american society of colon and rectal surgeons 95th annual convention podium and poster abstracts...

American Society of Colon and Rectal Surgeons

91st Annual Convention Podium and Poster

Abstracts

June 7-12, 1992 San Francisco, CA

This section is made possible through an educational grant from Marion Merrell Dow, Inc., makers of CITRUCEL | Fiber Therapy.

PODIUM PRESENTATIONS

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

Colonoscopy , Surve i l l ance

Anti-CEA Immunoscintigraphy with a 99mTC-Fab' Frag- ment (Immu-4) in Primary and Recurrent Colorectal Can- cer--A Prospective Study

(1) P. Lechner, P. Lind, G. Binter . . . . . . . . . . Graz, Austria

37 pts. with suspected primary (PCRC) or recurrent (RCRC) colorectal cancer had radioimmunoscintigraphy (RIS) with 1 mg (i.c. 925 m Bq) of Immu-4 (Immu- nomedics, Warren, N.J.). RIS revealed PCRC in 31 and RCRC in 5 pts. The findings were confirmed by means of surgery in 34 pts., in one pt. the result could not be verified, neither by CAT scan nor by surgery, so that it has to be considered false positive. In another pt. endoscopy and laparotomy showed a poorly differentiated cancer in the transverse colon, unidentified by RIS. In the remaining two RIS-negative pts. microscopy of the specimen revealed inflammatory disease of the sigmoid. 34 correct positive, 2 correct negative, one false positive and one false negative result represent a specificity and a sensitivity o f 9 7 p , c. each. Especially in recurrences after abdominoperineal resection RIS is more reliable than CAT or MRI and justifies second-look-surgery also in CAT-negative pts. Metastases to the liver, detected in 5 pts., were all confirmed by biopsy. The accuracy of Immu-4 in liver metastases is due to the fact that the Fab' fragment does not induce HAMA production and accumulation in the liver. Though diagnosis of metastatic lymph nodes requires malignant lesions of more than 1.35 cm in diameter, the positive predictive value in these cases is still more than 75 p.c. in RCRC. In conclusion, Immu-4-RIS is a highly sensitive method in the detection of PCRC and RCRC.

Colonoscopic Bowel Preparations--Which One? A Blinded Prospective, Randomized Trial

(2) R.W. Golub, B.A. Kernel W.E. Wise, Jr., D.M. Meesig, R.F. Hartmann, K.S. Khanduja, J.W. Sayre, P.S. Aguilar

Columbus, OH

Three hundred and twenty-nine patients undergoing elective ambulatory colonoscopy were prospectively randomized to one of three bowel prep regimens. Group 1 received 4 liters of Colyte. Group 2, in addition to Colyte, received oral metoclopramide. Group 3 received Fleets Phospho-soda. All groups were evenly matched according to age and sex. Ninety-one percent of all patients completed the preparation received. Fifty-four percent

of patients suffered significant sleep loss with a bowel preparation.

When comparing the three groups, there is no difference when assessing nausea, vomiting, abdominal cramps, anal irritation or quality of the preparation. Com- pared to the other preparations, the Fleets Phospho-soda was better tolerated. More patients completed the preparation (P < 0.001). Less patients complained of abdominal fullness (P < 0.001). More patients were willing to repeat their preparation (P < 0.02). Also, Fleets Phospho- soda was found to be four times less expensive than . either Colyte prep.

In conclusion, all regimens were found to be equally effective. Abdominal symptoms and bowel preparation were not influenced by the addition of metoclopramide. The Fleets Phospho-soda preparation was less expensive, better tolerated and more likely completed than any other preparation.

Colonoscopic Screening for Neoplasms in Asymptomatic First-Degree Relatives of Colon Cancer Patients: A Con- trolled, Prospective Study

(3) J.G. Guillem, K.A. Forde, M.R. Treat, A.I. Neugut, K.M. O'Toole, B.E. Diamond . . . . . . . . . . . . . . New York, NY

In order to estimate the potential yield of screening colonoscopy in asymptomatic high-risk and average-risk populations, we recruited and prospectively colono- scoped 181 asymptomatic first-degree relatives (FDR) of colorectal cancer (CRC) patients and 83 asymptomatic controls (no family history of CRC). The mean age for the FDR and control groups were 48.2 + 12.5 and 54.8 _+ 11.0, respectively. Adenomatous polyps were detected in 14.4% of FDRs and 8.4% of controls. Although 92% of our FDRs had only one FDR afflicted with CRC, those subjects with two or more afflicted FDRs had an even higher risk of developing colonic adenomas (23.8%) than those with only one afflicted FDR (13.1%). A greater proportion of adenomas was found to be beyond the reach of flexible sigmoidoscopy in the FDR group than in the controls (48% vs. 25%, respectively). Logistic regression analysis revealed that age, male sex and FDR status were independent risk factors for the presence of colonic adenomatous polyps (RR=I.08, 2.86 and 3.49, respectively, p<0.001). Those at greatest risk for harbor- ing an asymptomatic colonic adenoma are male FDRs over the age of 50 (40% vs. 20% for age-matched male controls). Based on probability curves, male FDRs appear to have an increased relative-risk of developing a colonic adenoma beginning at age 40. Our results support the use of baseline colonoscopy as a routine screening tool in FDRs of CRC patients, particularly males over the age of 40.

P2

Vol. 35, No. 5 MEETING ABSTRACTS P3

Fecal Occult Blood Testing for Colorectal Cancer: A Ran- domized Study in 68,366 Subjects.

(4) J. Kewenter, H. Brevinge, E. Haglind

G6teborg, Sweden

Mm: To study the value of fecal occult blood testing for early detection of colorectal neoplasms in a randomized study.

Method: All inhabitants in G6teborg, 68,366 persons (between 60 and 64 years of age at the time of the start of the study) were randomly divided into a test and a control group, The 34,175 subjects in the test group were invited to perform fecal occult blood testing with Hem- occult II | and retesting 1�89 years later. Two tests were taken from three consecutive stools and the test rehy- drated before development. Two letters of reminder were sent to those who did not answer.

Results: 21,341 completed the test. 943 of these had a positive test and 812 came for a full work-up including rectosigmoidoscopy and double barium enema. 75 subjects with carcinoma and a positive test have so far been diagnosed and 368 subjects with an adenoma (207 subjects _> 1.0 centimeter). The distribution according to Dukes' was significantly better in the test group than in the control group (p<_0.05) and there was significantly more Dukes' A carcinomas among the screen detected carcinomas than in the control group (P<0.001).

Diagnosis and Staging of Colon Tumors by Transabdomi- nal Hydrocolonic Sonography

(5) B. Limberg . . . . . . . . . . . . . . . . . . . Darmstadt, Germany

Within the scope of conventional abdominal sonography, only a cursory and insufficient evaluation of the gastrointestinal tract is possible. We investigated therefore in a prospective, controlled study whether the retrograde instillation of fluid into the colon would improve the diagnostic value of ultrasonography in evaluating neoplastic diseases involving the colon. 330 patients were examined whereby transabdominal hydrocolonic sonography with retrograde water instillation was performed prior to verification of the diagnosis by colonoscopy. Through the instillation of fluid into the colon it was possible to sonographically display the colon contin- uously from the rectosigmoidal transition to the cecum. In addition to making evaluation of the colon lumen possible, both five layers of the colon wall and the connective tissue surrounding the coion could be examined in detail. Colonic polyps and carcinomas appeared sonographically as echogenic structures project- ing from the intestinal wall into the lumen. Polyps larger than 7 mm could be identified in 91% of the cases, while polyps smaller than 7 mm could not always be visualized. The sensitivity for the detection of colonic carcinomas was 96% and the specificity was 100%. In 82% of colon tumors the T-stage was correctly determined by assessing the depth of infiltration into the colon wall. This study

shows that hydrocolonic sonography is a new diagnostic procedure that promises to facilitate greatly the diagnosis and staging of colon tumors utilizing transabdominal examination.

Incidence of Metachronous Adenomatous Polyps in Pa- tients with Hyperplastic Polyps

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

To determine if hyperplastic polyps (HP) are indica- tive of an increased risk of developing adenomatous polyps (AP), the charts of 526 consecutive patients who underwent total colonoscopy with polypectomy were reviewed. AP were found in 309 patients while 217 patients had HP only. Annual total colonoscopy was performed for 3 years on 514 of these patients (97.7%), and the results were reviewed. The cumulative occurrence of metachronous AP was 37.7%, 53.1%, 69.0%, for patients with a single AP and 36.2%, 69.0%, and 77.6% at 1, 2 and 3 years respectively for patients with multiple AP. The cumulative occurrence of metachronous AP was 29.2%, 40.8% and 48.5% for patients with a single and 23.9%, 39.4% and 47.9% at 1, 2 and 3 years, respectively, for patients with multiple HP. These data suggest that while the occurrence of metachronous AP is less for patients with HP compared to those with AP, it is still greater than the occurrence in the general population (p<.01). Also the occurrence of metachronous AP is increased in patients with multiple AP but unchanged in those with multiple HP. These findings suggest that frequent endoscopic colon surveillance is indicated for patients with hyperplastic colorectal polyps.

Technique, Technical

Transanal Endoscopic Microsurgery: An Introduction (7)

L.E. Smith, B. Orkin, T.J. Saclarides Washington, D.C., Chicago, IL

Transanal endoscopic microsurgery (TEM) permits a precise local excision of adenomas and selected cancers up to 20 cm from the anus. Conventional instruments have confined surgeons to the distal 5-8 cm of the rectum. TEM is performed through air-tight rectoscopes, 40 mm in diameter and 12 or 20 cm in length. The endosurgical unit regulates irrigation, suction, and con- stant COz insuffiation which distends the rectum, maintaining visibility. Tissue graspers, suction, needle hold- ers, and a cautery knife are inserted through sealed ports. Mucosal or full thickness excisions are performed; the defect is sutured transanally. We have used TEM in 31 patients (to completion in 28), removing 18 adenomas, 9 carcinomas, and correcting i anastomotic stricture. The adenomas averaged 3.7 cm in diameter (1.5-8 cm), the cancers 2.3 cm (1.5-3.5 cm). Four lesions were located

P4 MEETING ABSTRACTS Dis Colon Rectum, May 1992

0-4 cm from the anal verge, 16 were 4-8 cm, 9 were 8- 12 cm, and 2 lesions were located between 12-16 cm. Average blood loss was 94 cc, average operative time was 130.9 min (45-300 min). Most patients were discharged on the first or second day. Complications will be dis- cussed. TEM improves exposure and access to adenomas and selected cancers in the mid and upper rectum. Many of these lesions would otherwise require a transabdominal or transsacral approach.

Mobilization of the Splenic FlexurewThe Reason Why (8)

W.G. Sheridan, R.H. Lowndes, H.L. Young Cardiff, United Kingdom

Clinical assessment of tissue perfusion and viability is notoriously inaccurate. High ligation of the inferior mesenteric artery (IMA) has always been tempered with concern for the adequacy of blood supply to the left colon from the middle colic artery via the marginal vessel. We have performed tissue oxygen measurement (PtO2) comparing PtO2 and organ-PtOz index readings preresection and perianastomotically from the proximal side of the anastomosis in 49 patients. They were sub- divided into 6 groups depending on whether they had undergone high or low IMA ligation and on whether sigmoid, descending or transverse colon was used for the anastomosis. The sigmoid colon showed a significant decrease in both PtO2 and organ-PtOz (p<0.001); this was irrespective of the IMA ligation level. There was a mean fall in the sigmoid PtO2 (14.1 _+ 15.5 mmHg) with high ligation compared to a fall of 4.3 -+ 5.7 mmHg with low ligation (Mann-Whitney p<0.01). High IMA ligation resulted in a significant decrease in descending colon PtO2 (p<0.01). Transverse colon PtO2 and organ-PO2 index levels did not decrease with IMA ligation. Of the 5 clinical leaks in the series, all had diminished PrO2 on the proximal side. Although the left colon may appear to be adequately perfused at operation, it may suffer from relative hypoxia as a result of IMA ligation. Use of the left colon, particularly the sigmoid, for low anastomosis must be questioned. Mobilization of the splenic flexure and use of the transverse colon results in better perfused tissue for anastomosis.

An Artificial Sphincter for Anal Incontinence (9)

W.D. Wong, D.A. Rothenberger, D.C.C. Bartolo Minneapolis, Minnesota, Edinborough, Scotland

A modified American Medical Systems (AMS) 800 silastic sphincter has been successfully implanted in 11 pts. with fecal incontinence. Six of the pts. were male, 5 female. Average age was 32 yrs. (range 17-52 yrs). In- dications were birth trauma (3), major perineal trauma (3), spinal cord disorder (3), imperforate anus (1), and neurogenic incontinence of unknown etiology (1). A

previously established colostomy was present in 7 of the 11 pts. and was constructed in the other 4 pts. prior to successful implantation. Four complications--2 septic and 2 mechanical--have all been managed successfully with eventual establishment of a functioning artificial sphincter. Nine pts. have had their colostomies closed and are available for functional assessment. Mean duration of follow-up of these 9 pts. with a functioning artificial sphincter is 13 mos. (range 7-30 mos.). All pts. achieved excellent continence although 1 pt. is intermit- tently incontinent of gas and another pt. has occasional minimal soiling. Postoperative manometry characteristi- cally revealed a 2 cm high pressure zone with sphincter activated pressure ranging from 40-80 mmHg. Patient satisfaction has been uniformly high. This study estab- lishes that properly selected pts. with incapacitating fecal incontinence who fail conventional management can achieve satisfactory continence with acceptable morbidity by means of an artificial anal sphincter.

Evaluation and Treatment of Chronic Intractable Rectal PainmA Frustrating Endeavor

(10)

S.D. Wexner, G.C. GeL J.M.N. Jorge, E. Lee, J.J. No- gueras, D.G. Jagelman . . . . . . . . . . Fort Lauderdale, FL

A study was undertaken to assess the evaluation and treatment of chronic intractable rectal pain. 60 consecutive patients, 23 males and 37 females of a mean age of 69 (range 29 to 87) years with a mean length of symptoms of 4.5 years were evaluated by questionnaire, office exam, anal manometry, electromyography, cinedefecography, and pudendal nerve study. In all cases, organic abdominopelvic and anorectal etiologies for the pain were excluded by extensive radiologic and endoscopic evaluation. All patients had failed conservative and medical therapy. 95% of patients had one or more associated factors: constipation or dyschezia (57%), prior pelvic surgery (43%), prior anal surgery (32%), prior spinal surgery (8%), irritable bowel syndrome (10%), or psychiatric disorders (depression or anxiety; 25%). Possible etiology for the pain included levator spasm or anismus (LS) in 62%, coccygodynia (C) in 8%, and pudendal neuropathy (PN) in 39% of patients. Therapy for pain control included electrogalvanic stimulation (EGS) in 29, biofeedback (BF) in 14, and epidural block (B) in 11 patients. Pain control was assessed by an independent observer at a mean of 15 months after completion of therapy. Prolonged pain relief was classified by patients as good or excellent after EGS in 38%, after BF in 43%, and after B in 18%; overall success was reported by 47% of patients. The presence of LS, C, or PN did not influence outcome. The routine use of physiologic investigation of rectal pain may not be justifiable. Moreover, more than half of patients are refractory to these 3 currently available therapeutic options.


Awake Epidural Anesthesia is Effective and Safe in the High Risk Colectomy Patient

(11)

K. McKenna, W.A. Koltun . . . . . . . . . . . . . . Hershey, PA

In an effort to minimize the morbidity associated with the use of general endotracheal anesthesia (GETA), we have instituted the use of awake epidural anesthesia (AWA) in patients requiring colectomy who have significant comorbid conditions. We studied 15 consecutive high risk patients (mean age 72+3) who underwent colectomy (11 cancer, 3 diverticulitis, 1 AV malforma- tion) under AWA. 11 patients had severe heart disease, 6 significant lung disease, 2 chronic renal failure, 2 cirrhosis and 3 diabetes. These patients were compared to a group of 17 lower risk patients (mean age 60+4) undergoing colectomy with GETA during the same time period by the same surgeon. There were no deaths. There were 4 complications in the AWA group: 1 ileus, 1 urinary tract infection, 1 wound infection and 1 pneu- mothorax. The GETA group had 2 C. difficile infections and 2 patients with ileus. No differences were noted in length of operative procedure or number of lymph nodes in cancer specimens attesting to effectiveness of the AWA technique. There was a trend favoring AWA when blood loss (307_+70 vs 534_+92 cc, p=.06), length of hospital stay (7.6_+.5 vs 9.1_+.6 days, p=.08), and return of bowel function (4.3+.4 vs 5.5_+.5 days, p=.07) were considered. We conclude that AWA is safe and effective in high risk patients undergoing colectomy and achieves an operative risk that compares favorably with healthier patients receiving GETA.

The Role of in Vitro Technetium Bleeding Scans in Acute Lower Gastrointestinal Hemorrhage

(12)

B. Bute, W. Lichliter . . . . . . . . . Aurora, CO, Dallas, TX

Two hundred twenty-five consecutive patients with suspected acute lower gastrointestinal hemorrhage were evaluated with 248 in vitro technetium 99 bleeding scans. One hundred fourteen (46%) scans were positive; scan localization of bleeding site was confirmed by other methods in 60 (53%). Scintigraphy was the only positive test, localization unconfirmed, in 40 cases (35%). Incor- rect localization by scan occurred in 13 patients (11%). Colonoscopy was performed 183 times with 107 (58%) obtaining a definitive result. Forty-nine visceral angio- grams produced 14 (29%) positive and 35 (71%) negative results. Nine patients had both positive bleeding scan and arteriogram. Twenty five patients with positive scans required operation with bleeding site appropri- ately identified in 23 (92%). Six operations were guided by bleeding scans alone with 5 (83%) accurately localized. No blind total abdominal colectomies were performed; 15 of 19 colonic procedures were segmental resections with no postoperative rebleeding. Respec- tively, the sensitivity, specificity and positive predictive value for surgery (prior probability .15) were scintigra-

phy (.73, .57, .22), colonoscopy (.84, .40, .20) and angiography (.31, .73, .17). Bleeding scan as the first diagnostic procedure achieved the greatest gain in predicting the need for surgery. The combination of positive scan and positive colonoscopy doubled the positive predictive value, while angiography, regardless of when performed, added only .02 to the predictive value. The technetium bleeding scan is an effective initial test for evaluating Iower gastrointestinal hemorrhage.

Outpatient Bowel Preparation for Elective Colon Resec- tion

(13)

T. Le, A. Timmcke, J.B. Gathright . . . New Orleans, LA

Seven hundred twenty patients undergoing colectomy performed by surgeons of the Ochsner Clinic Depart- ment of Colon and Rectal Surgery between July 1987 and July 1991 were retrospectively analyzed. The study was conducted to determine the safety and cost-effectiveness of preoperative bowel preparation with Golytely performed by outpatients. Analysis was restricted to 182 patients that underwent elective segmental and total abdominal colectomy with primary anastomosis. Patients requiring protecting proximal stoma were excluded. The patients were divided into two groups, 82 patients who underwent outpatient bowel preparation (OP) and 100 patients who underwent inpatient bowel preparation (IP). The two groups were equally matched with regard to age, sex, procedure performed, and comorbid factors, except the patients in the IP group demonstrated a slightly higher incidence of cardiac and pulmonary disease. The two comparable patient groups had similar results regarding 1. Days hospitalized (10.2 _+ 3.4 IP vs. 9.4 --- 219 OP) 2. Days NPO (6.5 + 2.8 IP vs. 6.2 + 2.1 OP) 3. Days requiring nasogastric intubation (5.9 -+ 2.8 IP vs. 6.8 + 2 .20P) or gastrostomy tube (6.8 + 2.6 IP vs. 6.2 + 1.40P). Outcome was also similar with regard to postoperative complications. 1. Ileus/partial small bowel obstruction (5% IP vs. 6% OP) 2. Splenic injury (4% IP vs. 2.4% OP) 3. Wound infection (3% IP vs. 0% OP). There was no instance of intra-abdominal abscess or sepsis in either group. One patient in the OP group suffered an anastomotic leak which required re-operation and diversion. The patient's original surgery was for Crohn's disease, and at the time of operation the patient was receiving chronic high dose steroids. Two patients in the IP group experienced cerebrovascular accidents, and there was one death in the OP group secondary to pulmonary embolus. Overall analysis of the cost of bowel preparation by the two methods indicates that the OP preparation costs approximately $40 and the IP preparation, including the cost of a semi-private room, costs approximately $400, or a ten-fold increase. This study would suggest that outpatient bowel preparation with Golytely and oral antibiotics prior to elective colon resection can be performed with equivalent safety- and at a substantial cost savings.


Anorec ta l Cancer

Pattern of Lymph Node Metastasis from Low Rectal Cancer (14)

D. Mascagni, K. Hojo,* Y. Moriya,* K. Sugihara,* G. Di Matteo . . . . . . . . . . . . . . . . . Rome, Italy, *Tokyo, Japan

The effectiveness of lymphadenectomy for low rectal cancer is still debatable. The aim of this study was to determine the anatomical location of lymph node metastasis in order to have some objective data to guide the node dissection. Analysis was performed on data from 201 consecutive patients with rectal cancer located at/ below the peritoneal reflection that underwent surgery at NCCH of Tokyo, between 1985 and 1991. An extended lymphadenectomy--lateral and upward--was performed in every case of advanced cancer. The incidence of lymph node metastases and their topographic distribution were precisely defined and correlated with the features of the patient, tumor ad surgery. A mean of 38 lymph nodes were dissected from each patient; of the 7648 nodes examined 610 (7.9%) contained metastases. 109 patients (54.2%) had positive lymph node involvement: 102 patients (50.7%) had node metastasis in the perirectal area, 21 (10.4%) along the main vessels, 6 (2.9%) at the origin of the inferior mesenteric artery, 40 (19.9%) in the lateral lymph nodes and 13 (6.4%) in the para-aortocaval region. This pattern of lymph node metastasis and its correlation with the other considered parameters could be determinant to planning the extent of lymphadenectomy.

DNA Analysis and Local Therapy in Rectal Carcinoma (15)

G.C. Zenni, K. Abraham, P.B. Dobrin, F.J. Harford Maywood, IL, Hiues~ IL

It has been estimated that approximately 5% of middle and low rectal adenocarcinomas are amenable to local therapy, however these modalities are limited by their failure to identify and treat regional metastases. This study was undertaken to evaluate the role of tumor DNA ploidy analysis in the prediction of nodal spread in conjunction with other characteristics (histology, depth of wall penetration, and size). One hundred thirty-three patients without evidence of distant metastases underwent abdominoperineal resection for rectal carcinoma from July 1, 1971 through December 31, 1989. Of these, one hundred twenty-nine paraffin-embedded archival pathologic specimens were available for DNA flow cytometry. Tumors were less than or equal to 3 cms. in 27 (20%), node negative in 79 (59%), had complete wall penetration (T3) in 90 (66%), were poorly differentiated in 23 (17%), and diploid in 88 (68%). Average location above the dentate line was 6.5 cms. (range 0 to 15 cms.). Using logistic regression analysis only degree of differentiation predicted nodal status (p<0.0001). When tumors for which local therapy is not considered appropriate are excluded (i.e., complete wall penetration, poor

differentiation) DNA ploidy significantly correlated with nodal status (p<0.02). In this population aneuploidy increased the risk of nodal spread greater than three times compared to diploid (50% vs. 15%, respectively). These data indicate that ploidy status may help to identify those patients whose tumors are less likely to have regional metastases and are therefore more suitable for local therapy.

Reoperation for Locally Recurrent Rectal Cancer (16)

K. Suzuki, L. Gunderson, R.M. Devine, R.R. Dozois Rochester, MN

Between 1981 and 1988, 225 patients were operated for locally recurrent rectal cancer. 137 men, 88 women; average age 62 years. Most patients (149 or 66%) had their initial surgery performed elsewhere. The initial surgery consisted of low anterior (127 pts; 57%), abdominal perineal (66 pts; 25%), local excision (27 pts; 12%), and Hartmann's procedure (5 pts; 2%). The operation for recurrence was done an average of 24.7 months after the initial cancer surgery. The recurrence was symptomatic in 80% of patients; in 20% the recurrence caused no symptoms and was discovered during intensive follow-up evaluations. Different procedures were done for the recurrence, most commonly abdominal perineal resection (31.6%), local excision (13.8%), and Hartmann's procedure (8.4%). Complications requiring readmission or surgical reintervention occurred in 30% of patients.

The mean overall survival after surgery for recurrence was 30 months; 26 months for fixed tumors and 46 months for those not fixed.

Of 51 patients who received intraoperative radiation surgery at surgery, 35 had gross residual disease and eight had microscopic residual. The mean survival for patients receiving intraoperative radiation was 34 months and 25% of these patients are currently disease-free.

Coloanal Anastomosis: Survival, Recurrence, and Func- tional Results in Patients with Rectal Cancer

(17)

F. Cavaliere, J.H. Pemberton, V. Fazio, M. Cosimelli, R.W. Beart, D. Giannarelli

Rochester, MN, Cleveland, OH

Increasingly, rectal cancer is managed by coloanal anastomosis (CAA) and not abdominal perineal resection. In order to determine functional outcomes and rates of survival and recurrence, we documented the experience of two referral centers with CAA. Between 1977 and 1991, 117 patients (61 at Center M and 56 at Center C) underwent CAA. 18/117 patients (15%) had a J-pouch. The rest had a straight CAA. 38% had no diverting stoma. Tumor stages were: A (18%); B1 (28%); B2 (17%); C, (9%); C2 (23%); D (5%). The median distance


of the tumor from the anal verge was 6.7 cm. The median tumor free margin was 2 cm for low rectal tumors and 3 cm for mid rectal tumors. 39% of the patients had a major complication (stricture, leakage, failure) while 23% had a minor complication. Complications were not mitigated by a diverting stoma or worsened by adjuvant therapy. Median followup was 50 months. The local recurrence rate was 6%. The 5 year survival was fully 68% in patients with low rectal cancer and 64% in those with mid rectal cancer (p>0.05). Straight CAA patients had 4 stools per day while J-pouch patients had 3. Excellent continence was achieved by 75% of patients; no J-pouch patient had frequent incontinence. Conclusion: Despite considerable morbidity, CAA preserves sphincter function in the great majority of patients with rectal cancer. Moreover, the 5 year survival of 68% and local recurrence rate of 6% provides evidence that CAA is an effective cancer operation as well.

Prognostic Value of DNA Ploidy and Sialomucin in Rectal Cancer Determined by Multivariate Analysis

(18)

M. Moran, A. Ramos, D. Rothenberger, S. Goldberg, D. Antonenko . . . . . . . . . . . . . . . . . . . . . . Grand Forks, ND

DNA ploidy is a well known significant variable in rectal cancer. Not much information is available on sialomucin, but it has been shown to predict local recurrences in colorectal neoplasms. However, so far no study has analyzed both variables together nor is it known if they are independent prognostic factors. The aim of this paper is to establish if both variables are independent prognostic factors which could be used to predict local recurrences in rectal cancer when studied with other known variables.

One hundred forty-three patients with rectal cancer underwent "curative" resections and were included in the study. Univariate analysis was performed on 36 variables. Then, significant variables were included in a multivariate analysis. The only statistically significant variables remaining were: 1) >3 positive lymph nodes (p=0.0009), 2) nondiploid DNA (p=0.0041), and 3) abnormal sialomucin content at the resection margins (p=0.014). Macroscopic local invasion of the tumor was almost significant (p=0.09).

Multivariate analyses can determine if new prognostic factors provide additional useful information. This study shows both DNA ploidy of the tumor and sialomucin at the resection margins to be independent variables useful in predicting local recurrences.

It is concluded that DNA ploidy and sialomucin are independent variables and could be used as markers in clinical trials to evaluate new forms of adjuvant therapy for rectal cancer.

Research and Physiology

MMPI Psychological Assessment of Patients with Func- tional Bowel Disorders

(19)S. Heymen, S.D. Wexner, A.D. Gulledge Fort Lauderdale, FL

This prospective study was undertaken to assess personality differences among patients with chronic pelvic floor disorders. The Minnesota Multi-phasic Personality Inventory (MMPI) was utilized for psychological assessment in all patients. 75 consecutive patients (53 female and 22 male) of a mean age of 58 (range 33-87) years with fecal incontinence (N=30), constipation (N=31), or levator spasm (N=14) had a mean duration of symptoms of 35 years. Mean MMPI validity scale scores were within the normal range. Mean scores for scales 1 (hy- pochondriasis), 2 (depression), and 3 (hysteria) were significantly elevated for the levator spasm (LS) group (72, 76, and 73, respectively). Similar elevations were also noted for the constipation (C) group. Scales 1, 2, and 3 are referred to as the "neurotic triad" and these patterns indicate that these subjects may manifest their psychological distress as physical symptoms. Thus, the LS and C patients tend to somaticize their psychological distress. Although the C group appears somewhat less depressed than the LS group, they are more aware of their depression, which makes them more likely to respond to psychological treatment. Conversely, LS patients may resist any psychological approach to treatment and rigidly focus on getting their body "fixed". This may result in less successful outcomes for the LS group. The incontinent patients were within the normal range on all scales, and, thus, do not tend to use somatization as a defense mechanism. The information from the MMPI can be used to understand the personality and emotional composition of these patients to assist in their evaluation and treatment.

Immunohistochemical Detection of Mutant P53 Protein and HPV-Related E6 Protein in Anal Cancers

(20)

S. Jakate, T. Saclarides . . . . . . . . . . . . . . . . . Chicago, IL

The P53 gene located in the short arm of chromosome 17 and its protein product, wild P53 protein, normally suppress tumor development. Colorectal oncogenesis is associated with P53 gene deletion resulting in production of a nonfunctional mutant P53 protein from the remaining allele. Certain serotypes of human papilloma viruses (HPV) such as 16 and 18 have been implicated in the causation of anal cancer. Twenty-nine anal cancers (19 squamous cell cancers, 7 adenocarcinomas, 1 anaplastic, 1 lymphoma, 1 carcinoid) were examined for E6 (protein associated with HPV 16, 18) and mutant P53 protein using immunohistochemical techniques. The adenocarcinomas arose within the anal canal. Formalin-

P8

fixed sections were stained with antibodies Ab-2 (for P53) and Ab-1 (for E6), Oncogene Sciences. Results are:

Expression

Mutant P53 E6

Tot. cases (29) 17 (58.6%) 5 (17.2%) Squamous cells (19) 8 (42.1%) 5 (26.3%) Adenocarcinoma (7) 6 (85.7%) 0 Anaplastic (1) 1 0 Lymphoma (1) 1 0 Carcinoid (1) 1 0

Conclusions: Anal adenocarcinomas appear oncoge- netically similar to colorectal cancers as shown by the high expression of mutant P53 protein. A significant proportion of anal squamous cell cancers show HPV 16 and 18 associated E6 protein expression of which 80% produce mutant P53 protein. It would appear therefore that HPV may play a role in the inhibition of normal tumor suppression.

An Electrostimulated Skeletal Muscle Neosphincter in a Canine Model of Fecal Incontinence

(21)

J.A. Heine, D.A. Rothenberger, W.D. Wong, J.G. Wil- liams, E.H. VanBergen, W.D. Buie, S.M. Goldberg

Minneapolis, MN

A canine model of fecal incontinence was developed to assess the feasibility of an electrostimulated skeletal muscle neosphincter (NS). A 20 cm segment of small bowel was isolated and a stoma fashioned in both lower quadrants. The sartorius muscle of one leg was transposed intra-abdominally and wrapped around the ipsi- lateral stoma at the subfascial level to create a NS. Elec- trodes were placed in proximity to the NS pedicle and connected to an implantable stimulator. The ability of the electrostimulated muscle wrap to develop occlusive force was assessed every 2 weeks by infusing water into the loop at a pressure of 115 mmHg. NS fatigue was defined as loss of 50% of developed loop pressure (P50). Follow-up for 10 NS ranged from 8-26 wks. Two NS did not function due to lead breakage. Two maintained complete continence to water for 3 hrs. Six achieved initial continence but leaked after a variable period. The average time to P50 (+ S.E.M.) for these latter 6 NS at 4, 8, and 12 wks. was 40 + 14, 76 --- 23, and 119 ___ 48 minutes, suggesting improved fatigue resistance with time. A 4- channel manometer was used to directly measure pressure in 5 NS. The mean stimulated (maximum minus resting) pressure was 5 volts, 15 Hz was 159 • 40 mmHg (5 volts/20 Hz = 276 + 50 mmHg). Microscopically, fibrosis of the inner aspect of the muscle wrap was apparent. We conclude that a transposed electrostimulated skeletal muscle wrap can generate significant occlusive force and may have potential application as a NS.

MEETING ABSTRACTS Dis Colon Rectum, May 1992

Reticuloendothelial Stimulation: Levamisole Compared (22)

N. Davies, J. Yates, S.A. Jenkins, B.A. Taylor Liverpool, United Kingdom

Combined adjuvant therapy with fluorouracil and the immunomodulatory drug Levamisole has been shown to significantly increase survival in patients with Dukes C colorectal cancer. The reason for Levamisole's efficacy is not known. We have compared the effect of Levamisole on the hepatic and splenic reticuloendothelial system (RES) with other known RES stimulants.

Groups of 10 male wistar rats received either Saline (control), Glucan, Zymosan, Chlormethiazole, Octreo- tide (somatostatin analogue) or Levamisole. RES was assessed by the hepatic and splenic uptake of 99m Tc sulphur colloid (sc), 20 minutes after an intravenous injection of 2.5 MBq of colloid. Hepatic uptake was significantly increased in all the treatment groups (p<0.001 Mann-Whitney U), when compared to the control group (median 4- range). Controls (4.8 ___ 13.7), Glucan (14.9 + 22.6), Zymosan (12.6 + 28.4), Chtor- methiazole (24.1 + 13.7), Octreotide (34.4 -+ 22.2), and Levamisole (15.4 ___ 31.3).

Splenic uptake was significantly increased except in the Levamisole group. Octreotide increased uptake of sulphur colloid significantly more than Levamisole in both liver and spleen (p< 0.005).

The results of this study suggest that Levamisole is a stimulator of hepatic RES function and this may account for its efficacy in adjuvant therapy. Octreotide is a more potent stimulator of RES activity and its use as an adjuvant in the treatment of colorectal cancer deserves further investigation.

Presymptomatic Diagnosis of Familial Adenomatous Polyposis by Molecular Analysis: Implications for Screen- ing Guidelines

(23)

B. Bapat, H. Stern, T. Berk, J. Parker, P.N. Ray, R. McLeod, Z. Cohen . . . . . . . . . . . . . . . . . . . . . . . Toronto, Ontario

Familial Adenomatous Polyposis (FAP) is an autosomal dominant disorder predisposing to colon carcinoma. It is characterized by the presence of multiple colonic polyps and in some cases, with certain extra-colonic manifestations such as the congenital hypertrophy of the retinal pigment epithelium (CHRPE).

Recently, the polyposis gene, APC, has been cloned and mapped to chromosome 5q21-22 and several closely linked RFLP (restriction fragment length polymorphism) markers have been identified. Due to the lack of a major mutation(s) in the FAP kindreds screened so far, direct mutational analysis is not yet practical and RFLP linkage analysis is still preferred for presymptomatic molecular diagnosis. We have analyzed 141 individuals in 14 FAP kindreds using ten intragenic and closely flanking RFLP markers. Thirty-six at-risk individuals had 50% a priori risk of inheriting the APC allele segregating with the disease status. Molecular analysis indicated with >95%


accuracy, that 13 individuals were at a significantly higher risk (mean age 16.3 yrs) and 22 individuals at a lower risk (mean age 22.8 yrs) of developing polyposis. CHRPE analysis of at-risk individuals indicated that CHRPEs when present, were consistent with the molecular diagnosis.

Presymptomatic carrier risk assessment by molecular analysis has significant implications for modifying the frequency of colonic screening among at-risk individuals.

Protective Effect of RibCys Following High Dose Irradia- tion of the Rectosigmoid

(24)

J.K. Rowe, R.T. Zera, R.D. Madoff, M.P. Bubrick, J.C. Roberts, G.R. Johnston, D.A. Fenney, H.L. Young

Minneapolis, MN

RibCys (ribose-cysteine) is a precursor of L-cysteine that stimulates glutathione biosynthesis. Increased glutathione levels have been shown to have a protective effect against radiation induced injury and oxidative stress. The following study was done to evaluate this effect in a swine model. Methods: Domestic swine were divided into 3 groups: group A (control) served as a non- radiated control; group B (Rad) received 6000-6500 rad to the rectosigmoid; and group C (Rad+RibCys) received RibCys 1 gm/kg prior to receiving 6000-6500 rads. Ra- diated animals and controls underwent rectosigmoid resection after a 3 week rest period. Intraoperative anastomotic PtOz was checked with a modified Clarke electrode. Anastomoses were evaluated radiographically at 3 and 7 days; animals were sacrificed and bursting strength recorded at 10 days. Results: Mean bursting pressures were 243.8+_59.4, 199.5+_37.8 and 209.5+_54.9 mmHg (NS) for groups A, B, and C. Anastomotic PtO2 ranged from 19-90 mmHg and could not be correlated with anastomotic leaks. Outcomes were as follows:

Radiation Radiation

Anastomotic Related Related

Leaks Deaths Deaths

+Leaks

Control 0/12 0/12 0/12 Rad 8/15 3/7 11/15 Rad+RibCys 3/12 1/9 4/12"

* p= 0.04 Rad+RibCys vs Rad

Conclusion: RibCys protected animals against radiation related deaths and anastomotic leaks following high doses of pelvic irradiation.

To assess this, we performed ambulatory anal sphincter electromyography and manometry on 28 patients with neurogenic fecal incontinence (26 female; median age 51 years, range 32-78) and 15 controls (7 female; median age 36 years, range 24-73).

The median IAS relaxation rate per hour was CON- TROL 5 (range 4-6) and INCONTINENT 9 (range 7-12) (p <0.03). Upper anal canal pressure (UAC) decreased by a median of 20 cm. I-I20 (range 10-35) in the control group while mid-anal canal pressure (MAC) did not change significantly. Both UAC (median 20 cm. H20, range 15-30) and MAC (median 21 cm. H20, range 14- 26) fell in the incontinent group of whom only 16 exhibited external sphincter recruitment. Rectal pressures increased (median 11 c m . H 2 0 , range 2-20) above UAC in the control group but never exceeded MAC. In the incontinent group, rectal pressures also increased (median 21 c m . H 2 0 , range 7-35) (p < 0.05) but exceeded the MAC in 65%, accounting for episodes of incontinence. Moreover, whereas internal sphincter relaxation never exceeded 10 seconds in controls, 35% of incontinent patients exhibited episodes of prolonged relaxation (median 28 seconds, range 25-34) (p < 0.001).

We conclude these episodes contribute to the pathogenesis of incontinence, and would be missed using conventional laboratory methods.

Anastomotic Technique Alters Colonic Crypt Cell Prolif- eration

(26)

J.L. McCue, R.K.S. Phillips London, England

Accelerated cellular proliferation may explain enhanced carcinogenesis at experimental colonic anastomoses. As tumour yield is influenced by anastomotic technique we explored the effect of a "sutureless" closure as well as different types of sutured closure on crypt-cell production rate (CCPR) at the suture line. Method: 80 male F344 rats were used. A 5 mm transverse colotomy was created which was repaired with 1) 4 interrupted 5/0 sutures of silk, stainless steel or poly- glactin 910 (Vicryl) or 2) a "sutureless" closure. 5 animals in each group were killed after ] week, 4 weeks, 3 months, or 6 months. CCPR was assessed by the stath- mokinetic technique. Results: In the sutured animals anastomotic CCPR was significantly greater than adjacent descending colon CCPR for at least 3 months postoperatively (See Table). By contrast there was no significant elevation of the C C pR at the sutureless anastomosis compared to the adjacent colon at any time point.

Abnormal Internal Anal Sphincter Relaxation is an Under- estimated Problem in Neurogenic Fecal Incontinence

(25)

R. Farouk, G.S. Duthie, D.C.C. Bartolo Edinburgh, Scotland

Prolonged internal anal sphincter (IAS) relaxation may contribute to the pathogenesis of fecal incontinence.

CCPR (Cells Crypt -1 Hour -1) Sutured Rats Anastomosis Desc. Colon

1 week 10.3 7.8 ~ 4 weeks I0.6 7.9 b 3 months 8.7 7.7 ~ 6 months 7.9 8.8

= f=9.48, p<0.005; b f=10.3, p<0.005; c f=4.4, p<0.05

P10 MEETING ABSTRACTS

Conclusion: Cellular proliferation is elevated at sutured but not sutureiess anastomoses for at least 3 months. This may explain why fewer experimentally induced tumours occur at anastomoses closed without sutures.

Pudendal Nerve Somatosensory Evoked Potentials ((PN)SsEP) in the Investigation of Incontinence

(27)

M. Viamonte, J. Cole, L. Gottesman, . . . , New York, NY

Anal incontinence can result from local sphincter pathology, neuropathies, primary enteric pathology, or combinations thereof. Single fiber and pudendal nerve terminal motor latency investigate only the pudendal nerve and sphincter mechanism. PNSsEP with sphincter mapping surpasses previous electrodiagnostic techniques.

Since 1990 29 patients were investigated, excluding patients with known neuropathies or urinary incontinence. Where the SsEP was abnormal, electrospinograms were performed to differentiate between central and peripheral lesions. Direct sphincter injuries were studied with concentric needle mapping. 6 of 13 patients with direct sphincter injury had concomitant peripheral nerve injury. Of 16 patients with "idiopathic" incontinence, 7 polyradiculopathies, 4 peripheral neuropathies, 1 Hg sacral neuropathy, 1 polymyositis, 1 steroid myopathy, 1 primary pudendal nerve injury, 1 normal exam.

SsEP + EMG can discriminate between cortical, spinal, and peripheral levels as well as structural, neuropathic, and myopathic conditions affecting continence. SsEP is helpful in assessing pudendal nerve integrity in direct sphincter injury. This reliable and objective methodol- ogy surpasses previous techniques in the pathophysio- logical investigation of incontinence.

Clinical Studies in Surgical Journals: Have We Improved? (28)

MJ. Solomon, R.S. McLeod . . . . . . . . Toronto, Ontario

A critical appraisal of all clinical studies published in 1980 and 1990 in three journals, Diseases of the Colon & Rectum (DCR), Surgery (SURG), and the British Journal of Surgery (BJS), was made to ascertain the frequency with which research designs appeared, the standard of clinical studies and changes in the past decade.

Clinical studies were classified into case studies or comparative studies (CS). CS included Randomized controlled trials (RCT), Nonrandomized Controlled Trials, Retrospective Cohorts and Case-Control studies. A 10- point index score (range 0-10) was used to assess each CS. A sample of articles was analyzed for inter- and intra- observer variation with strong agreement between re- viewers for classification of studies (unweighted kappa 0.87) and index scores (0.67).

Of 1060 articles classified as clinical studies, 16% were CS (7% RCT) in 1980 compared with 17% (7% RCT) in 1990. Eighty percent were retrospective reviews in 1980 compared with 79% in 1990. In 1980, 6% of clinical studies in DCR were CS, 19% in BJS and 18% in SURG. In 1990, 11%, 18% and 18% respectively were CS, In

Dis Colon Rectum, May 1992

1980, the proportion of RCTs in DCR was 0%, in BJS 12% and SURG 4% compared with 3%, 8% and 8% respectively in 1990. Overall, 52/76 (68%) RCTs were published in BJS.

The standard of CS increased overall from 5.5 to 6.0. The greatest was in RCT (5.7 to 7.7). The standard of CS in DCR was lower than BJS and SURG both overall and in RCT, despite improving from 1.7 to 5.5. In conclusion, although a small increase in the standard of CS has occurred, there has been no overall increase in the proportion of stronger clinical trial designs in the journals reviewed.

Medical Malpractice Involving Colon and Rectal Disease: A Twenty-Year Civil Court Review

(29)

K. Kern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hartford, CT

To determine objectively the causes of malpractice litigation involving colon and rectal disease, a retrospective review was undertaken of all such cases tried within the state and federal civil court system over the twenty- year period from 1971 to 1991. Ninety-eight malpractice cases were identified from a computerized legal data- base, involving 103 allegations of negligence. Allega- tions fell into five major categories: (1) sphincter injury with fecal incontinence (n=10/103, 10%); (2) failure to timely diagnose disease (n=44/103, 43%); (3) lack of informed consent (n=8/103, 8%); (4) iatrogenic colon injury (n=25/103, 24%); and (5) iatrogenic medical complications during diagnosis or treatment (n=16/103, 15%). Major findings within categories included: (1) equal responsibility between anorectal surgery and episiotomy for sphincter injury; (2) 46% of delayed diagnoses involving colorectal cancer, with a mean diagnostic delay of 11___1 mos. (range: 2-19 mos.); (3) 48% of colonic perforations from lower endoscopy; and (4) lack of consent focused on failure to warn about the risk of endoscopic perforation and magnitude of operations. Wrongful deaths occurred in 14% (14/98) of cases. The specialty breakdown of 86 defendant physicians included: Internists/FP, 26%; Gen Surg, 21%; OB/Gyn, 15%; Gastroenterology, 12%; Radiology, 6%; Colorectal Surg, 4%; ER Med, 4%; and Other, 12%. This review should prove to be of great educational value to clinicians involved in the diagnosis and treatment of colorectal disease.

Anorectal Physiology

Physiological Assessment of Colorectal Functional Disor- ders: Use or Abuse of Technology?

(30)

S.D. Wexner, J.MN. Jorge, J.J. Nogueras, D.G. Jagelman Ft. Lauderdale, FL

A prospective study was undertaken to assess the value of colorectal physiologic testing (CPT) in 308 consecutive patients (pts) with functional disorders. 138 females (F) and 42 males (M), ages 12-85 years (yrs) had constipation (C); 66 F and 14 M ages 25-83 yrs had incon-

Vol. 35, No. 5 MEETING ABSTRACTS P l l

t inence (I) , and 36 F and 12 M ages 29-81 yrs had chronic intractable rectal pain. Pts underwent deta i led functional assessment by questionnaire, anorectal examination, and CPT-transit study, anal manometry, cinedefecography, electromyography, and pudendal nerve assessment.

Definitive Diagnoses (Dx) After Questionnaire & Examination: Consti- pation: 8%; Incontinence: 16%; Pain: 14%

Definitive Dx Afier CPT C: 75% (N=180) Nonrelaxing puborectalis 59 (33%) Colonic inertia 31 (17%) Nonemptying rectocele 19 (10%) Intussusception 18 (10%) Obstructing enterocele 8 (5%) No diagnosis 45 (25%)

Definitive Dx After CPT I: 71% (N=80) Muscle fiber loss 21 (26%) Pudendal neuropathy 10 (13%) Fiber loss and neuropathy 15 (19%) Intussusception 7 (9%) No diagnosis 27 (33%)

Definitive Dx Afier CPT Pain: 33% (N=48) Pudendal neuropathy 6 (12%) Nonrelaxing puborectalis 3 (6%) No diagnosis 39 (82%)

In summary, in 67% of pts with constipation and in 55% with incontinence, a treatable condit ion was identified only through CPT, emphasizing the importance of physiologic testing in these pts. However, since definitive diagnosis was achieved by CPT alone in only 18% of pts with rectal pain, the value of these studies in this group must be reassessed.

cont inence with biofeedback is associated with increased rectal sensation, not with increased manometr ic pressures.

Pudendal Neuropathy and the Importance of EMG Evalu- ation of Fecal Incontinence

(32)

A.M. Vernava III, W.E. Longo, G.L. Daniel St. Louis, MO

A prospective study was undertaken to evaluate pudendal neuropathy in fecal incontinence. METHODS: Fifty two patients (38 women/14 men) with fecal incon- t inence underwent manometr ic and electromyographic evaluation (sphincter muscle mapping + measurement of pudendal nerve latency (PNL)). RESULTS: fifty-two percent (27/52) were found to have a pudendal neuropathy (PNL>2.1 msec) which was bilateral in 63% of the patients (17/27). Nine patients had a sphincter defect identif ied and of these 6 (67%) had a neuropathy; 4 (67%) were bilateral.

SL=SPHINCTER LENGTH RP=RESTING PRESSURE MVC=MAXIMUM VOLUNTARY CONTRACTION

NO ANATOMIC DEFECT

No Neuropathy Neuropathy (n=22) (n=21) p Value

Age 51.9-+16.2 63.7-+12.3 0,01 #Females 12 18 0.03 SL (CM) 3.9-+1.0 3.0-+0.9 0,01 RP (mmHg) 69.4-+36.6 60.8-+34.5 0.43 MVC (mmHg) 94.9-+50.1 86.2+34.I 0.52

Biofeedback for Anal Incontinence: What is the Mecha- nism of Success?

(31) g.g. Jensen, A.C. Lowry . . . . . . . . . . . . Minneapolis, MN

Biofeedback has documented efficacy as a treatment modal i ty in some patients with anal incontinence. The mechanism responsible for success has not been defined. Augmented sphincter contraction and/or rectal sensation may explain the therapeutic benefit. We re- v iewed the pre and post b iofeedback manometr ic pressures in 12 pts. Eleven pts. were female with a mean age of 48 yrs. (range 30-70 yrs.). Six pts. were S/P birthing injury, four pts. had idiopathic incontinence, 1 pt. was S/ P rectal surgery and 1 was S/P colon resection. The incont inence score decreased from 25 to 4 fol lowing at least 3 b iofeedback sessions. Manometry was done an average of 19 mos. (range 2-29 mos.) post biofeedback. Manometric resting pressures did not change, whereas squeeze pressures increased an average of 11 mmHg (N.S.). Overall rectal sensory thresholds decreased by 24 cc, with a mean of 26 cc (range 15-55 cc). Five pts. had normal sensory thresholds prior to treatment. In these pts. ave. sensory thresholds decreased by 5 cc (range 0-15 cc). In the 7 pts. with abnormal sensation, ave. thresholds decreased by 38 cc (range 20-60 cc) with biofeedback (p=.002). In our review, improvement in

In the 43 patients who did not have an anatomic sphincter defect pudendal neuropathy was significantly associated with advancing age and female gender. There was no difference in RP or MVC in patients who had a neuropathy compared to those who did not although neuropathic patients had a shorter sphincter length. Bi- lateral .pudendal neuropathy tended to occur more frequently in women (p=0.07) and was not associated with poorer RP, MVC or shorter sphincter length. CONCLU- SION: Pudendal neuropathy is a common cause of fecal incontinence particularly in older women and frequently occurs in association with a sphincter defect. Manometric evaluation alone is not helpful in identifying the neuropathic patient. EMG should be routinely performed in the evaluation of incontinence.

Does Perineal Descent Correlate with Pudendal Neurop- athy? (33)

J.M.N. Jorge, S.D. Wexner, E. Ehrenpreis, J.J. Nogueras, D.G. Jagelman . . . . . . . . . . . . . . . . . . Ft. Lauderdale, FL

A prospective study was undertaken to assess the potential correlation between perineal descent (PD) and pudendal neuropathy (PN) in 205 consecutive patients.


These 155 females and 50 males of a mean age of 62 (range 18-87) years had either constipation (N--112), incontinence (N=61) or proctalgia fugax (N=32). All 205 patients underwent cinedefecography (CD) and bilateral pudendal nerve terminal motor latency (PNTML) assessment. PD of more than the upper limit of normal of 3.0 cm during evacuation was considered increased. PN was diagnosed when PNTML exceeded the upper limit of normal of 2.2 msec. Although 69 patients (34%) had PD, only 18 (27%) of these patients had neuropathy. Moreover, PN was also found in 41 of 136 patients (30%) without PD. Conversely, only 18 of 58 patients (31%) that had PN had PD and PD was present in 51 of 147 patients (35%) without PN. The frequency of PN according to the degree of PD was: 3.0-4.0 cm: 28%, 4.1-5.0 cm: 24%, 5.1-6.0 cm: 36%, 6.1-7.0 cm: 25%, and 7.0 cm: 0%. Spearman correlation coefficients were undertaken to compare the relationship between PD and PN. These values for all 205 patients were r = 0.10 (p -- 0.14), for the 69 patients with increased PD, r = -0 .06 (p = 0.64), and for the 58 patients with PN, r = 0.06 (p = 0.65). In summary, no correlation was found between PD and PNTML. The lack of a relationship was seen for the entire group, as well as for patients with increased PD or prolonged PNTML. This suggests that the often espoused relationship between increased PD and PN is incorrect. Specifically, although increased PD and prolonged PNTML may coexist, they are independent findings.

Physiology of Normal and Dysfunctional Reflex Defeca- tion

(34)

J.M. Stone, B.C. Cosman, V.A. Wolfe, M. Nino-Murcia, I. Perkash . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stanford, CA

Spinal cord injured (SCI) patients induce reflex defecation via digital stimulation. 29 asymptomatic (Asx) SCI patients and 20 symptomatic (Sx) SCI patients (> 60 min/day spent on bowel care, or need for routine manual disimpaction) were studied. Basal anal and rectal pressures, rectoanal inhibitory reflex (RAIR), ability to increase intrarectal pressure with Valsalva, effect of digital stimulation, and anal and rectal response to continuous filling of an intrarectal balloon (20 ml/min) were measured.

Sx (n=20) Asx (n=29)

Anal-basal (cm H20) 59.1+15.5 63.0+15.8 Rectal-basal (cm HaO) 2.7+3.3 3.1+-3.1 Valsalva (cm H20) 13.3+22.0 24.5+22.9 % w/Spont. Evac. of Rectal 25t 87f

Balloon

(+ p<.05, Student's t-test)


digital stimulation. During rectal filling, Asx patients had: 1) tight linkage between rectal and anal pressures (every rectal contraction associated with a decrease in anal pressure), 2) a threshold of rectal pressure (30 cm H20), above which anal pressure went to zero, and 3) sponta- neous evacuation of the rectal balloon when rectal pressure exceeded anal pressure (mean vol 241.6+96.1 ml). Sx patients displayed either loss of the linkage between rectal and anal pressures (dyssenergia), or insufficient expulsive forces (rectal pressure + Valsalva) to overcome sphincteric resistance.

We conclude: normal reflex defecation occurs when expulsive forces (rectal pressure + Valsalva) exceed sphincteric resistance. Digital stimulation lowers sphincteric resistance transiently, but does not cause rectal contraction. Patients with dysfunctional reflex evacuation have loss of coordination of rectal and anal pressures, or expulsive forces that are insufficient to overcome sphincteric resistance.

Pouches I

Obstruction After Ileal Pouch-Anal Anastomosis (IPAA) - - A Preventable Complication?

(35) P.W. Marcello, P.L. Roberts, D.J. Schoetz Jr., J.J. Murray, J.A. Coller, M.C. Veidenheimer . . . . . . . Burlington, MA

One of the most common complications after IPAA is small bowel obstruction (SBO). This review of 369 patients examines the frequency of SBO and determines potential risk factors. The leading indication for IPAA was ulcerative colitis (84%). In 1/3 of patients the loop ileostomy was rotated 180 ~ to facilitate ileostomy emptying and pouching.

Ninety obstructive episodes occurred in 76 patients (21%). Obstruction occurred after pouch creation (31 cases), ileostomy closure (22 cases), or subsequent follow up (37 cases). The mean length of stay related to the obstructive episode was 10 days. Operative intervention was required in 38% of cases. At surgery, the most common point of obstruction was at the ileostomy closure (53%). In 14 of 18 of these cases, the ileostomy had been rotated.

Multiple risk factors including age, sex, primary diagnosis, surgeon, pouch type, prior colectomy, steroid usage, stomal rotation, method of ileostomy closure, and prior obstruction were analyzed.

# Obstructed # Patients Rotated Stoma 39 122 (32%) Nonrotated Stoma 37 247 (15%)

P= 0.0003 (Fisher's Exact Test)

No differences between Sx and Asx patients were found in the threshold to induce RAIR, or the duration (Sx=21.2, Asx=28.1 sec) or magnitude (Sx=55.8, Asx=70.5% of basal) of anal relaxation after digital stimulation. There was no increase in rectal pressure after

Of all factors, only stomal rotation was statistically significant.

CONCLUSION: Rotation of the loop ileostomy during IPAA, while an apparent technical refinement, is unnec- essary and predisposes to obstruction.


Randomized Controlled Trial of Loop Ileostomy in Re- storative Proctocolectomy

(36)

M.R.B. Keighley, S.P. Grobler, K.B. HoMe Birmingham, United Kingdom

A randomized controlled trial assessed the role of loop ileostomy (LI) in totally stapled restorative proctocolectomy (TSRPC). Entry criteria included all patients who underwent TSRPC who were not receiving steroids and where on-table testing revealed a water-tight pouch with intact ileo-anal anastomosis. Of 59 patients undergoing RPC over a 36 month period, 46 were eligible for the trial (23 LI; 23 no LI).

The two groups were comparable for age and diagnosis. Median operating time was 180 min for RPC & LI and 45 min for LI closure, compared with 150 min for RPC without LI. There were no deaths. 12 patients developed complications of LI (1 fistula, 4 hernias, 4 re- tractions, 5 flux, 1 bowel obstruction). Ileoanal anastomotic leak occurred in 1 with LI and 2 without LI. The latter 2 required proximal diversion and repair. Ileoanal stenosis occurred in 4 with and 1 without LI. 1 patient in each group required pouch excision. The incidence of sepsis, obstruction and pouchitis was similar. Total hospital stay was 21 (range 13-75) days with LI against 13 (range 7-119) days without LI (p=0.1 Wilcoxon).

This trial revealed a 9% risk of ileoanal leak without covering ileostomy compared with a 30% incidence of serious loop ileostomy complications.

The Fate of Retained Mucosa After Non-Mucosectomy Ileoanal Reservoir

(37)

S.L. Schmitt, S.D. Wexner, K. James, F. Lucas, J.J. No- gueras, D.G. Jagelman . . . . . . . . . . Fort Lauderdale, FL

A study was undertaken to assess the incidence of inflammation and dysplasia in retained mucosa after non- mucosectomy ileoanal reservoir (IAR). Between Septem- ber 1988 and September 1991, 48 patients (pts) with mucosal ulcerative colitis (MUC) underwent an IAR. 37 pts had a double-stapled IAR (DS-IAR) and 11 pts had a transanal pursestring stapled IAR (PS-IAR). The distance from the dentate line to the ileoanal stapled anastomosis was a mean of 1.0 cm, ranging from 0-2.5 cm. Mucosa from the distal donuts of 37 patients was qualified as squamous epithelium (SE), transitional epithelium (TE), or columnar epithelium (CE), and was examined for evidence of inflammation or dysplasia. 12 pts had either SE, TE, or both, 13 pts had only CE, 1 pt had SE and CE, 2 pts had CE and TE, 7 pts had all 3 types, and in 2 there was no mucosa in the donut. There were 12 pts in whom the donut revealed ulcerative proctitis. 2 of these 12 pts had persistent MUC in follow-up biopsies obtained at 11 and 21 mo. after IAR. An additional 2 pts, with a history of MUC from 6-8 years, had MUC evident on follow-up biopsies but not on the distal donuts. None of the 14 pts with MUC present in either the donuts or subsequent biopsies were symptomatic. None of the specimens examined had any evidence of dysplasia. In 21 pts no MUC was present in either the initial donuts or follow-up

biopsies. The retained distal mucosa after non-mucosectomy IAR had not been associated with either dysplasia or symptomatic inflammation in any pt. The technique is safe although periodic monitoring is suggested.

Single Stage Rectal Mucosal Replacement (38)

Donald A. Peck . . . . . . . . . . . . . . . . . . . . . . San Jose, CA

Total colectomy and Rectal Mucosal Replacement with an ileal reservoir is an accepted alternative to total proctocolectomy in the management of familial polyposis and chronic ulcerative colitis. Replacement of rectal mucosa with an ileal reservoir conserves continence without the risk of recurrent disease or the development of carcinoma.

Colectomy and Rectal MucosaI Replacement is usually performed as a two stage operative procedure. The healing reservoir and the reservoir-anal anastomosis have been protected with a diverting ileostomy. In 1985 excellent results with the stapled reservoir-anal anastomosis prompted a trial of Rectal Mucosal Replacement without an ileostomy.

Eighty five of one hundred three patients (83.3%) have been managed with a one stage operative procedure over a six year period (1985 to 1991). Eleven patients had familial polyposis and the remainder underwent surgery for ulcerative colitis.

One stage patients had a resumption of bowel function two to seven days after surgery. Acceptable fecal continence was regained two to six weeks after operation. Seventy two patients had complete healing per primam of the stapled reservoir-anal anastomosis. Twelve patients had a minor partial separation and one patient had complete separation which healed by secondary inten- tion. There has been no pelvic sepsis. Ninety one percent of patients enjoy a good to excellent functional result. Stooling frequency averaged 5.8 in 24 hours.

Optimal surgical therapy for chronic ulcerative colitis or familial polyposis should include complete eradica- tion of the disease with preservation of fecal continence as a single operative procedure. Single stage total colectomy and Rectal Mucosal Replacement with an ileal reservoir fulfills these criteria.

Results of 3D Vector Manometry in Incontinent Patients After Ileal Pouch Anal Anastomosis (IPAA)

(39)

A. Ferrara, J.H. Pemberton, R.L. Grotz, R.E. Perry, R.B. Hanson . . . . . . . . . . . . . . . . . . . . . . . . . . . Rochester, MN

Incontinence can occur after IPAA. Conventional manometry has failed to determine the etiology. Aim: To analyze anal canal anatomy in continent and incontinent IPAA patients, using three-dimensional computerized vector manometry. Method: In 12 healthy controls (C), 9 continent IPAA patients (C-IPAA) and 10 incontinent IPAA patients (I-IPAA), manometry was performed using a flexible 4.8 mm 8-port catheter. Directional pressures were recorded at 0.5 cm intervals across the sphincter. The maximum average pressure (MAP; cm H20) at rest


and during squeeze at each 0.5 cm level was plotted as an anal vector diagram. The pressure vector volume (PW, mm/cm HiOX103) which measures sphincter efficiency was then calculated. The vector symmetry index (VSI) was calculated as the ratio of the smallest to the largest sector volumes. Table: Data (mean+SEM) were compared using Student's t-test (*=p<0.05).

Controls C-IPAA I.IPAA

Rest MAP 89+-7 71+8 39+-4* PVV 35+-5 29+6 8.3+-1" VSI .77+-.02 .69+-.1 .41+-.05"

Squeeze MAP 176+-13 1614-9 1494-15 PVV 186+-33 1954-25 148+-34 VSI .70+-.03 .684-.1 ,65+-.02

At rest, anal sphincter pressures, PVV and VSI were significantly reduced in I-IPAA compared to C and C- IPAA. During squeeze there were no differences among groups. Conclusion: Anal sphincter asymmetry, and sphincter inefficiency, not low resting pressures alone, are important determinants of incontinence after IPAA.

Ileal Pouch-Anal Anastomosis: Is It Ever Too Late? (41)

T.G. Perry, S.A. Strong, V.W. Fazio, I.C. Lavery, J.R. Oakley, J.M. Church, J.W. Milsom . . . . . Cleveland, OH

Proctocolectomy and ileal pouch-anal anastomosis (IPAA) has emerged as a standard of care for patients needing operative treatment of ulcerative colitis. Despite this, some surgeons are reluctant to perform an IPAA in the older patient because of alleged morbidity and poor functional results.

The purpose of this study was to determine morbidity and functional outcome in "older" patients (>-50 y/o) undergoing IPAA compared to those younger (<50 y/o).

All "older" patients receiving an IPAA between 1985 and 1990 were studied. Collected data included operative morbidity (MB) and mortality, post-IPAA maximal resting (MRP) and squeeze (MSP) pressures, nocturnal seepage (NS), stools per day (S/D), quality of life index (QLI), and follow-up. The younger patient group of matched gender, pouch configuration, and anastomotic technique was randomly chosen.

With a median one year follow-up, (age:median, others:mean+se),

Restorative Proctocolectomy (RP) with Intact Anal Sphincter in Patients over the Age of Fifty

(40)

W.G. Lewis, P.J. Holdsworth, P.M. Sagar, D. Johnston Leeds, Yorkshire, England

RP is the operation of choice for "young" patients with UC, but the Mayo report of bowel frequency of 11 in 24 h after RP+J pouch in patients over 50, (cf 7, <50 yr) has, together with considerations of risk to life, tended to limit the use of RP to younger patients.

Between 1986 and 1991, 18 patients aged 50 to 66 yr underwent RP with ileo-anal anastomosis, end to end without mucosal stripping (12W, 4J, 2 no, reservoir). The results were compared (Table) with those of 18 matched patients (same sex, reservoir, operative technique, follow up) aged under 50 (median, 34 yr).

Over 50 Under 50 yr

Max. RAP 80 77* Bowel freq/24 h 5 (2-9) 4 (2-9)* Defer > 30 min 14 17" Discriminate flatus 12 I7" Clinical failure 0 0

RAP = Resting anal pressure * P= NS

Thus, function of the anal sphincter was well preserved in the older patients after RP without mucosal stripping. The clinical outcome was slightly (NS) inferior to that of younger patients. RP with intact sphincter is recommended for use in "fitter" older patients with UC.

MB MRP* MSP* NS* S/D* QLI N AGE % mmHg mmHg % 1-10

>50 42 56 31 46+-13 169+-84 67 7.5+-2.4 8.6 <50 40 31 30 62+20 223+84 23 5.9+-1.5 8.5

* p<0.05; chi-square, Fisher's Exact

Neither group suffered an operative mortality. IPAA can be performed in "older" patients without

increased operative risk. Ileal pouch-anal anastomosis is a reasonable option in the patient over 50 years of age requiring operative therapy for ulcerative colitis.

Pregnancy, Birth and the Ileal Pouch-Anal Anastomosis (42)

J.B.J. Fozard, H. Nelson, R.R. Dozois .. Rochester, MN

Women undergoing ileal pouch-anal anastomosis (IPAA) are frequently within reproductive years and eager to bear children. Management issues have been raised regarding the effects of pregnancy and delivery on the pouch, particularly with respect to obstetrical care. We have updated our experience to search for delayed sequelae of delivery and to establish whether multiple pregnancies have an adverse effect on pouch function.

We reviewed the records of 43 women who had a successful pregnancy and delivery following IPAA, including eight women with more than one pregnancy (2 to 3). Pregnancy was generally well tolerated with the exception of one episode of pouchitis and three episodes of intestinal obstructive symptoms, all managed nonop- eratively. Twenty-four women had a vaginal delivery and


19 had cesarean section. Stool frequency (p < 0.01), fecal spotting (p < 0.01) and pad usage (p < 0.05, sign rank test) were significantly increased during pregnancy, but prepregnancy function was restored following delivery. Multiple births, length of labor, vaginal delivery, and birthweight had no adverse permanent effect on subsequent pouch function. Longer follow-up after vaginal delivery (mean, 3.4 years; range, 1-7 years) demonstrated no compromise of pouch function.

Pregnancy and childbirth are well tolerated in women who have undergone the IPAA procedure. Provided there are no obstetric contraindications, a vaginal delivery with mediolateral episiotomy can be recommended.

Colon Cancer

The Role of CEA in Predicting Resectability of Recurrent Colorectal Cancer

(43) S. Schneebaum, M.W. Arnold, D. Young, G.J. LaValle, L. Petty, A. Berens, C. Mojizisik, E.W. Martin

Coiumbus, OH

The reported low resectability rate for patients with recurrent colorectal cancer and carcinoembryonic anti- gen (CEA) levels > 11 have led us to perform this study. 119 patients who underwent Radioimmuno-guided surgery for recurrent colorectal cancer from 1986 to present were studied. In surgery, all patients underwent a tradi- tional exploration followed by survey with a hand-held gamma-detecting probe. Sites of metastases included: 67 liver (58.0%), 22 pelvis (18.5%), 15 distant lymph nodes (12.6%), 2 anastomotic (1.7%), and 11 other sites (9.2%). Resectability rate was 43.5% (52 patients). The mean preoperative CEA level was 65.I. The mean preoperative CEA level for patients with resectable disease was significantly lower (p = .017):

Mean STD Min Max

Nonresectable 82.1 141.0 0.3 501 Resectable 36.6 59.3 0.3 329

The CEA level for patients with liver metastasis did not vary significantly from those patients without, 70 vs 58.2 (p = 58). Those patients with resectaMe liver tumors had lower mean CEA levels than those with unresectable liver approaching significance, 41.6 vs 91.9 (p = .065). Other metastatic sites had a mean CEA level of: pelvic 72.6, distant lymph nodes 47.8, anastomotic 2.7, and other 53.8. Our data suggests that there is a significant difference between the preoperative CEA level of the resectable and nonresectable recurrent colorectal cancer patients, but the large standard deviation does not justify abandonment of exploration for any CEA level.

Relation Between Sialomucin at the Resection Margins and Recurrences and Survival in Patients with Rectal Cancer

(44)


Although the likelihood of tumor recurrence and sialomucin at resection margins has been studied in patients with colorectal cancer, this is to our knowledge, the first time that patients with rectal cancer undergoing anterior or abdominoperineal resections have been analyzed for this association.

Sialomucin at the resection margins of 93 patients was analyzed retrospectively using high iron diamine alcian blue stain.

Patients with abnormal sialomucin content at the resection margin underwent more palliative resections (33.3% vs. 14.5%, p=0.0001), had more local recurrences (33.3% vs. 10.1%, p--0.02) and no relation with distant recurrences was noted.

Considering only those patients undergoing "curative" resections, the sialomucin positive group had five times more local recurrences (43.7% vs. 8.5%, p=0.0025) and much worse survival (5 year = 71.3% vs. 34.3%, p=0.002). Again, no relationship with distant metastases was found (p NS). Using multivariate analysis siatomucin was an independent prognostic variable both to predict local recurrences and survival.

It is concluded that patients with an abnormal sialomucin pattern at the resection margins have more local recurrences and worse survival.

Prognostic Value of Tumor "Budding" in Patients with Colorectal Cancer

(45) K Hase, C. H. Shamey, M. Trollope, D. Johnson, M. Vierra . . . . . . . . . . . . . . . . . . San Jose, CA, Palo Alto, CA

From 1970-85 663 patients underwent curative resection of colon and rectal adenocarcinomas. All surgical specimens were examined retrospectively for histologic evidence of tumor "budding", defined as small clusters of undifferentiated cancer cells ahead of the invasive front of the lesion. Patients were divided into two groups according to degree of budding: none or mild (BD-1) and moderate or severe (BD-2). BD-1 occurred in 493 patients (74.4%), and BD-2 was found in 170 patients (25.6%). More severe budding was associated with sig- nificantIy worse outcome: 55.4% of BD-2 patients had recurrence, compared with 11.2% of BD-] patients (p<0.005). The five-year cumulative survival rate was worse in BD-2 than BD-1 (22.2% vs 70.7%; p<0.001). The 10-year cumulative survival rate was also worse in BD-2 than BD-1 (13.8% vs 50.6%; p<0.001). As might be expected, the incidence of BD-2 rose with the Dukes' stage: 1.8% in Dukes' A, 15.5% in Dukes' B, and 49.2% in Dukes' C. However, the five-year cumulative survival rate of Dukes' B patients with BD-2 lesions was worse


than that of Dukes' C patients with BD-1 cancers (29.1% vs 66.2%; p<0.001). Moreover, there was no difference in five-year survival among BD-1 patients with either Dukes' B or C lesions (68.0% vs 66.2%). The presence of more severe budding appears to indicate a vigorous biological activity of colorectal cancer. Thus, meticulous followup--and possibly adjuvant chemotherapy--may be beneficial for patients with marked budding, regardless of their Dukes' stage.

Malignant Obstruction of the Large Bowel--One Stage Subtotal Colectomy

(46)

A.A. Deutsch, H. Tulchinsky, I. Nudelman, H. Gutman, R. Reiss . . . . . . . . . . . . . . . . . . . . . . Petach-Tiqua, Israel

Thirty-eight patients with obstructing carcinoma of the left colon were treated by subtotal colectomy and ileocolic or ileorectal anastomosis. There were 21 males and 17 females aged 51-83 years (mean age 71 years). The mean symptomatic period was 90 hours. All patients had abdominal pains and obstipation, 47% vomited, and 6% bled rectally. Abdominal distention was pronounced in 70%. There was an abdominal mass in 11% and a rectal lesion in 6%. The site of the tumor was rectum 3%, and colon in the remainder. The tumors, adenocarcinomas, were well or moderately differentiated in 94%. Twenty- three percent had liver metastases. Post operative complications included wound infections 8% and intra-abdominal infections 24%. Fourteen percent had anastomotic complications requiring surgery. Seven patients died (18%), in three cases mortality was connected to anastomotic complications. Mean follow-up on 25 patients was 4.6 years (1 to 12). Bowel movements averaged 3.5 daily at three months and 1.5 at one year. Ten died of extention of their disease and five of unrelated causes. Survival was 45% at five years and 25% at ten. Subtotal colectomy relieves obstruction, resects the tumor, restores continuity and eliminates the risk of additional tumors. Morbidity and mortality rates are acceptable in this high risk group.

Recommendations for Optimal Followup of Colon Can- cer--Results of a Prospective Surgical Series

(47)

Brian M. Taylor, A. Araujo . . . . . . . . . . London, Ontario

We followed prospectively 164 patients surgically treated for carcinoma of the colon. A history and physical, routine hematology, liver function tests, and CEA determination were done every 3 months. At yearly intervals colonoscopy or barium enema exam was performed, along with routine blood work, ultrasound, chest x-ray, and CT or MRI scan selectively as indicated. A combination of CEA and clinical exam detected the recurrence initially in 87% of patients. CEA sensitivity was 92% in patients with liver metastases, but only 62% in patients with isolated pelvic recurrences. Mean post-recurrence survival was longest (38 months) in those patients de-


tected by CEA elevation and undergoing "second-look" operation and curative resection. Twenty-four percent of patients with recurrences were resectable. Colonoscopy and barium enema were of low value (6%) in detecting recurrence of the initial tumor. Routine hematology, liver function tests, and ultrasound were not helpful in followup. Optimal followup should be based simply on CEA testing and clinical exam.

Increased Risk of Early Colorectal Neoplasms After He- patic Transplant in Patients with Inflammatory Bowel Disease (IBD)

(48)

R. Bleday, E. Lee, J. Jessurun, J. Heine, W.D. Wong Boston, MA

Inflammatory bowel disease (IBD) is associated with an increase in colon and rectal carcinoma. Immuno- suppression after transplantation increases the incidence of certain types of tumors. We reviewed the postoperative course of IBD patients who had undergone hepatic transplantation for primary sclerosing cholangitis (PSC) to see if there was an increase in the rate of colorectal neoplasms. The charts of 43 patients from two institu- tions who had undergone a hepatic transplant for PSC were reviewed. Of these 43 patients, 32 had IBD (30 chronic ulcerative colitis (CUC), 2 Crohn's). Of these 32 patients, two had previously undergone total colectomy/ proctectomy and four died in the perioperative period. The remaining 26 patients had all undergone colonoscopic evaluation just prior to transplant. Postoperatively all patients were given prednisone, cyclosporine, and imuran. Minimum follow up was 6 months; median follow up was 37 months. Three of the 26 patients (11.5%) developed early colorectal neoplasms (2 cancers, 1 large villous adenoma with severe dysplasia) at 5, 12, and 13 months posttransplant. All three patients were successfully treated with resection of all the colon and rectum. These 3 patients had a mean 18 year history of IBD (range 9-27), while the 23 patients without tumors had a mean 22 year history of IBD (range 6-39). We conclude that there is a subset of transplant patients with PSC and IBD who rapidly develop colorectal neoplasms in the posttransplant period. Frequent endoscopic surveillance is recommended especially in the first year post-op.

Anorectal Benign

Treatment of Delayed Hemorrhage Following Surgical Hemorrhoidectomy

(49)

Les Rosen, Paul Sipe, Robert Riether, John Stasik, James Sheets, Indru Khubchandani . . . . . . . . . . Allentown, PA

Delayed hemorrhage following surgical hemorrhoidectomy is a well recognized complication. Emergency treatment may include surgical ligation or other means of tamponade. At The Allentown Hospital--Lehigh Val-


ley Hospital Center, 27 patients were seen with this complication from 1983-1990. The mean interval from operation to hemorrhage was 6 days. Twenty-five patients (92%) underwent surgery primarily for hemorrhoidal disease; 1 patient had hemorrhoids removed in addition to a sphincterotomy for anal fissure, and the remaining patient had hemorrhoidectomy with fistulotomy. On admission 1 patient (3%) presented in shock, 5/27 patients (18%) required blood transfusions and 10/27 (37%) were on anticoagulants. Treatment modalities included bedside anal packing in 20 patients (74%), observation alone in 5 patients (18%), and 2 patients (7%) underwent surgical ligation in the operating room. Of the 20 patients who were packed, none required further surgery for hemorrhage, but 7/20 (35%) developed complications; anal fissure (4 patients), recurrent hemorrhoidal symptoms (2 patients), and abscess-fistula (1 patient). Three of these seven patients required surgery which included sphincterotomy, hemorrhoidectomy, and fistulotomy respectively. Anal packing was successful in con- trolling postoperative hemorrhage in 20/20 patients, but late complications requiring reoperation developed in 3/20 (15%).

Is Aggressive Management of Perianal Ulcers in HIV- Positive Patients Justifiable?

(50) S.L. Schmitt, S.D. Wexner, W. Reiter, G. Friedberg, G. Morey, J.J. Nogueras . . . . . . . . . . . . Fort Lauderdale, FL

A study was undertaken to assess the etiology, optimal diagnostic method, preferred treatment, and incidence of perianal ulcers in HIV+ patients (pts). Between De- cember 1989 and August 1991, 21 HIV+ homosexual or bisexual males were referred with perianal ulcerations. According to the Centers for Disease Control criteria, 13 (62%) were Class IV, 6 (29%) were Class III, and 2 (9%) were Class II. 15 pts. had one ulcer, 3 had two ulcers, and 3 had three ulcers. Ulcer diameters ranged from 0.5-0.9 cm in 5 pts., 1-2 cm in 14 pts., 3 cm in 1 pt., and circumferential in 1 pt. Biopsies in 18 pts. were obtained for routine microscopy, HIV, cytomegalovirus (CMV), herpes simplex virus (HSV), and acid fast bacilli. Microscopy revealed CMV in 2 specimens, HSV in 1, and an immunoblastic lymphoma in 1. Cultures were positive for CMV in 1 specimen and HSV in 6. A positive HIV probe was the only finding in 2 pts. Thus, cultures had greater sensitivity of diagnosis than did routine microscopy. Medical treatment included reverse transcriptase inhibitors such as Zidovudine, oral and topical Zovirax, IV Ganciclovir, and oral broad spectrum antibiotics. Sur- gical treatment included 4 lateral internal sphincterotomies and 1 seton placement. 4 of these 5 pts. wounds healed. The fifth pt. died before adequate follow-up could be obtained. Overall, healing occurred in 13 pts (62%): 8 Class IV (62%), 3 Class Iit (23%), and 2 Class I I (15 %). In conclusion, appropriate aggressive diagnostic maneuvers allow the use of both medical and con-

servative surgical measures to successfully treat the majority of HIV+ patients.

Subcutaneous Morphine Pump for Post Operative Hemor- rhoidectomy Pain Management: A Pilot Study

(51)

E. Goldstein, P. Williamson, S. Larach . . . Orlando, FL

Many anorectal procedures are currently being performed on an outpatient basis, hemorrhoidectomy being the exception due to the need for parenteral narcotics postoperatively and the fear of urinary retention. We investigated the effectiveness of a subcutaneous morphine pump (SQMP) for outpatient post hemorrhoidectomy pain control.

Twenty-two patients undergoing radical hemorrhoidectomies were started on a SQMP protocol postoperatively. A control group of 29 patients received IM and PO pain medication postop. No patient in the study group and two in the control group required additional hospitalization beyond 23 hours for pain control. The rate of catheterization was similar in both groups. Pain control was considered satisfactory in 21/22 study patients. There was no correlation between pain level and SQMP dose taken. Minor side effects were experienced by 18/22 patients and necessitated early pump removal in 2 patients.

The combination of outpatient hemorrhoidectomy and SQMP provides substantial potential cost savings compared with either 23 hour stay or inpatient admission. Our conclusions are that the SQMP 1) provides effective pain relief after a hemorrhoidectomy, 2) does not alter the incidence of catheterization, 3) alleviates the need for in hospital parenteral analgesia, 4) has a high rate of patient satisfaction, and 5)offers a cost effective method of outpatient pain control as compared with hospitalization for parenteral analgesia.

Laser Hemorrhoidectomy: "Enlightened Surgery" or a Flash in the Pan?

(52)

A.J. Senagore, M.A. Luchtefeld, J.M. MacKeigen, W.P. Mazier, T. Wengert . . . . . . . . . . . . . . . Grand Rapids, MI

There has been little scientific evaluation of the use of the Nd:YAG laser for excisional treatment of hemorrhoidal disease. The purpose of this study was to perform a prospective randomized study of the Nd:YAG laser vs. scalpel excision, when performing a standard Ferguson closed hemorrhoidectomy. Patients presenting for internal-external hemorrhoidectomy were eligible for study. Hemorrhoidectomies were performed under epidural or caudal blocks. The standard Fergnson closed hemorrhoidectomy technique was used. Data evaluated included: age, sex, estimated blood loss, operative time, postoperative pain scores, postoperative analgesic use, wound healing, and time for return to work. Fifty-eight patients were eligible for study (laser N=32; scalpel N--26). There were no significant differences in terms


of operative duration, estimated blood loss, postoperative pain within 48 hours, inpatient or outpatient analgesic use, duration of hospital stay, or time off from work. The only significant difference between the groups was a greater degree of wound inflammation and dehis- cence at the ten day postoperative visit for the laser group (laser 1.7+.2; scalpel 0.75+.2; p<0.05 t-test). An- other very significant difference between the two groups was the added cost of $480 per case for use of the Nd:YAG laser. Therefore, the results indicate that there are no patient care advantages to the use of the Nd:YAG laser for excisional hemorrhoidectomy compared to scalpel excision. As new technology becomes available surgeons must rigorously assess therapeutic efficacy and cost-benefit ratio when deciding to employ this technology to patient care.

Aggressive Surgical Management of Refractory Pelvic Endometriosis

(53) M.T. Ott, H.R. Bailey, P. Hartendorp . . . . . Houston, TX

The authors have followed a policy of aggressive surgical management of colorectal involvement with refractory pelvic endometriosis and attempt is made to remove all visible bowel endometriosis by resection or laser vaporization of superficial nodules along with gynecologic management. Fifty women who had undergone low anterior resection for endometriosis were interviewed by an independent examiner a median of 5.9 years following their operation. 75% of the patients had undergone previous surgical procedures for endometriosis and 88% had been treated with hormonal suppression without success. Results of the survey revealed that pelvic/ rectal pain had disappeared or significantly improved in 92/96% of patients. Dyspareunia disappeared or improved very significantly in 89% and cyclic rectal bleeding was relieved in 89%. 66% of patients undergoing a fertility preserving operation were subsequently able to conceive. This was accomplished with low morbidity (no deaths, no anastomotic leaks, and one pelvic abscess). These data suggest that aggressive colorectal resection combined with gynecologic procedures to erad- icate pelvic endometriosis is highly effective in relieving pelvic and rectal pain, dyspareunia, and cyclic rectal bleeding. This can be accomplished with an acceptable fertility rate and, in experienced hands, with minimal morbidity.

Ulcerative Disease of the Anorectum in the HIV+ Patient (54)

M. Viamonte, T.H. Dailey, L. Gottesman New York, NY

Ulcerative processes are the most disabling of anal diseases in HIV+ patients. The spectrum ranges from "benign" fissures to invasive ulcerative processes. It is important to recognize their salient features in order to effectuate proper management.


Since 1989 74 HIV+ patients with ulcerative anal disease were evaluated. Of 33 patients with "benign" fissures, 13 had sphincterotomy, with symptomatic relief in 12 and healing in 11. 10 had improvement with standard conservative treatment and 10 did not return for reevaluation. Of 41 patients with "pathological" anal ulcers, 34 underwent operative evaluation, biopsy, viral culture, and debridement when indicated. 30 had significant pain relief and 17 showed evidence of healing. 4 patients with intractable pain had injection of Depomed- rol into the bed of the ulcer with significant pain relief. One patient was diverted.

We propose that anal ulcerative disease be classified into "benign" lesions and therefore treated as if HIV negative. In those patients with "pathological" ulcers, EUA, BX, culture and debridement should be performed and therapy directed against any neoplastic or viral agents found. Those patients with no identifiable agents may be helped with intralesional steroid therapy. This approach allows safe and effective treatment.

Pelvic Abscess After Colon and Rectal Surgery: What is Optimal Management?

(55) W.E. Longo, J.W. Milsom, I.C. Lavery, V.W. Fazio, J.C. Church, J.R. Oakley . . . . . . . . . . . . . . . . Cleveland, OH

The aim of this study was to compare treatment outcomes in the management of pelvic abscess (PA) after rectal surgery. METHODS: Over a 12 year period PA occurred in 56 patients who underwent rectosigmoid resection. The APACHE II Score was used to stratify illness. RESULTS: CT = CAT Scan; ANAS = Primary Anastomosis; IBD = Inflammatory Bowel Disease.

Treatment No. ANAS IBD Success APACHE II ~

Percutaneous-CT 13 10 5 85% 8.7 Transperineal 15 9 6 80% 8.2 Laparotomy 17 16 7 88% 9.6 Antibiotics 11 8 6 64% 8.8

p = NS between all groups. Chi-square Analysis.

The mean age at diagnosis was 39.2 years. Postopera- tive PA developed in patients with cancer (32%), ulcerative colitis (26%), diverticular disease (24%), and Crohn's colitis (18%). Overall, 24 (43%) of PA were after operations for IBD and 43 (77%) of PA were after ANAS. Recurrent PA developed in 10/56 (18%) of which seven required additional surgery. There were three deaths as a result of PA, 2 after laparotomy and i after percutaneous drainage. Long-term sequela in ANAS patients included loss of intestinal continuity (10/43) and anastomotic stenosis (7/43). There was no difference in APACHE II Score among the four treatment options. The mortality rate was 75% among patients whose APACHE II Scores were greater than 15. SUMMARY: Development of a PA after rectosigmoid resection was met with a 5% mortality,


and 39% functional morbidi ty (23% permanent stoma and 16% stricture rate).

CONCLUSION: CT-guided percutaneous or transperineal drainage of PA are as effective as laparotomy and should be a t tempted initially. Long term functional dis- ability is common after PA in rectal surgery with ANAS.

Constipation

Perineal Rectosigmoidectomy in the Elderly (56)

O.B. Johansen, S.D. Wexner, N. Daniel, J.J. Nogueras, D.G. Jagelman . . . . . . . . . . . . . . . . . Fort Lauderdale, FL

Between April 1989 and April 1991, 18 consecutive patients (pts) who underwent per ineal rectosigmoidectomy for a full thickness rectal prolapse were evaluated. These 14 females and 4 males of a mean age of 83 (range 71-101) years were evaluated by detai led functional assessment and physiological testing. A grading scale from 0-20 was based upon the frequency and type of incontinence, 0 represent ing full continence. 12 pts had frequent incont inence to both solid and liquid stools (mean cont inence grade 12), while the other 6 had lesser degrees of incontinence. The mean preoperat ive (preop) cont inence grade was 10. The mean length of rectosigmoid resected was 23 (range 7-40) cm. There was 1 postoperative (postop) death, and no significant local or systemic complications. Mean length of hospitalization was 7 (range 5-10) days. There were no recurrences at a mean follow-up of 18 (range 4-26) months. 8 of the 18 pts demonstra ted marked improvement in their postop continence, 8 had no change or moderate improvement, and 1 had deteriorat ion of function. The cont inence score for the entire group improved to 4.9 and to 6.6 in the most severely incontinent 12 pts. 6 of the 10 pts who underwent preop pudendal nerve terminal motor latency (PL) testing had markedly p ro longed latencies (> 2.2 msec). Prolonged PL was not shown to adversely affect postop cont inence as 5 of these 6 pts regained good to excel lent control. Perineal rectosigmoidec tomy is a safe, effective operat ion which can also improve fecal continence. Furthermore, p ro longed pudendal nerve latency does not appear to be a predictor of postop continence.

2 -9x (6). Small bowel TT was delayed in 11 (60-210 min, mean 125 min). A good result was obtained in 4 pts. Both groups were compared.

results good poor

pts 4 10 def. freq. preop 1/7d 1/6d def. freq. postop 3dd 1/3d colonic TT 5x 4x

SCTT right colon 4x 4x SCTT left colon 4x 4x SCTT rectosigmoid 6x 7x

small bowel TT 50 m 138 m

Results are poor when small bowel transit is delayed. Small bowel TT is a good parameter to predict the functional result after subtotal colectomy. "Slow Transit constipation" is a intestinal rather than a colonic disorder.

Subtotal Colectomy for ConstipationkA Long Term Fol- low-Up Study

(58)

J.P. Pena, J.A. Heine, W.D. Wong, C.E. Christenson, E.G. Balcos . . . . . . . . . . . . . . . . . . . . . . . . . Minneapolis, MN

Between 1976 and 1991, 105 pts. underwent subtotal colectomy for constipation. There were 3 postoperat ive deaths (2.8%). Small bowel obstruction deve loped in 25 pts (24%) with 12 (11%) requiring enterolysis. Eigh- tyone (78%)- -74 females and 7 m a l e s - - w e r e available for functional review. Mean age was 43 yrs. (range 21- 82 yrs.) and mean follow-up was 8 yrs. (range 1-15 yrs.). Long-term results were analyzed in 3 groups of 5 year intervals.

Group # Pts. Follow-up

I 21 1-5 yrs. II 46 6-10 yrs. III 14 11-15 yrs.

Factors analyzed included the following:

Slow Transit Constipation is a Systemic Rather Than a Colonic Disorder

(57) M. Korst, H.C. Kuijpers . . . Nijmegen, The Netherlands

From 1981 to 1990 subtotal colec tomy was performed in 14 pts with slow transit constipation (STC: delayed transit through all 3 colonic segments & normal rectal evacuation). 13 were female. Ages varied from 31-58 (40) years, defecation frequency from 1/1 d to 1/14 d (1/6 d). Defecography and pelvic floor EMG revealed normal pelvic floor function during straining. Mean total CTT (colonic transit t ime) was delayed 3 - 5 x (4), right CTT 1-8x (4) left CTT 1 -7x (3) and rectosigmoid CTT

Factors PreOp PostOp #ets. (%) #Pts. (%)

straining >20 min. 51 (63) 8 (10) Diarrhea 0 (0) 22 (27) Abd. Pain 57 (70) 19 (23) Bloating 43 (53) 18 (22) Laxative Use 76 (94) 23 (28) Enema Use 52 (64) 13 (16)

Stool frequency varied from 1 BM every 1 to 4 wks. preoperat ively and averaged 3 BM's/day postoperatively. Eighty-nine percent expressed satisfaction with the out-


come. There was no statistically significant difference with respect to factors analyzed between the 3 groups, indicating that the benefit achieved by this procedure persists long term.

IBD, Laparoscopy

Quality of Life After Restorative Proctocolectomy Com- pares Favorably with That of Medically Treated Colitics

(59)

P.M. Sagar, W. Lewis, PJ. Holdsworth, C. Mitchell, J. MacFie, D. Johnston . . . . . . . . . . . . . . . . Leeds, England

There remains some reluctance amongst physicians to refer patients for restorative proctocolectomy (RP). They argue that their patients would be worse off with a pouch because of urgency and frequent bowel actions. The aim of this study was to compare quality of life in patients who had undergone RP with that of patients with ulcerative colitis on long term medical treatment. A detailed questionnaire and tee Hospital Anxiety and Depression (HAD) test were completed by 84 patients who had undergone RP and by 60 medically treated colitics considered to be in remission. Patients with a pouch had a greater frequency of bowel action (4/24 h (3-6) vs. 2/ 24 h (1-3) P<0.01) but less urgency of defaecation (11/ 84 vs 43/60 P<0.001) than medically treated colitics. Efficiency of evacuation, discrimination between flatus and feces, use of perianal pads and perianal soreness were similar. Use of antidiarrhoeal medication was more common in the pouch group (57% vs 10%, P<0.05) whereas steroid use was more common in medically treated patients (33% vs 0%, P<0.05). Limitation of social activity and HAD anxiety and depression scores were significantly higher in medically treated patients. Quality of life in patients with a pouch appears to be as good as that of medically treated colitics.

Endosonographic Differentiation of Mucosal and Trans- mural Nonspecific Inflammatory Bowel Disease

(60)

U. Hildebrandt, K.W. Ecker, J. Kraus, T. Schmid, G. Feifel Homburg, Germany

~f the colectomy in inflammatory bowel disease is indicated it is of critical importance to know whether the disease affects only the mucosa of the colon such as in ulcerative colitis or whether it extends transmurally. In those patients in whom the disease affects only the mucosa of the colon restorative proctocolectomy with ileal reservoir is the ideal surgical procedure. With the Olympus ulttrasoundcolonoscope we examined 57 patients with nonspecific inflammatory bowel disease and classified the inflammation as mucosal or transmural. Mucosal inflammation is endosonographically characterized by the five-layer structure of the wall with thickening of the submucosa. Transmural inflammation is endoson- ographicaiiy defined as sectional interruption or toss of the five-layer structure. By this definition 18 patients had mucosal and 39 patients transmural inflammatory bowel disease. In 24 of the 57 patients a colectomy was per-

formed. The preoperative endosonographic definition of mucosal (9 of 24) and transmural (15 of 24) was compared with the endoscopic and histologic findings. The endosonographic definition was consistent in all cases with the histologic findings of mucosal and transmural inflammation. Endoscopy was consistent with the histologic diagnosis in 7 of 9 (mucosal) and 12 of 15 (transmural) cases.

In summary a colon with transmura! inflammation (Colitis Crohn) can be excluded from not indicated ileoanal pouch construction.

Long-Term Follow Up of Strictureplasty in Crohn's Dis- ease

(61)

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

Most series on strictureplasty (SXPL) in Crohn's disease comprised small numbers of patients with a short follow up. We reviewed 116 ~atiems with obstructive Crohn's disease undergoing 452 primary SXPLs (Hei- necke-Mikulicz, 405; Finney, 47). Twelve patients subsequently required a further 39 SXPLs (redo group). The median age was 34 years (range 13-72 years), M:F was 1.4:1 and the median follow up was 3 years (range 6M- 7 years). Perforative disease was present in 15% and 66% of patients had 1-4 previous bowel resections. The median number of SXPLs was 3 (range 1-15) and 61% of patients had synchronous resection. There was no mortality and SXPL-related morbidity was 14%: fistula/abscess 6%; hemorrhage 4%; prolonged ileus or bowel obstruction 4%. Septic complications were more common after redo-SXPLs (20% vs. 6%). Relief of obstructive symptoms was achieved in 99% of patients. After SXPL, median weight gain was 4 kg. and half the patients were weaned off steroids. Symptomatic recurrence occurred in 28 (24%) of patients and 17 (15%) patients needed reoperation_ Rates of restricture, new stricture and perforative disease were 2.8%; 18% and 4% respectively.

Conclusion: Strictureplasty is an effective and safe treatment for selected Crohn's strictures. Redo-SXPLs may have a higher morbidity. Recurrent symptoms are mainly due to disease in a new site.

Laparoscopic Bowel Resection (62)

Steve Scoggin, Richard C. Frazee . . . . . . . Temple, TX

The use of laparoscopic surgical techniques are now being applied to a variety of operations traditionally performed in an open fashion. Ten patients underwent laparoscopically guided large and small bowel surgery at our institution from 3/21/91 to 10/10/91. The indications for surgery included polyps, obstruction, and perforation and pathologic diagnoses included benign polyps, lipoma, inflammatory bowel disease, perforation of a jejunal diverticulum, colonic arteriovenous malforma- tions, and adenocarcinoma. Mobilization of the colon, ligation of the mesentery, and closure of the mesenteric defect was performed using the laparoscopic equipment.


One trocar site was enlarged to 3 cm. to deliver the bowel through the abdominal wall. All anastomoses were hand sewn extracorporeally. Postoperative hospitalization ranged from 3-17 days (median 4 days). There was no mortality or major morbidity. The patient who remained in the hospital for 17 days suffered from a severe postoperative urinary tract infection and a patient who remained in the hospital 12 days was severely malnour- ished secondary to inflammatory bowel disease but was discharged tolerating a diet. We conclude that laparoscopic guided bowel surgery is technically feasible and should translate into shorter hospitalization and less patient discomfort.

Methods. Nine patients (8 F, 1 M) were included in this study (fist = fistula, res = resection).

Sex Age Indication Procedure

F 44 Crohns, RV fist loop ileost* M 70 villous adenoma sigmoid res F 77 colon scleroderma loop ileost* F 33 fecal incont loop colost* F 35 Crohns, RV fist loop ileost* F 24 Crohns, anal fist loop ileost* F 48 fecal incont end colost* F 51 ileocolic Crohns ileocol res F 31 ileocolic Crohns ileocol res*

* plus adhesiolysis, previous surgery

Iaparoscopic-Assisted Partial Protectomy with Transanal Anastomosis: A Series of Six Cases

(63)

W.L. Ambroze Jr., C. Nezhat, E. Pennington, F. Nezhat Atlanta, GA

Symptomatic, deeply penetrating endometriosis of the rectum refractory to medical therapy usually requires open laparotomy with bowel resection and reanastomosis.

Aim: to use the laparoscope to mobilize the rectum so that it can be prolapsed through the anal canal, the bowel incorporating the lesion resected, and an anastomosis performed transanally.

Methods: Six females, mean age 32 years (range 27- 40 years) with symptomatic, extensive pelvic endometriosis underwent full mechanical and antibiotic bowel preparation followed by laparoscopic COg laser ablation of pelvic endometriosis. Five patients underwent ureter- olysis, one patient a right oopherectomy, one patient an appendectomy for appendiceal endometriosis. In each patient the rectum was mobilized to the levator ani muscles, and the rectum prolapsed through the anal canal. One patient with a deeply invading anterior lesion had the anterior rectum resected with linear stapled closure of the colotomy. Five patients had circumferential resections for stricturing lesions with circular stapled anastomosis.

Results: Incomplete anastomosis found at the time of surgery required open laparotomy and reanastomosis in one patient. The five patients not requiring laparotomy had an operating time of 198 + 15 minutes (mean + SEM), estimated blood loss of 76 + 12 cc, and hospital stay of 5 + 1 days. There were no visceral injuries or clinical anastomotic leaks.

Conclusions: Using the laparoscope a partial proctectomy can be performed safely for benign disease.

Laparoscopic Intestinal Surgery: A Preliminary Report (64)

V.M. Stolfi, J.W. Milsom, V.W. Fazio, J.M. Church Cleveland, OH

Laparoscopic cholecystectomy is now accepted as a standard surgical procedure. The aim of this study was to evaluate the feasibility of laparoscopic intestinal surgery.

Results. There were no intra- or postoperative complications. All resections were accompanied by primary anastomosis (extracorporeal). In one case of ileocolic resection for Crohns, after laparoscopic enterolysis, a conventional laparotomy was performed. Mean time to complete stoma: lh55m ( lh l0m-4h) ; for a bowel resection: 3h50m (3h30m-4h20m). Mean time to pass stool spontaneously: 4.1+0.5 days; to resume a soft diet 4.1+ 0.6 days. Mean hospital stay was 6+1.5 days.

Conclusions. These preliminary results indicate limited laparoscopic intestinal surgery is safe and feasible in selected patients with benign disease, even when previous abdominal surgery has been performed. Further evaluation of laparoscopic techniques in intestinal surgery is warranted.

Laparoscopic Colectomy--A Critical Appraisal (65)

A.G. Thorson, S.D. Wexner, R.W. Beart, D.G. Jagelman, P.M. Falk, R.J. Fitzgibbons, Jr . . . . . . . . . . . . Omaha, NE

A multi-center prospective study was undertaken to assess the efficacy and safety of laparoscopy in colon and rectal surgery, and to identify potential indications or contraindications for this technology. In order to minimize potential bias in interpretation of the results, all data were registered with an independent observer who did not participate in any of the surgical procedures. Twenty-three patients underwent a laparoscopic procedure. Surgical indications included colonic inertia, rectal prolapse, familial adenomatous polyposis, mucosal ulcerative colitis, granulomatous colitis and cancer of the cecum, right colon, sigmoid colon and rectum. Opera- tions performed included total abdominal colectomy with ileorectal anastomosis (1), low anterior resection (6), left hemicolectomy (3), ileoanal reservoir (2), sig- mold colectomy (6), and right hemicolectomy (5). Mor- bidity and mortality were 22% and 0% respectively. The average length of hospital stay was 4.5 days. These preliminary data suggest that laparoscopic colon and rectal surgery can be accomplished with acceptable morbidity and mortality when performed by trained surgeons. Length of hospital stay may be shorter than following formal celiotomy. However, appropriate registries will be necessary to adequately assess long term outcome.


Furthermore, the mere feasibility of laparoscopic colon and rectal surgery does not necessarily equate with the appropriateness of the decision to use the technique.

Pouches H

Anal Sphincter Activity After Restorative Proctocolectomy (RP) for Ulcerative Colitis--A Study Using Continuous Ambulatory Manometry (CAM)

(66)

P.J. Holdsworth, P.M. Sagar, W.G. Lewis, D. Johnston Leeds, Yorkshire, England

CAM explores the dynamic properties of the anal sphincter (AS) and their coordination with rectal function. We assessed AS activity for 3 hr in patients after RP for UC: CAM was performed in 19 healthy controls, 13 patients after mucosal proctectomy with sutured en- doanal ileoanal anastomosis (IAA) at the dentate line (MP+EAA) and 22 pts who had undergone RP without mucosectomy (RP+EEA). Simultaneous pressure recordings were made in the rectum/neorectum and in the AS. Controls and patients after RP+EEA had more sampling episodes (5.6/hr (1-31) and 4.5/hr (1-48) resp) than patients after MP+EAA (0/hr (0-30) (p<0.01). All controls and all patients after RP+EEA displayed both multiple episodes of AS relaxation (sampling) and basal internal sphincter activity, (slow/ultraslow waves) whereas only 5 of 13 patients displayed such sphincteric activity after MP+EAA. Function of the AS is impaired by MP+EAA: after end-to-end ileoanal anastomosis, with an intact sphincter, however, the intrinsic activity of the sphincter and coordination with "rectal" function are maintained.

Ileal Pouch-Anal Anastomosis: A Safe Option in Advanced Colon Carcinoma

(67)

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

Ileal pouch-anal anastomosis (IPAA) is an acceptable operation for the treatment of mucosal ulcerative colitis (MUC) and familial adenomatous polyposis (FAP) complicated by favorable (T1, T2, NO) adenocarcinomas. However, in advanced (T3 or N+) cancers, the use of IPAA as an initial procedure is suspect.

The purpose of this study was to assess morbidity, functional outcome, and survival following IPAA, comparing patients with benign disease (Normal), favorable carcinomas, and advanced carcinomas.

All patients undergoing IPAA for MUC and FAP complicated by cancer between 1985 and 1990 were studied. The operative morbidity (MB), occurrence of bowel obstruction (SBO), functional outcome (stool frequency, quality of life index), pouch loss (PL), tumor recurrence (TR), survival (SUR), and follow-up (F/U mos+se) were recorded.

In groups of similar gender, pouch configuration, and anastomotic technique,

GROUP N MB SBO PL TR SUR F/U

Normal 18 5 0 0 0 18 15-+4 * T1,T2,N0 18 3 1 0 0 18 334-5 T3 or N+ 15 4 1 1 1 15 41-+7

�9 p<0.05; ANOVA, Kruskal-Wallis.

Rectal tumors in the advanced group (N=3) did not differ from those in the favorable group (N=6). The functional results were similar between patient groups.

IPAA can be safely performed as an initial procedure in patients with advanced (T3 or N+) colon carcinomas complicating pre-existing MUC or FAP. Moreover, pouch function and patient satisfaction are not compromised.

Primary Ileal Pouch-Anal Anastomosis and Colorectal Can- cer--Results and Contraindications

(68) J.B.J. Fozard, H. Nelson, J.H. Pemberton, R.R. Dozois

Rochester, MN

Ileal pouch-anal anastomosis (IPAA) is the treatment of choice for chronic ulcerative colitis (CUC) and familial adenomatous polyposis (FAP). Whether IPAA is appropriate for patients with cancer complicating CUC or FAP is unknown, particularly as adjuvant chemotherapy or radiation treatment are frequently indicated.

Of 1218 patients who underwent IPAA, 45 patients had an adenocarcinoma complicating CUC (n= 34) or FAP (n--11). Cancer was diagnosed preoperatively in 22 patients (49%) with only 11 cancers detected by surveillance. Twenty-six patients (58%) were of advanced stage (TNM stage II and III), and 50% of cancers were proximal to the splenic flexure. Two patients in the FAP group (18%) and 10 patients in the CUC group (29%) required reoperation, usually for obstruction. Chemotherapy, when given (n = 10), had no excess morbidity and did not compromise a successful pouch outcome. Adjuvant postoperative radiation treatment for advanced rectal cancer (n = 4) was associated with high morbidity and a pouch failure rate of 75%. At a median follow-up of three years (range 0-9 years), 35 patients (78%) were alive without evidence of disease and had a satisfactorily functioning ileal pouch.

We concluded that primary IPAA is an appropriate operation to offer to patients with cancer complicating CUC or FAP. IPAA is contraindicated, however, in patients with advanced stage rectal disease.

Hand-Sutured vs. Stapled Ileoanal Anastomosis (69)

P. Luukkonen, H.J. Jfirvinen . . . . . . . . Helsinki, Finland

A prospective randomized study between hand-sutured (Group I) vs. stapled (Group II) ileoanal anastomosis was carried out in 40 consecutive patients during


restorative proctocolec tomy to compare complicat ions and functional outcome. Eight patients (42%) in Group I and 12 patients (57%) in Group II had one or more complications. Three patients in Group I and four patients in Group II deve loped septic complicat ions and anastomotic stricture occurred in four and three patients in respective Groups. One stapled anastomosis was con- verted to a hand-sutured one because of a stricture. Four patients in Group II had persistent inflammation in the remaining rectal mucosa and a temporary diverting ileostomy was constructed in one of them. Functional out-

come was assessed three and six months p.op. Mean defecation frequency was 6.3 vs. 6.2 after three months and 5.2 vs. 5.8 after six months in Groups I and II, respectively. Seven patients vs. eleven patients in Groups I and II had no nocturnal evacuations after six months. The mean basal anal pressure decreased 31% vs. 33% after three months and 30% vs. 28% after six months in Groups I and II, respectively. The stapled ileoanal anastomosis does not offer any functional advantage over hand-sutured anastomosis but leaves some of the disease behind.

POSTER PRESENTATIONS

Poster presentations wil l be on display in the exhibi t area beginning 10:00 am, Monday, June 8, and during the open exhibit hours.

Anorec ta l Cancer

Is Preoperative CT Scan Worthwhile in Patients with Rectal Cancer?

Booth P1

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

The need for preoperat ive CT scan in rectal cancer is debated.

Aim: To determine if routine preop CT in patients with rectal cancer is justified.

Methods: Retrospective study of 119 consecutive patients undergoing excision of rectal cancer who had preop CT was performed. Of these, 49 (41%) also underwent endorectal sonography.

Results: LM=Liver Metastases

PATH CT(+) CT(+) CT(-) CT(-) STAGE LM(+) LM(-) LM(+) LM(-)

A 0/13 0/13 0/106 23/106 B 1/13 2/13 0/106 53/106 C 7/13 3/13 3/106 27/106

U/STAGE

uT1 0/8 0/8 0/41 6/41 uT2 1/8 0/8 0/41 13/41 uT3 4/8 2/8 2/41 19/41 uT4 1/8 0/8 1/41 0/41

Seventeen patients had local treatment of rectal cancer. 102 patients had laparotomy of which 89 (88%) had a normal CT scan. This was verified at laparotomy in 86. Three patients (2.5%) with negative scans had LM while 5 patients with a positive scan had no metastases. Four (3.4%) patients underwent wedge resection of known LM; 3 (2.5%) underwent unplanned liver resection. CT scan al tered treatment in 5.9% of all or 7.5% of patients with Dukes' B & C lesions.

Conclusion: Preop CT is not justified unless rectal cancer is locally advanced. Endorectal ultrasonography identifies a group (uT3, uT4) of patients at high risk for liver metastases.

ligation for "curative" rectal cancer resections were compared.

Four hundred six patients included in a prospective audit were analyzed. One hundred one patients underwent abdominoper inea l resections, 277 low anterior resections and 28 high anterior resections. LL was carried out in 327 patients and HL in 79. Both groups were well matched.

No differences in survival or recurrences were found (p NS), nei ther studying all patients together nor subdi- viding them by Dukes' classification, number of positive nodes (1-3, >4) , differentiation and/or level of lesion in the rectum.

Although morbidi ty was not increased, it is concluded that no benefit was obtained with high ligation of the inferior mesenteric artery.

Prognostic Value of Four or More Positive Lymph Nodes in Rectal Cancer Determined by Multivariate Analyses and Including DNA Ploidy Studies

Booth P3

M. Moran, D. Rothenberger, S. Goldberg, E. James, D. Antonenko . . . . . . . . . . . . . . . . . . . . . . Grand Forks, ND

To the best of our knowledge, this is the first t ime multivariate analyses have been used to determine the prognostic value of the variables >3 positive nodes and DNA ploidy s tudied together and including other known factors.

Prognostic value of the variable: <3 or >3 positive nodes was de te rmined on 138 prospect ively s tudied patients undergoing abdominal "curative" resections for rectal cancer. DNA ploidy was studied retrospectively in all patients.

Local recurrences. Although several variables were significant in order to predict local recurrences, only three had an independent prognostic value. These three variables were: 1) more than three positive lymph nodes (p=0.0007), 2) macroscopic local invasion of the tumor (p=0.01) and 3) nondip lo id DNA (p=0.03). More than 3 involved nodes was the most significant variable.

Distant recurrences. More than three positive lymph nodes (p=0.004) was also the most significant variable.

In conclusion, _>4 positive lymph nodes was the most significant variable to predict both local recurrences and distant metastases and this factor should be included in clinical trials to evaluate new forms of adjuvant therapy for rectal cancer.

High vs Low Inferior Mesenteric Artery Ligation for "Cu- rative" Rectal Cancer Resections

Booth P2

M. Moran, D. Rothenberger, S. Goldberg, D. Antonenko Grand Forks, ND

Controversy still exists regarding the need of high inferior mesenteric artery ligation for rectal cancer resections. High (HL) and low (LL) inferior mesenteric artery

Rectal Cancer Treatment by Low Anterior Resection with Coloanal Anastomosis (LAR/CAA)

Booth P4

P.B. Paty, W.E. Enker, A.M. Cohen, G.Y. Lauwers New York, NY

LAR/CAA has gained popular i ty for treatment of rectal cancers that require division of the rectum at the pelvic

P24


floor. To determine the incidence and causes of local failure, we have retrospectively examined 131 patients with primary, invasive rectal cancer treated at one institution by LAR/CAA. 68 patients were treated by operation alone; 63 received pre- or post-operative pelvic irradiation (15-50 Gy). All resections rendered the pelvis grossly free of disease. Mean follow-up is 4.1 years. All histopathology was re-examined by one pathologist. Rates of pelvic recurrence were compared using Kaplan- Meier actuarial curves and the Log Rank Test. The following clinical and pathological features were analyzed:

feature group PelvRec/N %PelvRec p

T stage T1-2 2/65 3% T3 9/66 14% .03

N stage NO 7/85 8% N123 4/46 9% .98

tumor <4cm 6/76 8% -->4cm 5/52 8% .94

implants no 6/124 5% yes 5/7 71% <.001

grade 1-2 8/115 7% 3 3/11 27% .04

above AV <6cm 3/48 6% _>6cm 8/83 10% .64

dist marg -<2cm 5/73 7% >2cm 6/56 11% .51

PLND no 11/100 11% yes 0/31 0% .02

pelvic RT no 7/68 10% yes 4/63 6~ .32

ALL PATIENTS 11/131 8%

Pelvic recurrence occurs in about 8% of patients and is significantly associated with non-nodal metastatic tumor implants in the mesorectum, conventional pelvic dissection, transmural primary tumor, and poorly differentiated (grade 3) histology. These risk factors for local recurrence are identical to those established for conventional LAR and relate to the degree of tumor spread into mesorectum and plane of pelvic dissection. Current guidelines for LAR/CAA achieve good local control for rectal cancer.

Col,anal Anastomosis for Low Rectal Cancer--Is Cure Compromised?

Booth P5

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

Low rectal cancer may sometimes be treated by resection and col,anal anastomosis (CAA), avoiding a permanent col,st,my. There has been concern that this may lead to high rates of local recurrence. In this study we review the results of 154 rectal resections performed for cure and followed by a CAA, from 1977 to 1990.

Methods: A retrospective chart review was performed. Results: There were 100 men and 54 women. Median

age was 59 yrs (range 27-94). There were 64 Dukes A cancers, 40 Dukes B and 50 Dukes C. The median distance from the tumor to the anal verge was 7 cm (range 3 to 12) and the median margin in the fixed specimen

was 2 cm (range 0.1 to 10). 46 patients received preoperative radiotherapy. Local recurrence and survival are as shown.

Median follow-up was 45 months (range 0-159)

Local Local+Dist Distant All

Recurr

n 2 8 33 43 % 1.3 5.2 21.5 29.3

Age adjusted 5 yr survival A=91.5%, B=83.8%, C=58.3%, A11=78.7%

Conclusion: CAA can be performed in patients with low rectal cancer, avoiding permanent col ,s t ,my but maintaining low rates of local recurrence and acceptable survival.

Transanal Excision of Rectal Tumors: Is the Case Closed? Booth P6

S.A. Strong, I.C. Lavery, J.R. Oakley, V.W. Fazio, J.M. Church . . . . . . . . . . . . . . . . . . . . . . . . . . . Cleveland, OH

Transanal excision is a treatment option for select rectal adenomas and carcinomas. While the criteria for tumors suitable for transanal excision (TE) are well established, controversy exists as to whether the wound should be left open or closed following lesion excision.

The purpose of this study was to determine the morbidity following TE of lower rectal tumors comparing open (OP) wounds to those closed (CL).

All patients undergoing TE of tumors in the lower half of the rectum during a 10 year period were retrospectively studied. Data recorded included lesion size, partial vs full thickness (FT) excision, malignancy (CA), postoperative sepsis and hemorrhage (HEM), stricture, local recurrence (LR), and follow-up period (F/U).

In demographically similar groups (mean+se),

FT CA SIZE SEPSIS HEM REC F/U N

% % cm a % % % mos

CL 45 38 44 8.9--+2 4.4 0.0 15 27-+3 OP 21 33 43 7.8-+1 0.0 0.0 5 30-+6

NS; chi-square, Fisher's Exact, Student's t

No patients in either operative group developed strictures.

The postoperative morbidity of lower rectal tumors excised transanally is not lessened by closure of the residual wound. In fact, wound closure tends to have a higher associated morbidity. Future studies of a prospective, randomized nature are warranted.

Lateral Pelvic Lymphadenectomy for Rectal Cancer Booth P7

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

Lateral pelvic lymphadenectomy (LPL) has been performed for patients suspected by preoperative examina-


tions that tumors might penetrate through the proper muscle or metastasize to lymph nodes. Between 1979 and 1988, 265 patients with rectal cancer underwent curative surgery at the National Cancer Center Hospital, Tokyo. Of them, 201 (75.8%) received LPL: 60% in Dukes A, 80% in Dukes B and C. Lymph node metastases were found in 118: positive nodes of the perirectal region alone in 61%, those of the lateral region along the lateral l igament and the internal and common iliac artery in 14 %, those of the upward region along the superior rectal and inferior mesenteric artery in 14% and those of both the lateral and upward region in 12%. During the median follow up of 61.3 months, 66 (24.9%) deve loped recurrent tumors: local in 16, hematogenous in 44, local and hematogenous in 3 and others in 3. In the LPL group local recurrences were deve loped in 7%, as similar as in 7.8% in the conventional lymphadenectomy group. This figure might be acceptable in considerat ion that the LPL group included more patients with Dukes B and C. The 5 year survival rate was 86.6% in Dukes A, 78.3% in Dukes B and 65% in Dukes C. In conclusion, the high frequency of lateral node metastases and the low local recurrence rate after LPL indicate that LPL might be an effective procedure to reduce local recurrence in rectal cancer.

Anorectal Physiology

Rapid Continuous Pullout for Evaluation of Anal Squeeze Pressures

Booth P8

E. Birnbaum, W. DeVos, R. Fry, I. Kodner, J. Fleshman St. Louis, MO

A rapid continuous pul lout technique (5 mm/sec) for measuring maximal anal squeeze pressure was evaluated and compared to maximal anal squeeze pressure obtained by the station pul lout method. Anal manometry using a 4 channel capillary perfusion system was performed on 60 patients be tween March 1990 and July 1991. The studies were performed for evaluation of incontinence, constipation, and normal preoperat ive anal function. Resting pressure profile was obtained with a slow continuous pul lout (1 mm/sec) . Maximal squeeze pressure was obtained using stationary squeezes as well as 3 successive rapid pullouts (5 mm/sec) .

Maximal squeeze pressure in all 4 quadrants was slightly higher using the rapid pul lout technique (mean difference range=0.9-7.2 mmI-Ig). The correlation coefficient ranged from 0.83 to 0.88. The rapid pullout technique was reproducible (intraclass correlation ranged from 0.92 to 0.95).

Sphincter length was significantly longer when measured during rapid pul lout as compared to slow pullout at rest (p=0.0001). This may represent the longer external sphincter muscle active during voluntary squeezing.

The rapid continuous pul lout squeeze measurement is easity performed, reproducible , and gives a true profile of the voluntary muscle of the sphincter. The technique is applicable for evaluation of incontinent, constipated, and normal patients.

Rectopexy Without Resection Booth P9

R.L. Call, P.M. Falk, R.M. Pitsch, G.J. Blatchford, A.G. Thorson, M.A. Christensen . . . . . . . . . . . . . . Omaha, NE

Simple suture rectopexy without s igmoid colon resection was performed on 61 patients for complete rectal prolapse. Of those, 40 patients have been fol lowed for a mean of five years. Preoperatively, incontinence was present in 25 patients, constipation in 19 patients, and neither in six patients. Full thickness prolapse recurred in only one patient for a failure rate of 2.5%. Of the incontinent patients, 21 (84%) were improved and 4 (16%) remained unchanged. None were made worse. Of the constipated patients, 10 (53%) were improved, 5 (26%) remained unchanged, and 4 (21%) were worse. All constipation was easily managed by bulk laxatives. Poor functional results were seen in only two patients who remained incontinent to solid stool (5%). Simple suture rectopexy without resection is an optimal approach to rectal prolapse. Complications associated with anastomoses and foreign material are avoided.

constipation Incontinence

19 pts. % 25 pts. %

Improved 10 53 21 84 Unchanged 5 26 4 16 Worse 4 21 0 0

Simple Suture Rectopexy: Functional Results

How Reliable are Measurements of Anal Canal Pressures and Rectal Volumes?

Booth P10

J.M. Church, T.K. Schroeder, R. Saad, K.A. Easley Cleveland, OH

Anorectal manometry is widely used to assess the effect of various operations on the anal sphincter. This involves comparing pre- and post-operative measurements and calculating a difference. In order to know the significance of such a difference it is necessary to know the variability inherent in the manometry technique. This study is an attempt to measure some aspects of such variability.

Methods: A 4 channel perfused catheter technique was used to record maximum anal resting (MRP) and squeeze (MSP) pressures in 20 normal volunteers. A station pull- through was used. Volume of first sensation (VFS), of first urge (VFU), and maximum tolerated volume (MTV) were also recorded. The procedure was performed once by each of 3 different investigators in 10 subjects, and then by 1 investigator on 3 occasions at the same time in a further 10 subjects.

Inter-observer Intra-observer

Mean Mean diff 95%CI ICC* p diff ICC* p

MRP --3 -11 to 5 .84 .0001 --2 .77 .0001 MSP --6 --22 to 10 .97 .0001 1 .95 .0001 VFS 5 -15 to 25 .18 .20 1 .59 .001 VFU 10 --15 to 34 .81 .0001 -7 .34 .04 MTV 43 4 to 82 .68 .0001 --11 .78 .0001

* ICC=Intraclass correlation coefficient


Conclusions: the data show that there is reasonably low variability and good agreement for anal pressures, both between and within observers. The data are not so good for measurements of rectal volume, where observer variability is greater.

Electrogalvanic Stimulation (EGS) for Proctalgia Fugax Booth P11

C.N. Ellis, D.J. Coyle, J.D. Cheape . . . Birmingham, AL

Proctalgia fugax, while not life threatening, is a morbid condition that has proved resistant to many forms of therapy including muscle relaxants, antispasmodics and narcotics. EGS of the puborectalis muscle has shown promise for the treatment of this condition. The results of EGS treatment of 69 patients (30 males and 39 females) is reported. EGS was performed for 20 min at 60 cycles/sec, three times weekly at the maximum voltage that could be tolerated up to 500 v. EGS was continued until the patient was asymptomatic or had three treatments without benefit. Initially, 36 (52.1%), 20 (29.1%) and 13 (18.8%) patients had complete resolution (CR), partial resolution (PR) and no change (NC) of symptoms respectively. Patients with CR underwent an average of 3.0 treatments (range 1-4) at 400 v (range 320-440), those with PR 3.8 treatments (range 3-5) at 440 v (360- 480), and those with NC 4.6 (range 3-8) at 490 v (range 460-500). At one year after initial treatment, 14 patients who initially had CR remained asymptomatic, 19 had recurrence of the symptoms and 3 had returned for further EGS all with CR. All patients with PR initially continued to have occasional symptoms. Two patients underwent further EGS with PR. All the patients with NC continued to have activity limiting symptoms. These results suggest that EGS can provide acceptable long term control of proctalgia fugax. The ability to tolerate 480 or more volts initially is associated with poor results. Our EGS equipment can deliver a maximum of 500 v. It is possible that some patients with NC may have had improved results with higher voltages.

Anal Ultrasonography in the Evaluation of Fecal Inconti- nence

Booth P12

P.M. Falk, G.J. Blatchford, M.A. Christensen, A.G. Thor- son, R.L. Call . . . . . . . . . . . . . . . . . . . . . . . . . Omaha, NE

Twenty-one patients with fecal incontinence were evaluated with anal ultrasonography, anorectal manometry, and electromyography. Twelve were totally incontinent, eight were continent of solid stool, and one was continent of solid and liquid stool. Sonograms were recorded and labeled in centimeters from the anal verge. Data regarding the anatomy of the internal and external sphincters as well as operative changes and scar measurements were recorded. The internal sphincter was intact in seven patients with a mean maximum resting pressure of 71 cm of water. The internal sphincter was interrupted in 14 patients with a mean maximum resting pressure of 31 cm of water. When the internal sphincter was intact, mean maximum resting pressures were significantly higher (p=0.002). The external sphincter was disrupted anteriorly in 19 patients. Two remaining pa-

tients had circumferential scar and muscle loss from previous surgery. Scar width anteriorly was inversely proportional to mean maximum squeeze pressures (r=-0.61). Anal ultrasonography is a useful adjunct to manometry and electromyography in the evaluation of fecal incontinence. The anatomy of the sphincters and associated scar is seen. Differentiation between neurogenic and obstetric incontinence is established with de- lineation of anatomic disruption of either the internal or external sphincter muscles.

Normal Obstetric Injury

High Rectal Pressure Waves in Rectal Prolapse: Evidence of Rectoanal Inhibition Causing Fecal Incontinence?

Booth P13

R. Farouk, G.S. Duthie, D.C.C. Bartolo Edinburgh, Scotland

Recovery of continence frequently accompanies rectopexy for prolapse. We propose that the prolapse causes reversible rectoanal inhibition resulting in fecal incontinence. To investigate this, 22 patients (20 female; median age 74 years, range 56-77) with complete rectal prolapse, 28 patients with neurogenic fecal incontinence (FI) 26 female; median age 52 years, range 34-78), and 15 controls (7 female; median age 36 years, range 25- 71) underwent computerized ambulatory anorectal manometry.

The median resting anal pressure was PROLAPSE 32 cm. H20 (9-74) (p< 0.01)* FI 48 cm. HzO (26-61) (p< 0.01)* and CONTROL 90 cm. H20 (60-120). Median resting rectal pressures were PROLAPSE 15 cm. H20 (6- 31) (p > 0.1),* FI 14 cm. H20 (8-26) (p > 0.1),* and CONTROLS 10 cm. H20 (5-16). High pressure rectal waves (median 110 cm. H20, range 56-144 cm. H20; p < 0.001"*) associated with sphincter inhibition, lasting 16-45 seconds were seen in all of the patients with PROLAPSE. These were not seen in controls or patients with neurogenic fecal incontinence.

We suggest these high pressure rectal waves represent the prolapse entering the rectum resulting in rectoanal inhibition.

*Mann-Whitney U Test versus control group. * * Rank Wilcoxon Test.

Neorectal and Anal Canal Motor Activity After Coloanal Anastomosis

Booth P14

R.L. Grotz, J.H. Pemberton, A. Ferrara, R.B. Hanson Rochester, MN

Incontinence may occur after coloanal anastomosis (CAA) and be related to loss of an effective barrier


between the anal canal and the pulled through proximal bowel (neorectum). Aim: To determine in what manner anal canal tone and contractions and neorectal motility are related in controls (C) and in pts after CAA. Methods:

In 12 controls (7M/5F, mean age 35) and in 7 pts after CAA (6M/1F, mean age 65--4 continent, 3 incontinent), a 6-channel microtransducer catheter was positioned en- doscopically. 24-hr ambulatory motor activity was stored in a 2 MB portable recorder. Rectal motor complexes (RMCs) and cluster contractile activity (CCA) of the neorectum were characterized. Results: (Mean_+SD) RMCs and colonic (CCA) activity were similar in contractile frequency (2-3/min for both), mean peak amplitude (58 mmHg in C, 62 mmHg in CAA; ns), and frequency (16/24 hr in C, 18/24 hr in CAA; us). In controls, RMCs were accompanied invariably by a rapid increase of anal pressure. However, after CAA, only 48% of neorectal CCA activity was associated with an increase in anal canal motor activity and pressure. Moreover, while asleep, only 17% of burst activity was associated with anal canal motor activity in the incontinent pts. Conclu- sion: Compared to controls, CCA activity of the neorec- rum after CAA was frequently n o t associated with anal canal motor activity. As such, the neorectum/anal canal pressure gradient was not preserved consistently; this lack of a reliable pressure barrier likely contributed to fecal incontinence after CAA.

Electrogalvanic Stimulation for Levator Syndrome: How Effective Is It in the Long Term?

Booth P15

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

Electrogalvanic stimulation (EGS) has been proposed as a treatment for levator spasm (LS) and some centers report it as being effective in up to 90% of patients in the short term. The purpose of this study was to examine the benefits of EGS in the LS patients treated at one institution. Methods: All patients undergoing EGS for LS between 1985 and 1991 were studied. Initial complaints, physical exam and number of treatments were recorded. Through personal interviews and chart reviews, procedure tolerance and long term benefit were determined. Results: There were 52 patients (63% females, 37% males) with a medium age of 54 years (range 24-84). All patients presented with anal pain which was localized by exam to the left in 43%, right in 23%, bilateral in 8.6%, and normal in 2.6%. Fifty percent received <3 one hour treatments, 33% received 4-6 treatments, and 17% received >6 treatments. Seventy-seven percent felt the treatment was painless. Follow-up results are as follows:

Sx Partial No n %F/U RF/U Relieved Relief Relief

52 88% 28mos 19% 24% 57% (1-71)

Of 4 patients with a wrong diagnosis, 3 were ultimately

diagnosed with recurrent pelvic cancer and 1 had a

fissure. Conclusion: The diagnosis of LS is based on subjective criteria. At our institution EGS was a tolerable treatment but a substantial number of patients received no benefit. Organic etiology of anorectal pain must always be excluded.

The Role of EMG in the Diagnosis of Nonrelaxing Pubo- rectalis Syndrome

Booth P16

J.M.N. Jorge, S.D. Wexner, G.C. Ger, V. Salanga, J.J. Nogueras, D.G. Jagelman . . . . . . . . Fort Lauderdale, FL

A prospective study was undertaken to assess the correlation between electromyography (EMG) and cinedefecography (CD) for the diagnosis of nonrelaxing puborectalis syndrome (NRPR; anismus). Clinical criteria for NRPR included straining, incomplete evacuation, te- nesmus, and the use of enemas, suppositories, or digi- tation. EMG criteria included failure to achieve a significant decrease in electrical activity of the puborectalis (PR) during attempted evacuation. CD criteria included either paradoxical contraction or failure of relaxation of the PR along with incomplete prolonged evacuation. In addition, other etiologies for incomplete evacuation, such as rectoanal intussusceptions or nonemptying rec- toceles were excluded by proctoscopy and defecography in all cases. 112 patients with constipation, 81 females and 31 males, of a mean age of 59 (range 12-83) years were studied by routine office evaluation, CD and EMG. 42 patients (37%) had evidence of NRPR on CD (rectal emptying: None--24; incomplete--18). 28 of these patients (67%) also had evidence of NRPR on EMG. How- ever, EMG findings of NRPR were present in 12 of 70 patients (17%) with normal rectal emptying. Therefore, the sensitivity and specificity for the diagnosis of NRPR were 67% and 82%, respectively. The positive and negative predictive values for EMG were 70% and 80%, respectively. In summary, both the sensitivity and specificity of EMG were suboptimal. Consequently, EMG findings of NRPR should be confirmed by CD evidence of incomplete evacuation.

Psychosocial Screening of Patients at an Incontinence Center: Identifying Those at High Risk

Booth PI7

Joseph Kokoszka, Georgia Andrianopoulos, Richard Nel- son, Herand Abcarian . . . . . . . . . . . . . . . . . . Chicago, IL

Previous studies have identified an increased incidence of psychosocial disorders among patients with defecation disorders, however, only one facet, depression, was measured. The current study examines the incidence of psychosocial disorders among patients referred to an incontinence center utilizing a multidimen- sional psychologic assessment. Initial evaluation of the patient included psychologic testing upon referral to the Incontinence Center via the SCL-90-R. The test consists of 90 scaIed questions. This is able to provide a measurement of current, point-in-time, psychological symptoms in the following areas: somatization, obsessive- compulsive, interpersonal sensitivity, depression, anxi-


ety, hostility, phobic anxiety, paranoid ideation and psy- choticism. A total of 49 patients were initially referred with 47 patients completing the SCL-90-R. The patient demographics included 34 females and 13 males. Diag- nostic categories consisted of 23 patients with fecal incontinence, 8 with constipation, 10 with urinary incontinence and 6 with various disorders including levator syndrome, IBS and combined disorders. The SCL-90-R stratifies patients into one of three severity groups in addition to the above parameters; either normal study, moderate symptoms requiring further evaluation or extreme symptoms necessitating immediate psychiatric referral. The distribution of the various groups is expressed in the chart below:

CATEGORY NORMAL MODERATE EXTREME

Total (N=47) 19 18 I0 Males (N=13) 2 5 6 Females (N=34) 17 13 4 -<40 years old (N=16) 5 5 6 >40 years old (N=31) 14 16 4 Constipation (N=8) 1 2 5 Fecal incontinence (N=23) 11 10 2 Urinary incontinence (N=10) 5 4 1

Our findings demonstrate that there is a high prevalence of psychosocial disorders among our patient population. The distribution of identified disorders included all nine areas of psychologic symptomatology. Stratification has indicated that certain subpopulations have been found to have a higher risk of psychosocial disorders than others. These include males, those under forty years of age and those who are constipated. This global screening of patients in an incontinence center has proved to be an important tool in planning therapy for patients in such a clinic.

Colonic Neuropathy in Slow Transit Constipation (STC): A Histological Survey

Booth P18

D. Kumar,* M.J. Benson,J. Roberts,J.E. Martin, M. Swash, D.L. Wingate, N.S. Williams

*Birmingham, England, London, England

It has been suggested that a colonic neuropathy may be responsible for the delay in colonic transit in STC. However this hypothesis has not been supported histo- logically.

Colonic tissue from 12 female patients (age: 30-57 years) with STC [defecation Xl /7-14 days, prolonged marker retention (>80% at 5 days) and nlIn-DTPA transit studies], who underwent therapeutic subtotal colectomy for this condition and 12 control specimens removed for neoplastic disease, was studied. Samples were taken from both resection margins and at 5-10 cm intervals. Immunochemistry for neurofilament, S-100 and neuron- specific enolase (NSE) antigens, was performed. Every region sampled in all specimens from STC subjects showed an increase in small nerve fibers of the circular muscle layer of muscularis propria: this was not seen in

any of the controls. No other neural or myocyte abnormalities were detected. There was no correlation between distribution of histological changes and regional delay in colonic transit as detected on '11In-DTPA.

These changes are not similar to those reported in other gastrointestinal neuropathic conditions. Although we have identified definite abnormalities of innervation in the colon in STC, it is not possible to say whether these represent a primary defect or an adaptive response to functional abnormality.

The Rectal Motor Complex: Propagation at Night Booth P19

B.A. Orkin, L.E. Smith, H. Emsellem, John Dent, M.A. Tissaw . . . . . . . . . . . . . . . . . . . . . . . . . Washington, D.C.

The rectal motor complex (RMC) is a recently described, recurring motor entity found in the rectum. It is seen most frequently at night, and its function is unknown. The hypothesis was that the RMC is propagated orad, keeping the rectum empty at night. Prolonged manometric recordings were made from three levels 3 cm apart within the rectum in 25 healthy subjects (mean age 29 years, range 18-57; sex 11 F, 14 M). Subjects were studied overnight with perfusion manometry for an average of 496 minutes (range 430-540 min). 331 RMCs were identified in 24 of 25 subjects. Two types of RMC activity were observed: classic-appearing RMCs that were well-defined (258) and poorer formed, lower amplitude RMCs (LA-RMCs) (73). 16 RMCs appeared to be propagated in an orad direction across at least 2 channels while 21 were propagated caudally. 11 pairs of RMCs started simultaneously, and 25 RMCs began or ended well after another had begun. 185 RMCs were isolated to 1 channel. These different patterns were often seen in the same subject. This data confirms the presence of RMCs in healthy subjects but does not support our theory of orad propagation. It is likely that the RMC is initiated and influenced by a variety of conditions. Further investigation appears warranted.

This study was supported in part by a grant from the Colorectal Research Foundation.

Rectosigmoid Pacemaker: Role in Defecation Mechanism and Constipation

Booth P20

A. Shafik . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cairo, Egypt

The possible existence of a "pacemaker" at the rectosigmoid junction (RSJ) was studied in 26 normal volunteers, 16 constipated subjects, 6 patients with anterior resection for rectal cancer and 8 during operative inter- ference. In normal subjects, the passage of an inflated condom through the RSJ effected significant increase of rectal and decrease of rectal neck (RN) pressure (P<0.001); this response was absent in the anesthetized RSJ. Stools were passed in columns of 9.2+2.2 sd cm mean length and 2.8+0.6 cm mean diameter. In inertia- type constipation (10 patients), there was no pressure response in sigmoid, rectum or RN to RSJ distension. Stools were passed in columns thicker and longer than


normal. In obstructive constipation, RSJ distension caused a significant pressure increase in both the rectum and RN (P<0.001). Patients passed stools in small pieces. The rectum and RN in anterior resection patients did not respond to the inflated condom in the distal colon. A "pacemaker" seems to exist at the RSJ. It triggers rectal contraction when stimulated by stools traversing the RSJ. In constipation, the pacemaker is believed to be disordered.

An artificial pacemaker (AP) was applied to the rectum of 18 mongrel dogs aiming at assessing its effectiveness in inducing rectal contraction. It consisted of a hooked needle, a metal piece, a battery and a telegrapher's key. The needle was hooked into the dog's rectal muscle coat close to the RSJ. Upon electric pulsing of the pacemaker, the rectal pressure showed significant increase (P<0.0001), while RN pressure was significantly decreased (P<0.0001). It succeeded in expelling the balloon in all dogs.

The effectiveness of the AP in the treatment of 26 chronic constipated patients was demonstrated. 20 subjects acted as controls. Upon turning on the AP, a significant rectal pressure increase (P<0.0001) and a significant RN pressure decrease (P<0.001) occurred. Electric pulsing of the AP induced balloon expulsion.

Resection/Rectopexy is Superior to the Ripstein Proce- dure in Patients with Rectal Prolapse and Constipation

Booth P21

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

Although there are several options for the surgical treatment of rectal prolapse, the 2 most popular abdominal procedures are the Ripstein procedure and resection with rectopexy. We have examined the effects of these options on bowel function in order to see if either should be favored in constipated or incontinent patients.

Methods: A retrospective review was performed of the records of 147 patients undergoing either Ripstein (129) or Resection/Rectopexy (18) surgery over a 27 year period. Mean follow-up was 6 yrs (range 1-15 yrs). Incidence of documented functional bowel complaints was recorded.

Results:

Constipation Incontinence

Preop Postop Preop Postop

Ripstein 47(36%) 42(33%) 48(37%) 25(19%) Resection/pexy 12(67%) 2(11%) 5(28%) 3(17%)

Persistence of constipation was more common after Rip- stein procedure than after resection/rectopexy (27/47 or 57% vs 2/12 or 17%; P=0.03, x2). Some patients (n=15) developed constipation after the Ripstein procedure. Fecal incontinence improved after either procedure in about half the patients. Conclusion: Patients with preoperative constipation and rectal prolapse do better after resection/rectopexy than

after Ripstein procedure. Fecal incontinence is improved in a similar proportion of patients for each procedure.

Benign Anorectal

Autologous Fibrin Glue in the Treatment of Rectovaginal and Complex Fistulas

Booth P22

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

Interest in the use of fibrinogen as a surgical sealant dates to the early 1900's, with mechanisms for concen- tration of fibrinogen developed in the 1970's. Although used in many surgical disciplines, fibrin glue has had few proponents in general or colorectal surgery, due to lack of familiarity with the material and inexperience in its use.

Autologous fibrin glue, made from donated fibrinogen and commercial thrombin, seals in seconds, reabsorbs in days to weeks, and seems to promote local tissue growth and repair. The autologous source provides lack of risk of disease transmission from this product.

Patients: Four females, average age 36 y, all with rectovaginal fistula, all previously operated; one male, age 52, with extrasphincteric fistula. Two (1 F, 1 M) have Crohn's disease.

Procedures: All patients had complete bowel prep, short term prophylactic antibiotics, and regional or general anesthesia. Fistula tracts identified, carefully debrided, curetted and cleansed further with long iodoform gauze. Tracts then filled with 3-5 cc fibrin glue using dual syringe system. No sutures used, no tissue or sphincter divided.

Results: All 3 rectovaginal fistulas without Crohn's healed; male with Crohn's much improved and may heal. One Crohn's RV fistula failed.

Chronic Anal Fissure: Lateral Internal Sphincterotomy vs. Multiple Anal Sphincterotomies--A Prospective Study

Booth P23

G.L. Casillas, W.P. Mazier, A.J. Senagore, W.E. Mashas Grand Rapids, MI

The standard treatment for chronic anal fissure has become internal sphincterotomy. The purpose of this study was to perform a prospective randomized trial comparing two methods of internal sphincterotomy: lateral internal sphincterotomy (LIS) vs. multiple anal sphincterotomies (MAS). Parameters evaluated were: 1) sphincter pressures before and after surgery; 2) continence; 3) recurrence; 4) location; 5) length of fissure; 6) postoperative pain; 7) healing of fissure. The procedures were all performed in left lateral decubitus posi- tion with local anesthetic. For LIS, an incision was made 1 cm from the anal verge, the internal sphincter was identified and approx. 50% divided. For MAS, incisions were made at 3 o'clock, 7 o'clock and 11 o'clock posi- tions 1 cm from anal verge and the muscle superficially incised to level of the dentate line. In both procedures the wounds were left open. Twenty-four patients were


eligible, 20 had posterior midline fissures and 4 patients had anterior midtine fissures. The average fissure length in the LIS group was 0.98_+0.144 cm, and in the MAS group was 1.28_+0.45 cm. None of the fissures were secondary to inflammatory bowel disease. Nine patients (37.5%) underwent MAS and 15 patients (62.5%) underwent LIS. The mean maximal resting pressure (MMRP) in the LIS group were similar 76.39 cm water (_+6.88) preoperatively and 70.06 cm water (+8.16) postoperatively, and for the MAS group were 76.86 cm water (_+ 4.35) preoperatively and 60.89 cm water (+3.87) postoperatively (p<.05 t-test). None of the patients developed incontinence to gas or stool. There were recurrences, one in the LIS group (6.66%) and one in the MAS group (11.11%). Therefore, either LIS or MAS technique results in similar healing rates for chronic anal fissure without any adverse effects on anal sphincter function.

Hemorrhoidal Bleeding After Spinal Cord Injury: Results of Multiple Banding

Booth P24

B.C. Cosman, D.A. Eastman, I. Perkash, J.M. Stone Palo Alto, CA

Hemorrhoidal bleeding occurs in 3/4 of people with chronic spinal cord injury (SCI). 87 banding procedures were performed for bleeding on 62 men with spinal cord injury, mean age 50.7, mean duration of injury 14.3 years. Multiple bands per session were routinely necessary for circumferential bleeding areas. When bleeding sites were at or distal to the dentate line, these were also banded. No special preparation was used, and patients were allowed to stimulate reflex evacuation according to their regular schedule. None required readmission or treatment for hemorrhage, infection, or stricture. An outcome questionnaire was completed by 60 subjects (97%). Mean follow-up was 0.99 years, minimum 0.49 years. Eight (13%) reported subjective symptoms of low- grade autonomic hyperreflexia; 2 were treated for post- procedure hypertension. Forty-four (73%) reported significant reduction in bleeding post-banding, 12 (20%) moderate reduction, 2 (3%) no change, and 2 (3%) increased bleeding. Hemorrhoids are commonly ac- quired in chronic SCI, and hemorrhoidal bleeding often occurs at or distal to the dentate line. Absent sensation allows banding of external hemorrhoids, although symptoms of hyperreflexia may occur. Multiple banding is a safe and effective treatment for hemorrhoidal bleeding in chronic SCI.

External Anal Sphincter Function: Its Relationship to Hand Grip Strength

Booth P25

J.M. Church, T.K. Schroeder, R. Saad .. Cleveland, OH

The external anal sphincter is responsible for the voluntary anal squeeze that prevents urge incontinence. A decrease in strength of this muscle occurs with age, childbirth, and after surgical trauma. Striated muscle function is also impaired by malnutrition. To better de-

fine determinants of external sphincter function we have compared this with hand grip strength in a variety of patients and controls.

Methods: Maximal anal squeeze pressure (MRP) was measured by station pull through with a 4 channel, water- perfused catheter system in 127 patients referred for manometry and 28 controls. Also measured were mid arm circumference, triceps skinfold, and hand grip strength (GS), using a hand dynamometer.

Results: GS was well correlated with MSP in controls (r--.74), preoperative patients (n--56, r--.78) and postoperative patients (n=41, r=.73). There was no correlation of either GS or MSP with age although males were stronger than females.

No Wt Preop Postop Control Wt Loss

Loss

M F M F M F M F M F

GS 46 27 45 26 48 30 43 25 46 29 (Kg)

MSP 251 127 221 106 293 138 224 115 234 121 (mmHg)

Conclusions: External anal sphincter function correlates well with grip strength. The fall in anal squeeze pressures postoperatively reflects local damage to the muscle, rather than systemic effects secondary to malnutrition, anesthesia or operative trauma.

House Advancement Anoplasty: Operative Results Booth P26

P.M. Falk, M.A. Christensen, A.G. Thorson, G.J. Blatch- ford, R.L. Call, R.M. Pitsch . . . . . . . . . . . . . . Omaha, NE

Y-V anoplasties have limited ability to enlarge the entire length of the anal canal. The house advancement anoplasty overcomes this restriction. Eleven consecutive anoplasties using the house advancement pedicle flap were reviewed. The houseflap was performed bilaterally in two patients. Operative indications were stenosis and difficult evacuation (mean duration--72 mo.). Stenosis resulted from hemorrhoidectomy in nine patients and chronic diarrhea in two patients. Additional procedures included sphincterotomy in eight patients and a Y-V anoplasty on the opposite side in one patient. Two postoperative complications occurred in one patient; wound infection without flap displacement and fecal impaction. Mean length of follow-up was six months. Ten patients were completely satisfied. One patient had persistent pelvic pain unrelated to anal stenosis. Patients related a more normal stool caliber, less anxiety about defecation, and more rapid evacuation. Patterns of laxa-

Houseflap Anoplasty


tive use changed from stimulant to bulking agents. Three patients required no postoperative laxatives. Anal canal diameter was uniformly increased. The house advancement anoplasty is safe and opens the entire length of the anal canal. Operative results and patient satisfaction are excellent.

Perianal Streptococcal Sepsis--A Well Described but Poorly Recognized Condition

Booth P27

R.H. Grace, J.M. Anderson Wolverhampton, United Kingdom

Twenty one children (14 boys and 7 girls) between the ages of 2 and 10 presented with perianal cellulitis over a period of 4 years. All were referred to outpatient clinics (surgical [7], dermatology [2] and pediatric [12]), with diagnoses which included inflammatory bowel disease (3), sexual abuse (3), fecal impaction (8) and intertrigo (1). Symptoms included rectal bleeding (21), painful defaecation (11), white or blood stained discharge (7) and systemic upset (5). One boy had developed psoriasis. Topical preparations in fifteen cases had been ineffective.

The typical appearance was of erythema, skin denu- dation and a clear/white or blood stained discharge. Group A beta hemolytic Streptococci were cultured from a perianal swab in all cases. The average time from initial symptoms to actual diagnosis was 4 months (range 2 weeks to 13 months). Three children responded to Pen- icillin, ten to Erythromycin and two to Augmentin. Three other children failed to resolve on Penicillin but settled after Erythromycin. Three failed to respond completely to Erythromycin but responded to Augmentin:

Perianal Streptococcal sepsis is more common than is acknowledged; it is easy to diagnose and treat when recognized. It is suggested the treatment of choice is a 10 day course of oral Erythromycin.

Rubber Band Seton and Complex Anal Fistulas Booth P28

K. Hacker, J. Heryer, W. Conner . . . . . Kansas City, MO

Complex anal fistulas that involve the sphincter mechanism continue to be a difficult and challenging problem. Anal continence is maintained by the puborectalis and the sphincter muscles. Acute division of the puborectalis muscle may result in anal incontinence. Similarly, surgical division of the deep part of the external sphincter may lead to incontinence, even if the puborectalis is intact. A retrospective analysis was performed on 73 consecutive patients with a complex anal fistula between July 1979 and January 1991. A rubber band seton technique was utilized in these patients. The goal of the seton is to promote fibrosis, so that retraction of the puborectalis or sphincteric muscle is prevented and anal continence is maintained. These 73 patients, age 20 to 74, had setons placed at the time of surgery. The seton was kept in place for an average of 170 days. The setons required an average of 6.6 tightenings. One patient had mild problems with stool incontinence following seton removal. Three patients developed a perirectal abscess


following seton removal. The remainder of the 69 patients reported good results following seton removal. This method of seton technique continues to be a valuable method of treating patients with complex anal fistulas.

What is the Role of Computerized Axial Tomography Fistulography in Complex Anal Fistula?

Booth P29

R. Rubin, T. Eisenstat, E. Salvati, G. Oliver, E. Duberman Plainfield, NJ

Patients with complex, secondary, or tertiary fistulas may benefit from preoperative imaging using CT fistulography. Eleven patients with complicated fistula underwent CT fistulography over a five year period from 1986 to 1990. Eight of the eleven studies provided information about fistula anatomy not obtained by standard techniques. This data was subsequently used to plan an operative procedure. All patients who have had surgery have remained healed, without recurrence to date. All patients have been followed one to five years. Nine of eleven patients had previous fistula procedures. The etiology of the fistula was cryptoglandular in seven, Crohn's disease in three and trauma in one. Operative therapy was individualized based upon the findings of the CT fistulogram. The planning of surgery was modified in greater than two thirds of patients. We feel that CT fistulography provides clinically valuable information in patients with complex or recurrent anal fistula. Indi- cations include a) primary complex fistulas, b) recurrent abscess with no recognizable internal opening, c) abscess with very distal or remote external fistulous open- ings, d) fistulas with multiple internal or external open- ings, e) possible supra sphincteric or supra levator fistulas. CT fistulography provides an additional dimension of spacial information with regard to the site of internal opening of fistulas as well as the relationship of the fistulous tract to the levator mechanism and sphincter.

Anal Sphincter Reconstruction in the Elderly: Does Ad- vancing Age Affect Outcome?

Booth P30

C.L. Simmang, R.D. Fry, I.J. Kodner, J.W. Fleshman St. Louis, MO

Anal sphincter reconstruction performed on elderly patients was reviewed to determine if the functional outcome was adversely affected by advancing age.

Between July 1986 and 1991, 14 women, 55 to 80 years of age, underwent anal sphincter reconstruction using an anterior overlapping muscle repair. Patients were incontinent of solid (10) or liquid (4). Results at 6 months were as follows: 7 (50%) complete control; 3 (21%) incontinent to flatus; 4 (29%) incontinent to liquid (including the patient who failed to improve).

Anal manometry and pudendal nerve terminal motor latency (PNTML) were performed in 10 patients before and 6 months after operation. Mean maximal resting and squeeze pressure increased overall (35.02 to 37.9 mmHg; 63.5 to 71.1 mmHg, respectively). Mean sphincter length increased from 3.0 cm to 3.25 cm. A mean maximal


squeeze pressure reached 81.5 mmHg in patients achiev- ing complete control and 60.7 mmHg in patients with residual incontinence. PNTML was normal (2.0 + 0.2 m/ sec) on one or both sides in all 9 patients who improved (average 2.1 m/sec). The patient who failed to improve showed PNTML of 2.4 and 2.7 m/sec.

Total control can be achieved by restoring maximal squeeze pressure in a patient with normal pudendal nerve function. Advancing age is not a contraindication for performing anal sphincter reconstruction.

C o l o n C a n c e r

Role of Radiolabeled Antibody Imaging with 111In-CYT- 103 in Management of Colorectal Cancer Patients

Booth P31

M.L. Corman, S. Galandiuk, G.J. Weiner, D. Kahn, E. Mitchell, H. Abdel-Nabi, G.E. Block, the 1nln-CYT-103 Immunoscintigraphy Study Group .. Santa Barbara, CA

The present study was designed to assess the value of '~In-CYT-103 immunoscintigraphy in the medical/surgical management of colorectal cancer patients. Enroll- ment was restricted to cases where standard diagnostic modalities did not provide sufficient information for patient management decision. Single intravenous doses of mIn-CYT-103 were administered to 103 patients, including 49 with rising CEA levels and otherwise negative diagnostic workups, 31 with suspected isolated resectable recurrences, and 23 other patients for whom additional diagnostic information was required. 'a1In-CYT- 103 immunoscintigraphy made a beneficial contribution to the medical/surgical treatment of 43% of the patients. In most of these (31/44), antibody imaging detected occult disease; knowledge of these occult lesions directed (n=13) or indicated the need for (n=l) surgical exploration, contributed to the cancellation of proposed surgery (n=6) or to the selection of nonsurgical treatment (n=9), and indicated that more careful follow-up was required (n=2). Investigators judged the results of this diagnostic test as having provided useful information with an acceptable risk-benefit profile in 83% of patients studied.

Bolus (A) Versus Continuous (B) Hepatic Arterial Infusion (HAI) of Cisplatin (CDDP) Plus I.V. 5-FU Chemotherapy for Unresectable Colorectal Liver Metastases: A Phase II Randomized Trial by the Italian National Register of Im- plantable Systems (RNSI)

Booth P32

M. Cosimelli, E. Mannella, M. Tedesco, M. Anza', D. Civalleri, P. Di Tora, L. Capussotti, G.B. Morandi, C. Tirelli, P.P. Da Pian, E. Cortesi, E. Ruggeri, D. Giannarelli

Rome, Italy

A previous RNSI phase II study on bolus CDDP HAI plus i.v. 5-FU reported a 3-year survival rate of 26% in responders and a median survival of 27 months in stage II patients with unresectable colorectal liver metastases, with high rates of neurological peripheral, gastrointestinal and hematological G3 or G4 toxicity.

After administering CDDP HAI at 24 m g / m 2 / d i e for 5

days every 28 days plus i.v. 5-FU, 500 mg/m 2 on the same days, the objective responses, toxicity and survival rates were evaluated, comparing the modality of CDDP HAI (bolus vs. continuous infusion).

Since January 1989, 81 patients have been randomized with a total of 248 cycles (mean cycles/patient: 3). The operative mortality rate was 2.9%. According to Gennari's classification, 8 patients had unresectable stage I disease (9.9%), 40 stage II (49.4%), 29 stage III (35.8%) and 4 stage IVa (4.9%) with a median ECOG P.S. of 0. To date, 60 patients (74%) are evaluable for toxicity and 46 (56.8%) for response. Six CR (10.8%), 17 PR (37.8%), 9 SD (27.1%) and 14 DP (24.3%) were assessed by liver sonogram or CT scan. The CR + PR rates were 52% and 47.6% in the A and B subgroups, respectively. Twenty- two patients (A: 14 vs. B: 8) presented nausea/vomiting -> G3 and 11 (A: 7 vs. B: 4) hematological toxicity >_ G3 with an overall 6.7% chemotherapy-related death rate, all in group A. The overall renal toxicity rate was 15% but only 1 patient had a G3 event. Of 7 G1 neurological peripheral toxic events, 5 were observed in the A subgroup. Another 3 patients in arm A had either G3 fever, G3 pain during chemotherapy or G4 skin erythema. One hundred sixty-one toxic events were observed, 99 in group A and 62 in B. The 3-year actuarial survival rate in both arms was 27.5%, showing a difference between the two group (35.9% in A vs. 18.8% in B). According to stage and treatment response, the 3- year survival rate was 41.5% at stages I and II vs. 12.1% at stage III (p=.05) and the responders survived longer than the nonresponders (54.6% vs. 0%) (p=.05). These preliminary results show higher survival and toxicity rates with a bolus CDDP HAl.

Partially supported by Pharmacia S.p.A.-Italy.

Outcome of Treatment of Advanced Colorectal Neoplasia in the High Risk and Elderly

Booth P33

S.D. Fitzgerald, W.E. Longo, G.L. Daniel, A.M. Vernava III . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . St. Louis, MO

Colorectal neoplasia is routinely encountered in elderly patients with significant comorbid disease. Many of these patients present with advanced, incurable disease and their treatment remains controversial. AIM: To determine perioperative mortality and long-term survival in the elderly and high risk patient and to compare the results in patients with localized and advanced disease. METHODS: Over a five year period 82 high risk (major organ System disease) and elderly patients (>75 yrs) underwent operation for colorectal neoplasia. Forty- three (52%) had advanced disease (obstruction, perforation, hemorrhage or metastatic disease). Thirty-nine (48%) had localized disease. Morbidity, mortality and survival were determined.

DISEASE NO. MORTALITY* SURVIVAL**

LOCALIZED 39 2(5.1%) 91% ADVANCED 43 4(9.3%) 63%

p=0.76 p<0.05

* =30 DAY MORTALITY ** =18 MONTH ACTUARIAL SURVIVAL


RESULTS: The mean age of all patients was 78.2 years. Preoperative comorbid disease included: coronary ath- erosclerosis 59 (72%), previous MI or arrythmia 27 (33%), emphysema 32 (39%), renal failure 6 (7%), and cirrhosis 3 (4%). At the time of surgery, metastases to the liver 19 (23%) and abdominal wall 7 (9%) were present. Overall, 6 (7%) died in the perioperative period. The presence of advanced neoplasia did not significantly affect 30-day mortality. There was no difference in major morbidity between patients operated on for localized or advanced disease. The mean actuarial 18 month survival was less for patients with advanced disease (p<0.05). Sixty-eight patients are alive at a 17.7 +- 29 month follow up. CONCLUSION: Resection of colorectal neoplasia in elderly and high risk patients is associated with acceptable perioperative mortality even in advanced disease. Resection offers good palliation and may improve quality of remaining life.

Quantification of Sialomucin at Resection Margins of Pa- tients with Rectal Carcinoma to Determine Ideal "Cut- Off"

Booth P34


Sialomucin at the resection margins of patients with colorectal carcinoma, has been shown to be a useful variable to predict local recurrences. However, almost all studies group together malignancies of the colon and rectum. This is the first time quantification of sialomucin at the resection margins of patients undergoing abdominal "curative" resections for rectal carcinoma has been made in order to determine the best "cut-off".

Sialomucin at the resection margins of 75 patients included in a prospective study was analyzed retrospectively using high iron diamine alcian blue stain. Each slide was blindly interpreted by one person. The crypt with the most sialomucin-containing cells was selected and the percentage of cells with sialomucin was recorded for each margin. For each patient, only the margin with highest sialomucin content was used.

In order to predict local recurrences, the ideal subdi- vision of patients was: 1) absence of sialomucin: crypts containing _<82% of cells with sialomucin and 2) presence of sialomucin: crypts with ->83% of cells containing sialomucin. The difference in local recurrences between both groups was highly significant (p=0.002).

It is concluded that patients with rectal cancer and ->83% of cells containing sialomucin at any resection margin should be considered to have an abnormal sialomucin pattern predictive of local recurrences.

Body Iron Stores and the Risk of Colonic Neoplasia: A Case/Control Study

Booth P35

Richard Nelson, Faith Davis, Phyllis Bowen, Eileen Sut- ter, Waiter Kikendall . . . Chicago, IL, Washington, D.C.

We have investigated the role of body iron stores in colorectal cancer risk. This is the first investigation fo- cussing specifically on the colon in a human epidemio-

logic case/control study and also includes benign as well as malignant neoplasms of the colon. Body iron stores were measured in a population accrued by colonoscopy from a mandatory military colorectal screening program for an ongoing case/control study and dietary intervention trial relating to A vitamers. This group included 27 individuals with early (Dukes' A and B1) cancers, 154 patients with benign adenomas and 169 tumor free con- trois. Body iron stores were measured using serum ferritin. Quartiles of serum ferritin were defined based on distribution in controls and a comparison of the fourth (highest), third, and second quartiles relative to the first (lowest) quartile were made. Serum ferritin was the method of estimating iron stores. Results of this investigation show a positive association of both cancer and benign adenoma with serum ferritin. Excluding those individuals most likely to have hemochromatosis, (serum ferritin > 400 #g/l) from the analysis, a linear increase in risk of colonic neoplasia with an increase in ferritin was seen. Comparing the second quartile to the first, the odds ratio was 1.43 or an individual with an adenoma was 1.43 times more likely to be in the higher ferritin group. The third quartile to first comparison yielded an odds ratio of 2.31 and the fourth to first, an odds ratio of 3.43. This association was evident but the pattern was less stable for cancer, probably due to the small number of cases, Nevertheless, an increased risk of colonic neoplasia is clearly related to increased iron stores in this population and these results further call into question the wisdom of nationwide supplementation of iron in many foods and vitamins. In addition, the concordance of findings for both cancer and adenoma has rarely been found in the past for any dietary item and provides support for the adenoma-carcinoma sequence theory.

Familial Adenomatous Polyposis: Initial Diagnosis in the Sixth Decade of Life

Booth P36

J.J. Nogueras, D.G. Jagelman, S.D. Wexner, E. Mc- Gannon, P.A. Brantley . . . . . . . . . . Fort Lauderdale, FL

Familial adenomatous polyposis (FAP) is a genetic disorder with variable phenotypic expressions. It is widely assumed that all untreated patients will develop colorectal carcinoma by the fifth decade of life. Twenty- five patients were identified who were first diagnosed with FAP after the age of 50 years. These 15 females and 10 males of a mean age of 57 (range 50-72) years at the time of diagnosis have had a mean follow-up period of 80 (range 2-300) months. Diagnosis was established by the combination of multiple colonic adenomatous polyps with an autosomal dominant familial pattern. Carci-

n o m a of the colon or rectum was found in 16 patients (64%) at initial presentation. The modified Dukes' stage distribution of these carcinomas was as follows: A: 20%; B: 40%; C: 33%; D: 7%. One or more extracolonic manifestations were present in 10 patients (40%) in the following distribution: epidermoid cysts (24%), duo- denal polyps (16%), adrenal mass (8%), osteoma (8%), gastric polyps (8%), and desmoid tumors (4%). Three patients (12 %) have developed extracolonic malignancy: Leukemia 1, uterine carcinoma 1, pancreatic carcinoma


1. Eight patients (32%) have died of their disease, at a mean age of 67.8 (range 56-85) years. Seventeen patients (68%) of a mean age of 62.4 (range 50-77) years are alive and under surveillance. This study describes an interesting subgroup of patients with FAP in whom the diagnosis was establ ished later in life. These patients appear to have a more indolent course of disease; the genet ic mechanisms responsible for this less aggressive presentat ion of FAP remains to be elucidated.

Diver t icu l i t i s

Transanal Total Sleeve Advancement Flaps: An Alternate Approach to Complex Perianal Fistula

Booth P37

C. Czyrko, C. Falardeau, V.W. Fazio, J.W. Milsom Cleveland, OH

Chronic complex anal fistula, especial ly those associated with Crohn's disease, may recur as often as 30-50% of cases after standard surgical t reatment such as rectal advancement flap repair. As an alternative to total proctec tomy and permanent diversion we have used a total sleeve advancement procedure (TSAF), consisting of circumferential mobil izat ion of the rectal mucosa/submucosa and advancement of this to close the direct fistula repair.

METHOD: Six patients were treated with TSAF (5 female, 1 male) after failure of ei ther drainage or standard rectal advancement flaps. Selection criteria exc luded patients with active rectal inflammation. Anal canal ul- ceration did not preclude performing a TSAF.

RESULTS: Five of the six patients had Crohn's disease, three of the five had rectal-vaginal fistula. Duration of the fistula ranged from 1-12 years, median of 3 years. One patient had two previously failed rectal advancement flaps and is now 5 months postop with an unre- markable TSAF. Two patients underwent s imultaneous terminal i leum resection for Crohn's disease and had fecal diversion. With a median follow-up of 3 months there has been no recurrences. TSAF is an option for patients with complex perianal fistula and is an alternate choice to permanent diversion. Long term results are yet to be determined.

Determination of Inflammatory Bowel Disease Activity in Humans with Exhaled Pentane Assays

Booth P38

Joseph KoKoszka, Richard Nelson, Don Trepashko, John Skosey, Herand Abcarian . . . . . . . . . . . . . . . Chicago, IL

Quantitative determinat ion of pentane exhalation, a hydrocarbon generated by membrane l ipid peroxidation, has been used as a noninvasive determinant or index of inflammation in various organs. A positive relat ionship between exhaled pentane levels and a rodent model of colitis has been demonstrated. This report examines the relationship of exhaled pentane in humans to active IBD as identif ied with indium labeled WBC nuclear scans.

Patients ( n = l l ) , ei ther with a known history of IBD, present ing with symptoms suspicious of relapse, or those with new onset symptoms consistent w i t h IBD, were

evaluated with indium labeled WBC imaging to assess the presence or absence of active inflammation. At the time of the indium scan, the exhaled breath of the patients was obtained via a collecting tube. Gas chro- matography assay of the exhaled breath was used to quantify the pentane content. Previous studies on inflammation were able to determine normal levels of pentane which ranged from 0 to 3.5 nanomoles \ l i te r . Levels greater than 3.5 were associated with active inflammation. The range among our patient populat ion (n=11) was from 0 to 6.6 nanomoles \ l i te r . Indium scanning for the determinat ion of active IBD was interpreted at four and twenty-four hours and placed into one of three diagnostic groups. Scans were identif ied as negative if there was no visualization of large or small bowel with indium. Scans were identif ied as positive if there was definite localization of indium within the intestine. Fi- nally intermediate scans only displayed faint to mild foci of localization. Based on this grouping the results of our patient populat ion 's indium scans were compared with the pentane levels as demonstra ted below.

Range Mean

Negative indium scan (n=4) 0-4.2 2.0 Intermediate scan (n=3) 1.9-3.4 2.5 Positive indium scan (n=4) 4.2 6.6 5.3

Although there is a wide range of distributions among the obtained pentane levels in each diagnostic group, there exists a linear progression of mean pentane content with increased inflammation as identif ied by indium scan. At this early point of our study, the value of a positive pentane content correlates strongly with a positive scan and may serve to distinguish active IBD. Sub- sequently, pentane may be uti l ized as an adjunct to the diagnosis of active IBD when invasive tests are contraindicated.

Incidence, Diagnosis and Treatment of Enteric and Colo- rectal Fistulas in 639 Consecutive Crohn's Patients

Booth P39

F. Michelassi, G.E. Block . . . . . . . . . . . . . . . Chicago, IL

Between 1970 and 1988, 639 patients underwent surgical treatment for Crohn's disease. 222 patients (34%) were found to have 310 intra-abdominal fistulas. A fistula was diagnosed preoperat ively in 154 patients (69%), intraoperatively in 60 (27%) or only after examination of the spec imen in 8 (4%). Of 165 patients with an abdominal mass, 69 (42%) had a fistula. The fistula represented the only indication for surgical treatment in 14 patients (9%) and one of several indications in the remaining 140. 219 patients underwent a resection, with primary anastomosis in 160 and a temporary or permanent stoma in the remaining patients. The fistula was directly responsible for the need for a stoma in only 16 patients (7%). Resection of the diseased bowel accom- pl ished complete removal of 158 fistulas; in the remaining 152 fistulas, the bowel resection was complemented by closure of one fistulous opening on the stomach (14),


vagina (6), bladder (35), or rectosigmoid (49). When the fistula opened through the abdominal wall (n=46), the fistulous tract was debrided. One patient died and 20 (9%) developed postoperative septic complications. There were no anastomotic dehiscences. We conclude that fistulas are diagnosed preoperatively in 70% of cases and can be suspected in as many as 42% of patients with an inflammatory mass. Fistulas are the only indications to surgical treatment and are directly responsible for a stoma only in a minority of patients. Treatment is based on resection of the diseased bowel and extirpation of the fistula.

The Role of CT Scan in the Management of Acute Diver- ticulitis

Booth P40

R.J. Staniunas, P.V. Vignati, D.J. Schoetz Jr., P.L. Roberts, J.J. Murray, J.A. Coller, M.C. Veidenheimer

Burlington, MA

Computed Tomography (CT) is increasingly applied as a routine investigation in acute diverticulitis. Between 1980-91, 320 patients were hospitalized with the diagnosis of acute diverticulitis; 85 (27%) were evaluated with CT, most (75%) within three days of admission. Positive CTs for diverticulitis were seen in 48 (56%), while 37 (44%) were negative. Abscess was diagnosed in 21/48 positive scans; however 11 (55%) were successfully treated with IV antibiotics, without the need for other intervention. Of the 37 patients with negative CT, 6 (16%) required acute surgery and 9 (24%) had elective resection. Despite a negative CT, 75% of these patients had pathological evidence of diverticulitis, with perforation in six. Conversely in those with positive CT scans the pathological findings correlated in 95%.

CONCLUSION: (1) the CT diagnosis of acute diverticulitis is associated with a high false-negative rate: (2) CT does confirm the presence of abscesses which may resolve with IV antibiotics alone and (3) the diagnosis and treatment of acute diverticulitis should be based on the clinical course, utilizing CT in the medically unrespon- sive patient.


stapled using laparoscopic techniques. An electrocautery snare is then used to perform a full thickness polypectomy of the inverted bowel. Air insufflation is used to confirm the integrity of the closed bowel. The specimen is removed with the colonoscope and it is submitted for pathologic review. If invasive cancer or incomplete margins are identified a resection can be performed. This method as demonstrated in this videotape allows complete excision of moderate sized sessile polyps and may spare the patient a colonic resection.

Potpourri

The Microflora of the Large Intestine After Polyethylene Glycol (PEG) Lavage Preparation

Booth P42

R. Bleday, J. Braidt, K. Ruoff, F. Ackroyd, P. Shellito Boston, MA

Even though the PEG lavage prep is the most commonly used method of mechanically cleansing the bowel prior to colonoscopy and surgery, little is known about its effects on the colorectal microflora. We therefore studied the mucosa-associated microflora of the colon and rectum in 10 patients undergoing colonoscopy after a standard Golytely prep. No patient had taken antibiotics in the preceding 4 weeks. Sterile wire brushes passed through the colonoscope during advancement were used to sequentially culture the rectal, transverse colon, and cecal mucosa. All patients had either a normal colonoscopy or benign polyps. Total anaerobic, aerobic, gram+, and enteric bacterial counts were determined along with specific cultures for B. fragilis, C. difficile, E. coli, P. aeruginosa, Enterococcus, and staph species. The mean values for anaerobes and aerobes are shown in Table 1:

Anaerobes Aerobes

Rectum 1.5.10 s 1.6.104 T. Colon 2.5.106 2.9.104 Cecum 2.4.106 6.6.104

Laparoscopy

Laparoscopic Assisted Full Thickness Endoscopic Polyp- ectomy

Booth P41

D.E. Beck, R. Karulf, R. Roettger . . . Lackland AFB, TX

Selected patients with moderate sized sessile colonic polyps can be managed in a minimally invasive manner. Under general anesthesia, the lesion is identified with a colonoscope passed through the anus. A laparoscope is then inserted into the abdomen and the location of the lesion is confirmed. If necessary, the colon m a y be mobilized to produce a free surface over the lesion. Grasping forceps passed through the colonoscope are used to grasp the polyp and slightly dimple the colon. The inverted unopened colon is then oversewed or

Anaerobic counts were approximately two logs greater than aerobic counts for each area of the colon and rectum. There was a significant increase (p<.01) in aerobes, anaerobes, enterics, gram+, B. fragilis, and E. coli mucosal counts in the more proximal bowel. Clos- tridia difficile was not cultured from any patient. Pseu- domonas aeruginosa was found in only two patients. Enterococcus was cultured from 5 patients. Our quantitative results appear to be one to two logs less than other studies looking at luminal cultures after other types of mechanical preparation. We conclude that the PEG bowel preparation reduces the mucosa-associated aerobic and anaerobic microflora to the 104 and 106 range, respectively, and that there is an increase in the mucosal bacterial counts in the proximal colon compared to the rectum.


Association of Gallstones and Colorectal Cancer in an Oriental Population

Booth P43

H.S. Gob, L.W. Lin . . . . . . . . . . . . Singapore, Singapore

Since the establishment of a national cancer registry in 1968, Singapore has witnessed a dramatic increase in colorectal cancer that is fast overtaking lung cancer as the commonest cancer in the country. Gallstone formation from altered bile acid metabolism which reflects dietary changes, may be an important factor. This study compares the incidence of gallstones, as determined by ultrasound, in colorectal cancer patients and matched controls.

310 consecutive patients (181 males, 130 females, mean age = 60.6) and 113 controls (56 males, 57 females, mean age = 57.6) were studied using an Aloka 650 ultrasound machine. Accuracy of ultrasound findings were verified in 112 patients who had both pre- and intraoperative ultrasound as well as gallbladder palpation at laparotomy (sensitivity = 93%, specificity 100%).

99/310 (32%) colorectal cancer patients had gallstones compared with 8/113 (7%) of controls (p < 0.001). The difference was significant throughout all age groups (in percentages--16, 23, 26, 38 compared with 0, 0, 8, 11 for age groups < 40, 40's, 50's > 60 years respectively, p < 0.001); and in both sexes (M = 32:5 p < 0.001, F = 32:9, p = 0.001). Gallstones appear to be commonest in patients with right colon cancer and decrease progressively to the rectum (right colon:left colon:rectum = 50:32:26, p = 0.06). These findings suggest that factors in gallstone formation may be aetiologically important in populations with increasing incidence of colorectal cancer.

The Value of Dynamic Liver Scanning (HPI) in Large Bowel Cancer

Booth P44

R.H. Grace, E. Edwards, J. Farmer, C.A. Walters Wolverhampton, United Kingdom

Perfusion in the postoperative period with Heparin and 5-FU may influence the development of liver mets. It has been suggested that dynamic liver scanning (HPI) may predict patients who will develop liver mets. An important group of patients who might benefit from liver perfusion will have been identified. We use the technique taking 0.40 as the upper limit of normal. 305 patients were studied between May 1985 and May 1990. The results relate HPI to laparotomy and follow-up.

Table (2) Follow up: No liver Mets at Laparotomy.

HPI

Development Died of of Liver Malignant Disease

Metastases Dukes B Dukes C

Normal 150 9(6.0%) 6/94 15/46 (6.4%)* (32.5%)

Abnormal 94 5(4.3%) 12/59 13/31 (20.3%)* (41.9%)

* p<0.0005

Two groups (table 1) have been identified. 16 (9.4%) of 170 patients with normal HPI had liver metastases at laparotomy compared with 36 (26.7%) with a raised HPI (p<0.005). Follow-up has not identified any difference in the subsequent incidence of liver mets but 25 (26.4%) with an abnormal HPI have died of malignant disease compared to 21 (14%) of those with normal HPI (p<0.005). When related to Dukes status B significance lies at p<0.0005.

Do General Surgery Residency Programs Adequately Train Surgeons to Perform Anorectal Surgery?

Booth P45

N.H. Hyman, J.C. Hebert . . . . . . . . . . . . Burlington, VT

Anorectal diseases have traditionally been a major component of general surgical practice. With the continued movement of anorectal surgery to the outpatient setting, there is concern that residency programs in general surgery provide an inadequate experience in anorectal procedures.

Data on the anorectal experience of residents completing general surgery programs over the most recent five year period (1987-1991) was obtained from the Residency Review Committee for surgery. The mean number of cases per graduating resident throughout the course of their training is indicated below:

Hemorrhoidectomy 8.3 Sphincterotomy/sphincteroplasty 3.2 Anorectal abscess drainage 7.7 Anorectal fistula 4.8 Prolapse 0.8 Pilonidal cystectomy 4.2 Other operations for incontinence 0.3 Other major 2.3

Total number of anorectal procedures 30.0 throughout residency

It is concluded that general surgery programs tend to provide an inadequate training experience in anorectal surgery.

Table (1) HPI: Findings at Laparotomy.

HPI Liver Clear Liver Mets

Normal 170 154(90.6%) 16(9.4%)* Abnormal 135 99(73.3%) 36(26.7%)*

* p<0.005

Use of Toradol ~ in Anorectal Surgery Booth P46

Irving M. Richman . . . . . . . . . . . . . . . . . . Encinitas, CA

Toradol is a nonsteroidal anti-inflammatoI T drug intro- duced for intramuscular injection to control postoperative pain.


Its action is peripheral. (Slide 1) Therefore, it seemed appropriate to inject it directly into the sphincter muscles when these are exposed during anorectal procedures.

A total of 60 mgm. (2 cc) are used, divided among the three quadrants usually resected. (Slide 2)

Four hours postoperatively 30 mgm are given i.m. and the patient is discharged.

Results: pain has been so well controlled that patients have to be cautioned not to participate in excessive activities.

Most remarkable is the fact that none of the patients have needed catheterization for urinary retention.

Failure to control pain occurred in two patients. The first was a 77 year old lady who complained bitterly until she had her first bowel evacuation. Thereafter Darvocet N-100 controlled her pain adequately.

The other was a 38 year old man who on direct questioning admitted to drug use.

Complications: (Slide 3) none of the complications listed have been noted in the patients seen to date.**

*KETOROLAC TROMETHAMINE ** 53 Cases

Malignant Carcinoid: A Term to be Discarded Booth P47

T.J. Saclarides, E.D. Staren . . . . . . . . . . . . . . Chicago, IL

Between 1980-1990, 988 patients had resections for colorectal cancer. Thirty-nine patients (3.9%) were found to have neuroendocrine (NE) carcinomas by immunohistochemical evaluation. Many of these tumors were initially diagnosed as poorly differentiated adenocarcinomas or malignant carcinoids. Average age was 65.5 (28-89); there were 25 males and 14 females. Nine- teen tumors were located in the right colon, 11 were in the left, and 9 were in the rectum. In 35 cases, sections were immunostained with one or more NE markers including neuron-specific enotase, human chromogranin A, synaptophysin, serotonin, VIP, substance P, and somatostatin. Tumors were also stained with monoclonal antibody A-80, an exocrine marker. Three histopathologic patterns were identified: pure NE (11), predomi- nantly NE (17), and cancers with equal exocrine and NE differentiation (7). Three subtypes were seen: small cell (15), intermediate cell (15), and well differentiated NE cancers (5). Cancer stage was as follows: Duke's A 1, B 7, C 16, D 15. As a group, these tumors have poor prognosis: 6-month survival was 58%, 3-year survival 15%, 5-year survival 6%. Survival correlated with tumor stage (p=.01) but not with age, sex, tumor location, histopathologic pattern or NE subtype. The term "carcinoid" was initially intended to describe benign "carcinoma-like" tumors; we recommend the term "NE carcinomas" to describe their malignant counterparts. In conclusion, NE differentiation in colorectal carcinomas occurs more frequently than is recognized and bodes for a poor prognosis.

Enterovesicular Fistula; A Twenty Five Year Experience with 68 Patients

Booth P48

S.C. Sessions, R.S. Scoma, B. Clements, R.D. Smink, Jr. Philadelphia, PA

Vesicoenteric fistulas represent a relatively uncom- mon surgical problem. This retrospective study was undertaken to define the incidence, anatomic location, etiology, clinical manifestations, diagnostic techniques, and surgical management of vesicoenteric fistulas. Dur- ing the twenty five year period between 1965 and 1990, 68 patients with vesicoenteric fistulas were diagnosed. Three types of fistulas were encountered; colovesicular fistulas (94%), ileovesicular (4.4%), and rectovesicular (1.4%). The etiology was diverticular disease in 51 patients, carcinoma in 13, and Crohn's Disease in three. Urinary complaints were the most common presenting symptoms. Recurrent urinary tract infection and dysuria occurred in 49 patients (72%), terminal pneumaturia in 46 (68%), and fecaluria in 27 (40%). Cystoscopy was the most reliable diagnostic study, demonstrating a fistula in 30 of 58 patients (52%). Excretory urogram demonstrated a fistula in 6 of 20 patients (30%). Barium enema revealed the exact site of colovesicular fistula in 24 of 64 patients (38%). Operative repair using single or multiple stage procedures was performed in 53 of 68 patients. Three patients had various palliative procedures. During the last 10 years of study the majority of patients underwent single stage resection and repair. Excellent long term results were obtained in patients with diverticular disease. Awareness of vesicoenteric fistula can avoid delay in diagnosis and treatment.

Urinary Changes in J Pouch and Ileostomy Patients Booth P49

K. Arai, A. Sugita, Y. Yamazaki, H. Harada, T. Fukushima Yokohama, Japan

After proctocolectomy, urinary output and electrolytes are changed due to loss of colonic function. Urinary substances and pH were measured in J pouch (n=24), ileostomy patients (n=8) and healthy controls (n=22). Urinary output in J pouch (978-+203 ml/day) and ileostomy (744+262) were significantly reduced compared to that of control (1563_+728, p<0.05). Urinary Na in J pouch (135+55 mE'q/l) and ileostomy (95+48) were also significantly lower than that in control (180---52, p<0.05), On the contrary, urinary uric acid in J pouch (78-+18 mg/dl) and ileostomy (72---14) were increased compared to that in control (40-+18, p<0.05). Urinary pH in the morning, noon and in the evening was 5.7+ 0.5, 6.1+_0.7, 6.1+_0.6 respectively in J pouch and 5.2_+ 0.3, 5.2+0.6, 5.2+0.4 in ileostomy, both of which were significantly lowered compared to control (5.9_+0.3, 6.3+- 0.3, 6.4+-0.3, p<O.05). Urinary K, Ca, Mg and oxalate were not changed in three groups. To alkalinized ac-


iduria, patients were given citrate mixture 3 g/day containing Na 104 mg/g, K 178 mg/g. Subsequently, urinary Na and pH were elevated and uric acid was reduced. Citrate mixture was effective to normalize their urine and to prevent uric acid complication.

Myoelectrical Activity in Chronic J-Shaped Pelvic Ileal Reservoirs (J-PIRs)

Booth P50

D.N. Armstrong, G.H. Ballantyne, L.F. Sillin New Haven, CT, Syracuse, NY

Proctocolectomy and construction of J-PIRs result in adaptive changes in gut motility and absorption. We investigated the long-term changes in myoelectrical activity in the smooth muscle coat of J-PIRs.

METHODS. Nine dogs underwent pancolectomy, construction of J-shaped PIRs and PIR-anal anastomosis. Bipolar strain-gauge/electrode combinations were sutured onto the serosal surface of the PIRs at 5 locations around the component limbs. The instruments weie implanted either during the initial operation (5 dogs) or 6 months postop (4 dogs). Electrical recordings were made on a weekly basis. For control purposes, myoelectrical activity in normal terminal ileum of sham operated animals (2 dogs) was recorded.

RESULTS. Myoelectrical activity in control ileum consisted of phases I, II and III of the migrating myoelectrical complex (MMC). In J-PIRs, the MMC was replaced by short duration spike complexes, resembling those seen in small bowel obstruction. Up to 6 months, the complexes migrated around the J-PIRs in a circular pattern. After 6 months, the complexes migrated synchro- nously, down both limbs of the reservoir, toward the anus.

CONCLUSION. Myoelectrical activity in J-PIRs consists of short duration spike complexes. Up to 6 months, these migrate around the J-PIRs in a circular manner. After 6 months, the complexes migrate in a coordinated wave, passing distally. This may result in more efficient emptying of the reservoir.

Loop Ileostomy Adversely Effects Ileal Mucosal Function Booth P51

R.J. Davie, K.B. Hosie, S.P. Grobler, L.K. Harding, N.J. Birch, M.R.B. Keighley

Birmingham, United Kingdom, Wolverhampton, United Kingdom

Changes in human ileal mucosal function before and after restorative proctocolectomy were assessed. Ileal mucosal specimens were obtained at initial operation or by endoscopic pelvic ileal pouch biopsies postoperatively. Active mucosal bile acid uptake (BA), mucosal glucosamine synthetase activity (GS) and histological changes were assessed.

BA uptake GS activity

1. Preop ileum 12.3 21.5 (n=39) (11-15) (17-25)

2. Ileal pouch: (a) defunctioned 8.0* 8.3*

(n=18) (4-12) (7-18) (b) 1-3 months-- 11.0 14"

prior ileost (8-14) (6-18) (n=ll) 11.2 25

no ileost (6-22) (14-38) (n=9)

(c) ->4 months-- 13.7 19.4 prior ileost (11-18) (14-24)

(n=26) 13.3 20.2 no ileost (7-20) (14-27)

(n=13)

BA uptake and GS were lower in defunctioned pouches. In the first 3 months after ileostomy closure GS remained significantly lower than in patients who had not had an ileostomy. In pouches established for at least 3 months BA and GS were similar to preoperative values.

Units: BA #g.g-1 wwt.45 min-1; GS #mol GlcNAc. hr-l.g-1 wwt; Median (95% CI); *p_0.01 (Wilcoxon).

Pouch Patients Are Less Likely to Suffer Excess Bile Acid Loss

Booth P52

R.J. Davie, K.B. Hosie, S.P. Grobler, L.K. Harding, N.J. Birch, M.R.B. Keighley

Birmingham, United Kingdom, Wolverhampton, United Kingdom

Bile acid absorption is determined by the absorptive capacity of the mucosa and the duration of exposure to the mucosal surface. A miniature flux chamber was used to measure ileal mucosal uptake and transport of tauro- cholic acid following restorative proctocolectomy (RPC) and in controls.

Uptake Transport

Pouch (n=20) 12.7(4.7) 1.0(0.6) Ulc. colitis (n=19) 13.0(4.8) 1.3(0.8) Constipation (n=ll) 14.5(5.5) 0.8(0.8) Cancer (n=7) 13.1 (4.2) 1.0(0.8)

[Values: mean(SD) #g.g-1 tissue wet weight-45 min-1].

Gastric, small bowel, pouch and whole gut transit were measured using a 99mTc DTPA-labelled solid meal followed by gamma camera in 14 pouch patients and 10 ileostomy controls. The whole gut residence time was longer in pouch patients [11.8 (2.6)] than ileostomy patients [6.6 (2.2)] (p<0.002 Wilcoxon). Because gastric residence [pouch 1.6 (0.4); ileostomy 1.3 (0.5)] and small bowel residence [pouch 4.3 (1.9); ileostomy 5.3 (2.0)]


were similar, it was concluded that the increased whole gut residence was due to time spent in the pouch [5.9 (1.5)]. [Results: mean (SD) in units of 'meal hours'].

RPC did not impair active ileal bile acid absorption, and the increased residence time in the pouch may promote absorption.

Motor Determinants of Incontinence After Ileal Pouch- Anal Anastomosis (IPAA)

Booth P53

A. Ferrara, J.H. Pemberton, R.L. Grotz, R.B. Hanson Rochester, MN

After IPAA, incontinence may be related to loss of the anal canal pressure gradient (ACPG). Aim: To analyze the ACPG and ileal pouch motor activity in continent (C) and incontinent (I) pts after IPAA. Methods: A mul- tichannel microtransducer catheter was positioned in 8 C (SM, 3F; mean age 38) and in 8 I pts (SM, 3F; mean age 36) 15 months or longer after IPAA. 24-hr motor activity was recorded by a 2 MB portable recorder. Rest- ing anal canal pressure, pouch large pressure waves (LPWs) and the pouch-anal canal pressure gradient were measured. Results: (All mean_+SEM.) Resting anal pressures were significantly lower in I during the daytime (I: 48_+6 vs C: 66-+9 mmHg; p<0.05) and during sleep (31-+4 vs 61-+7 mmHg; p<0.02) ~. In C pts, anal pressures showed brief cyclical relaxations (duration: 5-25 min). In contrast, in I pts, prolonged relaxation of the anal canal (45-90 rain) occurred. The frequency of LPWs was identical in both groups (12/hr daytime, 5/hr sleep), but peak pressures were higher (52-+6 vs 33-+7 mmHg; p<0.05) in I pts. In C pts, each LPW was accompanied by a rapid increase in anal canal pressure such that P anal canal was always > P pouch. In I pts, this response was often absent such that P pouch > P anal canal occurred 29_+5 times/24 hr. Conclusion: Compared to C after IPAA, I pts had lower resting pressures, more prolonged anal canal relaxations, higher amplitude LPWs and a non- responsive anal canal. As such, the anal canal pressure gradient was frequently reversed, thus predisposing these patients to fecal incontinence.

Before After op.

Max. RP (cm H20) 93 71" AS length (cm) 3.5 3.5 Threshold--upp. 8.7 8.7 Sensation in

AS (mA)--mid 6.8 7.4 --low 4.2 6.2

Median & range. * P<0.01 (RP = Resting anal pressure).

The "recto"-anal reflex was demonstrated in all patients before operation and in 23 patients after operation. All patients were continent, only one experienced minor leakage. Thus anorectal eversion during RP does not impair function of the anal sphincter.

Ileal Pouch Morphology and Fecal Short Chain Fatty Acids (SCFA) in Patients with J-Pouch Anal Anastomosis

Booth P55

T. Yamanouchi, A. Sugita, Y. Yamazaki, H. Harada, T. Fukushima . . . . . . . . . . . . . . . . . . . . . . Yokohama, Japan

The relationship between morphology of ileal pouch mucosa and fecal bacteria and SCFA was investigated in 17 IAA patients.

Method: Total mucosal thickness (TMT), villous height (VH) and crypt depth (CD) were measured in biopsy specimen of the ileal pouch, and fecal bacteria and SCFA were analyzed.

Results: Mean TMT was 435 -+ 43 micro m. was significantly higher than healthy control (347 -+ 35). No difference was found in mean VH between two groups but CD (183 + 47) was significantly higher than healthy control (95 -+ 15).

Mean fecal bacteria and SCFA were 10.2 -+ 1.2 log 10/ gm, 4.06 _+ 2.73 mg/gm significantly lower than healthy control (11.2 -+ 0.2, 5.63 -+ 0.80) and higher than ileostomy (9.4 -+ 0.5, 2.32 --- 1.26) respectively. Fecal changes preceded the pouch mucosal changes.

These results suggest that ileal mucosal change to colonic pattern was related to increased bacteria and SCFA in the pouch.

Is the Anal Sphincter Damaged by Anorectal Eversion and Double Stapling of the Pouch-Anal Anastomosis?

Booth P54

W.G. Lewis, P.J. Holdsworth, P.M. Sagar, D. Johnston Leeds, Yorkshire, England

The aim of this study was to find out whether anorectal eversion during restorative proctocolectomy (RP), to ensure the pouch-anal anastomosis is made at the correct level, impairs function of the anal sphincter (AS). 26 patients underwent RP with end to end ileoanal anastomosis, without mucosectomy, by the eversion technique. Before operation, each patient had anorectal function tests, which were repeated 8 (3-21) months after operation. The clinical outcome was assessed by interview.

Research

Proliferative Activity of Colon Mucosa One to Five cm from Primary Adenocarcinoma as Determined by Statin

Booth P56

I. Bayer, B. Mitmaker, P.H. Gordon, E. Wang Montreal, Quebec

It has previously been shown that normal appearing mucosa 1 cm adjacent to a colon carcinoma exhibits an increase in the mucosal proliferative rate but at 5 cm the proliferative rate is similar to the remaining colon. The aim of this study was to determine at what distance from a carcinoma this change occurs. S-44, a monoclonal antibody directed against statin, a nuclear protein expressed in quiescent cells was used to determine the


proliferative rate of colorectal mucosa at different dis- tances from carcinoma. The specimens of 16 patients undergoing resection of colorectal carcinoma were opened after operation and a 5 cm long strip of mucosa was obtained and cut into 1 cm segments. For each location, 10 longitudinally oriented crypts were evaluated for statin-positive cells identified by the presence of a dark brown reaction product. The average percentage of statin-positive nuclei at 1, 2, 3, 4, 5 cm from the carcinoma was 22.47 --- 1.83, 32.3i -+ 2.03, 36.77 + 2.2, 36.04 +- 1.76, and 36.15 + 1.10 respectively. The mean percent of statin-positive nuclei progressively increased from 1 to 3 cm (P < 0.001) indicating an expansion in the size of the proliferative compartment of the colonic crypt. This may indicate that a 3 cm margin may be wise to obtain when performing a resection for colorectal carcinoma.

Octreotide Inhibits the Growth of Liver Tumor in Two Animal Models of Colorectal Liver Metastases

Booth F57

N. Davies, J. Yates, H. Kynaston, S.A. Jenkins, B.A. Taylor Liverpool, United Kingdom

The treatment of metastatic colorectal liver metastases cancer remains poor, the majority of patients dying within one year of diagnosis. We have developed two models of liver metastases which reliably produce hepatic tumor following intraportal inoculation of tumor cell lines. We have investigated the effects of Octreotide, a long acting analogue of somatostatin, on the growth and development of hepatic tumor in these two models of liver metastases.

Following intraportal injection of I x 107 K12\Tr cells (an adenocarcinoma of colonic origin syngeneic to the BDIX rat), or 4 Xl06 HSN ceils (a fibrosarcoma syngeneic to the Hooded Lister {HL} rat), groups of 12 rats received either Octreotide 2 #g bd or saline (control) for 3 (HL rats) or 4 (BDIX rats) weeks.

There was a significant reduction (Mann Whitney U, P<0.001) in liver tumor, as assessed by percentage hepatic replacement in the Octreotide treated groups. In BDlX rats, median 0.6% (range 0-2.5%) compared to controls, median 17.5% (5.7-24.2%) and in HL rats, median 2.7% (0-26.5%) compared to controls, median 76.4% (56.3-85%).

These results indicate that Octreotide significantly inhibits the progression of hepatic tumor in two animal models of liver metastases and may be of benefit in the treatment of hepatic metastases in man. Further studies are required to evaluate this hypothesis.

pH in Normal and At-Risk Human Colonic Crypts Booth P58

P.S. Edelstein, S.M. Thompson, R.J. Davies San Diego, CA

The role of colonic cetl pH, phi, in the development of colorectal cancer is unknown; furthermore, pHi has

not been measured in the colon's functional unit, the crypt. Numerous studies suggest the presence of a "field defect" wherein alterations in ion transport and mitotic index are found at colonic sites distant from the cancer. We have measured pH~ as an expression of this field defect in isolated crypts from normal human colonic mucosa, from mucosa distant to a malignancy, and from mucosa of patients with previous adenomatous polyps.

Intact colonic crypts were isolated, loaded with the fluorescent pH indicator BCECF, and placed in physiological solution on a microscope connected to a spectro- fluorometer. Ratios of emission intensities at 530 nm resulting from alternately exciting the dye at 440 nm and 500 nm were measured on every tenth cell along the crypt to determine pHi.

Mean pH, in crypts isolated from grossly normal-appearing mucosa from cancer patients (n = 14) was 0.64+ 0.09 pH units higher (p < 0.001, unpaired t-test) than pH~ measured in control crypts (n = 6), while cell pH from patients with a history of polyps (n = 10) was intermediate. These data suggest that increased cell pH may be associated with hyperproliferative tissues. Our finding that this alkaline "field defect" is present in "at- risk" tissue may play a future role in treatment and prevention of colorectal cancer.

Supported by the American Cancer Society PDT382.

Acetylator Status: A Link Between Hepatic Metabolism and Colorectal Cancer

Booth P59

K.C,R. Farmer, S.E. Oliver, A.D. Spigelman, P. Bennett, R.K.S. Phillips . . . . . . . . . . . . London, United Kingdom

Bile influences gastrointestinal neop~asia, perhaps by hepatic metabolism of environmental carcinogens. The enzyme N-acetyltransferase detoxifies gastrointestinal carcinogens and its activity (fast or slow) is inherited. Slow acetylators may therefore excrete more carcinogen in the bile than fast acetylators.

We determined acetylator status in FAP patients (N=41), sporadic colorectal cancer (CRC) (n=10) and normal healthy controls (n=232). Following ingestion of 300 mg of caffeine and an 8 hour urine collection, urinary metabolites were measured by liquid chromatog- raphy and metabolic ratios used to determine acetylator status. The Chi-squared test was used for statistical analysis.

Resu[ts:

Acetylator status

Slow Fast

Controls 122 (52%) 110 (47%) FAP 31 (76%) 10 (24%) Sporadic CRC 9 (90%) 1 (10%)

There were significantly more slow acetylators in FAP and sporadic CRC patients compared with controls


(p<0.005). This supports the hypothesis that liver metab- ol ism plays a role in colorectal carcinogenesis.

Inhibitory Neurotransmission in the Human Internal Anal Sphincter: The Role of Nitric Oxide

Booth P60

T.J. O'Kelly, A.F. Brading, N.J. Mortensen Oxford, United Kingdom

Internal anal sphincter (IAS) relaxation is media ted by nonadrenergic, nonchol inergic (NANC), intramural nerves but the nature of the neurotransmitter(s) is unknown. We have explored the role of nitric oxide (NO) in this process.

Small strips of IAS circular muscle (n=18 strips from 3 abdominoper ineal resection specimens for each response) were mounted for isometric tension recording in a perfused organ bath at 36~ Cholinergic and adre- nergic neurotransmission was inhibi ted by the presence of atropine (10 -6 M) and guanethidine (3• -6 M) throughout. Tone was establ ished by loading the strips with the equivalent of a 1 gm weight but increased spontaneously thereafter. In this state, transmural stimulation of the nonadrenergic, nonchol inergic nerves (10 V, 0.5 ms duration and 8-20 pulses per second) produced tetrodotoxin (3• 10 -6 M) sensitive relaxations. Sodium nitroprusside, which acts by l iberating NO, also relaxed the muscle strips in a dose dependen t manner (10-s-s• -6 M). The inhibitory nonadrenergic, non- cholinergic responses were d iminished by antagonists of nitric oxide synthase; partially by 5x ]0 -5 M L-N-mon- omethyl arginine (L-NMMA) (mean 73.4+3.3% of original NANC relaxation, p<0.05 unpaired t-test) but completely by L-nitroarginine (L-NOARG) at the same con- centration. The effects of L-NMMA and L-NOARG were competi t ively reversed by increasing concentrations of L-arginine (5x10-5-30 -4 M) but not its s tereo-isomer D- arginine. Oxyhaemoglobin (5x10 -5 M), which scavenges endogenous nitric oxide, also abol ished the relaxations.

These results suggest that NO is or is very closely associated with, the neurotransmitter responsible for NANC nerve media ted relaxations of the human IAS.

A New Technique for the Genetic Analysis of Polyposis Families: A Significant Advance?

Booth P61

P. Paul, J.M, Church, E.M. McGannon, P. Huth, S. Hull- Boiner, D.G. Jagelman . . . . . . . . . . . . . . Cleveland, OH

Progress in molecular biology has led to the development of an array of genetic markers with the potential to detect inheritance of the APC (familial polyposis) gene on chromosome 5. Not all markers are equally useful in all families. We reviewed results of conventional DNA markers and compare them with a newer technique based on polymerase chain reaction (PCR).

Method: Probe analysis of the long arm of chromosome 5 was performed using material from the b lood of 14 polyposis families. Four families were also tested using a PCR technique.

Results:

Individuals Test Families

at Risk Helpful

Individuals

Not Affected

Affected

DNA Probe 14 38 23 9 14 PCR 4 8 8 3 5

Conclusion: DNA probes are helpful in identifying some of those individuals at risk for familial polyposis who have inheri ted the abnormal gene. The newer PCR technique appears more promising in that it is helpful in a higher proport ion of cases.

Creation of a Pedicle Valve Unit (PVU) for Establishment of Enteric Continence: Experimental Observations

Booth P62

M.E. Pezim, H.W. Johnson, K.D. Gillespie, P. Willard, D.A. Owen . . . . . Vancouver, British Columbia, Canada

Aim: The aim was to develop a natural tissue valve that could be anastomosed into any area of the GI tract to act as a fecal "brake" and so establish enteric continence at that site.

Method: A 4 cm long valve created from an intussus- cepted small bowel pedic le was anastomosed into the cecum and brought out through the abdominal wall as a stoma in 11 rabbits. The animals were re-explored 5 weeks later for assessment of valve viability and continence, and microscopic appearance.

Results: In all cases, the valve was fully continent in vivo. All valves were viable and there was no anastomotic leakage. Pressure testing of the valve at reoperat ion revealed that 7 of 10 valves withstood pressures of 30 mm Hg before and after catheterization and 6 of 10 were fully continent to cecal "blanching" pressure (50 mm Hg). Valve failure was due to deintussuscept ion in 3 cases. In 4 cases valves were continent over 50 mm Hg and showed no tendency to incontinence to bursting pressure of the cecum.

Conclusion: We conclude that a continent Pedicle Valve Unit (PVU) for p lacement in a variety of locations in the GI tract is feasible. The PVU has implications in the management of short-gut syndrome, incontinent ileostomy, continent cecostomy, and as a continent valve placed in the per ineum for restoration of perineal defecation following proctectomy.

Cytokine-Induced Augmentation of Cell Adhesion Mole- cules on Colon Tumor Cells

Booth P63

P.S. Ramsey, H. Nelson . . . . . . . . . . . . . Rochester, MN

Many of the effector immune cells investigated in adoptive cellular therapy achieve tumor cell lysis through contact-dependent cytotoxic mechanisms. Recent studies demonstrate that cell adhesion is critical in contact- dependen t cytotoxicity and that cell adhesion is mediated by cell surface molecules, referred to as cell


adhesion molecules (CAMs). Cellular adhesion and effective adoptive immune therapy may be enhanced by increasing the expression of CAMs on tumor cells. We investigated the in vitro expression of CAMs on human colon tumor cells, both as baseline expression and following exposure to cytokines. Methods: Five human colon cancer cell lines (COLO205, HT-29, LS174T, SW620, and WiDr) were analyzed by flow cytometry using fluorescent antibodies recognizing the CAMs; in- tercellular adhesion molecule-I, ICAM-1, endothelial- leukocyte adhesion molecule-i , ELAM-1, and vascular adhesion molecule-l , VCAM-1. The number of tumor cells positive for CAM antibodies was compared to the number positive for control antibodies in both the non- induced state, and after 24-hour exposure to 1000 U/ml gamma-interferon (glFN). Results: While ELAM-1 and VCAM-1 were not expressed, nor induced by cytokines, the expression of ICAM-1 on colon tumor cells was significantly enhanced (p<0.001) by cytokine exposure.

Percent Antibody Positive Cells

Tumors N o n - I n d u c e d gIFN-Induced

Control ICAM Control ICAM

COLO205 1.0 1.4 0.9 98.7 HT-29 0.9 15.7 1.0 98.0 LS174T 12.0 4.4 17.0 96.1 SW620 3.6 12.6 3.3 94.5 WiDr 6.9 42.4 3.0 98.8

Conclusion: Cytokine-induced augmentation of tumor cell adhesiveness may greatly promote cell mediated tumor cell lysis.

Surveillance, Colonoscopy, Polyps

Colonoscopy: How Difficult? How Painful? Booth P64

T.L. Hull, J.M. Church, J.W. Milsom, J.R. Oakley Cleveland, OH

Colonoscopy is sometimes painful for the patient and often difficult for the endoscopists. It is hard to predict how difficult or how painful the examination will be for an individual patient. The purpose of this study was to identify variables affecting difficulty and pain during colonoscopy. Methods: Consecutive patients undergoing colonoscopy were prospectively studied. A standard questionnaire was completed by nursing staff and attend- ing colonoscopist immediately after the procedure. Dif- ficulty and pain were assessed independently by the endoscopy nurse. Results: 577 patients (322 males and 265 females) with age range 12-94 years (mean 60 yrs) were studied.

Nil Mild Moderate Severe

DIFFICULTY 24% 33% 26% 17% PAIN 28% 36% 26% 10%

Significant variables: Hysterectomy vs pain (p=0.013);* difficulty of male vs female (p=0.0007),* females more difficult; pain of male vs female (p=0.001),* females experiencing more pain.

No significance: Hysterectomy vs difficulty; left colon resection vs pain or difficulty; quality of prep vs pain or difficulty; different attendings vs pain or difficulty; different premeds vs pain or difficulty; body habitus vs pain or difficulty. Conclusion: Female patients are more difficult to colonoscope and experience more pain. Fe- males after hysterectomy experience significantly more pain but the colonoscopy is not more difficult. Previous colon resections, medications, quality of prep, body habitus, or colonoscopist do not seem to influence pain or difficulty.

* Chi-square

Automated Quantitative Detection of Fecal Occult Blood for Screening of Colorectal Cancer

Booth P65

S.Y. Leu, H. Hsu . . . . . . . . . . . . . Taipei, Taiwan, R.O.C.

The effective detection of colorectal cancer in an early curable stage has become the focus of considerable interest in recent decade. A fully automated immunochemistry analyzer (OC-Sensor) using kinetic measurement of latex agglutination by nephelometry was applied to compare with the conventional guaiac test (Hemoccult II) in detecting fecal occult blood associated with colorectal cancer. One-day fecal testing of 50 patients with colorectal cancer and another 50 normal subjects proved by colonoscopy as negative control were studied. There was no dietary restriction. The sensitivity, specificity and accuracy of OC-Sensor immunoassay were 90%, 100%, and 95% respectively, superior to 88%, 90% and 89% calculated for Hemoccult II. OC-Sensor was a labor- saving and timesaving fecal occult blood analyzer which processed a maximum of 90 samples an hour. Its within- run precision of 3 different hemoglobin concentrations were 626.8+29.5, CV=4.7%; 471.5---34.5, CV=7.3%; 176.9+12.2, CV=6.9% (n--10, Mean+SD ng/ml). OC- Sensor immunoassay has additional advantages of simple technique and objective numeral detection of fecal occult blood. It is recommended for the future clinical application and mass screening of colorectal cancer.

Technique/Technical

Modified Kraske Procedure Booth P66

Adil H. A1-Humadi . . . . . . . . . . . . . . . . . . . . . Olean, NY

Paul Kraske in 1886 described a transrectal approach for mid and upper rectal lesions. A new Modified Kraske approach has been described in the literature in which the left ala of the sacrum as originally described was not removed and it was not necessary to remove the coccyx either in any of the cases documented. The Modified posterior approach to the rectum studied in 18 selected cases over a 12 year period, from 1979 to 1991, does


provide a sphincter-saving approach with no mortality and acceptable morbidity. The patients ranged in age between 34 to 84 with an average of 64 years. There were 11 males and 7 females. Indications for surgery were as follows; 1 Adenomatous, 5 Villous Adenomas, 1 Adenom- atous/Villous, 1 Mixed Tubulovillous Adenoma, 7 Villous Adenoma/Carcinoma in situ, 1 Adenomatous/Carcinoma in situ, 1 Endometriosis and 1 Infiltrating Adenocarci- noma. Most of the lesions were in the mid-upper rectum with an average location of 11 cm. The hospital stay ranged from 7-9 days with a mean of 8 days. The average followup for 16 patients was 4.2 years with only two patients having a recurrence of a Villous Adenoma and a Villous/Carcinoma in situ. There were no major complications like fecal fistula, stricture, or incontinence. The technical feasibility and management studied proved the Modified Kraske approach is a safe procedure that should be included in the surgical armamentarium to resect mid and high rectal lesions.

Endoluminal Ultrasound Guided Biopsy of Mesorectal Lymph Nodes Rectal Cancer

Booth P67

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

Endorectal ultrasound (ELUS) in patients with rectal cancer may detect pararectal lymph nodes and has previously been unable to determine histology. In this study we evaluated the ability of ELUS to procure a tissue diagnosis of pararectal lymph nodes.

METHOD: Direct ELUS guided fine needle aspirate (22 gauge) and core biopsy (18 gauge) of pararectal lymph nodes was carried out in nine patients with rectal cancer using a 7 MHz longitudinal sector scanner. The biopsy site was marked with India ink for later confor- mation. Eight patients had adenocarcinoma and one a melanoma of the anal canal with satellite nodules in the rectum.

RESULTS: ELUS directed biopsies revealed lymphoid or malignant tissue in seven out of nine biopsies with histologic confirmation by direct removal of the specimen in 66% of the cases, (adenocarcinoma n=3, lymphoid tissue n--3). In one patient whose biopsy was positive for metastatic adenocarcinoma, preoperative chemotherapy/radiation therapy was given and there was no subsequent evidence of lymph node metastasis in the operative specimen. Therapy was guided by lymph node biopsy in six of the nine patients. There were no complications in any patient.

CONCLUSION: These preliminary results suggest ELUS directed lymph node biopsy is a safe and accurate tool for the staging of rectal cancer with possible lymph node metastases and may impact on subsequent therapy.

A New Probe for Measuring EMG from Multiple Sites in the Anal Canal

Booth P68

E. Eisman, J. Tries . . . . . . . . . . . . . . . . . . Milwaukee, WI

The purpose of this paper is to describe a new multiple electrode probe (MEP) designed to measure surface

EMG simultaneously from the subcutaneous and the deep portions of the external anal sphincter.

Although measures of skeletal muscle EMG obtained with needle electrodes have good specificity, the output is usually presented in an unintegrated form which makes quantification difficult. Moreover, needle electrodes are not practical for use in situations which require repeated measurement, e.g., in biofeedback therapy several sessions are usually necessary for completion.

Using the MEP, integrated EMG was sampled 15 times per second during rest, a voluntary contraction, and a defecation maneuver in asymptomatic subjects and in patients with incontinence and disordered defecation. Comparisons of EMG data, between and within subjects and across sessions, indicate that the MEP clearly dis- criminates muscle activity from different sites along the anal canal. The recording method described is capable of identifying synchronized patterns of muscle recruitment which have not been shown before using surface EMG. For example, after the defecation maneuver, the distal portion of the anal canal is observed to contract before the proximal in what seems to be the closing reflex. Furthermore, the absence of these patterns may indicate abnormality. Accordingly, the MEP promises to be a reliable diagnostic and re-educative tool.

Positron Emission Tomography for Preoperative Staging of Colorectal Neoplasms

Booth P69

P.M. Falk, A.G. Thorson, N.C. Gupta, M.P. Frick, B.M. Boman, M.A. Christensen, G.J. Blatchford, R.L. Cali

Omaha, NE

Positron emission tomography (PET) is a cross-sectional imaging technique based on cellular metabolism. Enhanced metabolic processes in neoplastic cells are detected by PET. Computerized tomography (CT) dem- onstrates variations in anatomic relationships. In an ongoing pilot study, PET is compared to CT for the preoperative staging of colorectal neoplasms. Ten patients were evaluated with both PET and CT for findings in the liver, colon and rectum. Results were compared to operative findings. Twelve lesions were found in ten patients. PET had a positive predictive value (PPV) of 90% and a negative predictive value (NPV) of 50%. By comparison CT had a PPV of 100% and a NPV of 22%. Early results indicate that PET has increased sensitivity f o r staging colorectal neoplasms, whereas CT has higher specificity. The predictive value of a positive PET compares favorably with CT. Furthermore, the predictive accuracy of PET is 83% whereas CT is 36%.

PET Result Disease Present Disease Absent

Positive 9 1 Negative 1 1

CT Result

Positive 2 0 Negative 7 2

Table 1


3D Reconstruction of Rectal Ultrasound: A Novel Com- puterized Approach

Booth P70

D. Franceschi, M.L. Eckhauser, T. Pritchard Cleveland, OH

Intraluminal or endoscopic ultrasound evaluation has recently become a useful tool for the diagnosis and staging of rectal neoplasms. Interpretation by clinicians can be difficult since a considerable amount of experience is required for three-dimensional (3D) mental reconstruction from two dimensional visual images. To address this problem, we have developed a computerized approach that allows the creation of realistic 3D images from two dimensional contiguous slices obtained from a rectal ultrasound.

All manipulations are done on an IBM/AT compatible computer equipped with appropriate hardware. Cross sections from a continuous transverse scan of the rectal segment are digitized with a resolution of 512 x 480 pixels, and a dynamic range of 8 bits/pixel (256 gray scale). The dynamic range of the pixel gray levels is digitally enhanced and edge detection and enhancement are performed with convolution filters through the original binary data. The intraluminal and outer edges of normal and pathologic segments are traced and con- verted to a polygon vector within a defined 3D space. Serial cuts, 2 mm apart, are then "stacked" by connecting the contours to form a 3D mesh structure. The model is then rendered to a high resolution display frame buffer where the normal rectum and the pathologic segment (tumor) can be represented by different colors. Once created, angles of rotation around the X, Y and Z axes are assigned for image reconstruction, allowing the op- erator to obtain the best perspective. Furthermore, the model can be "cut" and cross sections recreated in any plane. Hardcopy of the model can be obtained from a photographic unit or a graphics printer. The 3D model data is stored on the hard disk.

Utilizing the described technology, it is feasible to perform 3D reconstructions of a rectal ultrasound on a personal computer, with detailed and accurate surface information. This permits an improved understanding of the normal and pathologic anatomy as well as provides a useful tool for teaching and research.

Morphology of Dynamic Graciloplasty Compared with the Anal Sphincter

Booth P71

J. Konsten, C.G.M.I. Baeten, M.G. Havenith, P.B. Soeters Maastricht, The Netherlands

Introduction. Dynamic graciloplasty (a new technique for fecal incontinence) is transposition of the gracilis around the anal canal and subsequent Electrical Stimu- lation (ES). The aim of ES is to transform the gracilis into a muscle which is capable of sustained contractions like the external anal sphincter. Material and Methods.

The gracilis muscle composition (type 1 fibers (I) capable of sustained contractions, the mean type I fiber diameter (DIA), and the collagen (COL) content) was investigated before and after ES in 7 patients. Further- more, the external anal sphincter was investigated in 5 autopsy cases. Results are expressed as mean and 95% confidence interval (CI). Statistical analysis was performed, using a paired t-test.

Results.

Gracilis Gracilis Sphincter before ES after ES

I 76 45 * 62% c.I. (58, 94) (41, 49) (57, 66)

DIA 24 32 ** 29x10-6m C.1. (20, 28) (26, 39) (23, 35)

COL 12 5 *** 7% C.I. (9, 14) (3, 6) (4, 9)

(*) P < 0.01, (**) not significant(***) P < 0.05

Conclusion. ES induces morphological changes, which allow dynamic graciloplasty to function as the external anal sphincter.

The Role of One-Stage Surgery in Acute Left Sided Colonic Obstruction

Booth P72

P.W.K. Lau, T.G. Lorentz, J. Wong . . . . . . . . Hong Kong

From 1989 all patients with acute obstruction requiring emergency surgery were prospectively evaluated to assess the role of immediate resection and primary anastomosis as opposed to a multi-stage procedure. There were 30 patients with a mean age of 66 (range 35-87). All but one had an obstructing carcinoma distal to the splenic flexure. The remaining patient had a volvulus. On pre-op assessment, two patients were unsuitable because of a low rectal tumor. 28 patients were taken to theatre with a view of performing a one-stage procedure. This was successful in 26 (87% overall). One patient had a subtotal colectomy and the remaining 25 had intra-op colonic irrigation prior to a resection and anastomosis as one would perform in an elective setting. The two fail- ures were due to extensive local tumor in one and unhealthy bowel ends for anastomosis in the other.

Restricting the analysis to the irrigation group, there were two deaths due to pulmonary complications (this was also the overall mortality), but there was no clinical evidence of anastomotic leakage in any of the patients. Wound infection occurred in 5 patients (20%). The operative time for the procedure was 3.8 hrs (range 2.5- 6.0) and the mean hospital stay was 16 days (range 7- 44). In conclusion, one-stage surgery is safe and effective and is applicable to most patients with acute left-sided colonic obstruction.

american society of colon and rectal surgeons 95th annual convention podium and poster abstracts...

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