Rectal Amputation Research Articles

Adjuvant treatment of patients with rectal cancer

Adjuvant postoperative radiotherapy combined with chemotherapy is considered a standard management of rectal cancer patients with increased risk of local recurrence. In this study we evaluated the results of adjuvant chemo- and radiotherapy after radical surgery in 64 patients with rectal carcinoma with special reference to tolerance of treatment. All patients underwent radical surgery: anterior abdominal resection in 26, abdominoperineal resection in 19 and Hartman resection in one. Thirty three patients were postoperatively staged as Dukes B2 and 31 patients – as Dukes C. All patients received postoperative chemo-radiotherapy. Treatment included megavoltage irradiation with two parallel opposed fields to small pelvis at a dose of 45 Gy in 23–25 fractions and concomitant chemotherapy with 5-Fluorouracil during first three and last three days of irradiation. Main early complications from chemoradiation included diarrhea (58%), nausea and vomiting (15%), dysuria (6%), leukopenia (31%) and anaemia (4%). In total, acute side effects occured in 42 patients (66%) and in 16 of them (25%) were of grade 3 or 4. Three patients did not complete the treatment due to exacerbation of side effects and/or serious deterioration of performance status. Late complications, mainly from bowels and urinary bladder, occured in 19 patients (30%) and six of then (9%) were severe. Nineteen of the 64 evaluated patients have deceased ill now. Median survival was 29 months (4 to 50 months). Local recurrence was seen in 14 patients (22%) and distant metastases – in 18 (28%). Results of our study show that postoperative radiochemotherapy in rectal cancer patients is accompanied by a large number of acute and late complications. Literature data demonstrate that better tolerance of treatment may be achieved with the use of special surgical techniques preventing the replacement of small intestines to the pelvis after rectal amputation. Further improvement may be achieved with the use of multiple radiation fields, computerized treatment planning and customized blocking. Another option is an application of preoperative radiotherapy – the approach becoming recently more commonly used.

Colorectal carcinoma. Which factors are decisive for development of postoperative complications?

This retrospective study analyses the prognostic effect of different factors on morbidity and lethality based on selected, primarily resecting colon carcinoma operations (n = 222). In all, 12.2% of our operations were performed under emergency conditions. The total complication rate was 31.5%, the lethality rate 7.7%. The left hemicolectomy cases showed the highest morbidity (48.4%), the rectum amputation the highest lethality (11.8%). Tumour staging tumour differentiation and the sex of the patient showed no significant influence on the postoperative morbidity and lethality. However, a correlation was proved between the age of the patient, tumour localisation, co-morbidity, duration of operation and the conditions under which the operation was performed (emergency or elective), on the one hand, and morbidity and lethality on the other.

ANORECTAL MALIGNANT MELANOMA -REPORT OF A CASE-

A 44-year-old woman with known progressive systemic sclerosis was seen at the hospital because of anal discomfort and bloody stool. Digital examination revealed a grayish polypoid lesion in the posterior wall of the anal canal. With a preoperative diagnosis of internal hemorrhoid or anal polyp, the lesion was extirpated. Histopathologically the extripated tumor was malignant melanoma. So rectal amputation with lymph node dissection through abdomino-sacral approach was carried out. About one month later a metastasis to the inguinal lymph node developed. Malignant melanoma has a poor prognosis, because of delayed diagnosis, the high vascularity of the anal region, and high biological malignancy such as vascular and lymphatic spread. Though there was no statistical difference in the prognosis between local resection and rectal amputation, a few patients undergoing rectal amputation could live for more than 5 years. Rectal amputation of the abdomino-sacral method with lymph node dissection is recommended. The disease presents difficulty in diagnosis from macroscopic findings and absolutely demands intraoperative or emergent microscopic frozen section diagnosis.

門脈ガス血症の２例

Hepatic portal venous gas is a rare condition that may be encountered in bowel necrosis. We report two successfully treated cases of hepatic portal venous gas associated with superior mesenteric artery (SMA) syndrome and ischemic colitis, respectively. In first case, a 28-year-old woman with progressive myoclonic seizures presented with complaints of vomiting and fever. Computed tomography showed a characteristic gas pattern in the liver and marked dilatation of the duodenum proximal to the superior mesenteric artery with a collapsed distal intestine, confirming the diagnosis of SMA syndrome with portal hepatic venous gas. Emergency laparotomy revealed an edematous stomach with phlegmon of the fundus. Fundectomy and gastrojejunostomy were performed. The second case involved a 78-year-old man who was admitted in shock. Colonofberscopy revealed mucosal necrosis and hemorrhage from the dentate line to the sigmoid colon, indicating ischemic colitis. Computed tomography showed hepatic portal venous gas and retroperitoneal emphysema around the rectum. Rectal amputation was performed. Hepatic portal venous gas is considered a serious condition with an overall mortality rate 75%, which actually reflects the outcome of coexisting septicemia. Diagnosis and treatment of the primary disease in the early stage may improve the outcome.

A CASE OF PERIANAL SKIN METASTASIS OF CANCER OF THE SIGMOID COLON, WRONGLY DIAGNOSED AS PERIANAL ABSCESS

A case of perianal skin metastasis of cancer of he sigmoid colon wrongly diagnosed as perianal abscess is reported. A 58-year-old man have been treated for his perianal skin tumor diagnosed as abscess with his home-doctor for about 8 months. A colonoscopic examination was done, because the lesion hardly healable. As a result, a tumor was found at the sigmoid colon. The patient was referred to the hospital, Histological studies revealed that the tumor of the sigmoid colon was well-differentiated adenocarcinoma, and the perianal skin tumor was its metastasis. Then, rectal amputation inculding both lesions, was performed. Histological examination is useful for atypical skin tumor or abscess, because they are possibly metastasis of internal cancer.

Malignant lymphoma of the rectum treated preoperatively with hyperthermia and radiation

A 58-year-old Japanese woman with primary malignant lymphoma of the rectum was treated preoperatively with radiation and intraluminal hyperthermia, after which abdominoperineal rectal amputation (Miles' operation) was done. The rectal tumor disappeared and there were no lymphoma cells in the resected specimens. The postoperative course was smooth and she is being followed in the outpatient department. At this writing, five years after the surgery, she remains well.

Bioavailability of Diclofenac Sodium after Anal or Stomal Administration

The purpose of this study was to evaluate the bioavailability of diclofenac sodium following stomal or rectal administration in patients after rectal surgery, and to compare it with that following rectal administration in healthy volunteers. Research into the efficacy of different routes of administration of a single dose of a nonsteroidal analgesic suppository (Voltaren® suppository) was carried out in order to investigate the degree of efficacy in patients after rectal surgery, i.e. in patients following rectal amputation (Miles group, n = 5), in patients after sphincter- and anus-preserved colorectal resection (LAR group, n = 5) and in a control group (n = 5). The Miles group demonstrated half the maximum plasma drug concentration (Cmax) and area under the plasma concentration-time curve (AUC) values found in the control group. However, the LAR group showed a plasma concentration curve similar to that of the control group. With regard to absorption of the suppository after rectal surgery, preservation of the proctal canal is a key factor in obtaining normal absorption. In the present study, none of the participating patients complained of discomfort at the application site. As one form of administration for nonsteroidal analgesics, the suppository was found to be effective and useful in patients of both the Miles and LAR groups after rectal surgery in whom oral administration was not possible.

Perineal pain after rectal amputation: A 5-year follow-up

A long-term study was undertaken on 286 patients who underwent perineal resection for rectal cancer to ascertain the incidence of chronic post-surgical pain in this group and to determine the likely cause for these pains. In 33 patients (11.5%) experiencing persistent perineal pain over the 5-year follow-up, most (70%) developed pain within weeks after surgery. The remaining 30% presented with pain several months later. This group with late onset pain died from known recurrence of adenocarcinoma in 80% of cases, giving this symptom the highest early confirmatory sign for tumour over other clinical tests. Those with early onset pain had a 26% tumour recurrence rate and clinical features of pain indicative of phantom anorectal pains in most cases. While the pain-onset time from surgery was the most sensitive predictor of cause and outcome, other distinguishing features in respect of site and quality of pain as well as differing responsiveness to drug therapy allowed for further separation of deafferentation from nociceptive pain for these two clinical groups.

A CASE OF METASTATIC LIVER TUMORS OF THE RECTAL CARCINOID TREATED WITH HEPATIC ARTERY LIGATION AND CATHETERIZATION

A 69-year-old man was admitted to the hospital because of anal bleeding. There was an elevated lesion in the rectum which was histologically diagnosed as a carcinoid. Urinary 5-HIAA was normal. The patient was not with carcinoid syndrome. CT scan and ultrasonography revealed several liver tumors and the biggest one was 5×4 cm in size. Celiac arteriography didn't reveal hyper-vascular lesions. He underwent rectal amputation, hepatic artery ligation and catheterization into the hepatic artery. The rectal tumor was 3.0×3.5cm in size. Operative findings were RbRa type 1, A2P0H2N3(+). After the operation, intrahepatic infusion of 5-FU, MMC, and FAR were carried out. Forty-two days later, tumor in the right lobe which was 5 cm in diameter was reduced clearly. Metastatic liver tumors of the rectal carcinoid generally reveal hyper-vascularity in the angiography. Then, the interruption of the hepatic arterial blood supply is effective. But we experienced that hepatic artery ligation and intrahepatic chemotherapy were also effective for metastatic liver tumors that revealed normo-vascularity.

APPLICATION OF FIBRIN GLUE FOR INTRACTABLE FISTULA

We sometimes have difficulities to treat fistulae which are formed due to anastomotic leakage after surgery for gastrointestinal disease. Here we describe our study of infusing fibrin glue to such fistulae which could successfully close them. From May 1988 to October 1989, 321 cases underwent operation of GI tract. Anastomotic leakage was recognized in 27 cases, and 12 were subjected to this study. The patients were comprized of each 6 males and females, and had undergone total gastrectomy in 5, pancrreatoduodenectomy in 3, rectal amputation in 3, and other in one. Each patient received conservative treatment for 2 weeks to 5 months, which could not yield cure. Then fibrin glue was infused, and in 9 cases fistulae were closed and cured. Excepting such fistulae as those producing sustained and large quantity of exudate, those in acute stage of infection, and those infiltrated by a tumor, this technique is able to heal almost intractable fistulae for a short period without any surgical treatment. Extremely effective this method would be recommended.

Phantom-related phenomena after rectal amputation: prevalence and clinical characteristics

Phantom sensations are well known and almost inevitable sequels to limb amputation, whereas similar phenomena are only rarely described after rectum amputation (phantom rectum). Our study attempted to assess the frequency and character of phantom rectum. All surviving patients (n = 22), who had undergone abdominoperineal surgical resection of the rectum in the period 1980–1986 at our clinic, were interviewed by a standard questionnaire and underwent a physical examination. Sixty-eight per cent of the patients experienced a sensation of a missing rectum (phantom rectum), and in 27% of these or 18% of all patients this sensation was painful (phantom pain). The most common symptoms were sensations of flatus and/or faeces in a normal rectum, phantom flatus or phantom faeces. The phantom pains were described as either pricking and shooting or like haemorrhoids or hard stools that would rupture the rectum. Neither age, sex, preoperative pain, the Duke classification of the tumour nor the healing of the perineal wound seemed related to the likelihood of phantom rectum. The pathophysiological mechanisms underlying phantom-related phenomena following amputation have not yet been elucidated. This study describes a relatively unknown phantom-related clinical entity after amputation and may thus contribute to the understanding of this phenomenon.

A CASE OF ULCERATIVE COLITIS ASSOCIATED WITH RECTAL CANCER AND RECTAL CARCINOID

A 38-year-old man was admitted to our hospital with the chief complaint of mucobloody stool on May 30, 1990. The patient had been diagnosed as ulcerative colitis, left sided type, 21 years before. Barium enema and colonoscopy revealed a slightly elevated rectal tumor, 3 cm distant from the anal verge, where stricture of the lumen was seen. Rectal biopsy showed adenocarcinoma, and rectal amputation was performed. On histological examination of the specimen, well-moderately differentiated adenocarcinoma was infiltrated through the wall with nodal involvement, and dysplasia was found in the surrounding mucosa. Furthermore, rectal carcinoid (2 mm in diameter) was found at 8 cm oral to the carcinoma. In the treatment of long standing ulcerative colitis, it is important to pay careful attention for possible association of carcinoid as well as carcinoma.

A Clinical Pilot Study Combining Surgery with Intraoperative Pelvic Hyperthermochemotherapy to Prevent the Local Recurrence of Rectal Cancer

Intraoperative pelvic hyperthermochemotherapy (IOPHC) with mitomycin C (MMC) was prescribed for 14 patients with resectable advanced rectal cancer in an attempt to prevent a postoperative local recurrence. Immediately after rectal amputation and extended lymphadenectomy, IOPHC was performed using physiologic saline containing 40 micrograms/mL of MMC at 45.5 +/- 0.6 C for 90 minutes, with an apparatus devised for IOPHC. At the end of IOPHC, the esophageal temperature was 37.2 +/- 0.8 C and cooling was not required. Antitumor efficacy and complications in the IOPHC group were compared with findings in 12 rectal cancer patients who underwent surgery only within the same period of time. Operation time was not prolonged with IOPHC treatment. In cytologic examinations of the pelvic lavage just before IOPHC treatment, viable cancer cells were detected in 6 of the 14 patients but were never detected in the postoperative exudate drained from the pelvic cavity. Of the 12 patients in the control group, 2 had a local recurrence, while in the IOPHC group there was no local recurrence for 16.9 +/- 9.7 months at this writing. Postoperative complications did not differ between the groups. This IOPHC treatment is a favorable method in eradicating cancer cells for postoperative local recurrence of rectal cancer.

Pharmakokinetische Untersuchungen einer neuen 20 %igen Fettemulsion mit einem Anteil von 70 % mittelkettigen Triglyzeriden

Das Ziel der Untersuchung war es, erste Erkenntnisse über die Pharmokokinetik, den Stoffwechsel und die Verträglichkeit einer neuartigen 20 %igen Fettemulsion mit einem 70 %igen Anteil an mittelkettigen Triglyzeriden (MCT) und einem 30 %igen Anteil von langkettigen Triglyzeriden (LCT) in der postoperativen Phase nach einem mittelschweren Trauma zu gewinnen. - 12 Patientinnen, die sich einer elektiven Rektumamputation unterziehen und parenteral ernährt werden mußten, wurden in die Untersuchung aufgenommen. Das Ernährungsregime setzte sich aus 4,8 g/kg/Tag Glukose und 1 g/kg/Tag Aminosäure zusammen. Am zweiten postoperativen Tag erhielten sie 0,06 g/kg KG/h und am dritten postoperativen Tag 0,12 g/kg KG/h dieser neuen 20 %igen Fettemulsion über einen Zeitraum von acht Stunden. Blutproben zur Bestimmung der Triglyzeride, freien Fettsäuren, Phospholipide, β-Hydroxybutyrat, Acetacetat, Cholesterin, Glukose, Pyruvat und Laktat wurden vor, während und nach Fettapplikation entnommen. Die Urinmenge wurde semiquantitativ auf Ketone untersucht. Nebenwirkungen und Unverträglichkeiten traten nicht auf. Simultan zur exogenen Triglyzeridzufuhr wurde ein infusionsbedingter Anstieg der Serumtriglyzeride festgestellt. Nach vier Stunden erfolgte die weitere Fettapplikation unter steady-state Bedingungen. Bei einer graphisch ermittelten Halbwertzeit von ca. 17 Minuten für die MCT/LCT-Emulsion konnte eine prompte und vollständige Elimination in der ersten Stunde post infusionem beobachtet werden. Entsprechend der hohen Klärrate der infundierten Triglyzeride aus dem Serum steigen die freien Fettsäuren im Plasma signifikant an, ohne ein Plateau zu erreichen. 30 Minuten nach Beendigung der Fettapplikation sind die Ausgangswerte nahezu erreicht. Bei den Serumkonzentrationen von Phospholipiden, β-Hydroxybutyrat, Acetacetat, Cholesterin, Pyruvat und Laktat zeigten sich bei keiner Dosierung signifikante Änderungen. Eine fettinduzierte Ketonämie oder Ketoazidose konnte durch die simultane Glukoseapplikation vermieden werden. Aufgrund der Glukoseinfusion wurde ein leichter Anstieg der Blutglukose beobachtet, der jedoch im Rahmen des Postaggressionssyndroms und der damit verbundenen verminderten Insulinansprechbarkeit vertretbar ist. Die vorliegende Untersuchung über die Pharmakokinetik einer 20 %igen Fettemulsion zeigt eine gute klinische Verträglichkeit und schnelle Elimination der Triglyzeride aus dem Blut durch Hydrolyse und rasche Organaufnahme der freien Fettsäuren. Über die endgültige Oxidation der Fettsäuren und die nutritive Effizienz kann jedoch keine Aussage gemacht werden. Diese Fragen müssen durch weitere Untersuchungen geklärt werden.

The composition of anal basal pressure. An in vivo and in vitro study in man.

The maximal anal basal pressure (MABP) was measured with probes of 0.3, 1, 2 and 3 cm diameter in 21 subjects, 60 years old, without anal pathology. The components of MABP were analyzed by inducing a maximal internal sphincter (IS) relaxation, taking pressure measurements in the conscious state and during narcosis with curarization. In seven cases pressure measurements were done on isolated anorectum after abdominoperineal rectum amputation. MABP increases with probe diameter before as well as during anaesthesia with curarization. The contribution of the striated sphincter tonic activity is constant within the range of probe diameters used. At rest, i.e. when the 0.3 cm diameter pressure recording probe is used, 30% of MABP is made up by striated sphincter tonic activity, 45% of it is due to nerve induced IS activity, 10% to purely myogenic IS activity and 15% can be attributed to the expansion of the haemorrhoidal plexuses. Although MABP is mainly based on active forces generated by the smooth and striated sphincter apparatus, the presence of the anal cushions is essential for perfect anal continence, as they have to fill the gap within the IS ring to hermetically close the anal canal. The global IS activity, contributing 50-60% of MABP at rest, can completely be inhibited by a maximal rectoanal inhibitory reflex. Stretching of passive elements starts at 1 cm anal distension, but steeply increases thereafter, accounting for 65% of the MABP at 3 cm anal distension. It is deduced that optimal stool diameter is about 2 cm.

A LONG TERM SURVIVAL AFTER SURGICAL RESECTION FOR EACH REPEATED LOCAL RECURRENCE OF RECTAL CANCER

A long term survival case following surgical resection for each repeated local recurrence of rectal cancer was reported. A 49-year-old male patient was performed rectal amputation by abdomino-perineal approach on December 4, 1979. Histological study revealed that the cancer was mucinous type, a1, no, lyo, vo, aw(-), ow(-), ew(-), Po, Ho, and stage II. On November 1982, he underwent tumor excision with combined coccygeal bone resection for local recurrence around the perineo-pelvic cavity. On December 1984, a possible curative resection for locally recurred tumor was also tried. On August 1987, pelvic exenteration was finally performed according to MRI findings displayed that the cancer had extended from the cervical portion of urine bladder toward the prostate gland. He is still surviving without any distant metastases for 5 years and 6 months from the first diagnosis of recurrence. The other 6 recurrence cases out of 64 curative and resectable rectal cancer cases in our department were also presented.

Aparelho para irrigação intestinal em colostomizados, com um "cone" adaptado

Apresenta-se os resultados do teste de um equipamento para irrigação de colostomizados, com um cone adaptado, empregado tanto no preparo pré-operatório ou préexames radiológicos do cólon, como em pós-operatório de amputações do reto, para a reeducação do hábito das exonerações intestinais em pacientes portadores de colostomias esquerdas. O elevado custo e as constantes dificuldades de acesso aos equipamentos importados, motivaram o desenvolvimento e teste deste aparelho. Quanto aos resultados obtidos, cinco dos seis componentes do aparelho, mostraram índices satisfatórios em relação aos quesitos estudados, sendo que, nenhum paciente apresentou intercorrências durante o procedimento, em conseqüência do uso deste equipamento.

EVALUATION OF POSTOPERATIVE UPPER GASTROINTESTINAL HEMORRHAGE IN PRIMARY COLORECTAL CANCER

This paper describes upper gastrointestinal hemorrhage after surgical treatment of primary colorectal cancer. During the past six years, operations have been carried out on 127 patients with primary colorectal cancer. Of these, 13 patients (10%) had postoperative bleeding from the upper gastrointestinal tract. This type of bleeding occurred in 5 (26%) of 19 patients undergoing urgent surgery. With regard to the operation methods, low anterior resection and colostomy frequently induced postoperative hemorrhage, in 3 of 11 cases (27%) and 4 of 15 cases (27%) respectively; however, abdomioperineal rectal amputation did not give rise to such bleeding in any of 23 cases. Gastrointestinal hemorrhage was also noted in 4 of 11 patients having diabetes mellitus as a preoperative complication; 2 of the 4 died. This arouses prognostic concern.Of the 13 cases with postoperative gastrointestinal hemorrhage, 10 were relieved with conservative hemostasis.Therefore, prophylactic administration of Cimetidine seems to be effective in the high-risk group for postoperative gastrointestinal hemorrhage.

Prophylactic regimens in colorectal surgery: Comparisons between metronidazole used alone or with ampicillin for one or three days

AbstractThe purpose of this study was to compare as anti‐infectious prophylaxis in elective colorectal cancer surgery the effect of metronidazole alone and in combination with ampicillin, and the effect of a duration of 1 or 3 days of prophylaxis. The prophylactic regimens designated regimens A‐D given in randomized order were metronidazole 500 mg used alone or with 2.0 g ampicillin administered every 8 hours as separate but simultaneous infusions. All patients studied received preoperative mechanical evacuation of bowel contents. Eight surgical departments participated in the study. Two hundred thirty‐three patients were studied. The distribution of sex, age, and type of operation was similar among the groups of patients receiving each regimen, except that there were more cases of sigmoidectomy, low anterior resection, or rectal amputation in the group receiving regimen D. The duration of the operations was comparable, even for each type of operation considered separately. Samples for bacteriological examination were obtained by abscess punctures when relevant. The pus was taken and transported to the laboratory under anaerobic conditions. Moderate or severe infections were observed in 6 (10.3%) of 58 patients on regimen A, in 2 (3.5%) of 58 patients on regimen B, in 4 (7.0%) of 57 receiving regimen C, and in 2 (3.3%) of 60 given regimen D. The highest incidence of postoperative infections was observed in rectal amputation. The bacteria causing postoperative infections were similar in the regimens A and C receiving only metronidazole for 1 and 3 days, respectively and in regimens B and D in which ampicillin was added. Only one anaerobe, aClostridium perfringens, was recovered from regimen C; twenty‐two strains of anaerobic bacteria were recovered from regimen A. The number of aerobic bacteria was 25 in regimen A and 16 in regimen C. The yield of bacteria was much more sparse when metronidazole was combined with ampicillin. Eleven isolates (2 anaerobes) were recovered from regimen B, only one isolate was recovered from patients on regimen D, an indole positiveProteus. In conclusion, th'is study indicates that a combination of metronidazole and ampicillin is particularly useful in rectal surgery. Metronidazole alone may suffice in colonic surgery, but a combination with an agent against aerobes is recommended in rectal surgery. The difference between 1‐day prophylaxis and 3‐day prophylaxis was insignificant for metronidazole plus ampicillin; a single day of this prophylactic regimen would appear advisable.

手術時準備血液量と返却率についての検討

We surveyed all of blood units prepared and transfused for elective surgery, particularly 13 kinds of major operation, in our clinic for three annual terms, i. e. 1976, 1979 and 1982. Averaged amount prepared for transfusion was 6.9±3.2 units (one unit=200ml) for each operation and 47±19% of those was returned back to blood supply centre in our hospital from either our operation theater or ICU during the 3 years. Un-utilized units in the prepared blood were reduced in all of gynecological operations in 1982 compared with those in 1979, particularly from 60% to 3% with simple hysterectomy for myoma uteri. On the other hand, the un-utilized rate increased with mastectomy, rectum amputation and laminectomy, namely 22→41, 39→50 and 22→41% respectively. Either hemodilutional autotransfusion alone or its combination with homologous blood transfusion was used in all of operations, un-utilized rates of which were less than 50%, except mastectomy. On the other hand, un-utilized rate exceeded over 50% with gasterectomy, rectum amputation, laminectomy, open-heart or non-open-heart surgery and removal of brain tumor. Average of C/T ratio (units tested for cross matching/units transfused) remained mostly unchanged, as 2.07 in 1976, 2.11 in 1979 and 2.10 in 1982.