchronous or metachronous malignancies.

Peristomal Skin pH: Is There a Correlation with the Status of the Peristomal Skin?

(47)

K. Tsukada, J. M. Church, K. Tazawa, V. W. Fazio, E. C. Lavery, J. R. Oakley . . . . . . . . . . . . . Cleveland, OH

Normal skin has a pH of 5.5, which prevents bacterial growth and inhibits digestive enzyme activity. Rises in the pH of peris tomal skin may therefore predispose towards peristomal skin infection and excoriation. A prospective study was des igned to measure skin pH around i leostomies and to investigate any association be tween this and the skin appearance.

Methods: The pH of clean, dry peris tomal skin was measured using the Beckman pH Meter in 43 Brooke i leostomy and 11 Kock i leostomy patients. All patients had previously had ulcerative colitis. Patients were classified according to the condi t ion of their peris tomal skin.

Results: All Kock i leostomy patients had normal appearing skin. All, however, wore pads to control mucus, leading to a skin pH of 8.5 ---+ 0.4 (mean + SD). Results in Brooke i leostomy patients are shown in Table 1.

Table 1. Peristomal Skin Appearance

Normal Erythematous Ulcerated

pH 5.5 +-- 0.4 6.2 + 0.4 7.6 + 0.5

The pH of the skin barrier was 5.5.

Conclusions: Peri- i leostomy skin damage is associated with a high skin pH. The skin barrier has a protective effect on skin pH. Mucous leakage from the i leum pro- duces a marked rise in skin pH. Acidifying agents may have a role in the treatment of resistant peris tomal skin irritation.

A Reevaluation of the Radionuclide Scan in Patients with Lower Gastrointestinal Bleeding

(48)

G. R. Voeller, G. Bunch, L. G. Britt . . . . . Memphis, TN

The efficacy of technet ium 99 labe led red cell scintigraphy in localizing hemorrhage, direct ing surgical intervention, and in screening patients for arteriography was de te rmined in patients with lower gastrointestinal bleeding. The b leed ing scan in 56 patients was compared with the definitive b leed ing site de te rmined at surgery, endoscopy, or arteriography; 59 radionucl ide b leed ing scans were per formed in 56 patients; only 15 scans were positive for hemorrhage, three of which incorrectly localized the site of bleeding; 74% of the patients with lower gastrointestinal b leed ing had negative b leed ing scans yet had confirmation of a b leed ing site at endoscopy, arteriography, or surgery. Overall, the radionucl ide scan sensitivity was 20 percent. Surgical intervention for lower gastrointestinal b leed ing was required in 13 patients; seven of these requiring surgery had negative scans and six had positive scans. In the six patients with positive scans requiring surgery, in no instance did the b leed ing scan direct the surgical intervention; deterio- rating clinical condit ion, b lood loss, and other diagnostic procedures di rected surgery. In 12 patients with both scintigraphy and arteriography, half of those with positive scans had negative arteriograms; conversely, of those patients with negative arteriograms, half had positive arteriograms for active hemorrhage. In conclusion, scin- t igraphy failed to localize hemorrhage in 80 percent of the patients. Technet ium 99 labe led red cell scintigraphy did not direct surgical intervention nor did it adequately screen patients who needed arteriography for localization of hemorrhage.

Ambulatory Treatment of Hemorrhoids: A Prospective Random Trial

(49)

J. A. Reis Neto, F. A. Quilici, F. Cordeiro, J. A. Reis Jr . . . . . . . . . . . . . . . . . . . . . . Campinas, Brazil

A total of 228 patients with internal hemorrhoids were randomly al located into three groups: A, B, and C. Each group was treated by a different technique: Group A was submit ted to rubber band ligature, group B to cryother-

P16

apy, and Group C to infrared-photo-coagulation. Only patients with second degree internal hemorrhoids were admitted to this trial, with no distinction of age, sex, and race. All patients had a follow-up of, at least, 1 year. Symptoms before the treatment were noted and evaluated 1 year later. Localization and number of piles of each patient, number of piles treated, symptoms referred to during treatment, and the results obtained were reg- istered and compared. The analysis of the results per- mitted the following conclusions: 1) all methods were considered efficient; 2) rubber band ligature was the painless treatment during application, the most easily performed and the most effective for prolapse; 3) cryo- therapy created a painless post-treatment period with quick normalization of the bowel habit, but it took longer than the other methods for each application and also originated a greater incidence of anal margin edema; 4) infrared-photo-coagulat ion, cont ro l led hemor rhage more efficiently, it was easily performed, but painful during application and responsible for the most serious complications.

Pelvic Sepsis as a Result of Hemorrhoidal Banding: Incidence and Sequelae

(50)

J. B. Wojcik, S. R. Banerjee, D. L. Waiters, D. A. Cherry Hartford, CT

Case reports have established that pelvic sepsis may be a complication of rubber band ligation of internal hemorrhoids. No study has reported the incidence of septic complications and the clinical outcome in a large series of patients. A questionnaire was developed and sent to the membership of the ASCRS. The questionnaire was designed to ascertain the relative frequency of rubber band ligation, the technique used, the frequency and severity of complications, any potential predisposing factors of pelvic sepsis, therapy, clinical outcome, and the role of informed consent.

A total of 549 questionnaires were returned, of which 534 were complete and suitable for analysis. Patients with symptomatic internal hemorrhoids were treated by rubber band ligation in 53 percent. The Barron technique was used by 86 percent, whereas suction or a combination of both techniques were used by 14 percent of responders. Bands were placed in a single site by 80 percent and multiple sites in 20 percent of responders. Thirty-four physicians reported 54 patients with pelvic sepsis as a result of rubber band ligation. Hospitalized patients with pelvic sepsis received IV antibiotics, 53 percent had the band removed, 44 percent underwent debridement of the site, and 6 percent underwent proximal fecal diversion. Six patients expired of uncontrolled sepsis. As a result of the complications encountered, 44 percent of responders stated that they had altered their technique for treating symptomatic internal hemorrhoids. Technique and possible etiologies are discussed. In conclusion, septic complications as a result of rubber band ligation poses a rare but real risk and despite


aggressive therapy can lead to significant morbidity or even mortality.

Symptomatic Hemorrhoids: Current Incidence and Complications of Operative Therapy

(51)

R. Bleday, J. P. Pena, S. M. Goldberg, J. G. Buls Minneapolis, MN

Operative treatment of symptomatic hemorrhoids is common, but there is a paucity of information on its frequency and complications. We reviewed the experience from our large colorectal group practice from Jan- uary 1985 to July 1990. There were a total of 21,439 visits for symptomatic hemorrhoids (excluding thrombosed external hemorrhoids): 24.5 percent were treated with banding, 1 percent were injected or sclerosed, and 9.3 percent underwent surgical treatment. The operative experience of one office was reviewed for the same time period. There were a total of 214 patients: 59 percent men and 41 percent women. The mean age was 47.4 years; 23 percent of patients underwent urgent surgery for acute symptoms; 3.3 percent of cases were in the postpartum period; 80 percent of patients had either Grade III or IV rectal mucosal prolapse; 20 percent of patients had an associated anal fissure. A closed technique was used in all patients; 39.5 percent had simul- taneous internal sphincterotomies, 17.1 percent had urinary retention, 2.4 percent had major delayed bleeding, 2.4 percent had fecal impaction, and 2 percent had errors in diagnosis. Only one patient had an abscess (0.5 percent). Median length of stay (LOS) was 2.5 days; 6.5 percent were done as outpatients. We conclude that only a minority of patients require surgery (9.3 percent). There is a higher complication rate compared with our previous analysis from 1978, but this is probably due to more advanced disease at the time of surgery. Even with the higher rate, LOS has decreased about 2 days in the past decade.

Laser Hemorrhoidectomy: are the Claims Justified? (52)

R. Pascual, G. Tripodi, A. Padmanabhan Waterbury, CT

Laser hemorrhoidectomy has been advocated as being superior to surgical excision because of its claimed advantage diminishing postoperative pain, but there have been few well-controlled studies on this subject.

Two modalities of treatment performed on 109 patients at one institution between January 1, 1988, and June 30, 1990, were reviewed retrospectively. Because laser hemorrhoidectomy was performed by one surgeon, these patients (Group 1, n = 28) have been compared with two other groups, namely surgical hemorrhoidectomy by the surgeon carrying out the laser method (Group 2, n = 23) and the surgical hemorrhoidectomies carried out by the other general surgeons during the same period (Group 3, n = 50).


The extent of surgery, type of anesthesia, assessment of postoperative pain, clinical complications, length of hospital stay, number of days before return to work, and estimates of costs and charges for the operations have been compared.

Preliminary analysis of the data indicates no significant differences for the parameters in the three groups for clinical items, particularly pain and pain medication requirements. There is a substantially higher cost and charges for laser hemorrhoidectomy, raising questions about its value in clinical practice.

Ultra Slow Wave Pressure Variations in the Anal Canal Before and After Lateral Internal Sphincterotomy

(53) W. R. Schouter, J. D. Blankensteijn

Rotterdam, The Netherlands

Ultra slow waves (USW) in the anal canal are discrete, regular pressure fluctuations with a low frequency (1-2 / minute) and high amplitude (10 percent above or below baseline resting pressure). Between May 1987 and March 1989, we performed anorectal manometry, using a mi- crotranducer, in order to study USW in 20 control subjects (mean age: 45 years, male/female ratio 1:1) and 58 patients with anal fissure of hemorrhoids before and 2 weeks after lateral internal sphincterotomy (LIS) (mean age: 40 years, range 15-70 years, male/female ratio 1:1). USW could be demonstrated in two control subjects (10 percent) and in 29 patients (50 percent). The mean maximum anal resting pressure (MARP) in the two control subjects was higher than the MARP in the 18 control subjects without USW (160 + 1 vs . 103 +-- 35 cm H202, P < 0.0005 Mann-Whitney). The same difference was found between MARP in patients with and without USW (166 --- 26 vs . 143 --- 28 cm H20, P < 0.05, Mann-Whitney). Two weeks after LIS, USW disappeared in 50 percent of the patients. The pressure reduction in these patients was statistically significantly higher than the pressure reduction after LIS in patients with persistent USW (40 vs . 15 percent, P < 0.02, Mann-Whitney). The results of this present study demonstrate that USW are associated with high MARP and disappear when such a high anal canal resting pressure is reduced by LIS to a level found in control subjects without USW. These findings indicate that USW are the manifestation of increased activity of the internal anal sphincter.

Prediction of Morbidity by T4 Lymphocyte Count in the HIV Positive or AIDS Anorectal Outpatient

(54)

S. Moenning, P. Huber, C. Simonton, C. Odom, E. Kaplan, S. Nightengale . . . . . . . . . . . . . . . . Dallas, TX

A retrospective chart review of 39 ambulatory anorectal HIV+/AIDS patients was performed to establish a method of predicting morbidity in the HIV+/AIDS patients. All 39 patients had known T4 lymphocyte counts and HIV+/AIDS status and form the basis for this study.

The authors defined morbidity as a complication occurring within 1 month of treatment. Morbidity was correlated with T4 lymphocyte counts and the diagnosis of HIV+/AIDS. All the 39 patients were followed for an average of 4 months. The T4 counts were separated into two groups, Group 1 (n = 23) had T4 counts of <200 and Group 2 (n = 16) had T4 counts of >200. Group 1 experienced a 65 percent morbidity, while group two had a 7 percent morbidity following conservative (n = 29) or surgical treatment (n = 10). Those patients with AIDS (n = 14) experienced a 78 percent morbidity, while the HIV+ patients (n = 25) had a 20 percent morbidity. Comparison between the groups was investigated using the two tailed Fisher's exact test and found to be statistically significant ( P < 0.001). The authors conclude: 1) a T4 count of <200 may be used to predict the treatment associated morbidity, and thus influence the degree of aggressiveness in treating the ambulatory anorectal HIV+/AIDS patient; 2) the treatment of ambulatory AIDS patients is associated with a significantly higher surgical anorectal morbidity than HIV+ patients; 3) in high risk ambulatory individuals with anorectal complaints and unknown HIV status, the T4 count of <200 may be used to predict treatment morbidity.

Imperforate Anus: Results of Surgical Correction (55)

P. C. Shah, H. F. Hashami, P. Kottmeier, F. Velcek, D. Klotz, R. L. Whelan . . . . . . . . . . . . . . . . Brooklyn, NY

A retrospective review of 65 patients who underwent surgical treatment for imperforate anus during the period of 1965 to 1986 was performed. High anomalies (above the levator) were found in 44 patients (68 percent), while 21 patients (32 percent), had low anomalies. Fifty two patients (80 percent) required surgery within the first 48 hours of life, 8 had definitive repair, and 44 had colostomies constructed. Fifty-seven patients underwent definitive procedures at a mean age of 15 months. The following combined operative approaches were used: abdomino-perineal in 55 percent, sacroperineal in 8 percent, and abdomino-sacroperineal in 5 percent. A perineal approach was used in 32 percent. In 48 patients, of whom 38 had high anomalies, a poor result necessi- tated a total of 73 additional major operative procedures. These operations were Nixon flaps in 41 percent, leva- torplasty in 12 percent, and gracilis sling in 4 percent. A permanent colostomy was eventually necessary in three patients. The mean age of the patient population at last follow-up was 6 years. Of the 21 patients with low anomalies, seven reported incontinence to solid or liquid stool at last follow-up. Only one of these patients had frequent incontinence (>1 episode/month) . Five of the 21 patients reported soiling. At last followup, 38 of the 44 patients (86 percent) with high anomalies reported episodes of incontinence to solid or liquid stool; of these, 24 patients were incontinent at least once per week. Thirty-two patients reported soiling. Irrespective of the type of definitive procedure originally performed,

P 1 8 MEETING ABSTRACTS

all but 14 percent of the patients with high anomalies required at least one addit ional re-operation. The average rate of severe incont inence for all patients undergoing combined procedures was 58 percent. There was no significant difference in functional results be tween the various operative approaches. Low anomalies are associated with substantially bet ter functional results than those with high anomalies. The majority of patients with high anomalies will have poor functional results regard- less of the operative approach used or the number of operat ions performed.

Low Hartman Procedure for Severe Anorectal Crohn's Disease

(56) M. E. Sher, J. J. Bauer, I. Gelernt . . . . . . . New York, NY

Perineal wounds often fail to heal following proctectomy for Crohn's disease. Twenty-five patients with severe anorectal Crohn's disease and per ineal fistula, ne- cessitating excisionary surgery, underwent a low Hart- mann procedure in lieu of the standard proctectomy. Fifteen of the 25 (60 percent) patients had a comple te ly healed per ineum and required no further surgical therapy. Perineal disease pers is ted in the other 10 patients; however, their per ineum was much improved compared with the initial presentation. Following a low Hartmann procedure, the rectal s tump becomes atrophic and ano- per ineal disease "cools down," thereby permit t ing subsequent per ineal pro tec tomy in less inflamed tissues. Because only a 3-4 cm cuff of rectum was retained from the initial surgery, a perineal intersphincteric approach could be employed and no abdominal dissection was necessary. Of the 10 patients who subsequent ly underwent per ineal proctectomies, three patients still have an unhea led per ineum. Eighty-eight percent (22 of 25) of patients have a comple te ly healed per ineum (mean follow-up per iod 69.1 months). No at tempt was made to establish intestinal continuity in any of the 25 patients. We conclude that the p rob lem of the unhea led per ineal wound can be averted with this approach, and therefore, reduce the long-term morbidi ty to the patient.

The Kock Pouch: Historical Curiosity or Valued Alternative?

(57) D. P. Launer, A. Gerber . . . . . . . . . . . . . . . . . La Jolla, CA

After Kock introduced his idea of an internal reservoir in 1967, his technique was adopted and modif ied by many surgeons. From 1985 until 1989, 100 Kock pouches have been created by us employing a single technique. The reservoir is constructed in an "S" configuration. Three limbs of i leum measuring 12-15 cm are mobil ized. Fifteen cm are used to construct the cont inence valve (mult iple valves for urostomies) . The serosa of the i leum used for the n ipple valve is scarified and the per i toneum covering its mesentery is stripped. The posi t ion of the


nipple valve is maintained by the applicat ion of four custom-made, TA-55, 4.8 mm staple lines, the fourth of which incorporates the anterior wall of the reservoir. The outf low/inf low tracts are secured to the reservoir with 4- 0 Prolene (before 1986) and 4-0 Vicryl (after 1986). Eighty patients (42 m) received continent i leostomies for ulceractive colitis (26 percent) or conversion from Brooke i leostomies (25 percent) . There was no mortality. Fourteen patients (18 percent) required surgical revision because of fistula (5), valve prolapse (4), incon- t inence (3), valve sl ippage (1), and valve necrosis (1). Pouchitis occurred in 10 patients (13 percent) . All are now continent to gas and liquid. Twenty patients (11 m) underwent continent urostomies. Indications for surgery include patient request (40 percent) and b ladder cancer (30 percent) . There were no deaths and only one (5 percent) required revision. All remain comple te ly continent. The Kock pouch has evolved into an excel lent alternative to conventional i leostomy and urostomy. At- tention to detail is paramount in order to maintain a low revision rate.

The Double Staple Technique for Colorectal Anastomos is

(58) J.J. Nogueras, R. L. Whelan, A. C. Lowry, W. D. Wong, C. O. Finne . . . . . . . . . . . . . . . . . . . . . . Minneapolis, MN

This is a retrospective review of 110 patients who underwent a "double-stapled" colorectal anastomosis. With this method, a circular EEA stapler is passed per anum through a linear rectal staple line. All anastomoses were inspected intraoperatively, and the level of the anastomosis from the anal verge was recorded. The indications for surgery were: 1) adenocarc inoma (84 percent), 2) diverticular disease (8 percent) , and 3) miscellaneous (8 percent) . The clinical leak rate for ultra-low anastomosis (<4 cm) was:

No. of Patients Leak Rate (%)

<4 crn 26 15 >4 cm 84 7

Both groups were matched for age, sex, and intraoperative b lood loss. The overall clinical leak rate for the study was 9 percent . There was one perioperat ive cardiac death. Morbidity occurred in 30 patients. Elective proximal diversion was performed in 16 patients (12 i leostomies, 4 transverse colostomies) , and there were no clinical leaks in this group. Eleven patients received preoperat ive RT (one leak), and 5 patients were steroid dependen t (3 leaks). Functional results will be examined. Based on our observed leak rates, elective proximal diversion for double-s tapled colorectal danastomoses at 4 cm from the anal verge can be justified. Our preferred method of diversion is loop ileostomy.


Anal Dilatation Revisited; Successful Treatment of Anal Fissures Employing a Precise, Reproducible Method of Dilatation

(59)

N. Sohn, M. A. Weinstein, R. N. Lugo, M. M. Eisenberg New York, NY

Until the early 1970s, the standard operat ion for anal fissure incorporated an anal dilatation. At that t ime this procedure was supplanted by the internal anal sphincterotomy. The latter procedure was felt to be more precise, less traumatic, and associated with fewer complications and a higher cure rate. The technique of dilatation was not standardized, varied from author to author, and often from case to case.

The authors, in an effort to minimize the potential for complicat ions inherent to this technique, employed a precise and reproducible technique of dilatation, utiliz- ing a Parks retractor opened a standard measured distance for a measured amount of time; 107 procedures were performed with fissures being totally eradicated in 93 percent. Except for two cases of temporary and spontaneously corrected incont inence to flatus, there were no complications. More recent ly an even s impler technique of bal loon dilatation has been developed; 75 cases are in that group, with the fissure being eradicated in 96 percent and with no cases of incontinence. In both techniques, a precise, reproducible , and constant degree of dilatation is performed for a measured amount of time. Thus the variability of technique with inconstant results are el iminated.

Anal dilatation, thus performed, is associated with a high cure rate, rapid pain relief, nearly immedia te return to work and virtually no important complications. It should be considered as an alternative t reatment in patients with anal fissures, when operat ion is indicated.

much higher in the abnormal than in the normal pouchogram group. More significantly, an abnormal pouchogram was associated with an overall long term failure rate of 23 percent compared with 6 percent for a normal pouchogram (P < 0.001). Conclusion: Abnormal findings in a pouchogram prior to i leostomy closure indicated those patients at high risk of long-term complications of IPAA.

Pouchogram

Complications Abnormal Normal P (% of pts) (% of pts)

Significant stric- 33 4 <0.001 ture

Failure 23 6 <0.001

Fate of Preserved Anal Mucosa Following TPC and Stapled IPAA for MUC

(61)

W. B. Tuckson, I. C. Lavery, S. Strong, V. W. Fazio, J. R. Oakey, J. M. Church, J. w. Milsom

Cleveland, OH

The potential for persistent MUC or cancer in the preserved and transition zone (ATZ) following total proc tocolec tomy (TPC) and stapled ileal pouch-anal an- astomisis (IPAA) has been controversial. Of the 131 patients who had ATZ preservation, MUC was present at the distal margin of resect ion in 97, absent in 17, and not stated in 17. Seventy-eight of these patients subsequently had anal canal mucosal b iopsies a mean of (+95 percent CI) 12 (+1.7) months following IPAA (Table 1).

Table 1. Results of Anal Canal Biopsy Following IPAA

MUC MUC Total No. Type Mucosa Present Absent Patients

Pouchogram: A Predictor of Clinical Outcome Following Ileal Pouch-Anal Anastomosis (IPAA)

(60)

J. Tsao, S. Galandiuk, J. H. P e m b e r t o n . . Rochester, MN

After IPPA, an i leostomy diverts the fecal stream for two months to facilitate heal ing of the pouch and anastomosis. Among 914 patients undergoing IPAA be tween January 1981 and June 1989, 463 (51 percent) had a "pouchogram" (meglumine diatrizoate (Gastrografin | enema) to assess anastomosis and ileal pouch integrity before closure of the i leostomy. Our a i m was to determine whether a pouchogram was useful to predict ing clinical outcome. Results: Abnormal findings were present in 74 patients (16 percent) . These included anastomotic and pouch leaks and anastomotic strictures. Pouch- ograms were normal in the remaining 389 patients (84 percent) . The incidence of subsequent complicat ions in both the normal and abnormal pouchogram groups is shown in the table. The incidence of significant anastomotic stricture requiring dilatation under anesthesia was

Rectal 16 6 22 Anal 0 13 13 ATZ 1 1 2 Rectal + Anal 0 3 3 Rectal + ATZ 2 1 3 Anal + ATZ 0 1 1 Ileal + ATZ 0 1 1 Ileal 0 10 10 N/S* 14 9 23

Total 33 45 78

* N/S = not specified.

Excluding the 10 patients who had ileal mucosa only, MUC was found in 33 patients and absent in 35. None of the anal mucosal b iopsies had evidence of MUC. MUC was noted in 73 percent of the patients who had positive distal margins and in 50 percent who had negative margins when either rectal or ATZ mucosa was biopsied. One patient, with unspecif ied mucosa, had findings of MUC and low grade dysplasia. After 1 year, ATZ preservation appears to be safe, but because of persistent MUC these patients should have regular surveillance.


Does Retaining the Anal Transition Zone (ATZ) Fail to Extirpate Chronic Ulcerative Colitis (CUC) After Ileal Pouch-Anal Anastomosis (IPPA) ?

(62)

W. L. Ambroze, J. H. Pemberton, R. R. Dozois, H. A. Carpenter . . . . . . . . . . . . . . . . . . . . Rochester, MN

The anal transition (ATZ) composed in part by transitional epi thel ium (TE), is bordered by rectal epi the l ium above and squamous epi thel ium (dentate line) below. Whether to preserve the ATZ during IPAA in order to enhance continence is controversial. Our aims were to characterize the histology of the ATZ, measure its length, and determine whether it was involved by CUC. Meth- ods: Proctocolectomy specimens from 50 CUC patients and from 50 control patients with rectal cancer were stained with alcian-blue (0.5 percent; pH 2.5) to define the ATZ visually. Four biopsies from each spec imen (2 from the TE and 2 from the rectal mucosa) were scored for the degree of inflammation (0 = none; 4 = severe). Results: Rectalmucosa extended through �89 of the length of the ATZ in 75 percent of the specimens, through 6 of the length in 46 percent , was within 1 cm of the dentate line in 89 percent and actually approximated the dentate line in 9 percent. The length of TE varied about the circumference of the anal canal; the mean maximum and minimum lengths were 1.3 --- 0.6 cm and 0.4 _+ 0.3 cm, respectively. The mean TE inflammation score in controls and in patients with CUC was 0.4 and 0.5, respectively (ns). The inflammation score of the rectal mucosa, however, was 0.2 cm in controls and 2.6 in CUC (P < 0.0001). Conclusion: The ATZ is composed of TE and rectal mucosa. Although the TE is free of inflammation in CUC, the rectal mucosa is inflamed. Moreover, the proximal border of the ATZ is variegated and ill-defined. Preserving the ATZ would preserve the disease in most patients with CUC and, therefore, should be excised during IPPA.


operative hemoglobin and albumin levels, and a high PSC risk score (1). Remote IPAA-related complicat ions were 55 percent . The est imated risk of pouchit is at 4 years was 67 percent and correlated (P < 0.05) directly with advanced hepatic histology and inversely with age. Remote l iver-related complicat ions occurred in 25 percent and was associated ( P < 0.05) with advanced hepatic histology, low hemoglobin and albumin levels, and a high PSC risk score. No patient exper ienced perianastomotic varices or anal bleeding. The est imated survival was 80 percent at 6 years after IPAA. We conclude that in patients with both UC and PSC, IPPA is safe, is not associated with perianastomotic bleeding, but has a high complicat ion rate related primari ly to the extent of liver disease.

Treatment of Fistulas Following Ileal Pouch-Anal Anastomosis

(64)

W. Ambroze, R. Beart, R. Dozois, B. Wolff, J. Pemberton, K. Kelly, R. Devine, S. Nivatvongs, P. Metzger

Scottsdale, AZ

Among 52 patients with postoperat ive fistulas from an IPAA, eight were found to be due to Crohn's disease. In spite of routine preclosure radiographic studies, 32 percent were de tec ted prior to i leostomy closure and mul- t iple fistulas were identif ied in 16 percent . Fistula origin was the anastomosis 55 percent and pouch 45 percent. Various techniques of closure were used and repair was successful in 48 percent. Multiple procedures were required in 44 percent of successfully treated patients.

Conclusion: Fistula complicat ing the IPAA procedure can be successfully treated in about 50 percent of patients. The origin of the fistula or prior operative treatment did not affect the success rate while mult iple fistulae and abscess association had a poorer t reatment outcome.

Complications and Risk Factors After Ileal Pouch-Anal Anastomosis (IPAA) for Ulcerative Colitis (UC) Associated with Primary Sclerosing Cholangitis (PSC)

(63) A. H. Kartheuser, R. R. Dozois, N. F. LaRusso, R. H. Wiesner, D. M. Ilstrup, C. D. Schleck

Rochester, MN

Patients with UC and PSC treated by colec tomy and i leostomy are at high risk of t roublesome b leed ing from peristomal varices. To de termine predict ive factors for postoperat ive complicat ions and outcome in patients with UC and PSC, we evaluated 40 such patients after IPAA between 1/81 and 2/90. No intra- or immedia te postoperat ive deaths occurred. Overall, postoperat ive complicat ions after IPAA was 43 percent and 26 percent after takedown of ileostomy; 19 patients (47 percent) required b lood transfusions (mean, 4.8 units; range, 1- 13 units). The need for transfusion was associated ( P < 0.05) with advanced hepatic histology for PSC, low pre-

Role of Oxygen Free Radicals in the Etiology of Pouchitis

(65) K. E. Levin, J. H. Pemberton, S. F. Phillips, A. R. Zinmeister, M. E. Pezim . . . . . . . . . Rochester, MN

The hypothesis was that transient mucosal ischemia, resulting in oxygen-derived free radical product ion by xanthine oxidase, contributes to the clinical syndrome of "pouchitis" in ileo-anal pelvic reservoirs. We therefore evaluated the effect of al lopurinol , a xanthine oxidase inhibitor, in patients with acute and chronic pouchitis. Acute pouchit is was def ined by increased frequency and decreased viscosity of stools with fever, malaise, and pelvic pain. The syndrome usually responds to metroni- dazole. Chronic pouchit is was characterized by persistent pouchit is control led by antibiotics which recurred within 1 week of discontinuation of therapy. Methods:


14 patients (10M, 4F) with chronic pouchitis had chronic antibiotic therapy discontinued; they were then given allopurinol (300 mg PO b.i.d.) for 28 days. Eight patients (6M, 2F) with acute pouchitis were treated with allopurinol (300 mg PO b.i.d.) during the episode. Results: Seven of the 14 patients with chronic pouchitis re- sponded completely with no recurrence of symptoms during the 28-day period. The seven remaining patients failed, prompting return to standard therapy. Acute pouchitis resolved promptly in four of eight patients. The other four with acute pouchitis failed; they were then treated with their usual regimen. Three patients had transient side effects (headaches, joint pains, and skin rash). Conclusions: The allopurinol is effective in 50 percent of patients with pouchitis. This appears, therefore, to be a role for mucosal ischemia and oxygen free radical production in the etiology of pouchitis.

Avoidance of a Temporary Ileostomy in Restorative Proctocolectomy

(66)

P. M. Sagar, P.J. Holdsworth, D. Johnston .. Leeds, UK

A temporary ileostomy has been employed routinely by most centers to defunction the ileal reservoir after restorative proctocolectomy. The aim of this pilot study was to compare the early postoperative results in patients undergoing restorative proctocolectomy with and without the use of a temporary stoma.

A consecutive series of 34 patients was studied. Each patient underwent restorative proctocolectomy with quadruplicated ileal reservoir and stapled pouch-anal anastomosis; 17 with defunctioning ileostomy and 17 without. The two groups of patients were similar in age and sex distribution.

There was a reduced incidence of pelvic sepsis, anastomotic stricture, and intestinal obstruction (n.s.) in patients without an ileostomy compared with patients with an ileostomy. The overall complication rate (P < 0.05) and the total length of stay in hospital after operation ( P < 0.01) were both significantly reduced in the group of patients without an ileostomy.

The avoidance of a temporary ileostomy does not lead to an increase in postoperative complications and is associated with a shorter length of stay in hospital after restorative proctocolectomy.

Management of Diverticulitis in Patients -< 50 Years Old: 50-Year Follow-up of Medical Management

(67)

P. Vignati, J. Cohen . . . . . . . . . . . . . . . . . . . Hartford, CT

Controversy exists regarding management of the initial episode of diverticulitis in young patients. Several authors recommend surgery after one episode requiring hospitalization, whereas others feel this is too aggressive. To help resolve this conflict, we reviewed our experi-

ence with acute diverticulitis in patients aged -<50 years. Forty patients were hospitalized between 1980-85. The diagnosis was based on findings of fever (57 percent), abdominal pain (98 percent), WBC >10,000 (69 percent), and barium enema or operative findings consistent with diverticulitis. Age ranged from 21-50 years (mean = 44) and there was an equal sex distribution. Surgery was required on initial admission in 10 patients (25 percent) for acute abdomen or failure to improve with antibiotics. Thirty patients (75 percent) improved and were discharged after treatment with bowel rest and antibiotics. Five to 9-year follow-up was obtained of patients treated medically. Ten patients (33 percent) required readmission for diverticulitis, eight of whom (27 percent) underwent surgery, all elective; 73 percent of patients -<50 years old who resolved their initial episode of acute diverticulitis with medical treatment did not require surgery over the follow-up period. Although we agree that diverticulitis in young patients is a serious illness, we cannot recommend surgery after a single episode that resolves with medical treatment.

Crohn's Colitis and Cancer: Increasing Justification for Surveillance?

(68)

T. J. Stahl, P. L. Roberts, D. J. Schoetz Jr., J. J. Murray, J. A. Coller, M. C. Veidenheimer . . . . . . Burlington, MA

Colon cancer arising in patients (pts) with Crohn's colitis (CC) is reported with increasing frequency and is often diagnosed at a late and incurable stage. To clarify the clinical course of pts with cancer and CC, we reviewed 18 pts from 1957-1989. The incidence of colon cancer for all cases of Crohn's disease seen during this 32-year period was 18/3,290 (0.55 percent). There were 12 females and 6 males with a mean age of diagnosis of Crohn's colitis of 40.4 years (15-68), and a mean age of diagnosis of colon cancer of 51.6 years (32-70). The mean duration of CC before diagnosis of colon cancer was 11.2 years (0.2-27). Eight patients had CC for over 10 years. Thirteen patients had ileocolitis and 5 pts had left-sided colitis. Cancers arose in colitic segments with the most severe disease in 15, and away from such areas in 3. Five patients had associated dysplasia adjacent to the cancer. The diagnosis was not suspected preoperatively in five pts; cancer was detected in nine pts during evaluation of a presumed flare of CC after a period of relative quiescence, and was found in four pts during routine follow-up. There were two Dukes' A lesions, five Dukes' B lesions, five Dukes' C lesions, and six Dukes' D lesions. The majority of patients (7/8) with greater than 10 years duration of CC presented with Dukes' C or D lesions. Conclusion: All pts with longstanding Crohn's colitis who present with a flare of disease deserve thorough evaluation to exclude a concomitant cancer. A surveillance program may be justified particularly in patients with longstanding quiescent Crohn's colitis.


Malignant Colorectal Strictures in Crohn's Disease (69)

Y. Yamazaki, M. B. Ribeiro, D. Sachar, T. M. Heimann, A. H. Aufses, A. J. Greenstein . . . . . . . . . . New York, NY

In this study we examined the clinical features and outcome of Crohn's disease patients who develop malignant colorectal strictures. One hundred thirty-two of 980 patients (13.5 percent) with Crohn's disease (CD) in- volving the colon, admit ted to The Mount Sinai Hospital be tween 1959 and 1985, deve loped 175 colonic strictures. Ten malignant strictures were ident if ied in nine patients (3 ileocolitis, 6 colitis). The frequency of cancer in patients with stricture (6.8 percent) was higher than in those without stricture (0.7 percent , 6 of 848, P < 0.001). Seventeen of 165 benign strictures (10.3 percent) were long, extending over more than one anatomical segment of colon, but all 10 malignant strictures were short (P < 0.0001). The propor t ion of malignant strictures increased with duration of disease from 3.3 percent with less than 20 years of CD, to 11 percent with CD of 20 years or more. All nine patients with malignant stricture were treated surgically, and four of the nine d ied of colon cancer during a mean follow-up of 4.3 years. Prognosis was worse in six other nonstricture cancers in this series, with five colon cancer deaths during mean follow-up of 1.6 years.

In view of the high rate of malignancy, 6.8 percent in this series, colonoscopy with b iopsy is essential in Crohn's disease patients with colonic strictures, and surgery is mandatory when a stricture cannot be fully assessed during colonoscopy.

Coagulation Paremeters and Thrombosis in Patients with Inflammatory Bowel Disease

(70)

S.J. Stryker, D. Green . . . . . . . . . . . . . . . . . . Chicago, IL

Patients with inflammatory bowel disease (IBD) have f requent t h r o m b o t i c / t h r o m b o e m b o l i c compl ica t ions . The risk appears greatest during per iods of increased disease activity. To investigate the mechanisms that might predispose to thrombosis, we prospect ively studied coagulation parameters in 52 consecutive hospitalized IBD patients seen by one consult ing surgeon. De- tai led history was obtained concerning previous IBD illness and thrombotic events. Prothrombin t ime (PT), partial thromboplast in t ime (PTT), b leed ing t ime (BT), platelet count (PLT), f ibrinogen (FIB), ant i thrombin III (AT3), protein C (PRC), and protein S (PRS) were assessed. Follow-up for thrombosis was cont inued for >30 days. Results: PT, PTT, and BT were normal in all patients, but 31 of 52 (60 percent) had other abnormal values suggesting a hypercoagulable state, including six of seven with previous or current thrombosis. For specific abnormalit ies see the table. Two of 21 (10 percent) with ~'PLT, 1 of 10 (10 percent) with ~'FIB, 1 of 11 (9 percent) with ,~AT3, 3 of 5 (60 percent) with ,LPRC, and 2 of 8 (25 percent) with ~PRS had venous thrombosis. Conclusions: Parameters suggesting hypercoagulabi l i ty were common in hospi tal ized IBD patients. All but one patient with thrombosis had at least one detectable co-


agulation abnormality. An optimal benefi t / r isk ratio might entail aggressive thrombosis prophylaxis in those patients with laboratory parameters indicating a hypercoagulable state, especial ly PRC or PRS deficiency.

IBD + Thrombosis All IBD (n = 52) (n ---- 7)

PLT 2I 2 ~' FIB 10 1 J, AT3 11 1

PRC 5 3 J, PRS S 2

Natural History of Crohn's Disease (CD) Following Surgical Resection: Interim Report of the Postoperative Crohn's Disease Trial

(71)

R. S. McLeod, Z. Cohen, J. Cullen, G. R. Greenberg, C. S. Ho, R. Reznick, H. Stern . . . . . . . Toronto, Ontario

B. G. Wolff, J. Cangemi, R. Beart, P. Carryer, K. N. Jeejeebhoy, R. MacCarty, L. Weil land

Rochester, MN

A randomized control led trial was initiated in 1986 to de termine the effectiveness of mesalamine (Rowasa I) in preventing or delaying the recurrence of CD following a bowel resection (BR) in patients in whom there is no macroscopic residual disease.

During the first 40 months, 514 patients have had BR of whom 296 (56 percent) met entry criteria. One hundred seventeen of these (39 percent) were entered (70 males, 47 females, mean age 38 years). Forty-nine had SB, 29 had LB, and 39 had both SB and LB disease. The mean number of previous BR was 1.6. The mean length of SB resected in 70 patients was 42 cm. All patients have been fol lowed with yearly colonoscopies or small bowel enemas. Patients with symptomatic CD had radiological or endoscopic confirmation. After mean follow-up of 16 months, 27 patients (23 percent) have deve loped symptomatic recurrent disease (17 percent) overall recurrence rate at 12 months; 37 percent at 24 months) . In all but two patients, the recurrence was pre- anastomotic. Asymptomatic recurrent CD has been doc- umented in 25 patients (8.5 percent at 12 months, 13 percent at 24 months) . After a further mean follow-up of 13 months, only seven of these patients (2.8 percent) have deve loped symptoms requir ing treatment.

From this prospective study we conclude that recurrence of CD following BR may be higher than previously repor ted in retrospective reviews. In addition, many patients may have recurrent CD endoscopical ly without having symptoms.

Hidradenitis and Crohn's Disease---A Significant Association

(72)

J. M. Church, V. W. Fazio, I. C. Lavery, J. R. Oakley, J. W. Milsom . . . . . . . . . . . . . . . . . . . . . . . Cleveland, OH

Over the last 7 years, 55 patients with hidradenit is suppurativa (HS) have been treated in this department.

Vol. 34, No. 4 MEETING

Eighteen of these patients (33 percent) also had Crohn's disease. The association is examined in detail in this retrospective review.

There were nine male and nine female patients. Their median age was 35 years (range 19-75). All but four had already been diagnosed as having Crohn's disease before their HS presented, this being colonic in 14, i leocol ic in 3, and ileal in 1. Twelve patients had undergone bowel resection prior to present ing with HS, and 11 had stomas. By the end of the study, all had had bowel resections, 17 had stomas, and 14 had lost their rectum.

HS occurred in mult iple sites (per ineum in 18, groin in 9, scotum/vulva in 7, axillae in 4, and buttocks in 7). Seven patients underwent wide excision and split thickness skirl grafting, and 13 had local excision with or without closure. Granulomas were found in excised skin in six patients, but this f inding did not adversely affect outcome. At a mean follow-up of 3.3 years (95 percent C.L. 2-5 from their last procedure , 10 patients were asymptomatic for HS, 7 were symptomatic, and 1 patient had died. These data show that patients with Crohn's colitis may develop HS in mult iple sites. This compli- cates both the diagnosis and management of per ineal sepsis in such patients.

A Randomized Prospective Assessment of the Treatment of Nonspecific Proctosigmoiditis Using Hydrocortisone Enemas, 5-ASA Enemas, and Short Chain Fatty Acid Enemas

(73)

A.J. Senagore, J. M. MacKeigan . . . . . Grand Rapids, MI

The gold standard for t reatment of idiopathic ulcerative proctitis has been hydrocort isone (HCT) enemas. Recently, two addit ional t reatment options have become available, 5-aminosalicylic (5-ASA) enemas and short chain fatty acid enemas (SCFA). This project represents the first direct comparison of these three t reatment options in terms of efficacy, side effects, and cost-effectiveness in a randomized, double b l inded study design. All patients diagnosed with ulcerative proctosigmoidi t is were el igible for study (N = 19). Diagnosis was based on history, with endoscopic and histologic confirmation. Patients were randomly al located to one of three treatment groups: hydrocort isone (100 mg/60 cc pr qhs + Azulfidine 500 mg po qid); 5-ASA (4 gin/60 cc pr qhs); or SCFA (50 ml per bid). Treatment was cont inued for 6 weeks with clinical evaluation per formed at 2-week intervals. Data evaluated inc luded presence of hematoche- zia (B), mucus in the stool (M), endoscopic grade (G) (1-4) , and successful resolut ion (R) of the inflammatory process.

Initial 6 Week

B M G B M G

IICT (n = 6) 6 6 2 . 7 + . 5 1 1 1 . 6 + 1 5 5-ASA (n = 7) 7 6 2.7 -+ .8 1 0 0.5 "4" .2 6 SCFA (n = 6) 6 6 3 + .6 1 1 1.3 + .6 5

ABSTRACTS P23

There were no treatment related side effects. The cost for 6 weeks of t reatment for each group were: HCT: $31.08; 5-ASA: $246.96; SCFA: $21.00. The results indicate no difference in symptomatic and endoscopic response rates, incidence of side effects, or treatment failure. 5-ASA preparat ions were significantly more ex- pensive without significant clinical advantage compared with the other regimens. Therefore, we r ecommend the use of SCFA enemas for the treatment of idiopathic ulcerative proctosigmoidi t is , as a cost-effective treatment that avoids potential 5-ASA and cort icosteroids for resistant cases.

Factors Predictive of Recurrent or Persistent Crohn's Disease in the Excluded Rectal Segment

(74)

J. Guil lem, P. L. Roberts, J. J. Murray, J. A. Coller, M. C. Veidenheimer , D. J. Schoetz J r . . . Burlington, MA

The management of the exc luded rectal segment following excisional surgery for Crohn's disease remains poor ly defined. To de te rmine prognost ic factors relating to the fate of the rectal segment, 47 patients (pts) who underwent excisional surgery and creation of an ex- c luded rectal segment (ERS) were studied. Thirty-three pts (70 percent) had deve loped disease in the ERS by 5 years, 24 had a comple t ion proctec tomy (CP) by 2.4 years and, 9 retained a rectum with disease (W) at a mean follow-up of 4.9 years. Fourteen were without (WO) clinical disease at a mean follow-up of 7.5 years. The three groups were equivalent with respect to sex, duration of preoperat ive disease, indication for surgery, extent of colonic involvement, and histologic involvement of the proximal margin. The mean age of diagnosis of the CP group tended to be younger than those with a retained ERS (24, 39, and 37 years for CP, WO and W, respectively). Neither initial involvement of the terminal i leum nor inflammatory changes of the rectum predic ted eventual ERS disease. However, initial perirectal fistula, found in 70 percent of pts with disease in the retained rectum and 36 percent of patients without disease, was de te rmined to be predict ive of persistent ERS disease (P < .05). Conclusion: Since the presence of perirectal fistula disease in the face of Crohn's colitis predicts persistent or recurrent ERS disease, a primary total proctocolec tomy or early comple t ion proc tocolec tomy may be indicated in this subgroup of pts.

Outcome of Ileorectal Anastomosis for Crohn's Colitis (75)

W. E. Longo, J. R. Oakley, I. C. Lavery, V. W. Fazio Cleveland, OH

Ileorectal anastomosis (IRA) as treatment for Crohn's colitis remains controversial. We reviewed 131 consecutive patients from 1965-1988. Preoperatively, 63 percent were found to have mild or moderate proctitis and 37 percent had rectal sparing macroscopically. Fifty-two percent had associated small bowel disease and 15 percent had perianal disease. Sixty-five IRAs were per-


formed at the time of subtotal colectomy, while 56 were done as a staged procedure. There were no operative deaths. Anastomotic leaks occurred in 3 percent . Thir- teen (10 percent) with i leostomies and intact IRAs never had stomal closure. Among the remaining 118 patients, 30 (23 percent) required proctectomy, while 16 (13 percent) required proximal diversion. However, these 46 IRAs functioned a mean of 4.1 years. An addit ional 13 patients required pre-anastomotic resect ion and neo- IRA, while 11 others required proximal small bowel resection. Seventy-two patients (72/118 or 61 percent of those whose IRA currently functions) retained a func- t ioning IRA after a mean of 9.2 years. Forty-four are free of disease, while 28 are being treated with steroids or antidiarrheals. The average stool frequency is 5.9/day. In this study, the results of IRA for Crohn's colitis are better than general ly repor ted and suggest the operat ion should be considered as an alternative to proc tocolec tomy in se lec ted patients.

Multifactorial Index of Preoperative Risk Factors in Colon Resections

(76)

D. P. Ondrula, M. L. Prasad, R. L. Nelson, H. Abcarian . . . . . . . . . . . . . . . . . . . . . . . . . . . Chicago, IL

We analyzed the negative predictive value of a variety of preoperative risk factors on operative outcomes. We reviewed all colorectal resections per formed in a single hospital be tween January 1985 and May 1990; 972 resections were per formed on 825 patients. We s tudied 17 preoperat ive risk factors generated from various medical risk categories. Using the multivariate discriminant function analysis we calculated that 11 of the 17 risks were of significance in predic t ing outcomes (all with P _< 0.031). These factors included emergent operation, age ->75, CHF, radiation, steroid use, alb. <2.7, COPD, previous MI, diabetes, cirrhosis, and renal insufficiency. The discriminant analysis was used to categorize patients into 1 of 4 risk groups by developing a "risk score." The index used to develop each patient 's "risk score" ranged from 6 points for an emergency operat ion to 1 point for diabetes. The mortality rates for the various risk groups were: I, 0-4 points 1 percent; II, 5-8 points 10 percent; III, 9-13 points 19 percent; IV, >13 points 33 percent . In contrast to previous reports, we showed that age ->75 alone is not a major preoperat ive risk factor, but rather acts as a modifier for the other predictors of postoperative complications. We then assessed clinical questions concerning specific preoperat ive risks such as steroid use, obesity, IBD, COPD, and prior laparotomy and their associated specific postoperat ive complications. Through the use of this risk index we also were able to assess an individual pat ient 's operative risk more accu- rately and have deve loped prevention strategies based on these findings.

Total Abdominal Colectomy with Ileorectal Anastomosis: The Preferred Mternative

(77)

R.J. Coughlin, M. L. Corman, E. D. Prager Santa Barbara, CA

The indications for total abdominal co lec tomy with i leorectal anastomosis are debatable. Most surgeons agree that synchronous malignant lesions in different parts of the colon, colonic b leed ing without an identif ied source, and familial adenomatosis with relative rectal sparing are appropriate indications. With left-sided colonic obstruction, many bel ieve that abdominal colectomy with i leorectal anastomosis is preferred to l imited resection and colostomy. It el iminates the need for subsequent colostomy closure with its attendant complications. Two surgeons per formed 50 total abdominal co- lectomies with i leorectal anastomoses over a 10-year per iod (1980-1989) for synchronous lesions, for bleeding, and for obstruction. The mean age was 65. The mean operat ing time was 120 minutes. This includes 14 patients (28 percent) who required concomitant procedures. At 6 months follow-up, the average number of bowel movements per day was 2.6. There were two anastomotic leaks (4 percent) which required a diverting loop ileostomy. These were subsequent ly closed. There was one death by respiratory failure (2 percent) , not related to an anastomotic problem. We find that total abdominal colec tomy is safe, expedit ious, and results in satisfactory bowel function. This should be the preferred alternative to l imited resection if a stoma would otherwise be required.

Treatment of Entero- and Colocutaneous Fistulae with Early Surgery or Somatostatin Analog

(78) D. I. Borison, A. D. Bloom, T. J. Pritchard

Cleveland, OH

Traditional therapy of enterocutaneous (EC) and colocutaneous (CC) fistulae has consisted of "conservative" management with surgery reserved for failure of maximal medical treatment. We conducted a 5-year retrospective review of 27 patients with EC and CC low output fistulae in order to de termine the outcome of early surgical and nonsurgical treatment of these conditions. Twelve men and 15 women with a median age of 67 years presented with 21 EC and 6 CC. Seven patients had early operative intervention in an attempt to close their fistulae, while the remaining 20 patients were treated without surgery. In addition, four of the nonsurgical group received parenteral somatostatin analog (SA). None of the surgical patients was septic preoperat ively (median WBC = 9.7), median preoperat ive hospital stay was 11 days, and no patient required a proximal diverting stoma. All of the surgical group resumed normal GI function within 2 weeks, and six of the seven (86 percent) demonstra ted no recurrence of the fistulae at a median follow-up of 1 year. Of the 20 medical ly treated patients, three of the four who received SA healed their fistulae within 2

Vol. 34, No. 4

weeks. Only two of the other 16 medical ly treated patients (12.5 percent) healed their fistulae. Early surgery or the use of SA should be cons idered in the treatment of patients with low output intestinal fistulae.

MEETING ABSTRACTS P25

Results: 224 patients were identif ied (108 male, 116 female).

Gastroduodenal Polyps in Patients with Familial Adenaomatous Polyposis

(79)

J. M. Church, E. McGannon, D. G. Jagelman, M. V. Sivak, R. van Stolk, S. Hull-Boiner . . . . . . . . . . . Cleveland, OH

In 1986 we repor ted on the prevalence of upper gastrointestinal polyps in patients with familial adenomatous polyposis (FAP). As a result, esophago-gastro-du- odenoscopy (EGD) has become a routine part of our work-up of FAP patients. In this paper we provide a follow-up report on the results of the initial EGD in FAP patients treated at this institution.

Methods: A review of the endoscopy reports and pathology results from the initial EGD of all FAP patients undergoing such an examination was performed.

Before After 1986 Total

1986

n % n % n %

EGD normal 54 54 49 40 103 46 Gastric polyps 28 28 57 46 85 38 Duodenal polyps 33 33 53 43 86 38 Total Patients 100 124 224

After 1986, routine biopsies of "normal" duodenal papil la on initial EGD have shown adenomatous change in three. In follow-up EGDs, a "normal-appearing" pa- pilla was adenomatous in a further 33 patients.

Conclusions: Routine EGD is indicated for patients with FAP. There is a t rend towards an increasing prevalence of both gastric and duodenal polyps. A normal appearing duodenal papil la may not be histologically normal.

POSTER PRESENTATIONS

Poster presentations will be on display in Salons H through K beginning 10 a.m., Monday, May 13, and during all open exhibit hours. Authors have been re- quested to be present at their posters during all intermis- sion breaks on the days their posters will be discussed.

Does Fecal Diversion Affect Resting Anal Pressure in Patients with Ulcerative Colitis:

Booth P1

W, B. Tuckson, V. W. Fazio, I. C. Lavery, J. R. Oakley, J. M. Church, J. w. Milson . . . . . . . . . . . . Cleveland, OH

Following fecal diversion maximum anal squeeze pressure (MSP) decreases, but returns to normal values after restoration of bowel continuity. To de termine the effect of fecal diversion on anal sphincter resting tone, the maximum anal resting pressures (MRP) from 20 patients with mucosal ulcerative colitis (MUC), who had a subtotal colec tomy and i leostomy at least 12 months before manometry, were compared with the MRP from 20 age and sex matched controls with MUC, who had no previous surgery. Anal pressures were measured using a radially or iented four-port water perfused catheter and the station pull through technique. The results are l isted in the table below.

Table 1. Effect of Diversion on Anal T o n e

Not Diverted Diverted

Months diverted (mean / N/A 67/26 median)

MRP (ram Hg) 87 + 7 74 + 7 MSP (mm Hg) 216 + 41 200 + 37

Manometry data reported as mean -+ 95% confidence limits. P = N.S.

There were no significant differences be tween the MRP or MSP values. MRP values were equal even after p ro longed fecal diversion. Prolonged fecal diversion alone does not appear to represent a contraindication to sphincter preserving surgery or to at tempts at reestab- l ishing bowel continuity.

How Reliable Are Currently Available Methods of Measuring the Anorectal Angle?

Booth P2

S. D. Wexner, F. Marchetti, M. Sullivan, G. O. Rosato, J. M. Jorge, D. G. Jagelman . . . . . . . Fort Lauderdale, FL

This prospective evaluation was des igned to compare two different methods of measuring the anorectal angle (ARA): c inedefecography (CD) and bal loon proctogra- phy (BP). The aims of the study were to assess the correlat ion be tween these two methods as well as the reproduct ibi l i ty of ARA measurement; 74 consecutive patients with ei ther constipation (43 patients), fecal incont inence (17 patients) , or rectal pain (14 patients)

P26

underwent both CD and BP. Radiographs were made with the patient at rest and during both squeeze and evacuation. Measurement of the ARA was then undertaken. Between 2 and 12 months later the same interpre- tation process was repeated. At rest and during squeeze there were highly significant differences be tween CD and BP (P < 0.01). The mean difference at rest ranged from 12.6 ~ to 16.9 ~ . The differences were noted in all three CD measurements when the same interpreter 's sets of data were compared (5.2-7.5 ~ P < 0.01). Although more reproducible measurements were noted with BP, in a significant number of patients at least one of the three views was uninterpretable due to the bal loon 's configuration in the rectum. In conclusion there was poor correlat ion be tween CD and BP and poor repro- ducibil i ty of ARA measurement; BP was consistently more difficult to interpret. Neither of the currently available techniques of ARA measurement is consistently reliable.

Computer ized Defogram Analysis: An Objective Assessment

Booth P3

P. Durdey, M.J. Kennedy, M. Oster, J. Murray, P. L. Roberts, D. J. Schoetz Jr . . . . . . . . . . Burlington, MA

Defecography is an unpopular examination with surgeons and radiologists. Interpretat ion is open to subjective bias. We have deve loped a computer a ided drawing (CAD) program to objectively assess data from defo- grams. Anorectal angle (ARA), per ineal descent, and pelvic floor movement were computed in 20 patients with constipation (10 slow transit, 10 anismus) and 25 with incontinence. Anorectal angle (ARA) was similar at rest and strain. Mean ARA was more acute on squeeze and evacuation in const ipated patients (107 vs. 115, P = 0.04*: 118 vs. 137, P = 0.002*). Position of the pelvic floor was def ined as distance from sacral promontory, which is easy to identify, to the ARA. There was no difference in pelvic floor posi t ion at rest, strain, and evacuation. On squeeze the incont inent group had a significantly lower posi t ion ( P = 0.04*). Contribution of puborectal is to pelvic floor movement was de te rmined by comparing the ratio of distance from the inferior border of the pubis to the puborectal is impression at the ARA and from coccyx to ARA. The ratio significantly increased on squeeze in patients with slow transit (0.94- 0.67, P = 0.002*) and to a greater extent with anismus (0.94-0.55, P = 0.001"). The ratio did not alter in incon- tinents (0.96-0.98, P = NS*), indicating loss of puborectalis function. On strain and evacuation the ratio increased equal ly in all groups including those with anismus, indicating puborectal is relaxation. These data suggest that pelvic floor movement is achieved primari ly by puborectalis. Computer analysis improves data collection, removes subjective assessment, and may improve acceptabil i ty of the examination.

(*Student 's t-test)


"Goodsall 's R u l e ' - - I s It Accurate in Predicting the Course of Anal Fistulae?

Booth P4

W. C. Cirocco, L. C. Rusin, A. C. Brown, J. C. Reilly Erie, PA

Goodsal l ' s original observations on anal fistulae (ca. 1900) have been condensed and handed clown over t ime as "Goodsall 's Rule." The rule attempts to forecast the course of fistula-in-ano based on the relation of its external (secondary) opening to a hypothetical transverse anal line. External openings poster ior to this line are said to predict a curved course to a midl ine poster ior internal (primary) opening while external openings anterior to this line predict tracking radially inward to an internal opening. Our data call the predict ive accuracy of this t ime-honored rule into question.

Of 303 patients undergoing fistula surgery over an 8- year per iod (1982-89), 63 were exc luded on the basis of previous surgery, indeterminate findings and Crohn's disease. Of the 240 patients (174 male and 66 female) reviewed, 24 were subcutaneous and 216 were transsphincteric; 124 transsphincteric fistulae had secondary openings posterior to the transverse anal line. In this group the fistulae coursed to the midl ine poster ior 90 percent of the t ime in accordance with Goodsal l ' s Rule. Of the 92 transsphincteric fistulae with secondary openings anterior to the transverse anal line, only 49 percent obeyed Goodsal l ' s Rule. Anterior fistulae in women were more likely to violate the rule (69 percent) than those in males (43 percent) .

Goodsal l ' s original observations will be discussed as well as the implications of the present study for the clinician.

Intrarectal Ultrasound in the Evaluation of Perirectal Abscesses

Booth P5

P. Cataldo, A. J. Senagore, M. A. Luchtefeld, J. M. MacKeigan, W. P. Mazier . . . . . . Grand Rapids, MI

Experience with intrarectal ul t rasonography (IRUS) is l imited for the evaluation of perianal sepsis. The purpose of this paper is to report our exper ience with IRUS in evaluating perianal abscess and fistula.

Twenty-four consecutive cases were reviewed. All IRUS was performed intraoperatively under epidural anesthesia or with intravenous sedation. The patients were examined in the left lateral decubitus posit ion. A Bruel and Kjaer (Model #1846, Denmark) endoanal ul trasound with a 7-mHertz transducer was used. An abscess appeared as a hypoechoic area. Internal openings of fistulous tracts appeared as breaks in the normal ly smooth bal loon-mucosal interface and /o r disrupt ion of the integrity of the internal sphincter. After comple t ion of the IRUS, careful bimanual and anoscopic exams were performed. Subsequently the patient underwent appropriate surgical therapy. At surgery, 19/24 patients were found to have perirectal abscesses. In all 19 cases the

abscess was ident if ied correctly preoperat ively by IRUS. In 12 (63 percent) cases the relat ionship be tween the abscesses and sphincters was noted by IRUS corresponding to the Parks classification. In all 12 cases the rela- t ionship predic ted by IRUS was identical to surgical findings. At surgery, internal openings of fistulous tracts were found in 14/19 cases. IRUS correctly identif ied 4/19 internal openings. In 6/24 cases IRUS failed to demonstrate a perirectal abscess. Subsequent careful exam under anesthesia revealed no abscess in any of these patients.

In summary, we retrospectively reviewed 24 cases of IRUS for suspected perirectal abscess. IRUS correctly identif ied the abscess in all cases and correctly identif ied the relat ionship of the abscess to the sphincters in 12 cases. The internal opening could only be identif ied by IRUS in 4/14 cases. The role of IRUS in the evaluation of perirectal abscess is evolving. Certainly uncompli- cated abscesses can be managed without ultrasonog- raphy; however, IRUS can be an adjunct to careful evaluation of complex perianal suppurative disease to assess adequate drainage.

Surgery for Symptomatic Hemorrhoids and Anal Ulcers in Patients wi th Crohn's Disease

Booth P6

A. F. Wolkomir . . . . . . . . . . . . . . . . . . . . . . Red Bank, NJ M. A. Luchtefeld . . . . . . . . . . . . . . . . . . Grand Rapids, MI

The literature states that anal surgery in patients with Crohn's disease is fraught with danger. Recent papers indicate that select patients with Crohn's can undergo fistulotomy with minimal morbidity. This st imulated review of our exper ience with surgical t reatment of hemorrhoids and anal fissures in the Crohn's patient. A retrospective chart review was done of all Crohn's patients undergoing hemorrho idec tomy and fissure surgery from 1961 to 1989.

Seventeen patients with known Crohn's disease (9 colonic, 6 small bowel) underwent hemorrhoidectomy. On mean follow-up of 11.5 years, 15/17 healed without complicat ion, one patient required a proctec tomy 15 years later for causes apparent ly unrelated to the hemorrhoidectomy. Twenty-five patients with known Crohn's (7 rectal, 6 colonic, 1 colorectal, 11 small bowel) underwent 27 operat ions for anal fissure and ulcer. Twenty- two patients had uncompl ica ted healing by 2 months, while two required up to 2 years for healing. One patient was lost to follow-up at 4 months and had an unhealed wound at that time. Two patients ul t imately underwent proctectomy (at 5 months and 7 years), and nine others eventually deve loped other perianal disease on long- term follow-up (mean 7.5 years).

In summary, 15/17 patients with Crohn's disease had routine wound heal ing after hemorrho idec tomy and 22/25 patients had wound healing as expected following anal fissure surgery. We conclude that patients with s e v e r e symptoms secondary to anal f issures/ulcers and hemorrhoids in known Crohn's disease who cannot be


control led with conservative medical management may undergo surgery on a highly selective basis when the disease is in a quiescent state. Proctectomy is n o t an inevitable outcome.

clinical information to the surgeon and to the patient in identifying primary and affiliated disorders. CT obviates the need for IVP, permits superior staging and provides a more accurate comparison for postoperat ive follow-up in these patients.

Perineal Endometriosis--Report of 12 Cases Booth P7

F. Ruiz-Moreno, R. Alvarado-Cerna, U. Rodriguez, J. Amaro . . . . . . . . . . . . . . . . . . . . . Mexico City, Mexico

Endometriosis is the ectopic location of endometr ia l tissue under cyclic hormonal influence. There are two clinical forms: 1) endomet r ioma when the tissue becomes fibrous and nodular, into a well located mass and 2) diffuse form is badly de l imi ted with disseminat ion to the surrounding structures. Various theories try to explain the pathogenesis of endometriosis . The per ineal location is best expla ined by the implantat ion theory. We present 12 cases seen from 1978 to 1990. Eight are endometr iomas; four be long to the diffuse type. All are localized at an epis io tomy scar, forming a painful mass with inflammation which becomes larger and more painful at the time of menstruation. The ages ranged from 24 to 36 years. The symptoms appeared from 12 months to 9 years from the date of the epis io tomy or vaginal surgery. Three to 18 months lapsed from the beginning of symptoms to the surgical treatment. All the endome- triomas were easily resected with no recurrence, whereas the surgical treatment was difficult in the diffuse forms, special ly when the anal sphincters were involved; hormonal adyuvant t reatment was instituted. We do not r ecommend anorectal surgery during menstruation.

P-Glycoprotein as a Novel Tumor Marker in Human Colon Carcinoma

Booth P9

J. M. Dominguez, T. J. Saclarides . . . . . . . . . Chicago, IL J. S. Coon, R. S. Weinstein . . . . . . . . . . . . . . . Tucson, AZ

P-glycoprotein (P-Gp) mediates mult idrug resistance by functioning as an efflux pump that excretes "natural" l ipophi l ic drugs from cancer cells. Whereas the focus of attention has been on the role of P-Gp in anticancer drug resistance, we have now examined the influence of P- glycoprotein on the biological behavior of colon cancers in vivo. In an immunohis tochemical study using monoclonal ant ibody C219, we de tec ted immunoreactivi ty in 65 of 95 primary colon carcinomas, Astler-Coller stage B1 or greater. Solitary invading carcinoma cells and invading cell nests were present at the edge of the tumors. This subpopula t ion of invading cells expressed P-Gp in 47 cases. There was a higher incidence of lymph node metastases in cases with P-Gp+ invasive cells ( P < 0.01). P-Gp status in invading cells did not influence tumor grade, stage, size or mucin production. In some cases with P-Gp negative primary tumors, invasive cells and lymph nodes were P-Gp+. These findings indicate that P-Gp may be a useful novel marker for colon carcinomas with high metastatic potential.

The Preoperative Use of Computer ized Tomography in Patients with Colorectal Carcinoma

Booth P8

B. A. K e r n e l G. C. Oliver, T. E. Eisenstat, R. J. Rubin, E. P. Salvati . . . . . . . . . . . . . . . . . . . . . . . . . Plainfield, NJ

Controversy exists over the appropriate preoperat ive evaluation of colorectal cancer patients. Most surgeons agree that basic laboratory studies are indicated. Com- puter ized tomography of the abdomen and pelvis has been used in our practice to augment the preoperat ive evaluation of these patients.

This report represents a 2-year review of 158 patients with primary colorectal carcinoma who underwent a preoperat ive CT of the abdomen.

In 70 patients, CT scans revealed no addit ional information. In the remaining patients there were 120 additional findings. Of this number, 35 percent were clini- cally significant and al tered the p roposed operative procedure or added addit ional technical information for considerat ion preoperatively. These findings included liver metastasis, unilateral atrophic kidney, and abdominal wall or contiguous organ invasion. In addition, other sol id organ carcinomas were detected.

We have concluded that computer ized tomography is an effective aid in the preoperat ive evaluation of individuals with a colorectal carcinoma. CT offers important

The Level of Serum Gastrin as a Predictive Indicator of Liver Metastasis in Colorectal Cancer

Booth P10

M. Kameyama, I. Fukuda, S. Imaoka, T. Iwanga Osaka, Japan

It has been demonstra ted that gastrin has a t r o p h i c effect on colorectal cancer in animal, but it has never been shown that serum gastrin is associated with the liver metastasis of human colorectal cancer. The aim of this study was to investigate the relat ionship be tween serum gastrin and liver metastasis. There were 140 patients with colorectal cancer (T2, T3) who underwent surgery, and for whom the fasting serum gastrin concen- tration was de te rmined prior to the surgery. Liver metastasis was de tec ted in 12 of 102 (12 percent) patients with serum gastrin level of less than 150 pg/ml , and in 14 of 38 (37 percent) patients with a serum gastrin level of 150 pg /ml or more. Venous invasion was de tec ted in 55 of 102 (54 percent) patients with a serum gastrin level of less than 150 pg/ml , and in 19 of 38 (50 percent) patients with a serum gastrin level of 150 pg /ml or more. In the patients with venous invasion (v+), liver metastasis was de tec ted in 11 of 55 (20 percent) patients with a serum gastrin level of less than 150 pg/ml , but in 11 of 19 (58 percent) patients with a serum gastrin level of 150 pg /ml or more ( P < 0.01). Our results indicate that


serum gastrin is a risk factor, and in combinat ion with venous invasion, it is possible to predict liver metastasis of human colorectal cancer.

Proliferative Activity of Colonic Mucosa at Different Distances from Primary Adenocarcinoma as Determined by $44; A Nonproliferation-Specific Nuclear Protein

Booth P l l

S. Kyzer, B. Mitmaker, P. H. Gordon, E. Wang Montreal, Quebec

The field change is one hypothesis concerning the deve lopment of colorectal carcinoma. Removal of a car- c inoma without its entire surrounding al tered mucosa may result in the deve lopment of a recurrence. $44, a monoclonal ant ibody di rec ted against statin, a nuclear protein expressed in quiescent cells, was used to determine the proliferative rate of colorectal mucosa at different distances from carcinomas. The spec imens of 18 patients undergoing resect ion of colorectal carcinoma were immediate ly opened after operat ion and strips of mucosa were taken at distances of 1, 5, and 10 cm from the carcinoma. For each location, 10 longi tudinal ly ori- en ted crypts were evaluated for Statin-positive cells identified by the presence of a dark brown reaction product. The average percentage of statin-positive cells per crypt were significantly lower at a 1 cm distance from the carcinoma compared with the mucosa located 5 and 10 cm from the carcinoma (20.89 + 4.33 at 1 cm, 32.41 +-- 5.27 at 5 cm, and 34.23 --- 6.45 at 10 cm). None of the calculated parameters showed any significant difference be tween the 5 and 10 cm locations. The increase in mucosal proliferation rate disappears somewhere between 1 and 5 cm from the margin of the carcinoma. We conclude that failure to remove this transitional highly proliferative mucosa may result in subsequent development of anastomotic or perianastomotic recurrences.

The Fat Clearance Technique: Dukes' B to Dukes' C - - Does It Matter? Primary Rectal Cancer

Booth P12

R. H. Grace, P. Gibbons, K. M. W. Scott Wolverhampton, UK

Dukes' staging remains the best single indicator of prognosis in large bowel cancer. It has been shown that the fat clearance technique identifies a larger number of nodes than the standard dissect ion technique. A further study, using the fat clearance technique has shown that, along with the identification of extra nodes, 10 percent of apparent Dukes' B tumors were actually Dukes' C tumors. The 5-year survival rate of these patients has now been studied. Four of five of the patients converted by fat clearance from Dukes' B to Dukes ' C subsequent ly d ied of malignant disease; this does not statistically alter survival figures for the original standard dissect ion of Dukes' B and Dukes' C tumors, but it is obviously clini- cally significant in relation to the patients converted from Dukes' B to Dukes' C in that their potential prognosis

was more poorer than originally suggested by the standard dissect ion technique.

It is suggested that in any therapeutic trial, accurate establ ishment of Dukes' staging is essential because faulty Dukes' staging will negate the conclusions.

Classification

5-Year Survival 5-Year Survival Standard Dissection

Standard Dissection with Added Fat (%) Clearance

(%)

Dukes B 25/42 (59.5) 25/37 (69.6) Dukes C 12/33 (36.4) 13/38 (34.2) Dukes B + C 1/5 (20)

Is Endoscopic Nd-YAG Lasercoagulation with 192Ir-HDR Afterloading Radiation in Palliation of Rectal Cancer More Effective? Booth P13

A. Berger, H.J. Mischinger, K. Arian-Schad Graz, Austria

Introduction: Advanced disease, including local un- resectability, widespread distant metastases, and the presence of medical condit ions that preclude major surgery are the major indications for laser therapy of rectal cancer. Symptoms which can be pall iated by Nd-YAG laser tumor ablat ion are obstruction, b leeding, and mucous discharge.

Patient and results: From 1983 to 1987, 63 patients (40 males, 23 females, 70.1 years) with rectal cancer had been treated by Nd-YAG lasercoagulation alone. For desobli terat ion 5.20 (2-12) laser procedures were necessary. Adequate reeanalization could be achieved in 62/ 63 pa t i en t s - -one required a colostomy; 5.30 (2-12) subsequent laserprocedures were necessary with an interval of 8.4-10.1 weeks. Control of b leed ing was possible in 53 patients (10 of 63 rebled) . In a prospective study (since 1988), nine patients have been treated (5f, 4m age 78.7 years) after initial laser- therapywith Ir-192 HDR remote afterloading therapy; 5-7 Gy Ir-192 were appl ied through an inserted rectal tube. Each patient underwent four sessions within 2 months. Control of b leed ing and recanalization could be achieved in all patients (100 percent) . Restenosis occurred in one patient and required one addit ional laser session.

Summary: These prel iminary results of our prospective combined modal i ty t reatment showed a control of bleeding in 100 percent vs. 10/63 and control of stenosis in 1/ 9 vs. 9/63 with laser t reatment alone. The effect of pall iat ion seems to be encouraging but control led randomized trials have to be done.

Monoclonal Antibodies to Detect Lymph Node Metastases in Colorectal Cancer: An Expanded Study

Booth P14

M. Davis, D. Miller, L. P. Fielding . . . . . Waterbury, CT

The presence of local lymph node metastases in patients with eolorectal adenocarc inoma is the single most

P30

important factor in all studies which have used multivariate analysis to de termine the relative importance of prognost ic indices after "curative" resection. Tradition- ally, hematoxylin and eosin staining has been used to study lymph nodes until new techniques using monoclonal ant ibodies have been repor ted recently.

Our prel iminary report using a monoclonal ant ibody raised against cytokeratin (Pankeratin AEI:AE3, avidin- b io t in- immunoperoxidase technique) to bet ter evaluate lymph node status involved 144 patients and results using the Dukes' classification (Astler Coller modificat ion) showed that McAb usage led to a reduct ion (17.9 percent) in B2 tumor classification with a reciprocal rise (38.7 percent) in the C2 category (chi-square test for B2, C2 lesion distr ibution differences: 0.1 < P > 0.05). Furthermore, prel iminary data show that reassignment of specimens to a lymph node positive category changes the prognosis of the group in numeric terms; however, the data concerning 5-year survival were not statistically significant because of the small sample size.

Using an appropriate mathematical model for statistical significance ( Ipsen e t al., 1970; Cochran e t al., 1957; Fryer 1966), the required number of patients to address the question of lymph node tumor involvement was calculated to be 600. The patients have been identif ied through the Connecticut State Tumor Registry with the collaborat ion of three addit ional institutions (Yale, Nor- walk, and Bridgeport Hospitals). At the present time, data has been received from the CSTR and specimen blocks are being sect ioned by collaborat ing institutions for final staining. Comparison of the reassignment of these specimens with survival data will de te rmine whether the change in tumor stage associated with a higher yield of lymph node positive specimens by using the McAb technique has prognost ic significance in terms of 5-year survival for patients with large bowel cancer and will be presented.

Lymph node status in specimens of patients with colorectal cancer has he lped physicians advise patients about estimates of prognosis. A recent memorandum by the National Cancer Institute (NCI) has advised physicians to implement adjuvant chemotherapy for patients with positive lymph node status using a regimen of 5-FU and levamisole. Thus the NCI has changed the need to evaluate lymph node status from an interest in patients ' prognosis to an important evaluation for clinical deci- s ion-making to select optimal treatment in colorectal cancer patients.

The Value of Nuclear Morphometry in the Management of Patients with Colorectal Polyps Which Contain Invasive Adenocarcinoma

Booth P15

B. Mitmaker, S. Kyzer, L. R. Begin, P. H. Gordon Montreal, Quebec

The management of a patient who has undergone colonoscopic po lypec tomy for a large bowel polyp which contains invasive adenocarc inoma is controversial. Hag- gitt 's classification is a useful guide in that patients in


Levels 1 to 3 require no operation. Using Level 4 as an indicator for operation, approximately 75 percent of patients will exhibit no residual. Nuclear morphomet ry is a useful prognost ic discriminant for patients who suffer from invasive carcinoma of the large bowel. We studied the nuclear shape factor of 44 polyps with invasive carcinoma to de te rmine whether this parameter was of value to define those patients with Haggitt Level 4 who should have a resection. The shape factor of 50 interphase nuclei was obtained through the use of image analysis by tracing the nuclear profiles as digi t ized on a video screen. The nuclear shape factor was def ined as the degree of circu- larity of the nucleus, a perfect circle recorded as 1.0. Our previous exper ience showed a nuclear shape factor greater than 0.84 was associated with a poor outcome. The overall mean shape factor was 0.71 (0.59 to 0.85). Fifteen of the 17 patients with Level 4 underwent operation and 4 were found to have residual disease or lymph node metastases. There was a tendency for the patients with residual disease to have values in the upper range, but the small numbers l imited statistical assessment. Our findings suggest that nuclear morphometry fails to add valuable information in this clinical situation.

Decreased Rectal Wall Contractility in Chronic Severe Constipation

Booth P16

K. E. Levin, J. H. Pemberton, A. M. Bell, R. B. Hanson . . . . . . . . . . . . . . . . . . . . . . . Rochester, MN

The rectal barostat quantifies the volume of air within an infinitely complaint intrarectal bag maintained at a constant pressure; decreases in intrarectal volume reflect increases in rectal muscular contractility while increases in volume reflect decreased contractility. Aim: To identify differences in rectal wall contractility be tween healthy volunteers and patients with chronic severe constipation. Method: 15 healthy volunteers (10W, 5M, mean 36 years), and 8 patients (7W, 1M, mean 44 years) were studied. The barostat bag was pos i t ioned in the rectum just above the anal canal. Recordings were made for 1 hour prior to and 1 hour after a meal (750 Kcal). Neo- st igmine (0.5 mg) was then given IV, fol lowed in 1 hour by glucagon (IU) IV. Comparisons were made using unpaired t-tests. Results: Fasting rectal volumes were similar; patients 113 - 7 ml (SEM) vs. control, 103 - 4 ml. P > 0.05. However, const ipated patients had significantly less decrease in rectal volume after a meal and after neost igmine than did controls (Table). Moreover, patients had a smaller increase in rectal volume after glucagon then did controls (Table).

Intrarectal Volume

Fed Neos t igmine Glucagon G r o u p (% decrease) (% decrease) (% increase)

Controls 65 + 7 58 + 6 64 + 18 Constip. 35 - 8* 39 --- 6* 28 --+- 6*

* P < .05.

Vol. 34, NO. 4 MEETING ABSTRACTS P31

Conclusion: Changes in rectal wall contractility in response to feeding, to a cholinergic agonist and to a smooth muscle relaxant were decreased significantly in patients with profound constipation. These findings suggest that an abnormali ty of rectal muscular wall contractility is present in const ipated patients.

Fecoflowmetry, A New Parameter Assessing Rectal Function in Normal and Constipated Subjects

Booth P17

A. Shafik, K. Abdel-Moneim, A. Khalid . . . . Cairo, Egypt

Fecoflowmetry is a new technique by which the fecal flow rate is s tudied through recorded curves represent ing the changes occurring in the rate against t ime. Fecal flow rate is the product of rectal detrusor action against outlet resistance. The technique was per formed on 36 normal volunteers and 88 chronical ly const ipated patients. A l- liter water enema was given to the individual. Upon feel ing the desire to defecate, she /he was placed on the comode of a fecoflowmeter and was asked to defecate.

Evaluation of the obtained defecation flow curve com- prises report ing on the defecated volume, flow time, maximum and mean flow rates, and the shape of the curve. Developed to simulate natural defecation, the technique assesses all objective parameters in one test; it provides quantitative and qualitative data concerning the act of defecation.

In the 88 constipated patients, two fecoflowmetric patterns were recognized: nonobstructive (intertia) and obstructive. They differ from each other in parameters and curve configuration. The evacuated volume and maximum and mean flow rates were smaller in outlet obstruction than in the intertia type, whereas flow time and t ime to maximum flow were more prolonged. The ascending limb in the obstructive type curve rose less s teeply than in inertia; the curve had a long plateau and the descending l imb s loped more gradually.

To conclude, fecoflowmetric studies could differen- tiate be tween defecation of normal and const ipated subjects, and in the latter be tween the obstructive and the inertia type of constipation, The procedure is s imple, non-invasive and useful in screening defecat ion and rectal disorders.

The Changing Incidence of Diverticulit is in Rochester, Minnesota

Booth P18

R. M. Devine, R. W. Beart Jr., L. J. Melton, D. M. Ilstrup, B. G. Wolff . . . . . . . . . . . . Rochester, MN

Reports suggest that the incidence of diverticular disease has increased in the deve loped countries during this century. This popula t ion-based study looked at the incidence of hospitalization and surgery for diverticular disease in a relatively stable North American communi ty be tween 1946 and 1979. All patients living in Rochester, Minnesota, who were admit ted with diverticular disease

be tween 1946 and 1979 were identif ied and their charts reviewed; 403 patients were hospi ta l ized 598 t imes for diverticulitis, and 228 surgical procedures were done. Using the number of hospitalizations and operative procedures be tween 1946 and 1979, and the populat ion statistics for the community, the incidence of hospitalization and surgery was calculated. Between 1946-50 and 1976-79, the age- and sex-adjusted incidence of hospitalization increased from 9 to 54 per 100,000 per year, and the incidence of surgery from 3 to 18 per 100,000 per year. The female to male ratio has grown smaller from 4.5:1 in 1946-50 to 0.85:1 in 1976-79. This study provides evidence for an increase in the incidence of diverticulitis in the United States over the last four decades.

The Surgical Management of Right-Sided Colonic Diverticulit is in Singapore

Booth P19

S. S. Ngoi, J. Chia, P. Goh, E. Sire . . . . . . . . . . Singapore

Cecal diverticulitis is an uncommon surgical entity especial ly in Western countries in contrast to oriental communit ies . This may be due to the higher incidence of right s ided colonic diverticulosis in oriental popula- tions.

We reviewed 68 patients who were treated surgically for cecal diverticulitis over a 10-year per iod from January 1981 to January 1990. There were 36 males and 32 females with an average age of 37.9 years (range 20 to 85 years).

All of our patients had clinical presentat ions that were indist inguishable from acute appendici t is and were thus opera ted upon. Apart from three cases of emergency right hemico lec tomy that were done for a cecal mass, the rest had an appendicectomy. Divert iculectomy for an inflamed and perforated diverticulum was carried out in 25 patients. All had high-close antibiotics both intra- and postoperatively. In the follow-up of these patients, only one patient required an elective right hemicolec tomy for repeated diverticulitis. There was no mortality in our series. The morbidi ty was contr ibuted by a liver abscess in one patient, cecal fistula in another (both treated conservatively) and wound infection in eight. Our results suggest that cecal diverticulitis may be self-limiting and managed by a conservative surgical approach. A more radical surgical resect ion is indicated mainly for repeated attacks.

The Influence of Design of the Pelvic Reservoir on Ileal Ecology

Booth P20

P. M. Sagar, P. Godwin, P. Quirke, D. Johnston Leeds, UK

The influence of ileal reservoir design on bacterial content of reservoir effluent, volatile fatty acid concen- tration, efficiency of evacuation, and mucosal inflammation was assessed. Thirty patients were s tudied after restorative pro tocolec tomy for ulcerative colitis. A tripli- cated (S) reservoir was used in 10 patients and a quad-

P32 MEETING

ruplicated (W) reservoir in 20. Fresh fecal samples were collected and processed promptly. Efficiency of evacuation was determined by the use of radiolabeled synthetic stool. Mucosal changes in reservoir biopsies were scored by one pathologist. The effluent from S reservoirs had significantly greater numbers of bacteroides [12 x 107 cfu/ml (0.083250-18.7) vs . 0.0125 x 10 cfu/ml (0.0011- 1.75)] (P < 0.05) and concentrations of acetic [231.7 #mol /g (119.3-368.4) vs . 94.93 #mol /g (33.4-211.9)] and propionic acids [60.1 / ,mol/g (23.75-91.2) vs . 16.7 #mol /g (10.2-46.2)] (P < 0.05) than effluent from W reservoirs. Efficiency of evacuation was reduced in patients with S reservoirs [59.5 percent (38-68.5) vs . 97.4 percent (91.8-98)] ( P < 0.05). There were no significant differences between the two groups in ratio of anaerobes to aerobes, percentage of water content of the stool, or mucosal changes. In conclusion the ileal ecology of S and W reservoirs is different, and this may be related to stasis.

*Median (interquartile range).

ABSTRACTS Dis Colon Rectum, April 1991

Increased Bowel Permeability After Ileal Pouch-Anal Anastomosis

Booth P22

W. A. Koltun, R. J. Smith, D. Loehner, P. Durdey, J. A. Coller, J. Murray, P. Roberts, M. Veidenheimer, D. Schoetz . . . . . . . . . . . . . . . . . . . . . . . . Burlington, MA

Poorly understood are the physiologic changes that occur when small bowel is used as a reservoir, as in the ileal pouch-anal anastomosis (IPAA). The present study examined whole bowel permeability (WBP) in patients undergoing IPAA. WBP was assessed by measuring the urinary lactulose to mannitol excretion ratio (L/M) in a 5-hour urine collection after an oral dose of the test sugars. Five patient groups were studied: 1) normal healthy volunteers (nls), 2) unoperated patients with ulcerative colitis (uCUC), 3) colectomized patients with CUC and ileal stomas (sCUC), and patients with functioning IPAA done for 4) CUC, or 5) familial polyposis (FP)

Reduction of Resting Anal Pressure in Neurogenic Fecal Incontinence is due to Denervation of the Internal Sphincter

Booth P21

P. Durdey, J. A. Coller, R. C. Barrett, J. J. Murray, P. L. Roberts, D.J. Schoetz Jr . . . . . . . . . . Burlington, MA

Pudendal nerve damage in patients with neurogenic fecal incontinence cannot explain internal sphincter (IAS) dysfunction, reflected by low resting pressure (RP). Similar reduction in RP is present after ileal pouch- anal anastomosis (IPAA), possibly due to denervation of the IAS on rectal transection. We have, therefore, compared manometric data from 45 patients after IPAA with 52 incontinent patients and 21 constipated patients with normal anal sphincters. Median RP (mm Hg) was similar in incontinent patients and after IPAA (34.3 vs . 44.1, P = NS*), both lower than the constipated group (median RP 87.3, P < 0.001"). Squeeze pressures were lower in incontinent patients compared with both IPAA and constipated groups (52.5 vs . 125.0 and 126.3, respectively, P < 0.001"). Thirty-two (71 percent) of 45 after IPAA demonstrated large amplitude (16.5 mm Hg, 6-44 t ) low frequency (7c/minute, 5-9) waves. Similar waves (amplitude 12, 4-25, frequency 6.5, 4 - 9 t were present in 38 of 52 (71 percent) incontinent patients. These "intermediate waves" were not present in constipated patients (P < 0.001+). The data suggest a similar etiology of damage to the IAS in incontinent patients and after IPAA. "Intermediate waves" may represent intrinsic activity of the 1AS independent of autonomic regulation, and im- plies that low resting pressure is due to denervation of the IAS. (*Mann-Whitney, fmedian and range, +chi- squared).

his. uCUC sCUC IPAA-CUC IPAA-FP

L/M ratio 10 5 6 17 7 ( m e a n + 1.7 --- 4 1.8 + 5 1.5 -4- 2 3.6 --+- 5* 5.1 + 7* SE)

* P< 0.5 compared with nls and sCUC and uCUC by ANOVA.

There was no difference in WBP between normals and patients with CUC even after colectomy and ileostomy. The formation of an ileal reservoir, however, significantly increased WBP in both CUC and FP patients. We conclude: 1) patients with IPAA have significant alterations in bowel permeability and 2) this alteration is not due to the underlying pathologic diagnosis. The exact site, cause, and consequence of this abnormality is unclear but may represent compromised gut mucosal barrier function and may relate to local and systemic complications of the IPAA.

Do anal Sphincter Pressures Improve with Time Following Total Proctocolectomy and Ileal Pouch-anal Anastomosis?

Booth P23

W. B. Tuckson, V. W. Fazio, I. C. Lavery, J. R. Oakley, J. M. Church, J. W. Milsom . . . . . . . . . . . Cleveland, OH

Following total proctocolectomy (TPC) and ileal pouch-anal anastomosis (IPAA) incontinent patients have been found to have lower maximum anal resting pressures (MRP) than continent patients. There have been reports of a return to preoperative values in the postoperative period, but this has not been universally noted. Anal sphincter pressures from 26 patients, evaluated before and after TPC, IPAA, and ileostomy closure were compared for changes in MRP. The results are listed.

Vot. 34, No. 4 MEETING ABSTRACTS P33

Table 1. Pressure Changes with Time

Preop Initial Follow-Up Exam Exam Exam

MRP (inm Hg) 83 + 10" 55 ----- 8 53 --+ 7 MSP (mm Hg) 193 -4- 30 175 + 30 186 + 25 Pouch to Manome- 6 ----- .5 18 + 2

try (months)

All resuhs mean + 95% confidence interval; * ( P < 0.01).

After 1 year there was no significant change in either the MRP or MSP. Anal sphincter injury, when it occurs, appears to be permanent. Efforts should be made at the time of surgery to minimize anal sphincter injury.

The Ileal Pouch pH: A Regulatory Mechanism for Evacuation

Booth P24

M. R. B. Keighley, G. Chattopadhyay, D. Kumar, M. Oya . . . . . . . . . . . . . . . . . . . . . . . . . . Birmingham, UK

The role of pouch pH in the regulation of pouch evacuation following a restorative proctocolectomy is not known. To investigate the mechanism of ileal pouch evacuation, we have studied pouch pH for 240 hours (24 hours in each subject) in 10 patients who have had restorative proctocolectomy for chronic ulcerative colitis. pH was measured using a radiotelemetry capsule (Oxford Medical System 1000) tied to the end of a tether and positioned in the pouch. The tether was taped to the buttock. The signal was recorded continuously for 24 hours in a portable solid stage pH data logger. The mean pouch pH was 6.08 --- 0.64 (mean ___ SEM). There was no difference between the daytime pH (6.11 + 0.64) and that during sleep (6.13 --- 0.98). We recorded 53 episodes of pouch evacuation (mean of 5.3 per subject). The pouch pH exhibited a significant fall (P < 0.05) in the 30 minutes prior to evacuation (5.71 +_ 0.68) when compared with the 30 minutes immediately postevacua- tion (6.57 --- 0.71). Meals on the other hand had the opposite effect on pouch pH. There was a significant rise (P < 0.05) in pouch pH approximately 2 hours after a meal (5.99 + 0.66 vs , 7.08 -+- 0.74). These data suggest that pouch pH may be important in the regulation of pouch evacuation and may have significant implications on pouch function following restorative proctocolectomy. The exact role of pH in the regulation of pouch emptying needs further evaluation.

sessed the effect of pouch formation on gastric emptying and its relationship with functional result at a mean of 8 months (range 6-24) after surgery. Following an over- night fast, 15 pouch patients and 6 ileostomy controls ate a standard test meal labeled with 99mTc DTPA. Anterior scintigraphic imaging of the abdomen began immediately, and following complete ingestion alternate 2-minute anterior and posterior images were obtained at 15-minute intervals for a minimum of 6 hours. Images were corrected for movement scatter and decay. The geometric mean of the anterior and posterior images were calculated and stomach emptying (T1/2) was defined. The frequency of defecation was recorded for a total of 24 hours from ingestion of the meal during which time the subjects ate a standardized diet There was no significant difference between T1/2 in historical normal controls 40 minutes (range 28-80), ileostomy 57 minutes (range 25-144), and pouch patients 52 minutes (range 29-100), P > 0.05 (Mann-Whitney). There was no correlation between gastric emptying and frequency (P > 0.05) (Spearman rank). Gastric emptying is not affected by restorative proctocolectomy and is not related to frequency of defecation.

Colorectal Trauma: Primary Repair with Intracolonic Bipass v s . Ostomy, A Preliminary Report

Booth P26

R. E. Falcone, S. Wanamaker, S. A. Santanello, L. C. Carey . . . . . . . . . . . . . . . . . . . . . . . . Colurnbus, OH

Introduction: This is a preliminary report of an ongoing prospective randomized controlled study of primary repair using intracolonic bypass vs . ostomy for severe colorectal injury. Methods: After confirmation of severe colorectal injury at celiotomy, 16 patients were randomized to primary repair with intracolonic bypass (Group i) vs . ostomy (Group 2). Data gathered included: demographics, Trauma Score (TS), Injury Severity Score (ISS), Penetrating Abdominal Trauma Index (PATI), day bowel function returned (BM), hospital stay in days (LOS), hospital charges, and outcome. Statistical analysis was with a variety o f tools, significance established at P < 0.05.

Results:

N Age TS ISS PATI BM LOS Charge

Group 1 9 24 14 31 39 6 13 $29,663 Group 2 7 32 14 22 37 6 17 $28,715

Gastric Emptying of a Solid Meal Following Restorative Proctocolectomy

Booth P25

M. R. B. Keighley, K. Hosie, W. Kmiot, A. Mostaf, N. Tultey, I. Harding . . . . . . . . . . . . . . Birmingham, UK

The functional results following restoration proctocolectomy are variable. The frequency of defecation is likely to be related to the speed which food residue passes through the gastrointestinal tract. We have as-

Only age was statistically significantly different (P = 0.047). Additionally, Group 2 charges did not include the cost of subsequent readmission for colostomy closure.

Complications were also similar:

Wound Abscess Pneumonia Sepsis

Group 1 2/9 0/9 1/9 0/9 Group 2 3/7 1/7 3/7 1/7


There were no intra-abdominal complications as a result of primary repair. One patient died (Group 1) from associated injuries.

Conclusions: Preliminary study suggests primary anastomosis with intracolonic bypass may be a safe and cost- effective alternative to ostomy; ongoing study is war- ranted.

Anal Sphincteroplasty (AS): A Comparison of Functional (F) and Manometric Results

Booth P27

sis was obstetric or surgical trauma in 13 and neurogenic in 8. Sixteen patients had a direct sphincter repair, and 5 postanal repair. Thirteen of 21 patients (62 percent) improved symptomatically (Group A). In 11/13 (84 percent) the diagnosis was trauma. In 8/21 (38 percent) not improved (Group B); 6 (74 percent) had neurogenic incontinence (P = 0.003*). Group A was significantly younger ( P < 0.01+). Preoperative resting pressures (RP) (mm Hg, median) were similar (A: 32.5, B:32.1). Squeeze pressure and resting and squeeze pressure volume (PV, mm Hg3,) were higher (P = 0.001 +) preoperatively in those improved:

D. E. Rivera, J. w. Milsom, V. W. Fazio, I. C. Lavery, J. M. Church, J. R. Oakley . . . . . . . . . . . . Cleveland, OH

The purpose of this study is to determine if (F) results correlate with anorectal manometric (ARM) testing before and after AS for traumatic sphincter injuries. Twenty- eight patients (27 F:I M), mean age of 37, were catego- rized as to: 1) Grade (G) of incontinence (GO: none- G3: > 1 episode/week); 2) an (F) score determined by impairment of life-style (FO: none-F5: Homebound); 3) ARM to determine maximum resting pressure (MRP), maximum squeeze pressure (MSP), and anal canal length (ACL). As was done in all cases with median follow-up of 12.5 months. G, F score and ARM were reassessed postop:

Squeeze Pressure Resting PV Squeeze PV

A 56.2 47,259 124,127 B 43.6 39,915 94,224

Preoperative asymmetry, a measure of segmental sphincter loss was higher in Group A (P < 0.05+). RP, squeeze pressure, and PV increased in 11/13 (85 percent) improved after repair. All eight not improved had significant reduction (P = 0.002*) in these parameters indicating further damage to the sphincter. Thus, older patients with neurogenic damage and global sphincter loss are unlikely to benefit from surgical repair. (+Mann- Whitney U test) (* Fisher's exact test).

Preop (-SE) Postop (--+SE) P

G 2 . 7 8 + 0 . 1 1 1 . 2 2 + 0 . 2 8 <0.01 F 3.04 + 0.22 1.08 + 0.29 <0.01 ACL** 1.8i + 0.26 1.86 + 0.24 ns MRP* 30.21 -- 2.60 33.24 + 2.86 ns MSP* 60.69 _+ 5.12 64.58 + 5.87 ns

Note: R-squared = 0.133: pos top-preop MRP v s . F; * m m Hg; ** cm.

Postop, 13 had no incontinence, 13 had minor incontinence (flatus and leakage), and 2 had major incontinence. Although AS remains an extremely satisfactory method of improving continence in traumatic sphincter injuries, there was no correlation between functional and manometric results. ARM results did not improve postop compared to preop, although function (G and F) did. The value of ARM in managing traumatic sphincter injuries must be questioned.

Can Manometry Predict the Outcome of Patients Undergoing Surgery for Fecal Incontinence

Booth P28

P. Durdey, J. A. Coller, J. J. Murray, P. L. Roberts, D. J. Schoetz Jr . . . . . . . . . . . . . . . . . . . . . Burlington, MA

Results of surgery for fecal incontinence are unpre- dictable. We have performed comprehensive anal manometry in 21 patients before and after repair, to determine if manometry can predict outcome. Initial diagno-

Are the Poor Results of Surgery in Neurogenic Fecal Incontinence due to the Pathology or Operation?

Booth P29

P. Durdley, P. T. Gross, M. Oster, J. A. Coller, J.J. Murray, P. L. Roberts, D. J. Schoetz Jr.

Burlington, MA

Neurogenic fecal incontinence is associated with denervation and re-innervation of the external anal sphincter (EAS). It is unclear whether poor results after surgical repair are due to the procedure or progressive damage to the EAS. We have measured neuromuscular jitter, an indicator of progressive nerve damage, in the EAS of 29 patients presenting with incontinence (13 traumatic, 16 neurogenic etiology) and a matched group of 14 con- trois. Mean jitter (microseconds) was calculated by measurement of 100 discharges from a minimum of 10 fiber pairs. Mean fiber density (MFD) was determined con- currently. Mean jitter (+SD) was similar in controls [24.2 (4.9)] and patients with traumatic incontinence [27.8 (9.1)] (P = NS*). No control patient had a jitter of >35 microseconds. Jitter was significantly increased in neurogenic incontinence [39.9 (10.7)] ( p < 0.01"). Mean jitter in 10/16 (62 percent) with neurogenic etiology was >35 microseconds indicating active re-innervation. Jitter correlated with MFD (P = 0.01), but not with perineal descent. These data suggest that denervation is progressive in some patients with neurogenic incontinence, and this may explain a poor operative result. Measurement


of jitter may be valuable in select ing patients for surgery, to greatly facilitate the evaluation and differentiation of (* Student 's t-test for unpaired data), inflammatory large bowel diseases.

Sphincter Repair Without Overlapping for Fecal Incontinence

Booth P30

J. C. Sarles, A. Arnaud, I. Sielezneff, P. Orsoni, A. Joly Marseille, France

Forty patients who had sphincter repair by one surgeon over the last 15 years were reviewed. The e t io logy of sphincter trauma was previous surgery (22), chi ldbir th (14), and accidental trauma (4). Eleven patients had undergone at least one previous attempt at repair. Prior to operat ion 12 patients were incont inent of l iquid stool and 28 of formed stool. A technique of sphincter repair without overlapping was used. An associated diverting colostomy was made in seven patients who all had a previous failed repair. Follow-up was an average of 17 months after operat ion (range 2-96 months) . After operation, 25 patients were comple te ly continent, 6 had occasional leakage for l iquid stool, 4 were only cont inent for solid stool, and 5 did not show any improvement . Neither diverting colostomy nor overlapping sutures appear to be mandatory for successful repair of anal sphincter after trauma.

Diagnosis of Inflammatory Large Bowel Diseases by Transabdominal Hydrocolonic-Sonography

Booth P31

B. Limberg . . . . . . . . . . . . . . . . . . . . . . . Darmstadt, FRG

In diseases of the large intestine, the diagnostic value of conventional abdominal sonography is l imited. We have therefore s tudied if the instillation of fluid into the colon would improve the diagnostic value of transabdominal sonography in evaluating inflammatory diseases of the colon. In 96 percent of patients the entire length of the colon starting at the recto-sigmoid junction and ending at the cecum could be visualized with rectal instillation of water. The sonographic views obta ined using this technique show the echo-free intestinal lumen and the five individual layers of the colon wall. In acute colonic Crohn's disease the normal stratified appearance of the colonic wall is no longer in evidence and the wall appears visibly thickened. In contrast, patients with active ulcerative colitis will maintain the normal sonographic stratified appearance of the colonic wall. In our prospective study in 300 patients severe active colonic Crohn's disease and ulcerative colitis could be de tec ted by colonic sonography with a sensitivity of 91 and 89 percent, respectively. Pathological changes were subsequently confirmed by colonoscopy. In addition, the colonic resections of four patients with acute Crohn's disease were examined in vitro. The sonographic findings demonstra ted in vitro agreed within the scope of colonic sonography with those demonst ra ted in vivo. Colonic sonography is a new diagnostic procedure that promises

Endoluminal Ultrasound Defines Anatomy of the Anal Canal and Pelvic Floor

Booth P32

J. Tjandra, V. M. Stolfi, J. W. Milson, I. Lavery, J. Oakley, J. Church, V. Fazio . . . . . . . . . Cleveland, OH

Accurate del ineat ion of wall layers by endoluminal ul trasound (ELUS) in staging rectal cancers has led to interest in whether it can visualize structures of the anal canal and pelvic floor. The purpose of this study is to define the sonographic appearance of these structures and their anatomic relationships.

Methods: Bruel and Kjaer ul trasound equipment with a 7.0 mHz transducer was used to obtain images of the anal canal and pelvic floor of three human cadavers in the transverse plane. Anatomical layers of one half of anal canal and pelvic floor were sequent ia l ly removed and images were obtained and correlated with the opposite side.

Results: Coincident ul trasound images and anatomical photographs demonstra te (to be displayed) anal sphincters, puborectalis , and surrounding structures (anococ- cygeal l igament, per ineal body, levators, vagina, urethral sphincter) . The focal length (2-5 cm) of 7.0 mHz ELUS does not al low accurate visualization of the internal sphincter.

Conclusions: 1) ELUS can visualize anatomical structures in the pelvis and may have potential to define pathological processes in relat ion to them. 2) Higher frequency ELUS probes (shorter focal length) may be necessary to visualize the internal anal sphincter. 3) Further effort is needed to define the role of ELUS in pelvic floor diseases.

Sigmoid Volvulus in the High Altitude of the Andes: A Review of 230 Cases

Booth P33

H. J. Asbun, H. Castellanos . . . . . . . . . . . La Paz, Bolivia J. Asbun . . . . . . . . . . . . . . . . . . . . . . . . . . . Bakersfield, CA

Sigmoid volvulus (SV) is a rare cause of intestinal obstruction in the United States. The et iology is unclear. Little has been publ i shed in the English literature about the high incidence of SV among rural areas of the Boliv- ian and Peruvian Andes at 13,000 feet above sea level. A review of 230 cases of SV in a Bolivian hospital is presented. SV accounted for 79 percent of all intestinal obstructions. In all patients, nonoperat ive reduction was initially at tempted, except for those with peritonitis. Nonoperative reduct ion alone was per formed in 31 percent of the patients and 69 percent underwent surgical intervention, 66 percent as an emergency and 3 percent electively. Surgical t reatment consisted of s igmoidectomy and primary anastomosis (50 percent) , Hartmann's procedure (12 percent) , and reduction with s igmoid


plication (38 percent) . Overall mortali ty was 13 percent . Fifty seven (36 percent) of the surgically treated patients deve loped significant complications. High alti tude, along with other et iologic factors, may play an important role in SV. Intraluminal gas volume relates inversely with atmospheric pressure which at 13,000 feet is decreased by 483 mm Hg, thus contributing to a chronic distention of the redundant sigmoid. To our knowledge, these series represent the highest incidence of SV in bowel obstruction.

Combined Penetrating Rectal and Genitourinary I n j u r i e s : A C h a l l e n g e i n M a n a g e m e n t

Booth P34

E. R. Franko, R, R. Ivatury, D. Schwalb

New York, NY

Combined rectal and genitourinary (GU) injuries are exceedingly uncommon, which may be the reason that this has not been previously studied. Seventeen patients were treated for this at a major trauma center. All rectal exams revealed frank b lood and 70 percent had positive proctologic exams. Gross hematuria was observed in 82 percent of patients. Only 64 percent of urologic contrast studies were accurate. Operative findings included injuries to the extraperi toneal (15) and intraperi toneal (2) rectum, b ladder (13), urethra (3), and distal ureter (1). Treatment consisted of end or loop colostomy (17); presacral drainage, PSD (14); distal rectal washout, DRWO (13); rectal wound repair (5) debr idement and / or suprapubic drainage for b ladder and urethral injuries (16); and distal ureter reimplantat ion (1). One mortali ty occurred secondary to associated injuries. Patients not receiving PSD or DRWO had septic complicat ions (25 percent) . GU complicat ions included two rectovesical fistulas, two rectourethral fistulas, three chronic UTIs (two with b ladder stones), and two urethral stenoses. All fistulas occurred in patients without rectal wound repair. The complicat ion rate was greater for combined injuries than for rectal injuries alone. It was found that PSD, DRWO, rectal wound repair, and perhaps omental inter- posi t ion were essential in reducing the morbidi ty of combined rectal and GU injuries.

Adenocarcinoma of the Anal Glands

Booth P35

M. E. Abel, Y. S. Y. Chiu, T. R. Russell, P. A. Volpe . . . . . . . . . . . . . . . . . . . . . . San Francisco, CA

Anal gland adenocarcinoma is rare, and information about this lesion is communica ted mostly as case reports. A survey of ASCRS membersh ip revealed that most colorectal surgeons have not treated this malignancy. In 52 cases, sufficient data are available for analysis.

The following are important in evaluation and treatment of this tumor:

- - 54 percent will present with a fistula; - - the incidence of fistula is significantly higher in

males;


- - metastases are present at diagnosis in 13.5 percent; - - metastases may be inquinal, pelvic, or hepatic; - - 7 7 percent are eventually treated by abdomino-

per ineal resection; - - adjuvant therapy was used in 54 percent; - - survival without evidence of disease after 3 years

usually signals cure.

Adenocarcinoma of the Anal Glands

Symptoms % Location %

Anal pain 58 Posterior 37 Bleeding 40 Lateral 29 Perianal mass 37 Anterior 15

Associated Fistula

Total (%) Male (%) Female (%)

Present 28 (54) 20 (67) 8 (36) Absent 24 (46) 10 (33) 14 (64)

Surgical Treatment

Abdominoperineal 34 Local excision 9 Local excision and APR 6 No resection 3

Total 52

The Effect of Proctectomy with Colo-Ana Anastomosis on Anal Sphincter Function: A Manometric Study

Booth P36

R. Saad, J. M. Church, V. W. Fazio, I. C. Lavery, J. R. Oakley, J. W. Milsom, T. Schroeder

Cleveland, OH

Proctectomy with coloanal anastomosis (CAA) is an attractive alternative to colostomy in se lec ted patients with low rectal cancer. Its functional results are some- t imes unsatisfactory. The aim of this study was to examine the effect of CAA on objective indices of anal sphincter function. Methods: Anal canal length (ACL), maximum anal resting (MRP), and squeeze (MSP) pressures were measured before CAA and after subsequent ileostomy closure in 14 patients opera ted on for rectal cancer (median interval 10.5 months) . Results: There were 8 males and 6 females, median age 52 years (range 30- 69). Postoperatively, 10 patients were continent of sol id and l iquid stool while five patients had some leakage of l iquid stool (three at night).

All Pts

Technique Incontinence to Liquid

Hand Sewn Stapled None Stool Only

Change - 2 6 - 3 0 -22 - 2 2 - 3 3 MRP - -45 to- -7 --54 to --4 - 6 4 t o + 2 1 - - 5 1 t o + 7 - 6 5 t o - 1

Change -11 - 1 0 - 1 3 - 8 - 1 8 MSP - - 2 3 t o + 7 - - 2 3 t o + 4 - - 4 2 t o + 1 5 - - 2 1 t o + 6 - - 5 1 t o + 1 5


(Data = mm Hg, mean and 95 percent confidence limits). There was a highly significant relationship between preoperative MRP and the change in MRP with CAA ( r = 0.87). A low preoperative MRP is, therefore, not necessarily a contraindication to CAA. Conclusions: Proctectomy and CAA leads to a significant fall in MRP that is associated with nocturnal incontinence. MSP is not affected.

1 POD 4 POD

HS CEEA ACB HS CEEA ACB

AI 0.59 0.63 -- 0.65 0.73 -- _+0.06 _+0.06 _+0.03 _+0.04

BP mm Hg 148 + 9 110 • 63 218 -+ 13" 280 - 30 131 • 19" 41 + 25* CCg% 18-+3 21-+2 28 -+ 5 t 20_+4 2 0 + 2 24-+6

7 POD 28 POD

HS CEEA ACB HS CEEA ACB

AI 0.60 0.68 0.76 0.85 0.56 0.83 �9 +0.05 +0.05 +0.4 t "+0.04 -+0.04* -+0.08

B P m m H g 2 0 8 - + 3 4 198_+2 1 6 5 + 2 9 3 0 3 • 16 t 288-+40 CCg% 21-+ 1 2 8 • 2 4 • 2 5 • 1 2 5 + 2 2 7 • 1

Mean + SD; * P < 0.01; ~ P < 0.05 v s . HS.

Mid-Rectal Cancer: Pull-Through or Staples? A Prospective Random Trial

Booth P37

J. A. Reis Neto, F. A. Quilici, F. Cordeiro, J. A. Reis Jr. Campinas, Brazil

The choice of a surgical technique in low rectum anastomosis has been a controversial subject. A 5-year prospective randomized trial was undertaken to determine tumor recurrence, per and postoperative complications, and long-term survival rates in patients undergoing surgery for mid-rectum cancer, comparing stapled anastomosis with pull-through procedure. Only patients with adenocarcinoma situated between 6 and 12 cm from the pectinate line were admitted to this study; 39 patients underwent a pull-through technique (Group A) and 43 a mechanical anastomosis (Group B). The groups were similar as to age and sex. Level of the tumor, distal margin of resection, and Dukes' anatomopathological classification were noted in all the patients. A total of 61.5 percent of patients of Group A and 69.7 percent of Group B were submitted to preoperative radiotherapy. As to intra-operative complications, there was no significant difference between both groups. However, intraoperative colostomy was performed in 11.7 percent of patients of Group B against none in group A. Postopera- tive dehiscence was observed in 4.65 percent of patients of Group B and in none of group A. Anastomotic recurrence occurred in 4.65 percent patients of Group B. Long-term survival rates were similar in both groups: 61.5 percent in Group A and 60.5 percent in Group B.

Comparison of Three Techniques in Bowel Anastomoses Booth P38

A. J. Dziki, M. D. Duncan, J. W. Harmon, N. Saini, R. A. Malthaner, M. T. Fernicola, F. Z. Hakki, K. S. Trad, R. M. Ugarte . . . . . . . . . . . . . Washington, DC

The ideal bowel anastomosis would be safely and easily performed and would produce a secure, well- healed closure without stenosis. To this end, the anastomotic compression button (ACB) has been reintro- duced. We compared indices of healing and tissue cohe- sion in 12 dogs undergoing ACB anastomoses to our previous series of standard two-layer handsewn anastomoses (HS) and stapled anastomoses with premium CEEA. The largest ACB or CEEA that the bowel could accommodate was utilized. Burst pressure (BP), anastomotic index, the ratio of the diameter of the anastomosis to adjacent normal bowel (AI), and collagen content (CC) were measured and histologic sections evaluated.

All handsewn and ACB anastomoses by POD 28 had larger diameters than the widest CEEA anastomosis. HS and ACB showed more complete epithelialization and less inflammation on POD 28. Burst pressure was highest at all intervals in HS anastomoses except POD 1, while the ACB group had a markedly low BP on POD 4. One ACB animal not included above died POD 4 from an anastomotic disruption. Collagen content tended to be high in CEEA on POD 7, perhaps related to the increased incidence of strictures (lower AI). The handsewn technique remains superior to current ACB and CEEA methods.

Laser Closure of Experimental Colotomies

Booth P39

P. Ryan, S. Kuramoto . . . . . . . . . . . Melbourne, Australia

Low level laser energy has been used to anastomose various tubes (Fallopian tube, artery, vas deferens, ureter, urethra, and small bowel). Tissue welding occurs at lower energy levels than required to cut or vaporize, but the mechanism of bonding is unknown. Advantages of laser anastomosis include avoidance of foreign material and needle trauma, with minimal inflammatory and im- mune response.

Guy sutures were used to appose the edges of transverse colotomy wounds in rabbits. The anastomotic seam was lased using a neodymium-YAG laser, supplied through a hand-held 600-f,m gas-cooled noncontact optical fiber. An 0.5-watt wave of power was applied to the Indian-ink marked bowel edges, moving the laser light up and down the seam several times until tissue blanch- ing indicated a satisfactory weld. A control one-layer anastomosis was performed in the same animal with 5/0 maxon sutures.

Lased colotomy wounds up to two-thirds of the bowel circumference were successfully welded in 12 rabbits, with long-term survival. In 14 short-term experiments, there were three leaks (none of the controls). Eleven explored at 1 week showed an almost invisible seam without adhesions and, at 7 days, normal bursting pressure.


Carcinoma Specific Human Monoclonal Antibody Mediated Target Cell-Cytotoxicity

Booth P40

H. R, Chang, B. Chavoshan . . . . . . . . . . . San Diego, CA

SK1 has been shown to be a carcinoma specific human IgM monoclonal antibody (HuMAb). In this study, the complement dependent cytotoxicity (CDC) mediated by HuMAb SK1 was examined.

Chromium-51 (51Cr) release assay was used to measure the specific lysis of target cells in CDC assay. In that, 100#l of supernatent containing SK1 and 25#l of human serum containing complement were added to 20,000 ~Cr labeled target cells. The maximal release (MR) of radioactivity from lysed cells was obtained from NP40 treated cells. The spontaneous release (SR) of radioactivity was measured from cells growing in the medium. The specific cytotoxicity (SC) mediated by antibody is shown by: SC% = 100 x (CDC~xp~ -SR)/ (MR - SR). The target cells examined were two cells lines: HT-29, a colon cancer cell line; PANC-1, a pancreatic cancer cell line and also fresh tumor cells derived from a surgically removed colon cancer specimen. Our study showed that carcinoma specific HuMAb SK1 kills gastrointestinal (GI) cancer cells including both cell lines and fresh cancer cells.

Target Cells CDC%

HT-29 103 PANC 1 83 Fresh tumor cells 81

In the serial dilution study SK1 retains significant cytotoxicity at a dilution of 1:16. Fifty percent of fresh tumor cells were killed and diluted SK1. Specific target cell-lysis mediated by SK1 shows promise as a clinical application.


not cumulative. Calcium reduced the ileal (P < 0.02), cecal (P < 0.01), and colonic (P < 0.01), CCPR of the SBR, DMH and SBR + DMH group but not controls. It also reduced tumor yield in the DMH group (13 vs. 5, P

< 0.05) but not the SBR + DMH group (9 vs. 14). The inability of SBR to compound the effect of DMH and ability of calcium to reduce CCPR without affecting tumor yield confirms that hyperplasia alone does not increase susceptibility to malignancy. The influence of calcium in the DMH model is likely to be a direct action on mucosal cell membrane.

Effect of Glutamine Supplementation on Anastomotic Bursting Strength in Rats

Booth P42

D. M. Jacobs, C. A. Bundy, M. P. Bubrick Minneapolis, MN

Glutamine is essential for the maintenance of small intestine mucosal structure and function. Enteral glutamine supplementat ion has been shown to preserve mucosal integrity and function in stress models. Standard enteral and parenteral feeding formulae provide little or no glutamine, and this may contribute to anastomotic dehiscence in critically ill patients. We postulate that glutamine supplementat ion may improve small bowel anastomotic healing as determined by bursting strength measurement. Model: Using Sprague-Dawley rats (400- 600 g) we placed a feeding gastrostomy and divided the i leum 3 cm proximal to the cecum. The small bowel was reanastomosed with 6-0 chromic suture. Animals were kept NPO for 24 hours, given water a d l ib and randomized into four groups: U = unfed, RC = rat chow, E-GIy = enteral formula (EN) + 2% glycine, E-Glu = EN + 2% glutamine. Enterally fed animals were given 230 Kcal/ kg/day and 1.2 g nitrogen/kg/day. All animals were sacrificed at 6 days and bursting strength (mmHg) determined. Villous height was assessed histologically.

The Influence of Calcium Supplementation and Small Bowel Resection on Ileo-Colonic Cellular Proliferation and Hydrazine Induced Neoplasia in the Rat

Booth P41

M. R. B. Keighley, G. Barsoum . . . . . . Birmingham, UK

This study assessed the effect of 75 percent SBR resection and calcium supplementat ion (25 Ca lactate/ i /24 hours) on ileal (I), cecal (Ca), and colonic (Co) cellular proliferation (CCPR) and tumor formation in Wistar rats after 30 weeks DMH administration (40 mg/kg body wt/ wk for 5 weeks. CCPR was assessed by an i n v i v o stath- mokinetic method. CCPR was different at all 3 sites (I = 9.1 - 0.6, Ca = 4.7 _ 0.5, Co = 3.9 -+ 0.6, P < 0.01 ANOVA). SBR (I = 16.3 + 13, Ca = 6.6 - 1.1, Co = 11.2 4- 1.9, p < 0.01), DMH (I = 16.6 + 1.8, Ca = 9.6 + 1.6, Co = 9.3 -- 1.1, P < 0.01) and SBR + DMH (I = 21.1 -- 1.3, Ca = 12.0 --+ 1.0 Co = 9.4 --- 1.0, P < 0.01) increased CCPR at all three sites. The effect of SBR + DMH was

Burst Strength Villous Ht

U 168 4- 78 0.62 4- 0.07 RC 228 4- 46* 0.62 4- 0.07 E-GIy 218 4- 57 0.60 + 0.12 E-GIu 248 4- 59* 0.59 4- 0.06

* P< 0.05 vs. unfed.

Conclusion: Supplementation of a standard enteral feeding formula with glutamine improves anastomotic bursting strength at 6 days.

Evaluation of Colonic Microcirculation Pattern Booth P43

R. Bonardi, A. Scaramelo, A. Possebon, C. Peres, C. R6hrig . . . . . . . . . . . . . . . . . . . . . . . . . . Curitiba, Brazil

Etiology of microcirculation abnormalities in the colon are still unknown. The present study establishes a numerical pattern related to age, of mucosal and sub-


mucosal vessels, and tries to explain the behavior of the b leeding vessels. Thirty colons ei ther from autopsies or surgical specimens were studied. The age range varying from 0 to 96 years (medium 57.7 years). In four cases the colon was resected from male patients with history of lower G.I. b leeding. Segments of the mesenter ic border were cut 5 cm apart from the cecum to the distal s igmoid colon, stained with H.E., and s tudied under optical microscopy. The internal and external d iameter of the vessels of the mucosa and submucosa were measured on each specimen. The results in Table 1 are the average measurements on the different age groups (mi- cron).

Age Group Mucosa Submucosa

Int. Ext. Int. Ext.

0 40 14.5 17.4 15.9 19.9 41-60 16.8 20.7 18.7 23,4

>61 21.9 28.0 22.3 28.8

There was a progressive increase in the vessels ' diameter with aging, but no significant difference in the diameter of these vessels on the several colonic segments, showing that the dilatation occurs in an equal manner throughout the colon. On the other hand the "index of resistance" (R = e/D; e = thickness of the wall; D = external diameter) progressively decreases with aging as shown in Table 2.

Pelvic Peritoneal Reconstruction to Prevent Radiation Enteritis in Rectal Cancer

Booth P45

J. S. Chen, H. A. Fan, J. Y. Wang . . . . . . . Taipei, Taiwan

Some patients with rectal cancer who undergo exen- terative surgery require radiation therapy for recurrent or residual disease as adjuvant treatment. A devastating side effect of this t reatment is radiation-associated small bowel injury. The prevention of radiation enteritis is the common goal of the surgeon and the radiation oncologist .

We used a new technique in 18 patients with rectal cancer. After removal of the rectal lesion (eight APR, nine Hartmann's procedure, one LAR), the pelvic peri- toneum, transversalis abdominis fascia, and posterior rectal sheath were dissected out. Reconstruction of these structures part i t ioned the abdominal cavity at the level of the umbil icus to the sacral promontary. The small bowel was kept out of the pelvic cavity. X-ray films of the small bowel were per formed before radiation therapy and 7 months and 1 year postoperat ion. Most patients showed the small bowel remaining in the abdominal cavity. During the follow-up per iod of 4 months to 2 years (average 14.8 months) , one early complicat ion and three late complicat ions of pelvic per i toneum breakdown were noted. Two of these required laparotomy for intestinal obstruction, and radiation enteritis was noted in both.

The follow-up per iod is still short, but the results encourage us to perform this new technique for advanced rectal cancer.

Age Group Mucosa Submucosa

0-40 2.50 2.14 41-60 2.15 1.98 >61 1.79 1.71

Experimental Prevention of Adhesion Formation Booth P44

M. R. B. Keighley, A. M. Kappas, J. Ortiz, G. Barsoum . . . . . . . . . . . . . . . . . . . . . . Birmingham, UK

Post-ischemic release of oxygen radicals has been implicated in adhesiogenesis . We s tudied three drugs that may interfere with the product ion and release of free oxygen radicals (verapamil, cort icosteroid, and phosphat iodylchol ine) and may modify adhesion formation. An adhesiogenic model ( laparotomy and intra- per i toneal irrigation with saline at 40~ was used to assess these agents. Eighty rats were al located into four groups: irrigation and verapamil (Gv), irrigation and hydrocort isone sodium succinate (Gh), irrigation nad phosphat idylchol ine (Gp), and irrigation alone: controls (Gc). All animals were sacrificed at 2 weeks. Adhesions were found in: 13/19 control animals compared with 7/ 20 of Gv (P = 0.056, Fisher 's exact test), 6/20 of Gh (P = 0.025) and 3/20 of Gp ( P = 0.001). These data suggest that in this model postoperative adhesions can be significantly reduced by phosphat idylchol ine.

A Newly Designed Occluder Pin for Presacral Hemorrhage

Booth P46

V. M. Stolfi, J. Milsom, V. Fazio, I. Lavery, J. Oakley, J. Church . . . . . . . . . . . . . . . . . . . . . . . . . . Cleveland, OH

Inadvertent entry into the presacral fascia during mobil ization of the rectum from its sacral attachments may result in massive b leed ing from the presacral venous plexous and the sacral basivertebral veins. Suture and electrocautery as hemostat ic measures are often unsatisfactory in this instance. We have des igned a new type of t i tanium hemorrhage occluder pin that may be rapidly p laced into the sacrum to control bleeding. The aim of

this study is to measure the forces needed to pull this new occluder pin out of human sacrum compared with conventionally des igned ti tanium thumb tacks. Methods: Four fresh human cadaveric pelvises were isolated and


cut on a sagittal medium plane ancl the thickness of each vertebral body was measured. Titanium pins, both r idged (R) and smooth (S) were used. A 12-ram shaft pin was used for $1, $2, a 7 mm for $3, $4, $5. Pins were inserted in each sacral vertebra and the maximum load necessary to extract pins was measured by computer ized dynamom- etry. Results: Measured sacral widths indicate 7-mm pins can be used in all sacral vertebrae to avoid entry in the sacral canal: "

S1 S2 S3 S4 $5

m m _ + S E 2 7 • 1 8 + 1 12_+ 1 9_+ 1 8 + 1

Significantly more force is required to extract R vs, S

pins, both with 12-'and 7-mm shafts ( P < 0.01).

12 m m 7 m m

R '" S R S

Newtons -+ SE 33 + 4 13 -+ 2 29 -- 4 12 + 2

A newly des igned r idged hemorrhage occluder pin is more secure in sacrum than a smooth pin and may be an improved method of control l ing presacral hemorrhage.

Abdomino-Pelvic Omentopexy (APO)-Preparatory Procedure for Radiotherapy in Rectal Cancer

Booth P47

P. Lechner, K. Arian-Schad, P. Lind, H. Cesnik Graz, Austria

Adjuvant RT in adenocarc inoma of the rectum requires the application of be tween 5,500 and 6,600 cGy. On the other hand, the small bowel does not tolerate doses beyond 4,200 cGy without developing complicat ions like enteritis, perforation, and stenosis. Several attempts to form an artificial diaphragm between the abdominal cavity and the true pelvis were burdened with various sequels. So we deve loped a s imple technique to retain the small bowel outside of the RT target volume: From tile greater omentum we form a bag that houses the intestinal loops. The lower margin of the omentum is attached to the parietal per i toneum of the poster ior abdominal wall beyond the promontor ium. The lateral edges are sutured to the ascending and descending colon. RT starts immedia te ly after laparotomy has healed. With the help of APO we have per formed high dose RT following tumor resection in 43 patients. RT was free of complications, and there is no evidence of local recurrence in all patients after mean 26 months by now.

Triangulating Stapling T e c h n i q u e ~ A n Alternate Approach to, Low Anterior Anastomosis

Booth P48

K. S. Venkatesh, D. M. Larson, D. N. Morrison, P.J. Ramanujam . . . . . . . . . . . . . . . . . . . . . . . . . Mesa, AZ

Over 259 patients underwent triangulating stapling technique for low anterior anastomosis. The results when

Dis Colon Rectum, April 199'1

compared with EEA and hand-sewn anastamosis showed this method equal ly effective and advantageous.

The age of patients range from 33 to 86, the average being 68. The follow-up range from 6 months to 8 years, the average being 48 months.

The average hospital stay was 6 days postoperatively. The average level of anastomosis is approximately 6 to 6.5 cm from the anal verge; 85 percent of the patients represent anastomosis of the non-per i toneal ized upper and mid-rectum; 58 percent of the patients had carcinoma of the distal rectal sigmoid, upper mid-rectum; 38 percent of the patients had diverticular stricture and diverticular abscess.

Complications: Two patients had clinical leak from the anastamosis requiring diversion. One patient had a fecal fistula, which was control led with he!p of a drain, closing spontaneously over a per iod of 8 weeks. Two patients had anastamotic narrowing without any clinical symptoms. Anastamotic recurrence of cancer is the same as with EEA for upper and mid-rectal carcinoma.

From our exper ience this technique is s imple to use and the short and long term results compared very favorably with the EEA stapling technique.

Mechanical v s . Pressure (BAR) Intestinal Anastomoses: A Comparison

Booth P49

M. Rubbini, F. Mascoli, C. Mari, V. Bresadola, I. Donini . . . . . . . . . . . . . . . . . . . . . . . . . . . Ferrara, Italy,

Staplers significantly improved the quality of intestinal anastomoses by reducing complicat ions like dehiscence and hemorrage, and by improving functionality, o n e l imitation of staplers is the possibi l i ty of stenosis due to the foreign body reaction favored by metal clips and by the smaller d iameter of the stenosis with respect to the adjacent intestine, corresponding to the diameter of the inner blade of the stapler. The VALTRAC pressure bio- fragmentable suture system seems to avoid this p roblem performing a sutureless anastomosis with a diameter equal to that of the intestine.

Methods: We considered 40 patients with colorectal cancer divided in two homogeneous series of 20. In the first series we employed ILS, EEA, and CEEA staplers, in the second one, we used the BARs. Endoscopic, radiologic, and clinical exams were per formed 30, 90, and 180 days after surgery to evaluate the diameter, state, and distensibil i ty of the anastomoses.

Results: In the mechanical series there were three stenosis, two substenosis, and one Rx dehiscence. Fur- thermore, a diaphragm reduced the lumen caliber and distensibil i ty in all patients, somet ime to clinical evident level. The BAR series inc luded only one clinical dehiscence whereas the repair process of the anastomosis was slower.

Conclusions: BAR anastomoses are general ly superior in the long run, with fewer complications, virtually free of stenosis and functional limitations. The slower healing conceivably due to the pressure mechanism employed is not a serious drawback and is amply balanced by the more physiologic anastomoses obtained.

90th annual convention poster presentations and abstracts

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