Superior Rectal Research Articles

Proctectomy for inflammatory bowel disease

Between July 1973 and October 1984, we performed proctectomy either as part of a primary proctocolectomy or as a secondary staged procedure in 388 patients with ulcerative colitis and in 39 patients with Crohn's disease. The proctectomies were performed using a two-team synchronous approach. An intersphincteric or perimuscular technique was employed. All perineal wounds were closed and drained by suction drainage and the pelvic peritoneum was closed in all cases. Two patients died in the early postoperative period, one from a pulmonary embolus and one from sepsis. Three patients had to be reexplored for postoperative hemorrhage, in all cases from a branch of the superior hemorrhoidal artery. Postoperative perineal hematoma developed in two patients and perineal abscess developed in four patients which necessitated opening of the perineal skin wound. Nonhealing of the perineal wound occurred in 3 of 388 patients with ulcerative colitis and in 5 of 39 patients with Crohn's disease. No perineal dehiscence or hernias were seen. Postoperatively, one man was permanently impotent and two had prolonged but temporary impotence. Three patients had retrograde ejaculation at last follow-up.

Pelvic intra-arterial mitomycin C infusion in previously treated patients with metastatic, unresectable, pelvic colorectal cancer and angiographic determination of tumor vascularity.

Thirty patients with unresectable pelvic tumors from recurrent or metastatic colorectal cancer, after failing all conventional chemotherapy or radiotherapy, were treated with mitomycin C (MMC) regional intra-arterial (IA) infusion. MMC at a dose of 20 mg/m2 in 100 mL of 5% dextrose in water was infused for a one-hour period through the regional artery (eg, hypogastric, gluteal) approached percutaneously via the femoral artery. This treatment was repeated every four to eight weeks. Of the 26 patients who could be evaluated, three had objective responses, 14 had tumor stabilization, and nine had no response. Median survival time for the responders (Rs) was 435 days, for stabilized patients (Ss) was 263 days, and for nonresponders (NRs) was 195 days, giving an overall survival time of 239 days. Fourteen patients (2 Rs, 8 Ss, and 4 NRs) had good relief of pain after the IA infusion. Thirty-three pelvic arteriograms (including three patients who had never received IA infusion) showed an avascular tumor of grade 0 in eight patients, a hypovascular tumor of grades 1 and 2 in 16 patients, and a vascular tumor of grade 3 in nine patients. Neovasculatures were mainly derived from the hypogastric artery or its branches (eg, gluteal, obturator, and pudendal artery), and occasionally were found to be derived from the superior hemorrhoidal, lumbar, and sacral arteries. The major side effect after the pelvic infusion was necrotizing cellulitis occurring in the buttock. Myelosuppression was manageable and other toxic effects were mild. Metastatic colorectal cancer occurring in the pelvis was basically a vascular-deficient tumor. Regional IA MMC infusion given intermittently was found effective in palliating pelvic pain and improving the quality of these patients' lives.

Rectal lymphoscintigraphy.

Regional lymph nodes of the rectum are not demonstrable by pedal lymphoscintigraphy. We have evaluated the technique of rectal lymphoscintigraphy, using a technique similar to that which has been used in the assessment of lymph nodes in breast and prostatic cancer. Thirty-five patients were studied: ten normal subjects and 25 patients with rectal cancer. In normal subjects, the lymph nodes accompanying the superior hemorrhoidal artery and the inferior mesenteric artery are demonstrable in succession; after three hours the aortic lymph nodes are demonstrable. The 25 patients with rectal cancer underwent resection of their primary tumor and the stage was defined according to Dukes (1932). In five patients (stage A) no alteration was demonstrable. In 11 patients (stage B) the demonstration of regional lymph nodes was delayed vs. the control group. In nine cases (stage C) the demonstration of regional lymph nodes was delayed and defective versus the control group.

Transcatheter Arterial Occlusion in the Management of Rectosigmoidal Bleeding

Transcatheter arterial occlusion was performed in five patients with recurrent rectosigmoidal bleeding. Four had malignant neoplasms, and the fifth, an arteriovenous malformation. The superior hemorrhoidal artery was embolized in two patients, the inferior mesenteric artery in two, and the left internal iliac artery in one patient. In four patients, immediate and complete control of rectal bleeding was achieved, and gradual control was accomplished in the fifth patient. Left lower quadrant pain and fever developed in three patients. The possibility of rectosigmoidal bleeding from the internal iliac artery is stressed.

Arterial supply to the human rectum.

The arterial supply to the human rectum was studied in 42 autopsy specimens. 32 were fixed in formalin and dissected. Five were radiographed after filling their arterial bed with a radio-opaque substance. The remaining five specimens were used to prepare plastic casts of the arterial bed. The superior rectal artery is the chief rectal artery. It forms a recto-sigmoid branch, an upper rectal branch and then divides into right and left terminal branches. Terminal branches extend downwards and forwards around the lower two thirds of the rectum to the level of the levator ani. The middle rectal artery, of appreciable diameter, on one or both sides of the rectum, is found supplying a limited part of the rectum in 12% of the specimens. Its presence can be anticipated by observing the diameter of the superior rectal artery and its two terminal branches. The inferior rectal artery supplies the anal canal below the levator ani. Rectal twigs of other pelvic arteries terminate at the pararectal tissues occasionally reaching the wall of the rectum. Extramural anastomoses were not observed between the main rectal arteries, but intramural ones were present, mainly between the superior and the inferior rectal arteries.

3. Microangiographical and Histological Studies of Anal Vasculature in Japanese

In order to clarify the morphology of the anal vasculature, microangiograms were made in eight patients without anal lesion who underwent amputation of the rectum because of rectal cancer and they were histologically studied.Vascular running can be classified into six types.(1) That which is descending under the mucosa with twigs between the internal anal sphincter muscle bundles.(2) That which is divided into two branches one of which is descending the rectal longitudinal muscle and turning up under the mucosa at the upper end of the internal sphincter muscle and the other which is descending the conjoined longitudinal muscle.(3) That which branches, entering the conjoined longitudinal muscle along the levator ani muscle, into two, one of which turns up under the mucosa passing through the internal sphincter muscle and the other which shoots twigs in the internal anal sphincter muscle descending the conjoined longitudinal muscle.(4) That which enters the conjoined longitudinal muscle at nearly a right angle through the upper part of the external anal sphincter muscle from the upper exterior side to the lower interior side of the external anal sphincter muscle at the lower end of the levator ani muscle and penetrates the middle part of the internal anal sphincter muscle with branching.(5) That which reaches the conjoined longitudinal muscle passing through the external anal sphincter muscle from the exterior end of the middle external anal sphincter muscle and turns out under the ephithelium passing through the internal anal sphincter muscle with branching.(6) That which is coming from the exterior side bifurcates at the lower exterior end of the external anal sphincter muscle, the one of which (6') runs into the conjoined longitudinal muscle passing through the lower part of the external anal sphincter muscle and flows into the rete vasculosum taking a long way around the lower end of the internal anal sphincter muscle. The other one (6") ascends going around the exterior end of the external anal sphincter muscle.All of these blood vessels run under the ephithelium (submucosally and subcutaneously) and from the reticular vasculosum which tends to gathering in the crypt.Usually barium sulfate filled the small arterioles but did not pass beyond the capillaries when injected from an artery. In our cases barium sulfate injected from superior rectal artery, but in the histological study, barium was found also in the venous system. This was the barium which had entered the sinusoid vein entered the venous system accrossing the sinusoid vein.There is sinusoid vein into which the arterial capillaries flow directly in the submucosal and under layer of the anoderm. The wall of this vein differs in thickness with a very thin part. It is generally characterized by extremely scanty tunica media smooth muscle and abundant collagenous fibers. Hemorrhoids are thought to be produced by excessive stretch of the venous wall due to repeated congestion over a long period of time.

Prevention of anastomotic fistula formation after low-position Dixon Operation.

Objective: This study aimed to investigate the main points of preventing anastomotic fistula formation after low-position Dixon operation. Methods: From September 2004 to October 2007, our department continuously conducted 146 cases of low-position Dixon operations. The operation mode involved transabdominal radical resection based on total mesorectal excision for all cases. Except for tumor infiltration, one side of the pelvic vegetative nerve was maintained and ligations were conducted at the superior rectal artery root. Mesorectum at the anastomosis site was removed up to the tunica muscularis recti. The anastomotic stoma blood supply was good and had no tension. An anal tube was inserted when the anastomotic stoma was within 3 cm away from the anal margin. For all cases, a presacral drainage tube was placed via the perineal position. Results: For all 146 cases, no anastomotic leakage occurred and the post-operative complications included two cases of anastomotic bleeding, three cases of anastomotic stenoses, 48 cases of increased defecation (4-6 times of defecation daily), 34 cases of anal irritation symptoms, and 6 cases of poor loose stool control capacities. Conclusion: Ensuring enough blood supply for the anastomotic bowel on the two sides, eliminating tension and accurate anastomosis at the anastomosis site could be effective measures to prevent anastomotic fistula in the low position anus preserving surgery of colorectal cancer.

Atherosclerosis in the mesenteric circulation. Observations and correlations with aortic and coronary atherosclerosis

The mesenteric arterial bed of 88 adults was analyzed for atherosclerosis according to the number of vessels affected, the extent of involvement of the intimal surface, and the number and degree of stenoses. The mesenteric bed, defined as comprising the celiac, superior mesenteric, and inferior mesenteric arborizations, was divided into 23 named arteries comprising the 3 main stems and their major branches. The series had a nearly equal number of men and women, with an age range of from 28 to 86 years. Atherosclerosis in one or more of the 23 named arteries was found in 68 (77 per cent) of the cases. The vessels most frequently affected were the three main stems and the splenic artery. Also quite frequently involved were the gastrohepatic, superior hemorrhoidal, and gastroduodenal arteries. Among the 68 subjects with mesenteric atherosclerosis the disease was associated with luminal stenosis in 49. The majority of the stenoses were of mild to moderate degree. The propensity of atherosclerosis to be associated with stenosis varied considerably among the named arteries. Stenosing disease was particularly common in the main stems, occurring in 44 subjects, i.e., in 50 per cent of the total series or in 65 per cent of those with mesenteric atherosclerosis. Even though the aortic ostia of the main-stem arteries were often involved, it was rare for the stenoses to be confined to the aortic ostia. The incidence of myocardial infarction rose significantly with the severity of mesenteric atherosclerosis, and this was true also, although to a lesser extent, for peripheral vascular disease. The incidence of diabetes mellitus was exceptionally high in the group with severe mesenteric atherosclerosis and was quite low in all other groups. Hypertension, although occurring rather frequently with mesenteric atherosclerosis, did not clearly correlate with the severity of the latter. There was a good correlation between the severity of atherosclerosis in the mesenteric circulation and that in the abdominal aorta. The correlation, however, was one sided, in that severe atherosclerosis of the abdominal aorta occurred not infrequently with little or no mesenteric atherosclerosis, whereas the reverse was not observed. A fairly good but similarly one-sided correlation was found between mesenteric and coronary atherosclerosis, in that the chance of servere mesenteric atherosclerosis being associated with severely stenosing or occlusive atherosclerosis of the coronary bed was 2 to 2 1 2 times greater than the reverse. Finally, there was a fairly good correlation between coronary and (abdominal) aortic atherosclerosis.

Collateral circulation in the sigmoid colon.

The blood supply to the sigmoid colon and upper rectum is traditionally related to a critical point beyond which ligation will cause necrosis. Most surgeons doubt this theory, but experimental proof is lacking. The arteries to the sigmoid colon and rectum have been reinvestigated with special reference to this question in fresh human autopsy material. HISTORICAL REVIEW Sudeck,1in 1907, established a critical point in the superior hemorrhoidal artery after observing gangrene of the upper rectum in two patients whose superior hemorrhoidal arteries had been ligated just distal to the last sigmoid branch of the inferior mesenteric artery during perineal resection of the rectum. He later found by injection experiments that the vessels of the rectum became filled with injecting material from the inferior mesenteric artery only by traversing a marginal artery above the origin of the last sigmoid branch. If the ligature was placed below the origin of

EVALUATION OF CONSERVATIVE RESECTION

THIS PAPER is not a crusade for resection of the rectum with restoration of continuity. It is an honest endeavor to assess the place of conservative resection, if any, in the operative therapy of rectal carcinoma. Certain facts are presented, and certain conclusions are drawn. Facts cannot be questioned, but conclusions should be critically assessed. There are two basic arguments against anterior resection with end to end anastomosis as a means of dealing with carcinomas of the rectosigmoid and upper part of the rectum. One might be termed anatomic: the question of the blood supply of the upper end of the rectal stump after division of the superior hemorrhoidal artery. It has been established beyond question that, if the resection is carried down to the level of the levator ani muscles, the rectum distal to this has a perfectly adequate blood supply apart from the superior hemorrhoidal artery. One cannot,

The rationale of the surgical technique in carcinoma of the rectum and sigmoid

1. 1. Carcinoma of the lower bowel costs 35,000 deaths a year in the United States of America. 2. 2. The main cause is late or faulty diagnosis. This is unforgivable, since 50 per cent of these tumors are within reach of the examining finger; therefore, a digital examination must be done as a routine. 3. 3. The next greatest cause is improper treatment. 4. 4. The abdomino-perineal operation, popularized by Miles, is unnecessary. 5. 5. Metastatic spread is along the course of the superior haemorrhoidal artery and lateral or retrograde spread occurs only with the establishment of a collateral lymphatic circulation. 6. 6. The perineal stoma is much to be preferred psychologically and functionally. 7. 7. Reference is made to a simplification of the operation of perineal excision of the rectum for carcinoma. 8. 8. The advantages of the use of 10 per cent tannic acid in alcohol in large granulating wounds is explained.