Sacral nerve stimulation for faecal incontinence: response rate, satisfaction and the value of preoperative investigation in patient selection

OBJECTIVE

Before undergoing sacral nerve stimulation (SNS) for faecal incontinence (FI), patients are investigated with morphologic, dynamic and electrophysiologic tests. The purpose of our study was to evaluate their value in the selection of patients who may benefit most from neuromodulation.

METHOD

If temporary stimulation resulted in a good objective response, a permanent neuromodulator was implanted. Patients were reviewed at 3 months and then at 6 monthly intervals. Asked by telephone, patient's satisfaction was described as good, satisfactory or poor.

RESULTS

Forty-five consecutive patients (41 females, median age 59 years) with FI (Wexner 16.1 +/- 2.9) underwent SNS. Temporary stimulation was successful in 32 (71)% patients. At a median follow-up of 33 months, the neuromodulator remained in place in 25 (55%) patients, two do whom switched it off, leaving 23 (51%) with a functioning neuromodulator. There was no statistically significant difference between the characteristics (including manometry, ultrasound and electrophysiology) of patients undergoing implantation (n = 32) or not (n = 13) and those with or without a functioning stimulator (n = 23: n = 13). In the 23 patients with a functioning stimulator the result was good in 12, satisfactory in five and poor in six. There was no statistically significant difference in the patient characteristics between those with a good result (n = 12) and the remainder (n = 32).

CONCLUSION

The findings suggest that investigation for FI does not facilitate patient selection for SNS and cannot be used to predict outcome.

Radiofrequency ablation for recurrent pelvic cancer

OBJECTIVE

Local recurrence of pelvic cancer is a therapeutic challenge. The purpose of the study was to evaluate radiofrequency ablation (RFA, intra-operative or CT-guided) for the treatment of pelvic recurrence in patients not eligible for curative surgical resection.

METHOD

Charts of all patients treated for pelvic recurrence by RFA between March 2004 and March 2005 were reviewed.

RESULTS

Eight patients (two females) had RFA for inoperable local recurrence [rectal adenocarcinoma (six) and sarcoma (two)]. Surgical resection of the primary tumour had been performed at a median age of 50.2 (36.7-61.6) years. Recurrence occurred after a median of 49.5 (11.7-63.5) months. The mean size of the recurrence was 33.4 (20-45) mm. RFA was given on a median number of two occasions (1-3). Complications occurred in six patients including minor pain [pelvic (six); sciatic nerve irritation (four)]; ureteric obstruction requiring stenting (two) and colo-vesical fistula (one), requiring ileal urinary diversion. After a median follow-up of 18.2 months (11-32), six patients were still alive. Patients, who had experienced pain prior to RFA were pain-free. Five patients showed evidence of further tumour growth but were asymptomatic.

CONCLUSION

Radiofrequency ablation is a feasible therapeutic option for recurrent pelvic cancer. It allows good symptom control in patients with pain but morbidity is high.

Risk factors for development of desmoid tumours in familial adenomatous polyposis

Background

Desmoid tumours (DTs) are the primary cause of death of patients with familial adenomatous polyposis (FAP) following restorative proctocolectomy. The aim of this study was to identify risk factors for DT in a French population.

Methods

Clinical data for 442 patients with FAP from 1983 to 2004 were reviewed retrospectively.

Results

A total of 124 DTs were documented in 50 patients (25 female). DT sites were mesenteric (73 tumours), abdominal wall (44) and extra-abdominal (seven). Female patients developed DT earlier than males. Although DTs appeared after colectomy in 34 patients, the type of surgery did not influence the risk of DT. An identified point mutation in the adenomatous polyposis coli (APC) gene after codon 1444 was a significant risk factor (hazard ratio 3·3 (95 per cent confidence interval 1·5 to 7·3)). Belonging to a family affected by DT did not increase the individual's risk in this population.

Conclusion

No risk factor for life-threatening mesenteric DT could meaningfully modify the management of patients with FAP.

Colorectal neoplasia in Crohn's colitis: a retrospective comparative study with ulcerative colitis

AIMS

To determine the clinicopathological features of colorectal cancer (CRC) in Crohn's disease (CD).

METHODS AND RESULTS

All histological slides from surgical specimens with inflammatory bowel disease-related colorectal neoplasia examined in our hospital between 1990 and 2005 were reviewed. We identified 18 CRCs in 16 patients with CD and compared them with 57 CRCs in 41 patients with ulcerative colitis (UC). We also studied 25 patients with dysplasia without cancer (CD 2, UC 23). When CD and UC were compared, the median age at diagnosis of cancer (CD 52 years, UC 51 years), the frequency of mucinous adenocarcinoma (CD 16.7%, UC 17.5%) and the frequency of dysplasia adjacent to and distal from cancer (CD 56.3 and 37.5%, UC 65.8 and 39%, respectively) were similar. All neoplastic lesions occurred in areas affected by inflammatory bowel disease.

CONCLUSIONS

CRC complicating CD and UC shares many clinicopathological features, in particular similar frequencies of dysplasia, both adjacent and distal, with cancer. Thus, surveillance for patients with Crohn's colitis should be similar to that for patients with UC. Consideration should be given to a more extensive UC-like surgical approach instead of segmental resection of the involved area.

[Epidermoid carcinomas of anal canal treated with radiation therapy and concomitant chemotherapy (5-fluorouracil and cisplatin)]

PURPOSE

To evaluate our results after radiation therapy and concomitant chemotherapy in terms of local control, survival and toxicity in patients with anal cancer.

METHODS AND PATIENTS

Between November 1990 and January 2002, 60 patients (pts) were treated with radiation therapy and concomitant chemotherapy. The T-stage according to the 2001 UICC classification were: 2 T1, 26 T2, 25 T3, and 7 T4. There were 20 pts with nodal involvement at presentation. The treatment started with external beam RT (median dose: 45 Gy) and concomitant chemotherapy using 5-fluorouracil and cisplatin during the first week and the fifth week of external beam RT (EBRT). After a rest period of 4 to 6 weeks, a boost of 20 Gy was delivered by EBRT in 58 pts and by interstitial (192)Ir brachytherapy in 2 pts. Mean follow-up were 78.5 months.

RESULTS

At the end of RT with concomitant chemotherapy local tumor clinical complete response rate was 83%. Out of 10 non responders or local progression, 5 (50%) were salvaged with abdominoperineal resection (APR). Out of 5 local tumor relapses, 3 were salvaged with APR. The overall local tumor control (LC) rate with or without salvage local treatment were 88%. LC rate with a good anal function scoring (score 0 and 1) was 70%. Among 43 pts who preserved their anus, 98% had a good anal function scoring. The 5-year disease-free survival was 75%. After multivariate analysis, 2 independent predicting factors significantly influenced the disease-free survival: HIV-positive pts (negative vs positive, P=0.032) and clinical tumor response after the first course of radiotherapy (<50% vs >or=50%, P=0.00032). Acute grade 2 or 3 toxicities were low: haematological toxicity in 4 pts and intestinal complication corresponding to diarrhea in 10 pts. Late severe complication was observed in 3 pts: 2 pts with painful necrosis of the anus requiring colostomy and 1 pt with grade 3 rectal bleeding.

CONCLUSION

We confirm the good results with RT and concomitant chemotherapy. The clinical tumor response after the first course of RT and concomitant chemotherapy is probably the most important predictive factor on the disease-free survival. For patients with T3 or T4 lesion and tumor regression <or=50% after the first course of radiation therapy, surgical non conservative treatment should be discussed.

Outcome of antegrade continence enema procedures for faecal incontinence in adults

BACKGROUND

Faecal incontinence has major consequences. Colostomy has been the mainstay of therapy when other options fail. Operations such as the Malone procedure have been proposed as an alternative. The aim of this study was to evaluate the outcomes and quality of life of patients having a Malone procedure for the treatment of faecal incontinence.

METHODS

Charts of patients who had had a Malone procedure or equivalent between 1998 and 2004 were reviewed. The patients completed a Short Form (SF) 36 quality of life questionnaire.

RESULTS

The study included 25 patients (17 female; median age 47 years). In seven, the appendix was used; an ileoneoappendicostomy was performed in the other 18. Three patients were lost to follow-up; the remaining 22 were followed for a median (range) of 21 (1-61) months. Five patients had a cutaneous stenosis; another had the appendicostomy removed and replaced by a colostomy. Four patients no longer used the stoma for irrigation. All other patients were completely clean except one, who reported occasional night-time seepage. The mean SF-36 showed a good physical recovery (43.9) but persisting psychological distress (36.0).

CONCLUSION

The Malone procedure or equivalent achieves good results in the management of faecal incontinence, although psychological distress persists after surgery.

Causes and outcomes of pouch excision after restorative proctocolectomy

BACKGROUND

Pouch failure occurs in up to 10 per cent of patients after ileal pouch-anal anastomosis (IPAA). The aims of this study were to determine the reasons for pouch excision and to evaluate the outcome of the perineal wound after pouch excision.

METHODS

Between 1984 and 2002, 91 patients with severe ileal pouch dysfunction were treated. This was a retrospective analysis of data collected prospectively from 24 patients who underwent pouch excision.

RESULTS

Patients were grouped according to the final histological diagnosis. Fourteen patients with Crohn's disease developed extensive fistulous disease and/or recurrent abscesses, of whom six had a persistent perineal sinus after pouch excision. Five patients had familial adenomatous polyposis, in three of whom desmoid tumours were the cause of failure. Three patients had chronic ulcerative colitis and developed recurrent pelvic sepsis. Finally, two patients with multiple colorectal adenocarcinoma developed recurrent cancer (one) or sepsis (one).

CONCLUSION

Sepsis was the principal reason for pouch excision and was usually associated with recrudescent Crohn's disease in the pouch. Perineal wound healing was problematic after pouch excision for Crohn's disease.

Salvage reoperation for complications after ileal pouch-anal anastomosis

BACKGROUND

Surgical revision may be possible in patients with a poor outcome following ileal pouch-anal anastomosis (IPAA), using either a transanal approach or a combined abdominoperineal approach with pouch revision and reanastomosis.

METHODS

Sixty-four patients underwent revisional surgery. The indication for salvage was sepsis in 47 patients, mechanical dysfunction in ten, isolated complications of the residual glandular epithelial cuff in three and previous intraoperative difficulties in four patients.

RESULTS

A transanal approach was used in 19 patients and a combined abdominoperineal procedure in 45. Six of the latter had pouch enlargement and 25 received a new pouch. During a mean(s.d.) follow-up of 30(25) months, three patients required pouch excision because of Crohn's disease. Two patients had poor continence after abdominoperineal surgery. At last follow-up 60 (94 per cent) of 64 patients had a functional pouch. Half of the patients experienced some degree of daytime and night-time incontinence, but it was frequent in only 15 per cent. Of 58 patients analysed, 27 of 40 who had an abdominoperineal procedure and 13 of 18 who had transanal surgery rated their satisfaction with the outcome as good to excellent.

CONCLUSION

Surgical revision after failure of IPAA was possible in most patients, yielding an acceptable level of bowel function in two-thirds of patients.

Complete rectal prolapse in young patients: psychiatric disease a risk factor of poor outcome

OBJECTIVE

Complete rectal prolapse is rare before the age of 50. The aim of our study was to identify the risk factors of total rectal prolapse before this age and to determine the surgical outcome in this specific group of patients.

PATIENTS AND METHODS

The charts of all patients, younger than 50 years old, treated for total rectal prolapse between June 1995 and December 2001 were reviewed. Associated conditions were noted and pre and postoperative functions were compared in regards of constipation and evacuations problems, anal continence (Wexner score), recurrent prolapse and overall satisfaction. All patients underwent an abdominal rectopexy according to the Orr-Loygue procedure.

RESULTS

During the study period, 28 patients (21 females) with a mean age of 34 +/- 9 years were treated for a total rectal prolapse in our institution. Five patient (17.8%) had minor complications. After a mean follow up of 25 months, the global continence improved significantly (Wexner score: 4.9 vs 2; P = 0.014): 8 patients suffering from liquid stools incontinence before surgery were continent after rectopexy, while 2 continent patients became incontinent to liquid stools after surgery. Fourteen patients had chronic psychiatric disease requiring permanent treatment. These patients suffered more frequently from constipation (12/14 vs 5/14; P =0.006) and required more often a digital evacuation before surgery (6/14 vs 1/14; P = 0.07) than non psychiatric patients. They also suffered from more severe constipation and required more enemas after surgery (1/14 vs 6/12; P = 0.03) compared to patients without psychiatric disease. The only two patients, who had recurrence also had psychiatric disease.

CONCLUSION

Chronic psychiatric disease requiring long-term medication is observed in 50% of patients with total rectal prolapse under the age of 50 years. Moreover, the medically induced constipation in these patients could represent a cause of poorer functional outcome. Therefore, we recommend the identification of this preoperative risk factor to assess the results of total rectal prolapse treatment in patients younger than 50 years of age.

Primary rectus abdominis myocutaneous flap for repair of perineal and vaginal defects after extended abdominoperineal resection

BACKGROUND

Significant morbidity can result from perineal wounds, particularly after radiotherapy and extensive resection for cancer. Myocutaneous flaps have been used to improve healing. The purpose of this study was to evaluate the morbidity and results of primary rectus abdominis myocutaneous flap reconstruction of the vagina and perineum after extended abdominoperineal resection.

METHODS

Thirty-one consecutive patients undergoing one-stage rectus abdominis myocutaneous flap reconstruction of extensive perineal wounds were studied prospectively. Twenty-six patients had surgery for recurrent or persistent epidermoid anal cancer or low rectal cancer, and 21 had high-dose preoperative radiotherapy.

RESULTS

Three weeks after the operation, complete healing of the perineal wound was seen in 27 of the 31 patients. There were nine flap-related complications including three patients with partial flap necrosis, two with vaginal stenosis, one with vaginal scarring, one with small flap disunion and two with weakness of the anterior abdominal wall. There were no unhealed wounds at the completion of follow-up (median 9 months).

CONCLUSION

The transpelvic rectus abdominis myocutaneous flap for the reconstruction of large perineal and vaginal wounds achieves wound healing with only moderate morbidity in the majority of patients after extensive abdominoperineal resection with or without radiotherapy.

Sutured perineal omentoplasty after abdominoperineal resection for adenocarcinoma of the lower rectum

PURPOSE

This study was designed to describe and evaluate the efficacy of sutured perineal omentoplasty on perineal wound healing after abdominoperineal resection for adenocarcinoma of the lower rectum.

METHODS

Charts of patients who underwent abdominoperineal resection for adenocarcinoma of the rectum from June 1995 to December 2001 were reviewed for mortality, morbidity, and perineal healing. Abdominoperineal resection was accomplished according to Miles combined with total mesorectal excision. The omentum was pediculized on the left gastroepiploic artery and tightly sewn to the subcutaneous fatty tissue. The perineal skin was then closed primarily.

RESULTS

A total of 104 patients were included in the study. The mean age at surgery was 65 (range, 13-91) years. The distance of the tumor from the anal sphincters was 0.45 +/- 0.9 mm (range, 0-50). During the study period, 92 patients (88 percent) had sutured perineal omentoplasty. The rate of primary perineal wound healing was 80 percent. Postoperative perineal wound complications consisted of perineal abscess in seven patients. Six of these patients had a sutured perineal omentoplasty (6 percent). Only four patients required a surgical drainage. Minor perineal suppuration occurred in four patients (4 percent), whereas partial perineal wound dehiscence occurred in eight patients (8 percent). All wounds healed completely at three months. Intestinal obstruction occurred in three patients (3 percent). No complication of the pedicled omentoplasty was observed.

CONCLUSIONS

This study demonstrated that sutured perineal omentoplasty is possible in the majority of patients after abdominoperineal resection for adenocarcinoma of the lower rectum with excellent primary perineal wound healing.

[Ampullectomy in benign lesion: indications and results]

BACKGROUND

Surgical resection remains today the standard treatment of ampullary and papilla tumours. Whether pancreaticoduodenectomy (PD) or ampullectomy is indicated for presumed benign lesions remains debated. The feared potential post-operative morbidity of ampullectomies is balanced by the functional sequelae of PD.

AIM OF THE STUDY

This work reports our experience of ampullectomies for presumed benign lesion of the ampulla and papilla and analyses the indications and results of ampullectomies, considering both our series and published series of the literature.

METHODS

Since 1997, eight ampullectomies with frozen section have been performed for presumed benign lesions, taking account of morphologic criteria and pre-operative endoscopic biopsies.

RESULTS

Post-operative mortality was nil. Post-operative morbidity included one bilio-enteric fistula and four acute pancreatitis, all treated conservatively. Final pathological examination showed one benign and one malignant ampullomas, one benign fibrous stenosis of the papilla, one duodenal duplication and one choledococele, two adenomas and one adenomyomatosis of the papilla in patients with familial adenomatous polyposis (FAP). During follow-up, one de novo duodenal adenoma in FAP and one benign stenosis of the papilla were observed and treated endoscopically. All other patients remain asymptomatic.

CONCLUSION

Ampullectomy with accurate intra-operative frozen section appears adequate for presumed benign lesion of the papilla and ampulla.

Prognostic significance of microsatellite instability determined by immunohistochemical staining of MSH2 and MLH1 in sporadic T3N0M0 colon cancer

BACKGROUND

Microsatellite instability (MSI) has been identified as a factor with good prognosis and chemosensitivity in stage III C colon cancer. The purpose of this study was to evaluate the routine use of immunohistochemical analysis (immunohistochemical staining of MSH2 and MLH1) to identify T3N0M0 (stage II) colon cancer with MSI and assess the prognostic value of this analysis. The study was conducted in a large cohort of patients in a single institution who had a curatively resected T3N0M0 colon cancer and were not receiving adjuvant therapy.

METHODS

Between June 1995 and December 2001, 142 patients (77 females) with a mean age of 68 years, suffering from T3N0M0 colon cancer curatively resected and not receiving adjuvant therapy, were checked in terms of their follow up status. The results of colonoscopy, hepatic ultrasonography, chest x ray, and blood carcinoembryological antigen were noted. All tumours were immunohistochemically stained for MSH2 and MLH1. Perineural invasion, lymphovascular invasion, and the presence of vascular neoplastic emboli were assessed.

RESULTS

Twenty four patients (17%) had MSI tumours. Patients with MSI and microsatellite stable (MSS) tumours did not differ in terms of age, perineural or lymphovascular invasion, or the presence of vascular neoplastic emboli. Patients with MSI tumours were more frequently female (18/24 v 60/118; p = 0.001) and more frequently suffered from right sided cancer (19/24 v 58/118; p<0.001). Patients with MSI tumours exhibited significantly better recurrence free survival than those with MSS tumours (p = 0.02). Cox analysis identified age and MSI determined by immunohistochemistry as independent predictive factors of good prognosis (p = 0.009, odds ratio 1.04 (1.01-1.08); p = 0.04, odds ratio 7.9 (1.05-59.6)).

CONCLUSIONS

MSI determined by immunohistochemistry is an independent predictive factor of good prognosis in T3N0M0 colon cancer. The prognosis for MSI T3N0M0 colon cancer is excellent and chemotherapy should not be proposed in these patients as immunohistochemical analysis produces rapid results.

[Radiotherapy of carcinomas of the anal canal. Tenon Hospital experience]

Since 1980, curative-intent radiation therapy of epidermoid carcinoma of the anal canal is the standard first line treatment. The combined concomitant chemotherapy and radiation therapy is presently established for locally advanced tumors more than 4 cm in length and/or with nodal involvement. We report the Tenon hospital experience since 1972 concerning the long term results after radiation therapy, the modifications of the radiation technique, and the evolution of treatment strategy.

Ultralow anterior resection with intersphincteric dissection--what is the limit of safe sphincter preservation?

INTRODUCTION

In the treatment of low rectal cancer, the possibility of sphincter preserving surgery is increased by partial sphincteric resection which may allow an oncologically safe resection margin in some patients who would traditionally have been treated by abdominoperineal resection. The aim of this study is to evaluate the morbidity, mortality and the oncological and functional results of intersphincteric resection to determine whether the technique may be considered a safe means of sphincter preservation.

METHODS

Between May 1992 and December 1999, 26 patients (mean age 55 years, range 28-82) with adenocarcinoma of the rectum had partial sphincteric resection by an abdominal approach with a colonic J-pouch anal anastomosis. The mean distance between the tumour and the anal verge 4.25 (range 3.1-5.25) cm. Four tumours were T1, 14 T2 (3 N+), 7 T3 (3 N+), and 1 T4 (N+). Neoadjuvant radiotherapy was used in 10 patients. The distal resection margin was positive in one patient who then proceeded to safe abdominoperineal resection (APR). In the remaining patient the mean distal resection margin on the fixed specimen was 1.6 (range 0.3-3.5) cm.

RESULTS

There were no deaths. Morbidity was 30% with an anastomotic leak rate of 11%. At mean follow-up of 39 (range 11-93) months the local recurrence rate was 3.4%. Functional results were evaluated in 25 patients at mean follow-up of 27 (8-66) months: 65% had 0-2 bowel motions per 24 h, 31% had 3-5 and 4% between 6 and 9. Nine patients (36%) had nocturnal defecation. Continence was normal in 50% with 23% reporting incontinence to gas and 27% reporting minor episodes of incontinence. None had major incontinence and 85% considered their outcome satisfactory.

CONCLUSION

This study supports the current literature indicating that partial sphincteric resection is an oncologically and functionally safe alternative to abdominoperineal resection for some selected low rectal tumours.

[Epidermoid carcinomas of the anal canal treated with definitive radiation therapy in a series of 305 patients]

PURPOSE

To identify prognostic factors and treatment toxicity in a serie of epidermoid cancers of the anal canal without evident metastasis.

PATIENTS AND METHODS

Between June 1972 and January 1997, 305 patients (pts) were treated with curative-intent radiation therapy (RT). The T-stages according to the 1987 UICC classification were: 26 T1, 141 T2, 104 T3, and 34 T4. There were 49 pts with nodal involvement at presentation. Pretreatment anal function scoring according to our in-house system was: 22 scored 0, 182 scored 1, 74 scored 2, 7 scored 3, 11 scored 4, and 9 not available pts. The treatment started with external beam RT (EBRT) in 303 pts (median dose: 45 Gy). After a rest period of 4 to 6 weeks, a boost of 20 Gy was delivered by EBRT in 279 pts and by interstitial 192Ir brachytherapy (Bcy) in 17 pts. Seven pts received only one course of EBRT (mean dose: 49.5 Gy) and 2 pts were treated with interstitial 192Ir Bcy alone (55 and 60 Gy, respectively). Concomitant chemotherapy (5-fluoro-uracil and either mitomycin C or cisplatin) was delivered to 19 pts. Mean follow-up was 103 months.

RESULTS

At the end of RT local tumor clinical complete response (cCR) rate was 80%. Out of 61 non responders or local progressive tumors 27 (44%) were salvaged with abdominoperineal resection (APR). The rate of local tumor relapse (LR) was 12%. Out of 37 LTR, 20 (54%) were salvaged with APR and one with interstitial 192Ir Bcy. The orevall local tumor control (LC) rate with or without salvage local treatment was 84%. LC rate with a good anal function scoring (score 0 and 1) was 56.5%. Among 181/186 available pts who preserved their anus, 94% had a good anal function scoring. For a subgroup of 15 pts with length tumor <2 cm-N0, the LC rate after the end of RT was 100%, the LC rate with or without local salvage treatment was 100%, and among 13 available pts who preserved their anus, the anal function scoring was good in 12 pts (92%). The 10-years disease-free survival was 74%. After multivariate analysis, 3 independent predicting factors significantly influenced the disease-free survival: gap duration between 2 courses of RT (>38 days vs < or =38 days, P =0.0025), pretreatment anal function scoring (0 vs 1 vs 2 vs 3 vs 4, P =4.4 10(-6)), and cCR after the end of RT (no complete response vs complete response, P =2.5 10(-14)).

CONCLUSION

We confirm excellent results with RT in T1 and T2 lesions. However, chemoradiotherapy should be prefered to improve survival free of colostomy with a good anal sphincter function for tumors more than or equal to 2 cm in length and locally advanced tumors.

Oncologic results following abdominoperineal resection for adenocarcinoma of the low rectum

PURPOSE

The role of abdominoperineal resection for rectal cancer has changed because of advances in sphincter-preserving surgery. Our aim was to evaluate the results of this operation in the five-year period following introduction of the concept of total mesorectal excision

METHODS

Data on all patients undergoing abdominoperineal resection for very low rectal cancer between 1992 and 1997 were collected prospectively. All patients had had total mesorectal excision. Curative resection was defined as absence of macroscopic disease after resection and local recurrence as any infiltration or tumor identified in the pelvis, alone or combined with distant disease. Survival and local recurrence rates were calculated using the Kaplan-Meier method and log-rank analysis.

RESULTS

Of 165 abdominoperineal resections performed, 106 were for primary adenocarcinoma of the rectum. The male:female ratio was 50:56, with a median age of 65 (range, 33-85) years. There was one postoperative death. Twenty-seven patients received short-course preoperative radiotherapy (25 Gy over 1 week), whereas 22 had a longer course, with concomitant chemotherapy in 2. Postoperative chemotherapy was administered in 29, postoperative radiotherapy in 4, and combined therapy in 8. After curative resection (n = 91), survival at five years was 76 percent and differed significantly by stage. Recurrence at any site was 7 percent (3/34) for Stage I, 27 percent (6/26) for Stage II, and 53 percent (16/31) for Stage III. Nine patients presented with local recurrence, with an overall rate at five years of 10 percent. Isolated locale recurrence was observed in only 5 percent of patients

CONCLUSIONS

After abdominoperineal resection and total mesorectal excision, good rates of local control may be achieved provided surgical technique is meticulous.

[Massive rectal bleeding after appendectomy: report of 2 further cases and review of the literature]

Massive rectal bleeding complicating appendectomy is extremely rare. This study describes two cases of severe gastrointestinal haemorrhage from an appendiceal stump, occurring one and seven days after appendectomy respectively. The two cases were successfully treated by emergency cecal resection. We reviewed the other previously reported etiologies of massive rectal bleeding after appendectomy for appendicitis.

Mixed ductal-pancreatic polypeptide-cell carcinoma of the pancreas

AIMS

Mixed ductal-endocrine carcinomas of the pancreas are rare tumours with 10 cases reported in the English literature. We report the first case with a polypeptide-cell component.

METHODS AND RESULTS

: The tumour was fortuitously discovered in a 72-year-old woman during the exploration of an endometrial adenocarcinoma. It measured 100 mm and was located in the tail of the pancreas. On microscopic examination two intermingled endocrine and exocrine components were present. The endocrine component consisted of trabeculae and solid nests composed of cells immunoreactive for chromogranin A, synaptophysin and pancreatic polypeptide, but negative for p53 and Bcl-2 proteins. The exocrine component was composed of tubules lined by atypical cylindrical cells immunoreactive for CK19, CEA, p53 and Bcl-2. The stroma of the endocrine component contained amyloid deposits.

CONCLUSION

Mixed ductal-endocrine carcinomas of the pancreas are often described in middle-aged patients. The tumours are usually large and located in the head of the pancreas. An endocrine syndrome is rare and the prognosis is often unfavourable. We report the first case of mixed endocrine-exocrine carcinoma of the pancreas with a pancreatic polypeptide-cell component. The histogenesis of mixed carcinoma of the pancreas is still uncertain but the over-expression of p53 and Bcl-2 could play a major role in the neoplastic progression of the ductal component.

Treatment of postoperative peritonitis of small-bowel origin with continuous enteral nutrition and succus entericus reinfusion

HYPOTHESIS

Proximal intestinal stomas established by the exteriorization of leaking anastomosis in the presence of peritonitis can be used to reinfuse succus entericus and provide adequate enteral nutrition.

DESIGN

Retrospective analysis of prospectively gathered data from a cohort of consecutive patients admitted between January 1993 and December 1999 for postoperative peritonitis requiring laparotomy and the construction of one or more small-bowel stomas.

SETTING

Tertiary referral center with a surgical intensive care unit experienced in the treatment of intra-abdominal sepsis and succus entericus reinfusion.

PATIENTS

Twenty-one consecutive patients with postoperative peritonitis originating from a jejunal or ileal leak. We excluded patients with established enterocutaneous fistulae, abscesses amenable to percutaneous drainage or other conservative treatments, and postoperative peritonitis caused by ileocolic or ileorectal anastomosis.

INTERVENTIONS

Early laparotomy with exteriorization of small-bowel leak(s), and continuous enteral nutrition (CEN) and succus entericus reinfusion (SER) via the distal portion of the stoma until gastrointestinal continuity was restored.

MAIN OUTCOME MEASURES

Feasibility of CEN and SER with temporary, diverting small-bowel stomas and their associated postoperative morbidity and mortality rates.

RESULTS

One patient died, and 14 experienced complications. For technical reasons, CEN and SER were discontinued early on in 7 patients. The mean duration of CEN and SER was 58 days and 61 days, respectively. Enteral feedings allowed the suppression of central venous access after a median of 28 days, with 82 days as a median time to restoration of intestinal continuity.

CONCLUSIONS

Although the exteriorization of small-bowel leaks with CEN and SER is generally feasible and effective in the treatment of critically ill patients with peritonitis secondary to small-bowel leaks, it is associated with significant morbidity and mortality, in part relating to patients' underlying diseases.

Results of reoperations in colorectal anastomotic strictures

PURPOSE

The incidence of colorectal anastomotic strictures varies from 3 to 30 percent. Most of these anastomotic strictures are simple narrowings shorter than 1 cm that can be successfully treated by dilation or endoscopic alternatives. However, up to 28 percent of patients will require surgical correction. This can be technically difficult, with the possibility of a permanent colostomy. This study reports the outcomes after operative treatment of severe strictures of colorectal anastomoses.

METHODS

From August 1992 to October 1996, 27 patients were referred for surgical treatment of severe rectal anastomotic strictures. The reasons for the initial surgery were as follows: rectal cancer (13), diverticular disease (7), Hirschsprung's disease (2), rectal endometriosis (2), uterine carcinoma with rectal invasion (1), ruptured abdominal aortic aneurysm with rectosigmoid necrosis (1), and rectovaginal fistula (1). There were 15 (56 percent) stapled anastomoses, and 21 (78 percent) patients had developed a postoperative leak.

RESULTS

The median time between initial surgery and diagnosis of the stenosis was 7.2 (range, 1-24) months and between the last operation and referral was 15.1 (range, 1-44) months. Stenosis was located at a mean distance of 9.5 (range, 4-15) cm from the anal verge. Eleven patients (41 percent) had been unsuccessfully dilated before referral. Surgical correction of the stenosis required 7 colorectal anastomoses for upper rectal anastomotic strictures and 20 coloanal anastomoses for middle and lower rectal strictures (19 Soave's procedures and 1 colon J-pouch-anal anastomosis). Intestinal continuity was restored in all cases. After a mean follow-up of 28.7 +/- 14 months, no recurrences were detected and functional results were satisfactory.

CONCLUSIONS

Resection of the stenosis and construction of a new colorectal anastomosis can be performed successfully for upper rectal anastomotic stricture. For a stenosis located in the middle and lower rectum, Soave's procedure offers a good alternative, with satisfactory long-term functional results. Whichever technique is used, a permanent colostomy should rarely be required.

Adenocarcinoma complicating Crohn's disease of the duodenum

Duodenal obstruction is a classic complication of Crohn's disease with duodenal involvement. However, malignant transformation of duodenal lesions has very rarely been reported, and diagnosis of such a transformation is rarely made preoperatively. We report the case of a 32-year-old patient with an 8-year history of Crohn's disease who underwent bypass gastrojejunostomy for a duodenal stricture. A year later, weight loss and biliary obstruction led to a further laparotomy. At operation, an advanced carcinoma with peritoneal seedings was confirmed. Of the three patients previously reported in the literature with duodenal cancer arising in Crohn's disease stricture, only one had a preoperative diagnosis of malignancy made from endoscopic biopsies. When considering the surgical bypass of Crohn's duodenal stricture, if preoperative endoscopy and biopsy cannot be performed on account of duodenal stricturing, we suggest performing a peroperative endoscopy via a jejunotomy in order to eliminate the diagnosis of associated duodenal malignancy.

Endometrial stromal sarcoma of the rectosigmoid colon arising in extragonadal endometriosis and revealed by portal vein thrombosis

Malignant transformation is an infrequent complication of endometriosis. The ovary is the primary site in 76% of cases, and extragonadal sites are identified in 24%. Endometrioid carcinoma is the most common histologic type; sarcoma is very rare. We report a case of low-grade endometrial stromal sarcoma of the rectosigmoid colon presenting with epigastric pain due to portal vein thrombosis. This tumor arose from extragonadal endometriosis in a 61-year-old woman and was treated by surgical resection. The main differential diagnosis of this unusual colonic neoplasm includes primary mesenchymal tumors, such as gastrointestinal stromal tumors.

[Role of remaining ductal cephalad obstruction on the results of lateral pancreaticojejunostomy in chronic pancreatitis]

AIMS

To report the results of a pancreaticojejunostomy in the treatment of chronic pancreatitis, and to assess the role of residual cephalic ductal obstruction in pain recurrence.

METHODS

Thirty seven patients with painful chronic pancreatitis whose pancreatic duct diameter exceeded 6 mm were treated by lateral pancreaticojejunostomy and were retrospectively studied. Deobstruction of the cephalad portion of the main pancreatic duct was complete in 21 patients (group A), while residual obstruction was noted in 16 patients (group B).

RESULTS

One patient died post-operatively (2.7%) and 6 patients underwent complications (16%) that were treated without reoperation. With a median follow-up of 52 months, 26 patients were pain free (70%). Pain recurrence occurred in 3 patients in group A (14%) who were treated medically, versus in 8 patients in group B (50%) of whom 4 needed iterative surgery. Ongoing alcoholic addiction did not influence pain recurrence, which onset significantly altered the weight increase observed after pancreaticojejunostomy.

CONCLUSION

Lateral pancreaticojejunostomy has a low morbidity rate and offers long lasting pain relief in 86% of patients whose cephalad main pancreatic duct is completely deobstructed.

Primary adenosquamous carcinoma of the rectum. Report of 4 cases and review of the literature

OBJECTIVE

To review the experience of two referral centres in the management of an infrequent condition: primary adenosquamous carcinoma of the rectum, a rare disease.

MATERIALS AND METHODS

Four cases of primary adenosquamous carcinomas of the rectum are reported with a review of the literature. No preoperative diagnosis of adenosquamous carcinoma was established. All tumours were located in the rectum. Two patients presented with liver metastasis. No preoperative therapies were indicated. All patients underwent surgery.

RESULTS

Patients underwent anterior resections (n=2), recto-sigmoid resection (n=1) and abdomino-perineal excision (n=1). All resected specimens had positive lymph nodes and metastatic liver disease was confirmed in the two cases. No adjuvant therapy was carried out after surgery and patients died within 8 months after surgical treatment.

CONCLUSIONS

Adenosquamous carcinoma of the rectum is a rare and aggressive tumour characterized by coexisting of malignant glandular and squamous components. Presentation is usually at an advanced stage. The tumour is aggressive and metastatic disease at the time of diagnosis is common. Surgery is the treatment of choice. Adjuvant therapy is difficult to evaluate prospectively due to the rarity of the condition. Survival is less than 50% than that for adenocarcinoma.

[Intensive care after digestive surgery: the outcome in elderly patients]

STUDY AIM

In surgical intensive care, the results must be analyzed both in terms of mortality and quality of life; this is particularly important in elderly patients for whom recovery remains uncertain. The aim of this prospective study was to assess the early and late prognosis in elderly patients (aged over 75 years) admitted to a digestive surgical intensive care unit (DSICU) for mortality, quality of life, patient autonomy, and also the predictive factors involved.

PATIENTS AND METHODS

Over a one-year period, 182 patients were admitted to a tertiary referral DSICU; 30 of these subjects were over 75 years old, and formed the basis of this study. The following data were analyzed: hospital mortality rate; mortality rate at six months, and quality of life at six months (Kamofsky scale). These factors were correlated with the severity of the patient's state at admission and also with the causal disease, circumstances connected with admission, and duration of stay in the DSICU.

RESULTS

The hospital mortality rate of patients was 23% (7/30 patients), and the overall mortality rate at six months was 40% (12/30 patients). Of the 12 patients who stayed in the DSICU for more than ten days with a simplified acute physiology score (APS) = 10, not one was alive at six months post-DSICU admission. The 18 remaining patients were still alive at six months, and 72% of them (13/18 patients) had regained their previous post-operative autonomy.

CONCLUSION

These results provide reference data for this patient category. The results concerning long-term survival and the good functional outcome are encouraging. If the prognostic criteria defined in this investigation are confirmed by further studies, they may help in making the sometimes difficult decisions regarding elderly patients hospitalized in a DSICU.

Bile acid transport and regulating functions in the human biliary epithelium

Whether bile acids regulate biliary epithelial cell (BEC) secretory functions in human is poorly known. The purpose of the study was to determine if human gallbladder-derived BEC exhibit bile acid transport activity that affect their secretory functions and to evaluate the influence of bile acid hydrophobicity in this response by comparing the effects of tauroursodeoxycholate (TUDC) and of taurochenodeoxycholate (TCDC). Expression of the apical sodium-dependent bile acid transporter (ASBT) and of the organic anion transporting polypeptide (OATP-A) was detected and associated with sodium-dependent and sodium-independent [(3)H]taurocholate uptake in BEC. Sodium-dependent uptake (K(m), 66 +/- 2.5 micromol/L; Vmax, 39.4 +/- 4.6 pmol/mg protein/min) was significantly higher than sodium-independent uptake. TCDC stimulated Cl(-) efflux and mucin secretion in cultured cells, and both effects were sodium-dependent. Both TCDC and TUDC were efficiently transported in BEC, as assessed by competitive uptake experiments. However, as compared with TCDC, TUDC induced significantly lower mucin secretion whereas there was no significant difference between TCDC- and TUDC-induced chloride efflux. Protein kinase C down-regulation caused a 70% reduction in TUDC-induced mucin secretion, but did not affect TCDC-induced secretion, which was mediated predominantly by Ca(2+)/calmodulin-dependent protein kinase II activation. These results provide evidence that bile acids may be transported mainly via ASBT in human gallbladder BEC and stimulate hydroelectrolytic and mucin secretion in these cells. Individual bile acids activate different signaling pathways leading to a different balance between mucin and chloride secretion. The differential effect of TUDC may cause a reduction in bile inspissation and provide a benefit in biliary disorders.

Safety and efficacy of dynamic graciloplasty for fecal incontinence: report of a prospective, multicenter trial. Dynamic Graciloplasty Therapy Study Group

PURPOSE

Dynamic graciloplasty has been used for intractable fecal incontinence, and good results have been reported. The aim of this study was to assess prospectively the safety and efficacy of dynamic graciloplasty for intractable fecal incontinence in a prospective, multicenter trial.

METHODS

A total of 123 adults were treated with dynamic graciloplasty at 20 institutions. Continence was assessed preoperatively and postoperatively by use of 14-day diaries.

RESULTS

There was one treatment-related death. One hundred eighty-nine adverse events occurred in 91 patients (74 percent). Forty-nine patients (40 percent) required one or more operations to treat complications. One hundred seventy (90 percent) events were resolved. Sixty-three percent of patients without pre-existing stomas recorded a 50 percent or greater decrease in incontinent events 12 months after dynamic graciloplasty, and an additional 11 percent experienced lesser degrees of improvement. Twenty-six percent were not improved, worsened, or exited. In patients with pre-existing stomas, 33 percent achieved successful outcomes at 12 months. This number increased to 60 percent at 18 months. Seventy-eight percent of patients had increased enema retention time, and mean anal canal pressures improved significantly at 12 months. Significant changes in quality of life were also observed.

CONCLUSIONS

Objective improvement can be demonstrated in the majority of patients with end-stage fecal incontinence treated with dynamic graciloplasty. Reduction in incontinence episodes can be correlated with improved quality of life. Adverse events are frequently encountered, but most resolve with treatment.

Management of postoperative peritonitis after anterior resection: experience from a referral intensive care unit

PURPOSE

Anastomotic leakage is the main cause of death after anterior resection. If it causes a single abscess, it may be successfully cured by percutaneous drainage, but in case of extensive peritoneal infection (multiple abscesses and generalized peritonitis), it is associated with a 40 to 60 percent mortality. This study aimed at evaluating aggressive, one-stage surgical management in such cases.

METHODS

All patients referred to our surgical intensive care unit during the past ten years with generalized, multilocular, intra-abdominal sepsis after anterior resection were reviewed. There were 32 patients, with a mean age of 65 years, among which 15 (47 percent) were referred from other institutions. The mean Acute Physiology and Chronic Health Evaluation II score on admission was 18. All patients underwent a laparotomy with complete peritoneal exploration, intraoperative lavage, fecal diversion, capillary drainage of the pelvis excluding the rectal stump or the leaking anastomosis from the peritoneal cavity, and primary closure of the abdomen. A Hartmann's operation was done in 22 cases, and conservation of the anastomosis with proximal colostomy was done in 10 cases. The choice was based on the size of the leak, the viability of the colon, and the site of the anastomosis.

RESULTS

Four patients died (12 percent), and five patients (16 percent) had recurrent sepsis. When the anastomosis had been conserved, restoration of continuity was achieved in all cases. After Hartmann's operation 8 patients of 19 survivors kept a permanent stoma; 7 had undergone a low anterior resection.

CONCLUSIONS

Extensive intra-abdominal infection after anterior resection may be efficiently controlled by a surgical approach combining peritoneal debridement, fecal diversion, and capillary drainage of the pelvis. Intestinal continuity may be restored after diversion stoma or Hartmann's procedure after high anterior resection. This is not the case after a Hartmann's operation after a low colorectal anastomosis, and this procedure should be avoided whenever possible.

Vegf, Vegf-B, Vegf-C and their receptors KDR, FLT-1 and FLT-4 during the neoplastic progression of human colonic mucosa

Because the crucial role of angiogenesis has been demonstrated in tumor growth and metastasis, the present study was undertaken to characterize the relative expression of vascular endothelial growth factors VEGF (vascular endothelial growth factor), VEGF-B, VEGF-C, and their receptors KDR (kinase insert domain-containing receptor), FLT-1 (fms-like tyrosine kinase), and FLT-4 in human colonic cancers, in relation to the Astler-Coller pathological classification, and to prognosis. VEGF and VEGF-B gene expression was quantified by Northern blot in 72 tumor samples matched with control tissues. VEGF gene expression was 1.4 times higher in adenocarcinomas than in control tissues (p = 0.02), but did not increase further between Astler-Coller tumor stages A and D, and did not correlate with disease recurrence for patients at stages B2 or C. In adenomas, VEGF mRNA levels were not significantly different from those in the paired control colonic mucosa. The expression pattern of VEGF isoforms, mainly identified by RT-PCR (reverse-transcriptase-coupled polymerase chain reaction) as VEGF121 and VEGF165 and to a lesser extent VEGF189, was comparable in tumor and control tissues. VEGF-B mRNA levels were unchanged during the neoplastic progression of colonic mucosa. In contrast to KDR and FLT-4, the expression of VEGF-C and FLT-1 genes increased in some pathological tissues. These results provide evidence that the early and sustained increase in VEGF transcripts and the expression of multiple angiogenic factors and receptors contribute to the development of colon cancer, and thus constitute a putative target for anti-angiogenic drug therapy.

Vegf, Vegf-B, Vegf-C and their receptors KDR, FLT-1 and FLT-4 during the neoplastic progression of human colonic mucosa

Because the crucial role of angiogenesis has been demonstrated in tumor growth and metastasis, the present study was undertaken to characterize the relative expression of vascular endothelial growth factors VEGF (vascular endothelial growth factor), VEGF-B, VEGF-C, and their receptors KDR (kinase insert domain-containing receptor), FLT-1 (fms-like tyrosine kinase), and FLT-4 in human colonic cancers, in relation to the Astler-Coller pathological classification, and to prognosis. VEGF and VEGF-B gene expression was quantified by Northern blot in 72 tumor samples matched with control tissues. VEGF gene expression was 1.4 times higher in adenocarcinomas than in control tissues (p = 0.02), but did not increase further between Astler-Coller tumor stages A and D, and did not correlate with disease recurrence for patients at stages B2 or C. In adenomas, VEGF mRNA levels were not significantly different from those in the paired control colonic mucosa. The expression pattern of VEGF isoforms, mainly identified by RT-PCR (reverse-transcriptase-coupled polymerase chain reaction) as VEGF121 and VEGF165 and to a lesser extent VEGF189, was comparable in tumor and control tissues. VEGF-B mRNA levels were unchanged during the neoplastic progression of colonic mucosa. In contrast to KDR and FLT-4, the expression of VEGF-C and FLT-1 genes increased in some pathological tissues. These results provide evidence that the early and sustained increase in VEGF transcripts and the expression of multiple angiogenic factors and receptors contribute to the development of colon cancer, and thus constitute a putative target for anti-angiogenic drug therapy.

Management and long-term results of surgery for localized gastric lymphomas

BACKGROUND

High- and low-grade gastric lymphomas (GL) differ in their behavior and chemosensitivity. Surgery has to be reevaluated according to the histologic grade of malignancy. We aimed to assess the place of surgery in the management of GL and its results after long-term follow-up.

METHODS

Among 54 patients with primary GL prospectively enrolled from 1984 to 1990, 45 with localized disease were studied. Primary resection was done whenever safe. All patients received chemotherapy adapted to the grade of malignancy and/or to the completeness of the resection.

RESULTS

Among 18 low- and 27 high-grade GL, 35 patients had primary resections; of those, 23 were complete. The complete response rate for all patients with low- and high-grade GL was 67% and 89%, respectively. After a median follow-up of 8 years, the disease-free survival rates for low-grade GL and high-grade GL were 94% and 89%, respectively. It was better after complete resection.

CONCLUSION

Complete resection is a major determinant of prolonged complete remission.

Combined radiotherapy and chemotherapy (cisplatin and 5-fluorouracil) as palliative treatment for localized unresectable or adjuvant treatment for resected pancreatic adenocarcinoma: results of a feasibility study

PURPOSE

To evaluate a cisplatin-containing chemoradiotherapy (CRT) regimen followed by chemotherapy for unresectable (locally advanced group, n = 32) and resected (adjuvant group, n = 10) pancreatic adenocarcinoma. The quality of palliation and percentage of secondary resections were also studied for unresectable disease.

METHODS AND MATERIALS

The protocol comprised CRT (45 Gy over 5 weeks), combined with 5-fluorouracil and cisplatin during the first and fifth weeks, followed, 3 weeks later, by 4 cycles of the same chemotherapy plus leucovorin.

RESULTS

All patients completed CRT but only 50% of each group finished the entire protocol. Gastrointestinal toxicity and weight loss were the major side effects during CRT. Enhanced hematological toxicity limited the post-CRT chemotherapy. For the locally advanced group, median survival was 9 months; 1- and 2-year survival rates were 31 and 12. 5%, respectively. The overall response rate was 16% and 50% had stable disease. A lasting palliative effect defined as improved performance status and decreased analgesic consumption, was recorded for 43% of the patients. Only three secondary resections have been performed. For the adjuvant group, median survival was 17 months.

CONCLUSIONS

Although toxic in advanced disease, this regimen significantly lowered pain and analgesic consumption, but had poor impact on secondary resectability. In an adjuvant setting, although equally toxic, this series was too small to allow conclusions to be drawn.

Results of coloanal anastomosis for rectal cancer

It is now accepted that, in the absence of direct invasion of the anal sphincter, cancers of the middle and lower rectum can be successfully treated with sphincter-preserving surgery. Conservation of the sphincter mechanism should never compromise the oncologic outcome of surgery and the method of neorectum construction must provide acceptable function for patients. This review describes the results of coloanal anastomosis following rectal excision. The oncological and functional results of both straight coloanal and colonic-J-pouch anal anastomosis are presented in detail. The authors discuss recent evidence supporting the functional superiority of colonic-J-pouch reconstruction after rectal excision.

Possible first report of distant peritoneal metastases from a nodal mesenteric lymphoma after laparoscopic inguinal hernia repair

Laparoscopic surgery has gained wide acceptance. However, there is still debate as to its role in assessment and staging of gastrointestinal malignancies(1)since it may promote dissemination of cancer cells.(2)We report the first case of a low-grade mesenteric nodal lymphoma for laparoscopic hernia repair, complicated by distant implants both on the peritoneum and wall mesh.

Rectal excision and colonic pouch-anal anastomosis for rectal cancer: oncologic results at five years

PURPOSE

Preservation of the anal sphincter is now accepted as a primary aim in surgical treatment of rectal cancer. The use of colonic J-pouch-anal anastomosis after complete rectal excision is one method that permits retention of continence without compromising oncologic principles. This study aimed to assess carcinologic results of rectal excision followed by colonic J-pouch anal anastomosis, with particular reference to rate of locoregional recurrence.

METHOD

From 1984 to 1990 complete rectal excision and colonic pouch-anal anastomosis were performed in 167 patients for cancer of the middle or low rectum. A total of 154 patients were followed for this study for a minimum of five years, with evaluation of the frequency of locoregional recurrence.

RESULTS

Sixty-five patients died during the period of surveillance, giving a five-year survival rate of 68.8 percent. Twenty patients (13 percent) presented with locoregional recurrence at an average of 31 months after surgery. In 11 cases (7 percent) the local recurrence was not associated with metastatic disease, and six of these patients underwent further curative surgery.

CONCLUSIONS

These results confirm that coloanal anastomosis after complete rectal excision is a valuable option in the surgical treatment of rectal cancer and is accompanied by a frequency of isolated locoregional recurrence of less than 7 percent, of which half underwent surgical resection with curative intent.

Restorative proctocolectomy for distal ulcerative colitis

BACKGROUND

Chronic distal colitis may cause troublesome symptoms and alter quality of life. When medical treatment fails to control symptoms, patients and doctors are often reluctant to consider surgical resection because of the relatively small portion of the large bowel affected by the disease.

AIM

To assess the outcome of restorative proctocolectomy (RP) in patients with distal colitis who required surgery for chronic debilitating symptoms and failed medical management.

PATIENTS/METHODS

From 1986 to 1996, of 263 patients receiving RP for ulcerative colitis, 27 (16 men) were operated on for distal ulcerative colitis limited to the rectum and sigmoid colon. Bowel function and quality of life were compared before and one year after RP.

RESULTS

The mean (SD) duration of ulcerative colitis was 11 (6) years. RP was performed at a mean age of 46 (10) years. All the pouches were J-shaped, and a diverting loop ileostomy was always performed. Mean (SD) hospital stay was 25 (10) days. Seven complications occurred in six patients. Previously unknown severe dysplasia was discovered on the colectomy specimen in two patients. After RP there was a significant decrease in mean (SD) daytime stool frequency (8.2 (4) v 4.7 (2), p<0.05), night-time stool frequency (2 (2) v 1 (1), p = 0.05), and the number of patients with urgency to defecate (26/27 v 1/27, p<0.001). Sex life was improved in eight patients, social life in 26, and professional life in eight. Twenty six patients were satisfied with the results, and 25 wished that they had received surgery earlier in the course of their disease.

CONCLUSION

RP can improve bowel function and quality of life in patients with disabling chronic symptoms of distal ulcerative colitis.