The effect of abdominal ventral rectopexy on faecal incontinence and constipation in patients with internal intra-anal rectal intussusception

AIM

Optimal treatment of anal incontinence in a patients with a normal anal sphincter is controversial, as is the role of intra-anal rectal intussusception in anal incontinence. We evaluated the results of abdominal ventral rectopexy on anal continence in such patients.

METHOD

Forty consecutive patients with incontinence and intra-anal rectal intussusception without a sphincter defect were treated by abdominal ventral mesh rectopexy without sigmoidectomy. The Cleveland Clinic Incontinence Score (CCIS), patient satisfaction and constipation before and after surgery and recurrence were recorded.

RESULTS

The mean CCI scores were 13.2 (=/-4.25) preoperatively and 3 (±3.44) postoperatively (P<0.0001). Patient assessment was reported as 'cured' in 26 (65%), 'improved' in 13 (32.5%) and 'unchanged' in one (2.5%) patient. Constipation was induced in two (5%) patients and was cured in 13 of 20 (65%) patients who were constipated before surgery. One case of recurrent prolapse occurred after a mean follow-up of 38 months.

CONCLUSION

Intra-anal rectal intussusception may be associated with anal incontinence. For these patients, abdominal ventral mesh rectopexy appears to be an adequate treatment.

Oncological outcome of ultra-low coloanal anastomosis with and without intersphincteric resection for low rectal adenocarcinoma

BACKGROUND

The value of ultra-low coloanal anastomosis (CAA) for rectal cancer is dependent on the oncological and functional results. The aim of this comparative study was to evaluate the long-term oncological outcome of CAA with or without intersphincteric resection (ISR) for low-lying rectal tumours.

METHODS

The study population comprised consecutive patients with low rectal cancer who underwent CAA in a single institution between 1977 and 2004. Patients were divided into two groups according to whether or not a partial ISR had been performed. Cox multivariate models were used for survival analysis.

RESULTS

Some 278 patients underwent CAA with curative intent; 173 had ISR and 105 had CAA without ISR. Mean follow-up was 66.8 months. The 5-year actuarial rate for local recurrence, regardless of tumour stage, was 10.6 per cent in the ISR group versus 6.7 per cent for CAA alone (P = 0.405), and the 5-year actuarial overall survival rate was 86.1 and 80.0 per cent respectively (P = 0.318). Cox multivariable analysis revealed that resection of the anal canal was not a prognostic factor for local or metastatic recurrence.

CONCLUSION

Sphincter-preserving surgery appears to be oncologically adequate for very low-lying rectal tumours.

Preliminary results of peripheral transcutaneous neuromodulation in the treatment of idiopathic fecal incontinence

PURPOSE

Few therapeutic tools are available for treating idiopathic anal incontinence. Sacral neuromodulation appears to be effective in selected patients but requires surgical implantation of a permanent electrical stimulator. The aim of this work was to assess the efficiency of posterior tibial nerve (PTN) transcutaneous electrical nerve stimulation (TENS) in the treatment of anal idiopathic incontinence.

METHODS

Ten women were treated by PTN TENS, 20 min a day for 4 weeks. Functional results were evaluated by Wexner's incontinence score and anorectal manometry.

RESULTS

Eight of the ten patients showed a 60% mean improvement of their incontinence score after 4 weeks. This improvement remained stable over the 12-week follow-up period. Manometric parameters did not differ before and after stimulation.

CONCLUSION

PTN neuromodulation without surgically implanted electrode could represent a safe and low-cost alternative to permanent sacral neuromodulation for idiopathic anal incontinence.

Adjuvant chemotherapy after potentially curative resection of metastases from colorectal cancer. A meta-analysis of two randomized trials

3524

Background: Adjuvant systemic chemotherapy (CT) administered after resection of colorectal cancer (CRC) metastases (M) may reduce the risk of recurrence and improved survival but its benefit has never been demonstrated. Two phase III trials (FFCD 9002 and EORTC/NCIC CTG/GIVIO (ENG) trials) with a very similar design showed a trend for improvement in survival after adjuvant CT but had to close prematurely because of slow accrual, lacking the statistical power to demonstrate any significant difference in survival. We report here a pooled analysis based on individual data from these trials. Methods: Patients were required to have a WHO performance status ≤2 and a histologically proven CRC with a complete (R0) surgical resection of the primary tumour and of ≤4 liver or lung metastases. They were randomized between chemotherapy (CT arm) [5FU 400 mg/m2 (FFCD) or 370 mg/m2 (ENG) IV q.d. x 5 days plus dl-leucovorin 200 mg/m2 (FFCD) or l-leucovorin 100 mg/m2 (ENG) IV q.d. x 5 days, 6 cycles at 28 days intervals] or surgery alone (S arm). Results: 129 pts were included in the ENG trial between 1994 and 1998, 173 in the FFCD trial between 1991 and 2001. 24 pts (ENG: 22, FFCD: 2) were excluded from analysis for missing post-baseline data: 278 pts were included in the present analysis (CT: 138, S: 140). Patients’ characteristics by treatment arm (% CT/S): males 58.0/63.6, age <70 years: 79.7/79.3, stage IV primary tumor: 29.0/47.1 (p=0.02), liver M 94.2/93.6, ≥2 M resected: 33.3/31.4. Conclusion: Adjuvant CT with a 5FU bolus based regimen tends to improve survival after complete resection of CRC metastases. The observed improvement in median PFS was almost statistically significant whereas the improvement in median OS (more than 1 year) was not (lack of statistical power?). This pooled analysis supports the use of adjuvant CT, with a more effective regimen, after potentially curative resection of CRC metastases. Updated results will be presented. (Supported by AROLD)

[Table: see text]

No significant financial relationships to disclose.

Rectal excision with coloanal anastomosis for superficial distal third rectal cancer: survival and local recurrence

OBJECTIVE

Appropriate surgical treatment of distal third rectal cancer limited to bowel wall (i.e. T1 or T2) in medically operable patients is controversial. Transanal excision can deprive some patients of accurate pathological staging, prognosis and cure. In contrast abdominoperineal resection has considerable practical and psychosocial problems largely related to a permanent colostomy. We hypothesize that superficial distal rectal tumours can be effectively treated with rectal excision and coloanal anastomosis.

SUBJECTS AND METHODS

Prospective oncological study of 80 patients with distal third superficial rectal carcinomas treated by complete rectal excision with coloananl anastomosis from December 1977 to January 1993 was carried out. The resected specimens were examined for depth of spread and number of histologically positive nodes. The actuarial local recurrence and survival rates for superficial node-negative and node-positive tumours were analysed independently.

RESULTS

Seventy-eight patients had complete postoperative assessment. Thirty-one percent had received low-dose preoperative neo-adjuvant radiotherapy (3500 rads). Mean follow-up time in all patients was 70 months on average. The lymph node involvement rate for T1 and T2 tumours was 12.5 and 15.6%, respectively. The local recurrence rates for patients with (T1/T2) N0 and (T1/T2) N1 were 1.5 and 16.7%, respectively, and the five year actuarial survival rates were 96.6 and 90%, respectively. The overall local recurrence was 3.8% with five-year actuarial survival of 95.8%.

CONCLUSIONS

Lymph node involvement in superficial tumours is not rare. Rectal excision with coloanal anastomosis results in a high cure rate especially for node-positive superficial tumours. This treatment strategy avoids the psychological trauma of colostomy following abdominoperineal resection and the potential risk of undertreatment by local excision.

[Rectal prolapse]

Rectal prolapse and rectal intussuception correspond to two stages of the same disease. Rectal prolapse is unusual but requires surgical treatment. Abdominal rectopexy is the most effective procedure but increases the risk of postoperative constipation. This risk decreases when the lateral sides are not touched during rectal dissection. The Delorme procedure is associated with a higher rate of recurrence and must be reserved for patients presenting a high risk of postoperative complications. Rectal intussuception is more frequent and is pathological only when arising in the anal sphincter. Rectal intussuception may lead to solitary rectal ulcer and has in this case to be treated by rectopexy. Rectal intussuception involvement in terminal constipation is not yet proved. Internal mucosectomy seems to be the best treatment for terminal constipation.

[Surgery of rectal cancer: total exeresis of the mesorectum]

The authors review the recent literature about total mesorectal excision for rectal cancer. They report the actual management of such patients.

Fecal continence following partial resection of the anal canal in distal rectal cancer: long-term results after coloanal anastomoses

BACKGROUND

The aim of the study was to assess the influence of partial excision of the superior portion of the anal canal (AC) when necessary for tumor margin clearance in distal rectal cancer on fecal continence after coloanal anastomoses.

METHODS

Between 1977 to 1993, 209 patients with middle and lower third rectal cancers underwent complete rectal excision and coloanal anastomoses. For very low tumors, located at or below 5 cm from the anal verge (AV), varying portions of the superior segment of the AC were excised for tumor margin clearance. The magnitude of resections was inversely proportional to the height of the anastomosis from the AV. The patients were categorized into 3 groups according to their level of anastomoses from AV: group 1, patients with anastomoses from 0.5 to less than 2 cm from AV (1 to 2.5 cm of AC resected, i.e., major resection); group 2, anastomoses at 2 to less than 3 cm from AV (less than 1 cm of AC resected, i.e., minor resection); group 3, with anastomoses at 3 to 3.5 cm from AV (AC completely preserved). A standard questionnaire, physical examination, and anal manometry at intervals of 3, 6, 12, 24, 36, and 48 months were performed prospectively to assess anal continence.

RESULTS

The patients in the 3 categories were matched for age, gender, stage, presence or absence of a colonic J-pouch, preoperative neoadjuvant radiotherapy and surgical technique. Fourteen patients with postoperative radiotherapy were excluded from the clinical assessment. Mean follow-up was 33.5 months. There were 43 patients in group 1, 75 in group 2, and 73 in group 3 for clinical assessment. In the first year, there was progressive improvement in anal continence in all 3 groups. At 2 years, 50% in group 1, 73% in group 2, and 62% in group 3 were fully continent. The proportion of patients fully continent in group 1 remained unchanged as compared to continued improvement for groups 2 and 3 following the first year. At 4 years, 50% in group 1, 80% in group 2, and 68% in group 3 were completely continent. The difference among the 3 groups was not statistically significant.

CONCLUSIONS

For distal rectal cancer, where tumor margin clearance necessitates partial resection of the superior portion of the AC, when limited to less than 1 cm, the proportion of patients remaining fully continent is similar to those with complete AC preservation. More substantial excisions of the AC can still result in satisfactory anal continence, such that following the fourth year, one half of the patients can expect to be fully continent.

Coloanal anastomosis for distal third rectal cancer: prospective study of oncologic results

PURPOSE

Jeopardizing cure and risking high local recurrence have served as arguments against sphincter-saving resection for patients with distal third rectal cancer. This prospective study examines and compares the local recurrence and survival rates in patients with distal third rectal cancer treated by either coloanal anastomosis or abdominoperineal resection.

METHODS

Between 1977 and 1993, 174 patients underwent coloanal anastomoses and 38 patients underwent abdominoperineal resection. All tumors were located 4 to 7 cm from the anal verge. One hundred ninety-three patients (91 percent) underwent rectal excision with a curative intent. Mean follow-up was 66 months after sphincter-saving resection and 65 months after abdominoperineal resection.

RESULTS

Mean anastomotic height from the anal verge was 2.3 cm after sphincter-saving resection. Overall local recurrence rate was 7.9 percent after sphincter-saving resection and 12.9 percent after abdominoperineal resection. The five-year actuarial survival rate was 78 percent after sphincter-saving resection and 74 percent after abdominoperineal resection.

CONCLUSION

Local recurrence and survival are not compromised in patients with distal third rectal cancer when treated by sphincter-saving resection, provided that oncologic principles are not violated. Coloanal anastomosis can be performed with an acceptable morbidity.

Continent perineal colostomy after abdominoperineal resection: outcome after 63 cases

PURPOSE

For patients with distal rectal or anal tumors, quality of life can be compromised after abdominoperineal resection and iliac colostomy. This study examines our experience with a continent perineal colostomy constructed from a colonic smooth-muscle cuff wrap.

METHODS

Between 1987 and 1996, 63 patients with distal rectal or anal tumors (0-5 cm from the anal verge) underwent abdominoperineal resection and construction of a colonic smooth-muscle cuff at the site of the perineal colostomy. Postoperatively, all patients required colonic irrigations daily or every two days. The complications, continence at 6 and 12 months, and degree of satisfaction were prospectively evaluated using a standard questionnaire.

RESULTS

Early complications included partial perineal dehiscence in 14 (22.5 percent) patients, pelvic abscess in 2 (3 percent) patients, and colostomy necrosis in 1 (1.6 percent) patient. Late complications were colostomy stricture in 7 (11.8 percent) patients, perineal sinus tract in 4 (6.7 percent) patients, and mucosal prolapse in 12 (20 percent) patients. Satisfactory continence (complete continence to stool and incontinence to gas) at 6 and 12 months was achieved in 30 (55.6 percent) and 27 (59 percent) patients, respectively. Patient satisfaction was noted in 85 percent.

CONCLUSION

Continent perineal colostomy can serve as an alternative to conventional iliac colostomy. Most patients were satisfied. The modest complication rate can be minimized with patient selection.

[Surgical treatment of cancer of the pancreas]

Resection of the pancreas is still the only way to cure patients with pancreatic cancer. Morbidity and mortality rates following pancreatico-duodenectomy for adenocarcinoma of the pancreas have decreased. Survival has improved during the past several decades.

Is rectal intussusception a cause of idiopathic incontinence?

PURPOSE

The cause of rectal intussusception in patients primarily dominated by symptoms of anal incontinence has not been fully elucidated, especially for patients with idiopathic incontinence.

METHODS

Between 1991 and 1996, 51 patients referred with a diagnosis of idiopathic incontinence were prospectively evaluated by standard questionnaire, clinical examination, defecography, and anal manometry. Fourteen female patients were identified with rectal intussusception and were treated by transabdominal rectopexy. Postoperatively, clinical assessment and anal manometry were performed at regular intervals.

RESULTS

Continence was improved after rectopexy (P < 0.01). The postoperative increases in the anal resting pressure, maximum squeeze pressure, and maximum tolerated volume were not statistically significant.

CONCLUSIONS

Rectopexy improved anal incontinence in patients with rectal intussusception. The cause of rectal intussusception in anal incontinence could not be explained by functional improvement of the internal anal sphincter tone or an increase in the maximum tolerated volume. Rectal intussusception may be a cause of idiopathic incontinence in patients; however, larger prospective studies are required to support this concept.

Fournier's gangrene: an unusual presentation for rectal carcinoma

We report a case of a large perforated adenocarcinoma of the rectum manifesting as an ischiorectal abscess progressing to Fournier's gangrene in an insulin-dependent diabetic man. Recognition and management of this rare syndrome in the setting of a common disease is discussed.

[Preservation of sexual innervation in the surgery of rectal cancers]

Eighteen out of 55 rectal resections for cancer included preservation of sexual innervation, which was complete in 17 cases and partial in one case. Fourteen patients were evaluated by questionnaire one year after resection; 10 out of 14 (71.4%) did not report any sexual disorders.

[Local treatment of "small cancers" of the rectum: excision is preferable to electrocoagulation]

From 1973 to 1990, 50 patients with a "small cancer" of the rectum were treated locally either by electrocoagulation or by local excision using an electrical scalpel. 20 patients were treated by electrocoagulation. Their 5-year actuarial survival was 78.3% and the local recurrence rate was 16.5%. 4 treated patients by local excision had a lesion which invaded the serosa and should have been amputated as primary procedure. Three of them relapsed. 26 patients were treated by local excision for a lesion confined to the rectal wall. Their 5-year actuarial survival was 94.4% and the local recurrence rate was 4.5%. The difference in survival and recurrence was significant between electrocoagulation and excision of a lesion confined to the rectal wall. These results suggest that excision is preferable to electrocoagulation as it allows prediction of the result by pathological examination of the operative specimen.

Late clinical outcome in a randomized prospective comparison of colonic J pouch and straight coloanal anastomosis

BACKGROUND

Functional outcome after rectal excision with coloanal anastomosis is improved by construction of a colonic J pouch. Present prospective randomized studies lack follow-up beyond 1 year. The aim of this study was to assess the clinical outcome at both short- and long-term follow-up.

METHODS

Forty patients with low rectal cancer were randomized prospectively to either J colonic pouch-anal anastomosis or a straight coloanal anastomosis. Clinical assessments were performed 3, 12 and 24 months after colostomy closure using a standard questionnaire and physical examination.

RESULTS

There was no significant difference in the complication rate between the two groups. There was a significant (P < 0.01) improvement in frequency of defaecation at 3, 12 and 24 months for patients with a reservoir. Similarly, fragmentation (clustering of stools) was significantly less at 3 and 12 months (P < 0.01) in the reservoir group, and incontinence occurred less frequently in the first year (P = 0.09). By 24 months no patient in either group suffered from major or minor incontinence.

CONCLUSION

The functional improvement gained from a colonic reservoir in coloanal anastomosis continues to benefit the patient for at least 2 years.

Prospective, randomized study comparing clinical results between small and large colonic J-pouch following coloanal anastomosis

PURPOSE

Improved functional results can be obtained by construction of a colonic J-pouch after coloanal anastomosis. Variability in pouch size following coloanal anastomosis is prevalent in current literature. In this study, the authors compare clinical bowel function after complete rectal excision with coloanal anastomosis for patients with rectal carcinoma using either a small 6-cm or a large 10-cm colonic J-pouch anastomosis. The clinical outcome is assessed both at short-term and long-term follow-up.

METHODS

Fifty-nine consecutive patients with rectal cancers 4 to 8 cm from the anal verge were recruited into the study. Patients were randomized intraoperatively to either a 6-cm J-pouch group or a 10-cm J-pouch group. Clinical assessments were performed prospectively at 3, 6, 12, and 24 months postoperatively, following colostomy closure. Clinical parameters such as frequency, urgency, continence, and laxative and enema use were assessed and compared between the two groups.

RESULTS

There was no statistical differences in the mean defecation frequency, urgency, and fecal continence between the two groups at 3, 6, 12, and 24 months. In the first year, laxative and enema use between the two groups was negligible; however at two years, 30 percent of patients with a large reservoir compared with 10 percent of patients in the small-pouch group required laxative and/or enema for constipation and evacuation of bowels.

CONCLUSION

Similar clinical results can be expected from patients with either small or large reservoirs at one year. However, with long-term follow-up, patients with a large reservoir are more likely to require medication for constipation and evacuation. To avoid these inconveniences a small reservoir is advocated for patients undergoing coloanal anastomosis.

Prospective study of prognostic factors in patients with unresected hepatic metastases from colorectal cancer. Fondation Française de Cancérologie Digestive

Prognostic factors of unresected liver metastases in patients with colorectal cancer are not well established. A total of 544 patients with unresected liver metastases from colorectal cancer were registered in a national survey over a 1-year period and followed until death. Twenty factors were studied in a univariate analysis (log rank test) and 16 influenced survival (P < 0.01). These 16 factors were entered in a multivariate analysis (Cox model) and eight, ranging from the most significant (relative risk of death 1.9) to the less significant (relative risk of death 1.2), independently influenced survival: performance status, alkaline phosphatase level, number of involved liver segments, administration of chemotherapy, presence of extrahepatic metastases, site of the primary tumour, prothrombin time and resection of the primary lesion. Two simple classifications are proposed, taking into account the performance status and the alkaline phosphatase level, or the performance status and the number of involved liver segments.

[Unresectable giant hepatic hemangioma and Kasabach-Merritt syndrome]

The Kasabach-Merritt syndrome was first described in children with cutaneous hemangiomas, but it can exceptionally be associated with visceral hemangiomas, especially in adults. Clotting and fibrinolysis within the hemangioma are thought to cause the coagulopathy observed in the so-called Kasabach-Merritt syndrome. This localised form of intra-vascular coagulation can progress to a secondary increased systemic fibrinolysis with fatal outcome for 20 to 30% of the patients. A transient control of hematologic abnormalities can frequently be obtained with blood product support (platelets, fibrinogen, fresh plasma, cryoprecipitates) and heparinotherapy. But in the adult, the only radical alternative is surgical excision if technically feasible. We reported here the case of a 43 year-old woman with a giant unresectable hepatic hemangioma complicated with a Kasabach-Merritt syndrome.

[Local antibiotic prophylaxis for repair of inguinal hernia]

A controlled randomized trial was carried out in 324 patients with inguinal hernia. Efficacy was evaluated of a single injection of cefamandole (n = 162) administered at operative site during local anesthesia, using an untreated group as control (n = 162), as prophylaxis against post-operative local infection. Seven patients in the control group developed abscesses at the operative site after discharge, 6 of the 7 during one-month follow up, compared with none in the treated group (n = 0.07). No side effects were reported due to the antibiotic therapy. The cost of the antibiotic treatment was 10 times less than that for treating the suppurations in the control group.

[Anatomy of pelvic nerves and ileo-anal anastomosis]

The risk of sexual sequelae after proctectomy for inflammatory disease or polyposis is moderate, but real. The pelvic nerves can be easily spared at the sites where they are most frequently damaged, i.e. anterior to the sacral promontory and on the lateral walls of the pelvis. In contrast, damage to the cavernosal nerves situated on either side of the posterior surface of the prostate is more difficult to avoid, essentially because of the anatomy of these nerves is poorly understood.

Hepatectomy with initial suprahilar control of intrahepatic portal pedicles

In 1985 Couinaud described an original technique for left hepatectomy. This technique is based on initial control of the left intrahepatic portal pedicle after wedge incision of the hepatic capsule is made and the hilar plate is lowered before the hepatic parenchyma is opened. The vascular and biliary pedicular elements are dissected concomitantly at a point where they are protected by and contained within a sheath emanating from the hepatic capsule. After elective clamping of the pedicle at this level is done, the territory to be removed becomes obvious by the change of color produced by ischemia, and bleeding is minimized preventively. Although Couinaud's technique concerned only one case of left hepatectomy, we confirmed the ease, safety, and reproducibility afforded by this technique in four left hepatectomies. Based on the same principles, this technique may be used for other types of hepatic resections, notably, left hepatectomy extended to segments 5 and 8 (trisegmentectomies). We report our experience with this technique in 15 cases of major hepatic resections.

Local antibiotic prophylaxis in inguinal hernia repair

We compared the effects of single dose (750 milligrams) prophylactic cefamandole delivered directly into the operative wound with local anesthesia (n = 162) with a control group (no antibiotics) (n = 162) in a randomized trial. No adverse effects were observed. There were seven wound abscesses in the untreated group compared with none in the group receiving antibiotic prophylaxis (p = 0.007). Six of the seven abscesses occurred as late as one month after the patient was discharged from the hospital. The costs of antibiotics used were ten times less than the costs of treatment of wound complications in the control group.

Distal intramural spread of carcinoma of the rectum correlated with lymph nodal involvement

One hundred and nineteen operative specimens of carcinoma of the rectum were prospectively studied to evaluate distant microscopic intramural spread with respect to gross tumoral margins and to determine if the degree of spread was related to involvement of the lymph nodes. Eighty-eight of the 119 specimens (74 per cent) did not have intramural extension distal to the gross distal margin of the tumor. Twenty-five (21 per cent) had intramural extension of less than 5 millimeters from the gross distal limit of the tumor. In these instances, tumoral spread was contiguous. In six (5 per cent), tumoral spread was found at more than 5 millimeters from the gross distal margin of the lesion. In all six specimens, the tumoral extension was separated from the gross lesion by undiseased tissue, the foci being located between 5 and 15 millimeters from the distal margin of the lesion. Lymph nodal involvement was found in 19 of 88 lesions without distal intramural spread, in 14 of 25 tumors with intramural spread of less than 5 millimeters and in five of six with intramural extension of 5 millimeters or more, respectively. The difference was statistically significant. With respect to the same three categories of distal extension, more than one lymph node was involved in 11 of 88 lesions, six of 25 and five of six, respectively. This difference was also statistically significant. In the six instances with distal intramural extension, results of immunohistochemical staining demonstrated the presence of tumoral embolism in both the blood and lymphatic vessels. In carcinoma of the rectum, lymph nodal involvement and its multiplicity are directly related to the extent of intramural spread.

[Inguinal hernia. The Shouldice parietal repair]

Parietal repair according to the Shouldice technique consists of a double line of sutures on each of three musculo-aponeurotic layers of the groin, i.e. successively: plicature of the transverse muscle and attachments; aponeuroplasty by back-to-back suture of the internal and external oblique muscles, and plicature of the aponeurosis of the external oblique muscle. Parietal repair of this kind is only possible after wide dissection of the inguinal region. It can be performed under local anaesthesia during a short hospitalization period. Normal activity is rapidly resumed, and in the experience of those who favour this technique, the recurrence rate is a mere 1%.

Synchronous abdominotrans-sphincteric resection of low rectal cancer: new technique for direct colo-anal anastomosis

Sixty-five patients with low rectal cancer 4-9 cm from the anal margin were treated by rectal resection and direct colo-anal anastomosis. The procedure simultaneously combined abdominal dissection with the patient in the lateral position with a trans-sphincteric approach. In 57 cases a temporary defunctioning colostomy was performed. There were no postoperative deaths. Six patients (9 per cent) developed pelvic sepsis or anastomotic leakage. Faecal continence was normal in 46 of 51 patients (91 per cent) who were operated on at least 1 year previously. The remaining 5 complained of occasional minor soiling. No patients require a permanent colostomy for incontinence. Of 29 patients treated for potential cure greater than 3 years previously, 24 (82 per cent) were alive without recurrence. Local recurrence occurred in four patients (6 per cent). Direct colo-anal anastomosis using a combined abdominotrans-sphincteric approach has produced good functional results without impairing the patient's life expectancy.

Stapled colorectal anastomoses: peroperative integrity of the anastomosis and risk of postoperative leakage

Eighty-two patients underwent colorectal anastomosis using the circular mechanical stapling instrument. Integrity of the anastomosis was assessed intraoperatively by the air test and examination of doughnuts for completeness. A proctogram using a water soluble contrast preparation was performed in 79 patients postoperatively. In 68 patients doughnuts were complete and no air leak was found in any case. Postoperatively three clinical and one radiological leak occurred. In 14 patients at least 1 doughnut was incomplete. Of these, 4 had an air leak whilst 10 did not. There was no leak postoperatively in these 10 patients but 2 of the 4 patients with an intraoperative air leak developed a radiological leak postoperatively. The data suggest that the air test is useful since absence of air leakage in cases with an incomplete doughnut was followed by sound anastomotic healing. Further, the demonstration of air leakage enables immediate repair of the anastomosis perhaps avoiding subsequent clinical leakage.

Resection of the rectum with construction of a colonic reservoir and colo-anal anastomosis for carcinoma of the rectum

Rectal resection with colo-anal anastomosis was performed in 65 patients with carcinoma of the lower rectum. In 20 a pelvic colonic reservoir was constructed while in 45 a direct anastomosis was carried out. There were no postoperative deaths and morbidity was comparable in the two groups. Functional results were determined by clinical examination and manometry. The frequency of bowel movements was inversely related to the maximum tolerated volume (P less than 0.001). During the first year 60 per cent of the patients with a reservoir and 33 per cent of the patients without had one or two stools per day (P less than 0.05). After one year, 86 per cent of the patients with a reservoir and 33 per cent of the patients without had one or two bowel movements per day (P less than 0.01). The maximum tolerated volume was increased by the reservoir (P less than 0.05). The loss of reservoir capacity of the rectum increases frequency of bowel movements in colo-anal anastomosis. The creation of a colonic reservoir improves function by increasing the maximum tolerated volume without any increase in mortality or morbidity.

[Treatment of inguinal hernia using Shouldice's technic]

The very high frequency of recurrence of inguinal hernia after surgical repair during the 30s led Earl Shouldice to devote his efforts to the study of this affection. In 1945 he opened an institution for the purpose of treatment of hernia, and since then a total of 130,000 operations have been performed. Progressive advances in the techniques used have enabled the relapse rate to be reduced to less than 1%, and the procedure used at the present time is described.

Early and late complications after endoscopic sphincterotomy for biliary lithiasis with and without the gall bladder 'in situ'

Endoscopic sphincterotomy has gained wide acceptance in the treatment of biliary lithiasis. We attempted endoscopic sphincterotomy in 443 patients and were successful in 407 (92%). Sphincterotomy was carried out with the gall bladder in situ in 234 cases (57%) of advanced age or high surgical risk. Immediate complications occurred in 7%, of which haemorrhage was the most frequent. The mortality rate was 1.5%. Three hundred and sixteen endoscopic sphincterotomies were performed more than six months before writing and follow up was available for 226 (72%) from six to 78 months. Late complications were observed in 16 patients with gall bladder 'in situ' (12%); the most frequent was cholecystitis in 6%. In five patients of the group without gall bladder, four had cholangitis related to retained or recurrent stones, and one restenosed . No episodes of cholangitis were observed in patients without stones despite reflux of barium up the biliary tree as observed during a barium meal examination.

[Evaluation of systemic antibiotic preventive treatment in colorectal surgery]

A comparison was made of two methods of prophylactic antibiotic therapy against the septic complications of colonic and rectal surgery: --preoperative oral antibiotics associated with peroperative systemic antibiotics; --peroperative systemic antibiotics only, continued for 24 hours after surgery. Both types of antibiotic therapy were of short duration and were designed to cover aerobic and anaerobic organisms. Two groups of 30 patients were selected at random. They were homogeneous. The septic complication rate was 10% in the oral plus systemic and 24% in the systemic group. It is felt that the combination of oral and systemic antibiotics remains preferable, in particular bearing in mind the efficacy of oral metronidazole.

Comparison between oral and systemic antibiotics and their combined use for the prevention of complications in colorectal surgery

Ninety patients were included in this prospective randomized trial. Each required electric colorectal surgery and was prepared for operation with oral preoperative antibiotic therapy, systemic peroperative therapy, or by a combination of both. The number of each type of septic postoperative complication and their total did not differ between the group treated by oral antibiotics prior to operation and the group treated peroperatively with systemic antibiotic therapy. The total number of septic complications (wall abscesses, fistulas, subdiaphragmatic abscesses, septicemia, peritonitis), however, was significantly less (P less than 0.05) in the group treated by both preoperative oral antibiotics and peroperative systemic antibiotic therapy (3.3 per cent) than in either groups treated only orally preoperatively (30 per cent) or by systemic antibiotic therapy during the operation (23 per cent). The combination of oral antibiotic therapy prior to operation and of systemic peroperative antibiotic therapy, therefore, presents the most effective prophylactic effectiveness.