S. Arthur Localio

Abdominosacral Approach for Retrorectal Tumors

The relative rarity and anatomical position of retrorectal tumors may lead to difficulty in diagnosis and surgical treatment. The clinical features and management of 20 such tumors (chordoma 8, neurilemmoma 3, teratoma 3, hemangiopericytoma 1, chondrosarcoma 1, osteosarcoma 1, dermoid 1, lipoma 1, and undifferentiated sarcoma 1) have therefore been reviewed. Low back or sacral pain was present in 18 patients and, although all tumors were palpable on rectal examination, pain had been present for a median of 12 months before diagnosis. Mean tumor size was 9.4 cm (range: 2.5–17 cm). Sacral bone destruction was demonstrated radiographically in all chordomas and three sarcomas, but in none of the benign tumors. Three patients had undergone previous partial removal of their tumors. Surgical resection was carried out using a combined abdominal and transsacral approach in 13, a transsacral approach in the right lateral position in four and transabdominally in three. There was one operative death following secondary operation for chordoma. Four of 12 patients with malignant tumors arc alive and well at seven months to eight years. One died of a myocardial infarct without recurrence at 11 years. For small benign tumors, the right lateral position permits maximal flexibility for resection either by the transsacral, transabdominal or a combined approach. For bulky or malignant tumors, a combined abdominal transsacral approach in the right lateral position permits vascular control and provides good exposure for protection of vital structures and wide resection.

Resection of the perforated segment: A significant advance in treatment of diverticulitis with free perforation or abscess☆☆☆

As a result of improved medical management of chronic diverticular disease, perforation has become the most common indication for surgical intervention. During the past five years sixty-three patients underwent operation for colonic diverticular disease, of which forty-six were for perforation (generalized peritonitis in 8, abscess in 30, and fistula in 8). The eight patients with generalized peritonitis underwent emergency exploration for spreading peritoneal signs and were managed by resection of the perforated segment, end colostomy, and mucous fistula or Hartmanns pouch. Treatment of thirty-eight patients with abscess or fistula has also stressed primary resection of the perforated segment of colon. Resection and end colostomy without anastomosis was performed in three. Primary anastomosis with proximal diverting colostomy was performed in four. Primary anastomosis alone was done in thirty-one patients. There were no deaths. These results support primary resection of the involved colon with immediate or delayed anastomosis in the operative management of perforated diverticular disease.

Abdominosacral resection for carcinoma of the midrectum: ten years experience.

Abdominosacral resection allows curative resection of midrectal cancer with excellent preservation of sphincter function. In the last ten years 427 patients underwent resection for rectal carcinoma at University Hospital by one surgeon. (SAL) The operation, selected by preoperative sigmoidoscopic measurement, was anterior resection (AR) in 239, abdominosacral resection (ASR) in 100, and abdominoperineal resection (APR) in 88. Operative mortality was 1.7% for AR, 2% for ASR and 2.3% for APR. All patients were completely continent of stool and flatus after AR and ASR. Follow-up is complete in 194 of 195 patients treated five to ten years ago. Five year survival for curative resection (no distant metastases) was 67.3% after AR (66/98), 58.3% after ASR (21/36), and 50% after APR (15/30). For patients without tumor in lymph nodes, survival rates were 78.3% for AR, 64.3% for ASR and 63.2% for APR. With involvement of regional nodes, survival fell to 41.4% for AR, 37.5% for ASR and 27.3% for APR. For lesions at 5-8.5 cm, five year survival was 61.1% for ASR and 58.3% for APR. No statistical difference in survival time was noted when patients were matched for age, sex, level of lesion and extent of spread. Pelvic recurrences were detected in 16.7% after ASR, 15.3% after AR and 33.3% after APR. All of the pelvic recurrences after ASR and the majority of those after AR and APR occurred in patients with tumor invasion of perirectal fat. These data strongly support the applicability of ASR as an important advance in the treatment of midrectal cancer. Although technically demanding, ASR has permitted preservation of anal continence without sacrifice of long-term cure in approximately 50% of patients who would otherwise have required APR.

Management of diverticulitis of the ascending colon. 10 years' experience.

Diverticulitis of the ascending colon is an uncommon disease which mimics appendicitis. The correct diagnosis is rarely made, but can be suggested by the patterns of signs and symptoms and confirmed by barium contrast study. Diverticulitis of the ascending colon should be treated by the same plan as diverticulitis of the left colon. If the diagnosis is established, nonoperative management is indicated initially. Operation is indicated when the diagnosis is in doubt, when perforation has occurred, or when the patient does not respond to nonoperative treatment. At operation, ascending colon diverticulitis can be recognized as an inflammatory mass involving the wall and mesentery of the colon. The inflammatory mass is best treated by resection with primary anastomosis of the ileum to the ascending or transverse colon in an area removed from the site of infection.

Simultaneous abdominotranssacral resection and anastomosis for midrectal cancer

Abstract Clinical and pathologic study of rectal carcinoma at a level of 6 to 12 cm. from the anal verge indicates that in selected patients these tumors may safely be removed by a combined abdominotranssacral operation. Such a simultaneous procedure is described with reconstruction of the intestinal tract by direct suture and anastomosis. Fifteen cases are reported. All patients survived the operation and have satisfactory bowel function and control. It is emphasized that the use of this procedure at the present time is considered experimental and highly selective, and no long-term studies are yet available.

Malignant tumors of the rectum

Summary The aim of surgery in the treatment of malignancies of the rectum is eradication of disease and restoration of the patient to a useful place in society. That this goal is not always achieved is demonstrated by the generally recognized over-all 5-year survival of no more than 45%. Improvement in cure rate rests largely upon early detection of localized disease and new modalities for treatment of disseminated disease, but it is essential to emphasize that an appreciation of current knowledge of anatomy, pathology and physiology and the application of current methods of surgery and rehabilitation will achieve maximum benefit for each patient. Abdominoperineal resection and anterior resection are well-established methods of treatment of carcinoma of the rectum. Study of the spread of cancer and the increasing experience with sphincter-saving operations indicate that sacrifice of the anus is not always essential for the cure of rectal cancer. Our recent experience in treatment of carcinoma of the rectum by abdominosacral, abdominoperineal and anterior resection has been reported. 65 Data on sex, age and associated risk and operative motality for this group of 229 patients, treated by one surgeon (SAL), in a 6-year period are summarized in Table 1. The preponderance of males in the abdominoperineal group is not surprising since selection was based on level of lesion, and the wider female pelvis allows sphincter-saving procedures at a lower level. The three groups were otherwise comparable. The status of patients in this series in whom operation was considered curative is recorded in Table 2. A follow-up of up to 8 years shows that survival following abdominosacral resection compares favorably with abdominoperineal and anterior resection. Death from recurrence is correlated, with stage of disease, not with level of lesion. Sphincter function following low anterior resection is essentially normal. Patients are continent of stool and flatus but, as alluded to in the section on continence, they initially experience a period of frequent small bowel movements due to loss of reservoir function. It is gratifying to note that functional results following abdominosacral resection differ only in degree from those observed following standard anterior resection. All patients were continent of stool and flatus from the outset and, after a somewhat longer period, some 12 weeks, of aberrant reservoir continence, all regained satisfactory function. This process of adaptation is facilitated by early institution of a diet high in fiber content and moisture, and encouragement of the patient to suppress the frequent urge to defecate. Patients in this series undergoing abdominosacral resection would under other circumstances have had abdominoperineal resection. A colostomy, even well constructed, properly managed and accepted by the patient, is at best a poor substitute for a functioning anal sphincter. Patients undergoing abdominoperineal resection with permanent sigmoid colostomy are visited by the enterostomal therapist preoperatively. Instruction in colostomy irrigation and management of colostomy appliances begins as soon as intestinal function returns. At discharge on the 14th to 21st postoperative day, patients are confident in colostomy care, and rehabilitation may be continued on an outpatient basis. In 2–3 months 75% of patients achieve sufficient reservoir continence and regularity to spend the day without a colostomy appliance. Unless a patient is moribund from metastatic disease or has serious contraindications to operation due to severe intercurrent illness, an attempt at removal of the lesion should be made in every case. Little can be done to alleviate the suffering due to pain, tenesmus, infection and discharge of blood and mucus from an unresected rectal cancer. Indeed, the apparently inoperable growth may appear fixed because of its bulk rather than by invasion, and the surgical effort is then rewarded by effective palliation or cure.

Effect of stress upon the healing of wounds in rats.

Summary 1. A variety of situations, calculated to provide a chronic “stress” stimulus, have been studied in order to determine the effect of stress upon the bursting pressure of standard laparotomy wounds in rats. 2. With the exception of mild stress (skin incisions, single turpentine injection), in each case a depression of the bursting pressure of fifth day laparotomy wounds was observed. This was accompanied by increases in the weight of the adrenal glands at autopsy. 3. The duration of this period of stress-induced depression of healing appeared to vary with the magnitude and the nature of the stress stimulus.

Effect of Adrenalectomy on Wound Healing in Normal and in Stressed Rats.

Summary 1. The bursting pressures of healing laparotomy wounds, made 15 days after bilateral adrenalectomy were equal to or superior to those of normal control rats. 2. In adrenalectomized rats, maintained on a small fixed dosage of aqueous adrenal cortex extract, skin-excision-stress did not result in depression of the bursting pressure of 5th day laparotomy wounds, as is the case with non-adrenalectomized rats subjected to the same stress.

Partial Hepatectomy for Metastatic Carcinoma

Three years after colonic resection for a rectal carcinoma, the patient evinced some weight loss and alkaline phosphatase elevation. Detailed workup revealed what appeared to be a solitary, well-defined metastatic lesion of the right hepatic lobe. Since the patient could be considered a good candidate for surgery, and given the grim prognosis of alternative approaches, hepatic lobectomy was carried out, as described here.

One-Stage Colectomy for Acute Diverticulitis

In the developed case of acute diverticulitis, obstructive symptoms that fail to subside within a reasonable period probably mandate surgery. However, close observation may enable a simpler and safer one-stage operation, such as the one demonstrated, to be performed in preference to a two- or three-stage procedure. Medical management of the underlying disease, complications, and surgical criteria are detailed.