John M. MacKeigan

Transanal excision of large, rectal villous adenomas.

The purpose of this study is to demonstrate that a transanal excisional approach can be successfully used in most cases of large, benign, rectal villous adenomas with acceptable rates of recurrence and complications in comparison with historic controls. A retrospective review of all cases of benign, large, rectal villous adenomas at this institution from 1975 to 1985 was performed. A total of 122 patients had large, benign, rectal villous adenomas excised. All except five were treated by transanal excision. Thirty-eight percent of lesions were more proximal than 8 cm from the anal verge. The average follow-up was 55 months. Twenty-seven percent of patients were treated for residual disease after a known incomplete initial treatment or an adenoma at the same location within 6 months of the original treatment. Thirty percent of patients were treated for recurrent adenoma 6 months after complete initial treatment. Two patients (1.7 percent) with recurrences were found to have invasive carcinoma. Both patients had excisional therapy, and one had additional radiation therapy for these carcinomas. Ten postoperative hemorrhages and two perforations occurred as symptomatic or serious complications. This renders a 10 percent complication rate for the study group, which is lower than reported by others using the Kraske or transsphincteric approach to the rectum. Because of the expected higher recurrence rate, regular follow-up is necessary for this type of therapy. In conclusion, this study demonstrated that transanal excision of large, benign, rectal villous adenomas can be a safe and effective method of treatment.

Pudendal nerve latency. Does it predict outcome of anal sphincter repair

PURPOSE: Electrophysiologic evaluation has been suggested as a means of identifying prognostic factors for patients with fecal incontinence who undergo anal sphincter repair. The purpose of this study was to evaluate the results of anal sphincter repair in patients with documented pudendal neuropathy and to determine the usefulness of electrophysiologic studies for prognostication of sphincteroplasty. METHODS: A retrospective review of a series of patients undergoing electrophysiologic studies and anterior anal sphincteroplasty was performed. Data collected included age, standardized incontinence scores (preoperative, immediately postoperative, and current follow-up), and results of pudendal nerve terminal motor latency and monopolar electromyography. Outcomes of sphincteroplasty were designated as excellent, good, fair, or poor based on incontinence scores. Prolonged pudendal nerve terminal motor latency was defined as longer than 2.2 ms and evaluated as unilateral or bilateral. RESULTS: During the time period of the study (1991–1996), 15 patients had electrophysiologic studies and underwent sphincteroplasty. Twelve patients (80 percent) were available for follow-up and form the basis for this study. All patients were women, with a mean age of 45±18.6 (27–75) years and a mean follow-up of 49.7±18.6 (20.4–72.6) months. Mean duration of incontinence preoperatively was 13±16.1 (range, 1–58) years. The incontinence score was 15.8±3.5 preoperatively, 5.4±4.5 postoperatively, and 5±5.1 currently for all 12 patients. There was one patient with normal pudendal nerve terminal motor latency. In the four patients with bilateral prolonged pudendal nerve terminal motor latency, the incontinence scores were 15±4.2 preoperatively, 8.5±5.3 postoperatively, and 6±6.1 (statistically significant compared with preoperation) currently. Seven patients were found to have unilateral prolonged pudendal nerve terminal motor latency with incontinence scores of 16.3±3.5 preoperatively, 4.4±3.2 (statistically significant compared with preoperation) postoperatively, and 5.1±4.9 (statistically significant compared with preoperation) currently. Based on incontinence scores, results of the sphincteroplasty at the most current follow-up were as follows: no neuropathy, excellent in one patient; unilateral neuropathy, five with good/excellent results, two with fair/poor results; bilateral neuropathy, two with good/excellent results, two with fair/poor results (P>0.05 bilateralvs. unilateral). By monopolar electromyographic examination, external anal sphincter denervation was noted in 11 patients; their incontinence scores were 15.5±3.5 preoperatively, 5.9±4.3 (statistically significant compared with preoperation) postoperatively, and 5.5±5.0 (statistically significant compared with preoperation) currently. Monopolar electromyographic results in the puborectalis included four normal examinations and six that were unobtainable. In the two patients with puborectalis denervation, the incontinence scores were 19.5±0.7 preoperatively, 8.5±4.9 postoperatively, and 2.5±3.5 (statistically significant compared with preoperation) currently. CONCLUSIONS: Anterior anal sphincteroplasty in patients with unilateral or bilateral prolonged pudendal nerve terminal motor latency can provide significant improvement in continence with minimum morbidity. Therefore, correction of the anatomic sphincter defect should still be considered, even in patients with documented pudendal neuropathy.

Short-chain fatty acid enemas: A cost-effective alternative in the treatment of nonspecific proctosigmoiditis

The purpose of this study was to perform a randomized, prospective comparison of corticosteroid enemas (CS-100 mg of hydrocortisone/60 ccP.R. q.b.s.;n=12), mesalamine enemas (5-ASA-4 g/60 ccP.R. q.h.s.;n =19), and short-chain fatty acid enemas (SCFA-60 ccP.R. b.i.d.;n = 14) for the treatment of proctosigmoiditis. Patients presenting to the Ferguson Clinic with the diagnosis of idiopathic proctosigmoiditis were evaluated for age, sex, prior history of proctitis, duration of symptoms prior to presentation, endoscopic scoring, and mucosal biopsies. Clinical evaluation was performed at two-week intervals for six weeks, with repeat biopsies taken at six weeks. There was no significant difference with respect to age, male/female ratio, past history of proctosigmoiditis, length of colorectum involved at the time of initial presentation, symptom resolution, and endoscopic and histologic improvement among the three treatment groups. Recovery occurred in a similar proportion in each of the three groups: CS, 10/12; 5-ASA, 17/19; and SCFA, 12/14. The cost of six weeks of treatment was: CS,

Treatment of advanced hemorrhoidal disease : a prospective, randomized comparison of cold scalpel vs. contact Nd:YAG laser

71.82; 5-ASA,

Prophylactic oophorectomy and colorectal cancer in premenopausal patients

347.28; and SCFA,

Surgical treatment of chronic anal fissure. A retrospective study of 1753 cases.

31.50. This study indicates that SCFA enemas are equally efficacious to CS or 5-ASA enemas for the treatment of proctosigmoiditis at a significant cost savings.

Superior nitrogen balance after laparoscopic-assisted colectomy

PURPOSE: Recently, laser technology has been advocated for the treatment of hemorrhoids. However, there has been little scientific evaluation of the use of the Nd:YAG laser for excisional treatment of hemorrhoidal disease. The purpose of this study was to perform a prospective randomized study of the Nd:YAG laservs.scalpel excision, when performing a standard Ferguson-closed hemorrhoidectomy. METHODS: Patients presenting for internal-external hemorrhoidectomy were eligible for study. Hemorrhoidectomies were performed under epidural or caudal blocks. The standard Ferguson closed hemorrhoidectomy technique was used. Data evaluated included: age, sex, estimated blood loss, operative time, postoperative pain scores, postoperative analgesic use, wound healing, and time for return to work. Eighty-six patients were eligible for study (laser, N=51; scalpel, N=35). RESULTS: There were no significant differences between the groups, except for a greater degree of wound inflammation and dehiscence at the 10 day postoperative visit for the laser group (laser, 1.7±.2; scalpel, 0.8±.2;P<0.05,t-test). The use of the Nd:YAG laser added

Colonic endoscopy in perspective.

480 per case; as a result, the treatment cost for the laser group was

Anorectal and colonic disease and the immunocompromised host.

15,360 higher than that of the conventional group. CONCLUSION: The results indicate that there are no patient care advantages associated with the use of the Nd:YAG laser for excisional hemorrhoidectomy compared with scalpel excision. As new technology becomes available, surgeons must rigorously assess therapeutic efficacy and cost-benefit ratio before deciding to employ this technology for patient care.

Lymphocyte blastogenic responses to allogeneic leukocytes and autochthonous tumor cells in colorectal carcinoma.

ConclusionSince 1960, 162 patients with colorectal carcinoma have undergone oophorectomy at the Ferguson Clinic; 137 of these patients were operated on from 1969 to 1976 and were reviewed.Six of 12 patients developing metastasis to the ovaries were premenopausal. In review of the overall experience with premenopausal patients, metastasis to the ovaries developed in 22 to 25 per cent of patients. This is significantly higher than the usual overall rates of metastasis which are reported to occur with a frequency of 3 to 8 per cent.The survival rate of prophylactic oophorectomy for microscopic metastasis to ovaries and the high rate of metastasis in premenopausal patients, warrants prophylactic oophorectomy in all patientsregardless of age. Oophorectomy in patients with colorectal cancer can no longer be considered prophylactic, but therapeutic.