John J. Stasik

Endorectal repair of rectocele

A modification of Sullivans procedure for endorectal repair of “low” rectocele was completed in 59 patients with local anesthesia. Associated anorectal pathology was corrected in all patients. The technique is described. At follow-up, the results were as follows: 37 excellent (62.7 per cent), 10 good (16.9 per cent), eight fair (13.6 per cent), and four poor (6.7 per cent).

Management of anorectal horseshoe abscess and fistula.

Over a 10-year period 69 patients were treated consecutively for posterior and anterior horseshoe abscesses and fistulas. Fifty-nine patients had posterior and ten had anterior abscesses or fistulas. There were 52 patients with acute abscess. Treatment consisted of incision and drainage, incision and drainage with primary fistulotomy, incision and drainage with primary fistulotomy and counter-drainage, and incision and drainage with insertion of seton. Seventeen patients with chronic fistulas were treated by primary fistulotomy with curettage, or incision and drainage with insertion of seton. Patients were followed from three months to ten years with a mean follow-up of three years. No incidences of incontinence were reported in this series. The overall rate of recurrence was 18 percent, and included only patients with posterior abscesses and fistulas. Recurrence was related to the failure to maintain prolonged drainage in the midline after primary fistulotomy. The use of seton for delayed fistulotomy appears to promote wound drainage and precludes premature wound closure. More liberal use of the seton in the treatment of horseshoe abscesses and fistulas is advocated.

Metronidazole vs. erythromycin, neomycin, and cefazolin in prophylaxis for colonic surgery.

A prospective, double-blind, randomized study was undertaken to compare perioperative parenteral metronidazole and erythromycin. One neomycin, and cefazolinhundred fifty-five patients were randomized into two groups by the pharmacy department. The resulting difference between the overall septic complication rate in patients receiving erythromycin, neomycin, and cefazolin (10.9 percent) and the rate in patients receiving metronidazole alone (31.9 percent) was significant. This indicates that an antibiotic to cover aerobic bacteria should be added to the regimen when metronidazole is used.

Transanal endoscopic microsurgery for excision of rectal lesions: technique and initial results.

The aim of this study was to review experience with transanal endoscopic microsurgery (TEM) and to assess its applicability to an existing practice of colorectal surgeons. Patients undergoing TEM excision of rectal lesions from March 1997 through May 1999 were selected for this study. Medical records were reviewed retrospectively to obtain pertinent data, including indications for TEM, tumor size, distance from anal verge, duration of operation, completeness of tumor resection, postoperative complications, duration of stay and follow-up, and recurrence. Thirty-one patients underwent TEM during the 2-year period. Indications for TEM included benign disease in eight patients and cancer in 23 patients. Mean distance of the tumor from the anal verge was 8.3 cm. Mean size of the lesion was 2.8 cm, and mean specimen size was 4.5 cm. Larger specimen sizes allowed for tumors to be removed with negative margins (97%) in all cases but one. Mean duration of operation was 140 minutes (including set-up time), and mean duration of hospital stay was 1.2 days. Major postoperative complications occurred in one patient. Mean duration of follow-up was 15 months, and recurrence developed in two patients during this period. Transanal endoscopic microsurgery excision of rectal lesions with negative margins was possible in 97% of cases with minimal morbidity and a short-duration hospital stay. Follow-up was too brief to evaluate recurrence, but the thoroughness of resection of tumor in a high proportion of cases is promising.

Endoscopic retrieval of foreign bodies from the rectum

A technique is described and illustrated by case reports wherein removal of foreign bodies of the rectum is simplified by using the flexible sigmoidscope. Evidence from the literature indicates that delayed perforation is rare in this situation, and that outpatient management would suffice for most patients.

The Bacon pull-through procedure

Twenty-eight patients who underwent the Bacon pull-through procedure for carcinoma of the midrectum were reviewed retrospectively. The results were comparable to low anterior resection and abdominoperineal resection. Although the indications are limited, it is a viable option in a highly selected group of patients.

WDHA syndrome caused by pheochromocytoma: report of a case.

SummaryA case in which a pheochromocytoma secreted vasoactive intestinal peptide, causing WDHA syndrome, is reported. The patient, a 43-year-old woman, was seen because of intractable watery diarrhea, hypokalemia and weight loss. She was found to have a mass in the right adrenal area. Preoperatively, vasoactive intestinal peptide levels were elevated, and the diagnosis of WDHA syndrome was entertained. Exploratory laparotomy revealed a tumor of the right adrenal gland, measuring 15×15 cm, which was resected. Histologic examination revealed it to be a pheochromocytoma. Postoperatively, vasoactive intestinal peptide returned to normal. The patient had complete remission of symptoms, and has remained well since.

Rationale for medical or surgical therapy in anal incontinence

Seventy patients with anal incontinence referred to a colorectal service over a two-year period were evaluated and treated. In each case, a comprehensive history and physical examination as well as anal manometry were performed. Anorectal angle measurement was done when indicated. Patients were separated into groups of the four major causes of incotinence: 1) external/internal sphincter dysfunction, 2) puborectalis and anorectal angle, 3) alterations in rectal compliance, and 4) sensory deficits. Treatment was dictated by categorization of the patients. All patients were followed for a minimum of one year and, with the exception of patients with profound sensory loss, each believed that their symptoms had decreased substantially, enabling them to return to normal occupational and social activities.

A prospective study of continuous hepatic perfusion with implantable pump

The delivery of chemotherapy through the implantable hepatic infusion pump in the management of patients with hepatic metastases secondary to carcinoma of the colon and rectum is evaluated in this preliminary prospective study. Patients were selected according to hepatic lobar distribution and magnitude, age, and general systemic evaluation. Infusion pumps were implanted in a total of 14 patients who were judged to be unsuitable for hepatic resection. After pump implantation all patients were alive and well and receiving regional perfusion chemotherapy. For the nine patients in this study who have been monitored for a full six months, the median decrease in CEA levels was 49 percent. On computerized axial tomography (CT) and/or liver-spleen scan, five patients showed greater than 50 percent reduction in tumor size. All patients have demonstrated minimal systemic toxicity and have maintained a good quality of life. The results encourage further evaluation of perfusion chemotherapy.

Clinical and manometric evaluation of continence after the Bacon two-stage pull-through procedure

Twenty-eight patients who underwent the Bacon pull-through operation were evaluated for continence by clinical and radiologic means. Six patients were available for anal manometry. Eighty-three percent of those patients followed for function did not have the sensation to defecate spontaneously. They had normal functioning of the external sphincter, failure of reflex inhibition of the internal sphincter, and decreased rectal compliance secondary to fibrosis of the presacral space. These factors created a distal high-pressure zone which, when combined with sensory loss due to transection of the levators, rendered the patient continent but without the ability to defecate spontaneously unless an enema was administered.