Richard J. Strauss

Bowen's disease of the anal and perianal area: A report and analysis of twelve cases

Retrospective evaluation of twelve patients treated at the Cleveland Clinic for perianal Bowens disease showed that these patients can be cured by wide local excision with skin grafting when necessary. No recurrence or metastasis was found during the follow-up period when the systematic technic was used. Only involved anal mucosa was removed, and normal mucosa was preserved; this aids in controlling anal continence. The margins of the resected skin must be subjected to frozen section study to be sure that total excision has been achieved. In this study a diagnosis of perianal Bowens disease was made incidentally in six of the twelve patients during histologic examination of anorectal tissue removed for other reasons. Seven of the twelve either had had a systemic or cutaneous cancer previously or another systemic or cutaneous cancer subsequently developed, indicating the high association between Bowens disease and other cancers. Therefore, it is important that all excised skin from anal or perianal operations be submitted for histologic examination, and if the diagnosis is Bowens disease, the lesion must be completely removed using wide local excision. These patients should be evaluated and followed up because other malignancies may be present or evolve at a later time.

The surgical management of toxic dilatation of the colon: a report of 28 cases and review of the literature.

Experience with 28 patients with toxic dilatation of the colon is reviewed. The operative mortality in this series was 32% (9/28). Eight of the 9 patients who died were found to have colonic perforations at operation; in contrast, the group of patients with no perforations had a mortality rate of only 6%. Colonic perforation and sepsis were the most significant factors contributing to mortality and morbidity in this series. A review of the literature showed an overall operative mortality rate of 19.5% for patients with toxic megacolon; the mortality rate was 41% for patients with perforations and 8.8% for patients without perforations. It appears that the keystone to successful management is the avoidance of colonic perforation and sepsis; protracted medical management of toxic megacolon seems to have been at least partly responsible for these complications. Sixteen of the 18 survivors following subtotal colectomy required removal of the rectum within 9 months because of continued symptoms and disease in the rectal stump.

Surgical treatment of rectal carcinoma: results of anterior resection vs. abdominoperineal resection at a community hospital.

ONE OF THE MOST CRITICAL problems facing the abdomina l surgeon is the choice between anter ior resection (AR) and abdominoper inea l resection (APR) for carcinoma of the upper rectum. Preservation o f intestinal cont inui ty would be ideal if the chance for cure were not jeopardized. For carcinomas in the area o f the rectum below 7 cm, few surgeons would argue against abdominoper inea l resection. It is the area between 7 and 13 cm that is controversial. T h e purpose of this paper is twofold: first, we comp a r e d the resul ts o f a n t e r i o r resec t ion and abdominoper inea l resection obta ined at various major university centers and a t tempted to identify important differences between the two operations, such as differences in result ing morbidity, mortality, recurrence, and survival rates. Our aim was to answer the question whether anter ior resection is the equal o f a b d o m i n o p e r i n e a l r e sec t ion as an o p e r a t i o n for cancer cure. Second, the results in 86 patients who underwen t e i ther type o f resection for rectal cancer at the Long Island Jewish Hospital dur ing a six-year period f rom 1964 to 1969 are presented, to compare results when rectal carcinoma was t reated at a community hospital as opposed to the major university centers.

Gangrene of the stomach: A case of acute necrotizing gastritis

Of the several causes of gastric necrosis, the rarest is acute necrotizing gastritis which appears to be a variant of phlegmonous gastritis. In acute necrotizing gastritis all four major gastric vessels are patent, but gastric gangrene occurs secondary to an over-whelming necrobiotic infection. The case presented herein is of unusual interest because it appears to be only the third reported case of acute necrotizing gastritis with overt gangrene of the stomach. Review of the literature on suppurative gastritis emphasizes the rarity and high morbidity of acute necrotizing gastritis; the patient reported on in this study, however, survived after subtotal gastrectomy and antibiotic therapy. It is our opinion that debridement by gastrectomy must be performed in those patients with transmural, diffusely infected, nonviable gastric tissue.

Repeat colonoscopy after endoscopic polypectomy.

The records of all patients undergoing endoscopic polypectomy between December 1979 and December 1982 were reviewed. One hundred seventy-two patients underwent colonoscopic polypectomy in the absence of carcinoma or inflammatory bowel disease. Of these, the polyp could not be retrieved in 4, and 19 were lost to follow-up. One hundred forty-nine patients underwent subsequent endoscopy from one to four years after the initial polypectomy. Seventy-five (50.3 percent) of the patients developed new polyps. Although 61 of the 75 patients with new polyps were identified in the first two years, new polyps were noted throughout all four years. The presence of multiple polyps on the initial examination was statistically significant in predicting new polyps. The age and sex of the patients, size of the polyps, and the presence of atypia did not identify patients at higher risk for new polyps. The data indicate that new polyps are more likely to develop in patients who had a previous, polyp. It would appear that annual examinations should be performed until two successive examinations are negative. Following a second negative examination, reexamination at two- or three-year intervals, unless symptomatic, would appear to be adequate.

Prevention of stress ulcerations using H2 receptor antagonists

Abstract Cimetidine, an H 2 receptor antagonist, was instilled transorally into the stomachs of several groups of rats prior to a period of stress in order to study its possible prophylactic effect upon the formation of stress ulcers and its effect on gastric mucosal membrane potentials and pH. Each group consisted of seven rats. The control group (group I) was given 0.5 ml of saline every 6 hours for three days and then was stressed using a combination of restraint and cold. After the animals were sacrificed, the mean number of gastric ulcers was 7.3 and the pH of the gastric fluid was 1.3. These results were compared with the results obtained in five experimental groups of rats pretreated for varying amounts of time with cimetidine (5 mg/100 g) given every 6 hours. Group II had only two doses of cimetidine, which were then followed by a period of stress. Groups III, IV, V, and VI were pretreated with cimetidine for one, two, three, and four days, respectively, prior to stress. A statistically significant decrease in ulcers was present in those groups receiving cimetidine pretreatment for at least two days. Three additional groups were then studied to investigate the transmucosal membrane potentials of stressed rats with and without cimetidine and in a group of unstressed controls. The mean membrane potentials with and without cimetidine were −29 mv and −9 mv, respectively (p

Telescoping anastomosis of the colon: a comparative study.

SummaryThe incidence of large-intestinal anastomotic leaks remains unacceptably high. For this reason, we studied the resistance to dehiscence of a telescoping type of anastomosis and compared it with the conventional one-layer, two-layer, and stapled anastomoses in a canine model. These experiments demonstrated that the telescoping anastomosis provided a more resistant suture line during the early postoperative phase and did not cause encroachment of the lumen by the diaphragm, which was consistently produced when an inverting suture line was used. Three days postoperatively the mean bursting pressures of the one-layer, two-layer, and stapled anastomoses were 31±12, 120±46, and 52±21 mm Hg, respectively. The telescoping anastomosis had a mean bursting pressure of 210±44 mm Hg, which was significantly (P<0.01) higher than those of all the other anastomoses tested. However, seven and 14 days after opertion, there was no statistically significant difference among the bursting pressures of the various anastomoses. When the different types of anastomoses were examined histologically, it was found that there was considerably more suture-line inflammation, edema, micro-abscess formation, mucosal ulceration and pericolic inflammation of the fat in the one-layer, two-layer, and stapled anastomoses than in the telescoping anastomosis.

Hemangiopericytoma of the colon

A patient with a hemangiopericytoma of the colon is discussed. This is the second such case reported in the English medical literature. Soon after discovery of the tumor, the patient presented with a colonic intussusception with the tumor serving as the lead point. This was reduced by a hypaque enema, but the intussusception recurred twice more, being reduced again by hypaque enema and finally having to be reduced by colonoscopy. At surgery a left hemicolectomy with primary anastomosis was performed. The microscopic, ultrastructural, and pathologic aspects of hemangiopericytoma are discussed with special attention to lesions of the gastrointestinal tract.

Ileorectal anastomosis for inflammatory disease of the colon.

SummaryWe have reported long-term results in the cases of 42 patients following total colectomy and ileorectal anastomosis for inflammatory bowel disease. In this group, 35 patients had Crohns disease and seven had ulcerative colitis. Five of those seven patients with ulcerative colitis had carcinoma of the colon at the time of colectomy. A diverting loop ileostomy was constructed in 14 of the 35 patients who had Crohns colitis at the time of operation, and none of these patients had any anastomotic leakage either before or after the ileostomy was closed. However, there were three patients with Crohns colitis in whom anastomotic leaks developed postoperatively; all three patients died. In the group with ulcerative colitis, one patient had an anastomotic leak but there was no operative mortality. Of the 29 patients with Crohns disease followed for one to 18 years, 12 (41 per cent) developed recurrences in the ileum and/or rectum, and seven of these patients had to have their anastomoses taken down.