American Society of Colon and Rectal Surgeons

American Society of Colon and Rectal Surgeons

90th Annual Convention Poster Presentations

and Abstracts

May 12-17, 1991 Boston, Massachusetts

ABSTRACTS Abstracts appear in the order of presentation. Their number corresponds to the title listed in the scientific program.

There are many more depressed minute carcinomas than expected. They are considered to be the origin of some advanced colorectal cancers that were missed when small. Over half of the depressed lesions were in the proximal colon. To prevent advanced colorectal cancers, total colonoscopy is necessary.

Clinical Significance of Diminutive Polyps of the Rectosigmoid

(1) C.N. Ellis, D. J. Coyle . . . . . . . . . . . . . . Birmingham, AL H. W. Boggs, G. W. Slagle, P. A. Cole .. Shreveport, LA

Malignant Polyps: The Ochsner Experience

(3)

Diminutive colon polyps are a c o m m o n finding during examination of the rectosigmoid. To determine the clinical significance of these, 637 consecutive complete colonoscopies on 526 patients were reviewed. In 430 patients, only adenomatous or hyperplastic polyps 5 mm or smaller were identified in the rectosigmoid colon and removed for pathologic examination. In 156 patients (36.3 percent), additional polyps were identified in the proximal colon. Proximal colon polyps were found in 123 of 382 patients (32.2 percent) with one, 28 of 42 (66.7 percent) patients with two, and five of six patients with three or more rectosigmoid polyps (P < 0.05). Pathologic review revealed 211 patients with only hyperplastic, 179 with adenomatous polyps, and 40 patients with both hyperplastic and adenomatous rectosigmoid polyps. Of these patients, 70 (33.2 percent), 71 (39.7 percent), and 15 (38.0 percent), respectively, had additional proximal colon polyps (P = NS). These data suggest that diminutive rectosigmoid polyps, whether hyperplastic or adenomatous, are associated with proximal colonic neoplasia, with the incidence increasing as the number of rectosigmoid polyps increases. It is suggested that total colonoscopy is indicated for all patients with small polyps of the rectosigmoid colon.

J. Nichols, F. Opelka, J. B. Gathright, J. B. Green New Orleans, LA The proper therapy for polyps containing invasive carcinoma has been evolving since endoscopic polypectomy was first introduced. A review of the 16-year experience with endoscopic re'moral of malignant polyps at the Ochsner Medical Foundation was performed to assess the adequacy of treatment and prognosis for these patients. During the study period, 11,800 colonoscopies and 6,200 polypectomies were performed, with 53 malignant polyps removed. Ten patients were excluded due to fragmentation of the specimen and inability to assess depth of invasion (8), unavailability of the histologic slides, or the patient being lost to follow-up before treatment (one each). The remaining patients' records, histologic studies, and outcomes were evaluated according to Haggitt Level of invasion in the polyp. Follow-up for a mean of 65 months (range 24-196 months) showed no evidence of recurrence in 26 patients treated by endoscopic polypectomy and surveillance (4 Level 1, 13 Level 2, 5 Level 3, 4 Level 4). Residual disease without nodal disease was found in only 3 of 17 patients undergoing resection (1 of 10 Level 3, 2 of 9 Level 4). Colon cancer amenable to primary endoscopic therapy is rare. When present, endoscopic polypectomy appears to be adequate therapy for most patients. Further study may reveal reliable histologic criteria for primary endoscopic therapy of even Level III and Level IV polyps.

Minute Depressed Carcinomas of the Large Intestine

(2) S. Kuramoto, O. Ihara, T. Oohara . . . . . . . .

Tokyo, Japan

Until recently, colonic cancer in humans has been believed to develop from raised adenomas; therefore, depressed lesions of the large intestine have been ignored. However, the development of the videoimage endoscope improved the ability to distinguish endoscopic images. There are many small depressed lesions in the colon and rectum. We looked for them to analyze their characteristics. From January 1988 to March 1990, 1,208 colonoscopic examinations were carried out in the Third Department of Surgery, University of Tokyo, using videoimage colonoscope (Olympus CF type V10 I). 739 patients were men and 469 were women; 59 depressed lesions were endoscopically picked out and biopsies were performed. Three lesions were diagnosed as minute depressed-type early cancers (IIc; under 5 mm), and 17 lesions were confirmed as adenomas. The other 39 lesions included 12 lymphoid follicle hyperplasias and 9 artefacts. Thirteen of 20 carcinomas and adenomas were proximal to the sigmoid-descending colon junction.

Long Term Follow-Up After Endoscopic Polypectomy

(4) J. B. Poulard, A. Ott, S. Bank, I. B. Margolis Jamaica, NY In order to determine the yield of long term followup colonoscopy after endoscopic polypectomy, the records of 134 patients who had undergone at least one repeat colonoscopy were reviewed; 67 (50 percent) had polyps on the first reexamination (interval 1-9 years). Recurrent polyps were found in 36 percent on a second examination, 36 percent on a third examination, 29 percent on a fourth, and 25 percent on a fifth examination. When the first follow-up examination was negative, 8 of the 39 (21 percent) subsequent examinations revealed polyps. Following two negative examinations, 3 of 14 (21 percent) showed polyps, one patient had a polyp P2

Vol. 34, No. 4

MEETING ABSTRACTS

found on an examination 12 years after index polypectomy subsequent to three negative intervening examinations. It thus appears that although the risk of n e w polyps is initially approximately 50 percent; this does diminish following a negative examination to a plateau at the 20-25 percent level and continues throughout the length of time e n c o m p a s s e d by this study.

Colonoscopy in Patients with a Family History of Large Bowel Cancer

(5) A. Meagher, M. Stuart . . . . . . . . . . . . . .

Sydney, Australia

The m a n a g e m e n t of the relatives of a patient with colorectal cancer remains controversial. Since 1982, it has b e e n the coauthor's policy to advise all patients who have a positive family history of bowel cancer and who are over the age of 30 years to u n d e r g o colonoscopy. Up until August 1990, 600 such patients have had at least one colonoscopy. Colorectal neoplasia has b e e n detected in 270 patients (45 percent). The incidence was essentially the same for the 171 patients with only s e c o n d degree relatives affected (43 percent), for the 194 patients with more than one affected relative (45 percent), and for the 429 patients with an affected first degree relative (46 percent). Only the 55 patients with more than one affected first degree relative had a higher incidence (67 percent). The incidence in 136 totally asymptomatic patients was 36 percent but was 48 percent in the 464 with symptoms (37 with carcinoma). Even in the 30-39 year age group, there were over 20 percent with neoplasia. It is currently advised that all patients over the age of 30 years with a family history of colorectal cancer undergo c o l o n o s c o p y on presentation and, if clear, every 4 years thereafter unless two first d e g r e e relatives are affected when it should be every 3 years.

Extended Low Anterior Resection of the Rectum

(6) J. A. Heine, D. A. Rothenberger, F. D. Nemer, C. E. Christenson . . . . . . . . . . . . . . . . . Minneapolis, MN Ninety-seven patients (59 females, 38 males) with a mean age of 64 years underwent e x t e n d e d low anterior resections of the rectum for lesions (91 malignant) 7 cm or less from the anal verge. Nine of 12 patients with a covering stoma had restoration of continuity. There were three early deaths. Anastomotic d e h i s c e n c e resulted in pelvic abscess in 6 patients and rectovaginal fistula in five, all of w h o m required fecal diversion. Other significant complications occurred in 11 patients. There were no septic complications in patients with a covering stoma. More distal lesions (2-5 cm) had a lower rate of anastomotic dehiscence than lesions at 6 and 7 cm (chisquare, P < 0.05), Preoperative radiotherapy significantly increased the risk of anastomotic d e h i s c e n c e (chisquare, P < 0.01). Functional outcome was assessed in 41 patients at a mean of 46 months (3-130). Average n u m b e r of bowel movements per 24 hours was 3.2 --- 2.2.

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Nineteen patients (47 percent) had perfect or near perfect continence; 20 (49 percent) and two patients noted occasional minor and major incontinence, respectively. There was no correlation b e t w e e n functional outcome and the level of the lesion, sex, preoperative radiotherapy (chi-square, P > 0.1), or patient age (Student's two tailed t, P > 0.2). Ninety-five percent of patients were very satisfied with the outcome. Extended low anterior resection for very low rectal lesions was p e r f o r m e d with 3 percent mortality and 22 percent significant complication rate. Functional outcome is acceptable to most patients but difficult to predict. Covering stomas should be considered for patients who have received preoperative radiotherapy.

Functional Results of Proctectomy and Colo-Anal Anastomosis in Patients with Rectal Cancer

(7) R. C. Saad, J. M. Church, V. W. Fazio, I. C. Lavery, J. R. Oakley, J. W. Milsom, T. K. Schroeder Cleveland, OH Proctectomy and coloanal anastomosis offers preservation of per-anal defecation for patients with low rectal cancer, but carries a risk of impaired anorectal function. This study reviewed the postoperative functional status of patients u n d e r g o i n g proctectomy and CAA for rectal cancer, to d e t e r m i n e its suitability as a treatment option. Methods: A review of 49 patients u n d e r g o i n g proctectomy and CAA for rectal cancer was performed. Patients were classified as continent, or with minor (liquid stool, <2 times per week) or major incontinence (solid stool, or >2 times per week, or constant usage of pads); 36 patients u n d e r w e n t postoperative anorectal manometry. Results: Follow-up was available in 42 patients (mean duration 26 months); 29 were continent (69 percent), 10 had minor (24 percent) and 3 had major incontinence (7 percent). Mean stool frequency was 3.2/day (range 0.3-12). There was no difference in anal resting pressure, squeeze pressure, or anal canal length b e t w e e n continent and incontinent patients. Neither the use of perioperative radiotherapy, the choice of hand sewn or stapled anastomosis, nor time since CAA affected the incidence of incontinence. Incontinent patients had twice as many stools per day as continent patients (2.2 v s . 4.4); 11 of 38 (29 percent) patients used pads and 5 of 32 (16 percent) patients were unable to defer defecation. Conclusion: Patients u n d e r g o i n g proctectomy and CAA achieve acceptable functional results. The n e e d for perioperative radiotherapy or hand sutured anastomosis are not contra-indications to its use.

Perioperative Irradiation in Resectable Rectal Carcinoma: An Evaluation of late Secondary Effects

(8) L. P~hlman, G. Frykholm, B. Glimelius Uppsala, Sweden Between 1980 and 1985, 471 patients with a resectable rectal carcinoma were r a n d o m l y allocated to receive

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either preoperative irradiation (25 Gy in 1 w e e k ) or postoperative irradiation (60 Gy in 8 weeks) to a high risk group of patients, i.e., Dukes' stage B and C cases. After a m i n i m u m follow-up of 4 years, a statistically significantly r e d u c e d local recurrence rate was found in the preoperatively irradiated group. No difference in survival was noted. After a p r o l o n g e d follow-up (>5 years), 324 patients were evaluated in order to find possible late side effects from the bowel, urinary tract or skin; 170 patients had a survival e x c e e d i n g 5 years. Totally 16 (5 percent) of the 324 patients were reoperated because of late small bowel obstruction: 7 of 187 (4 percent) had preoperative irradiation, 6 of 80 (8 percent) had postoperative irradiation, and 3 of 57 (5 percent) had no radiotherapy. Significant morbidity from the urinary bladder occurred in two patients who received preoperative irradiation and in two after postoperative irradiation. Perineal pain and fibrosis were noticed in three patients treated with postoperative irradiation. Conclusion: Since the treatment results after preoperative irradiation was superior to postoperative irradiation and the incidence of significant morbidity was not higher, preoperative irradiation seems to be preferred as adjuvant treatment in patients with rectal carcinoma.

Dis Colon Rectum, April 1991

cinoma were reviewed retrospectively to analyze the results of a b d o m i n o p e r i n e a l resection (APR) for treatment failures. Mean follow up was 34.9 months. Pathology was 24 squamous and six cloacogenic cancers. Twenty-five had negative nodes and five had positive nodes. The group received 5FU, mitomycin-C, and RT 30-50 Gy plus 20 Gy boost for positive nodes. Biopsy was obtained at 6 weeks post therapy; 17 of 22 (77 percent) with primary tumor less than 5 cm and negative nodes are disease free at 37 months post CT-RT. None of the patients (n = 7) with primary tumor greater than 5 cm or positive nodes were free of disease. APR was done for positive biopsy in eight patients and for local recurrence (19 months post CT-RT) in one patient. Eight of nine who had APR d i e d of disease (mean 20 months) and one of nine d i e d of other causes. A review of published series, including our data, reveals 24 cases of APR post CT-RT for positive b i o p s y w i t h 17 of 24 (71 percent) dead of disease within 3 years. APR for CT-RT failures has a poor prognosis. Future protocols may d e t e r m i n e if further CT-RT will improve survival. APR for palliation should always remain an option.

Preservation of Anorectal Function in Advanced Epidermoid Anal Cancer

The Use of Photodynamic Therapy in the Palliation of Massive Advanced Rectal Cancer: A Phase I/II Study

(11)

(9) H. Kashtan, M. Papa, B. Wilson, H. Stern Toronto, Ontario Photodynamic therapy is a relatively n e w form of cancer therapy utilizing a photosensitizer such as Hematoporphyrin Derivative (HpD). We c o n d u c t e d a pilot study to d e t e r m i n e the efficacy of its use in palliating advanced rectal cancer, to d e t e r m i n e toxicity, and to establish objective outcome criteria. Six patients with very advanced, usually recurrent rectal cancer were treated with PDT after being photosensitized with Photofrin II. A protocol was established to measure clinical and radiologic response to therapy. A new intraluminal delivery system was incorporated. Five patients had both clinical and radiological responses to therapy. In two patients we observed such significant responses that they cannot be accounted for on a p h o t o b i o l o g i c basis alone. One patient d e v e l o p e d a significant sunburn, post discharge. There was no major toxicity of b l e e d i n g or sepsis even at maximum doses (200 joules/cm2). We are confident that PDT has a role to play in rectal cancer and speculate as to future applications.

The Results of Abdomino-Perineal Resections for Failures After Combination Chemotherapy and Radiation Therapy for Anal Canal Cancers (10) R. Zelnick, P. Haas, M. Ajlouni, T. Fox, E. Szilagy Detroit, MI Thirty patients treated with combination chemotherapy (CT) and radiation therapy (RT) for anal canal car-

B. J. Cummings . . . . . . . . . . . . . . . . . .

Toronto, Ontario

Although the treatment of e p i d e r m o i d anal cancer with radiation (RT) or c o m b i n e d 5FU, mitomycin, and RT (FUMIR) is widely accepted, some authors have reported that it is difficult to preserve anorectal function if the cancer is bulky, or d e e p l y invasive, or circumferential. Sixty-one patients with one or more of these characteristics were treated with RT or FUMIR (48-50 Gy uninterrupted or split course radiation plus one or two courses concurrent 5FU 1,000 mg/m2/24 hours for 96 hours, and mitomycin 10 mg/m2).

Control of Anal Cancer

Size > 5 cm Invading adjacent organ >-3/4 anal circumference

RT (%)

FUMIR (%)

9/17 (53) 6/14 (43) 2/10 (20)

27/34 (79) 13/17 (76) 12/14 (86)

Anorectal function was preserved in 8 of 23 (35 percent) treated by RT, and in 28 of 38 (74 percent) treated by FUMIR. Function was lost due to fibrosis or necrosis in one patient treated by RT and in three treated by FUMIR. Mild anorectal fibrosis caused increased frequency and urgency of defecation, without incontinence, in 10 percent treated by FUMIR. Radiation plus concurrent 5FU and mitomycin is effective against advanced anal cancers. The finding of a bulky, invasive, or circumferential cancer is not a contraindication to treatment i n t e n d e d to conserve anorectal function.

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Vol. 34, No. 4

Early Radiation Effect on the Anal Sphincter Function (12) J. W. Fleshman, Z. Dreznick, R. D. Fry, I. J. Kodner St. Louis, MO The early effect of pelvic irradiation on the anal sphincter mechanism has not b e e n previously investigated. The purpose of this study was to evaluate prospectively the acute effect of preoperative irradiation on anal function. Methods: A group of 20 patients with rectal carcinoma, mean age of 60.9 years (range 43-83), were subjected to 45 Gy of external beam irradiation. The field of irradiation included the sphincter mechanism in 10 patients and was delivered above the anorectal ring in 10 patients. Anal manometry was p e r f o r m e d in all patients before and 4 weeks after radiotherapy using a 4channel perfused catheter. Results: No significant difference of sensory threshold (SENS), maximal resting pressure (RP), or squeeze pressure (SP) was found before and after radiotherapy (Table 1).

Fine Wire

N e e d l e EMG (n)

Overall Activation No change Inhibition

EMG

EAS

PR

CG

EAS

PR

45 19 14 12

43 18 i8 7

34 10 22 2

16 9 4 3

14 7 3 4

Activation of the pelvic floor muscles occurred during straining in nearly half of the subjects. Most of the r e m a i n d e r showed no measurable change; inhibition of the EAS and PR occurred in only 26 and 16 percent, respectively. Fine wire electrodes and a bolus in the anus y i e l d e d similar results. We c o n c l u d e d that activation of the pelvic floor muscles during straining in the laboratory was a normal finding. Although the finding of pelvic floor inhibition during straining may be useful to exclude the diagnosis of NRP, the finding of paradoxical activation of PR or EAS during straining is of no diagnostic significance.

Table 1 (Mean). Irradiation

PFC Above Include Combined Post Above Include Combined

SENS (cc)

RP ( m m Hg)

SP ( m m Hg)

23 20 22

59 78 73

158 152 155

24 27 26

60 71 66

141 149 145

Rectoanal reflex and balloon expulsion test were normal in all patients before and after irradiation. Conclusions: External pelvic irradiation for rectal cancer was not associated with early dysfunction of the anal sphincter. Sensory threshold was slightly increased after irradiation. Inclusion of the anal sphincter in the field of irradiation had no impact on function.

Is There a Role for Electromyography in the Diagnosis of the "Non-Relaxing Puborectalis Syndrome? (13) R. E. Perry, J. H. Pemberton, W. L. Litchy Rochester, MN The "non-relaxing puberoctalis" syndrome (NRP) is diagnosed with electromyography (EMG) by failure of the pelvic floor muscles to relax during straining. To determine the frequency with which this occurs in normal subjects, concentric n e e d l e EMG of the external anal sphincter (EAS), puborectalis (PR), and coccygeus (CG) muscles was performed on 45 asymptomatic female volunteers aged 18-35, during rest, squeeze, and rehearsed straining. Sixteen subjects had, in addition, fine wire electrode EAS and PR EMG, with a 3-cc balloon in the anal canal to simulate a fecal bolus. Findings: There was an increase in EMG activity in all three muscles in all subjects during squeezing. The response during straining was less predictable.

Relationship Between Anal Canal Tone and Rectal Motor Activity (14) A. Ferrara, J. H. Pemberton, K. E. Levin, R. B. Hanson . . . . . . . . . . . . . . . . . . . . . . . Rochester, MN The anal canal sphincters maintain fecal continence partly by tonic contraction, but little is known about the influence of rectal motility upon this tonic activity. Aim: To evaluate the relationship b e t w e e n anal canal tone and rectal motor activity. Methods: A fully ambulatory system for p r o l o n g e d pressure recording was developed. In eight healthy subjects (5 males, 3 female, mean age 35 years, range 22-43), a flexible transducer catheter (OD 4.5 mm) was introduced endoscopically such that sensors were at 1, 2, 8, 12, 16, and 24 cm from the anal orifice; 24 hour spontaneous motor activity was stored in a 2 MB portable recorder for later transfer to a Microvax II for c o m p u t e r i z e d analysis and display. Mean anal canal tone was calculated and rectal motor c o m p l e x e s (RMCs) characterized. Results: During sleep, anal canal tone showed cyclic depressions (mean periodicity 1.6 hours, range 1-4) during which the mean pressure was 15 + 4 mm Hg (8 2 1 / m m Hg). RMCs were identified in all subjects occurring a mean of 16 times in 24 hours (range 12-22). RMCs had a mean duration of 15.3 minutes (range 8-35), contractile frequency of 2-3/minutes, mean peak amplitudes of 50 60 m m Hg, and a periodicity of 78 + 24 minutes (35-265 minutes). Importantly, a RMC was invariably a c c o m p a n i e d by a rise in anal canal tone and contractile activity (frequency: 2-3 minutes amplitude; 15-20 m m Hg) so that a recto-anal canal pressure gradient was always preserved. Conclusion: Anal canal tone varied greatly, particularly during sleep, when there was a significant decrease in pressure. However, this never occurred during a RMC. This temporal relationship b e t w e e n cyclic variations of anal canal tone

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and rectal motor activity represents a n e w and important mechanism preserving fecal continence. Normal Variation in Anorectal Manometry

05) R. L. Cali, G. J. Blatchford, A. G. Thorson, M. A. Christenson, R. M. Pitsch . . . . . . . . . . .

Omaha, NE

Interest in and use of anorectal manometry as a diagnostic tool has increased in recent years. Debate and uncertainty persist what constitutes normal variations. In an effort to define these variations, 60 volunteers were recruited to undergo anorectal manometry. No volunteers had any anorectal symptoms or pathology. Patients were divided into three groups (male, nulliparous females, and multiparous females). Anorectal m a n o m e t r y using an 8-port perfused catheter was performed. Values for maximum mean pressures and sphincter length were obtained at rest and squeeze and the vector symmetry index (VSI) was calculated. Ranges for each value were established (Fig. 1). The Student's t-test was used to calculate statistical significance. Significant variation was found b e t w e e n males and multiparous females for VSI ( P < 0.05), mean maxi m u m squeeze pressure ( P < 0.001), and calculated sphincter length at rest ( P < .05). These results help to establish a range of normal variation that can be e x p e c t e d in manometric data. Asymptomatic multiparous females tend to have lower pressures, shorter sphincter length, and less symmetry than males or nulliparous females. These variations should be taken into account when evaluating these various subgroups. Biofeedback: A Viable Treatment Option for Anal Incontinence

(16) L. L. Jensen, A. C. Lowry . . . . . . . . . . .

Minneapolis, MN

More and more frequently patients are seen in the office with complaints of anal incontinence. We offer biofeedback to selected patients. We have e n r o l l e d 44

NORMAL SQUEEZE PRESSURE cm water

300 27S L

1

250 > 228 F 200 t 175 I 150 H 125 100 75

patients in our program. Forty-three of these are female. Average age is 50 (range 11-77). Twenty-one patients had idiopathic incontinence. Nine patients were incontinent following sphincter repair or other rectal surgery. The remaining 14 patients were incontinent because of other miscellaneous problems. Twenty-six patients used a pad. Thirty-one patients have c o m p l e t e d treatment. Our results show that the mean change in the n u m b e r of a c c i d e n t s / w e e k was 3.5 (0-7). Using a previously p u b l i s h e d incontinence scoring system (max. score 30), scoring decreased from 16 (12-30) pretreatment to 2 (0-30) posttreatment. EMG pressures increased from 1.4 **V and 2.3 ~V at rest (R) and squeeze (S) prior to treatment to 2.0 #V (R) and 5.8 #V (S) following treatment. Treatment was considered successful in 28 of 31 patients as defined by at least a 90 percent decrease in frequency of incontinence. Of the three failures, two required p e r m a n e n t diversion and one required subsequent sphincteroplasty. Twenty-four improved patients are at least 6 months posttreatment. Twenty-one of those report that their continence level is the same or has continued to improve. The other three returned for a single refresher session and can now maintain continence. We believe biofeedback has a role in the management of select patients. With anal incontinence to improve their quality of life.

What is the Optimum Pelvic Floor Repair for Neuropathic Fecal Incontinence?

(17) M. R. B. Keighley, M. Oya, J. Oritz, M. Pinho, J. Asperer, G. Chattaphaday . . . . . . . . . Birmingham, UK The results of postanal repair (posterior repair) for neuropathic fecal incontinence are disappointing. Anterior levatoplasty and external sphincter plication (anterior repair) is claimed to provide improved results. A pilot study from this unit suggested that a c o m b i n e d anterior and posterior repair (total repair) might be superior to postanal repair. Twenty-nine w o m e n with postobstetric neuropathic incontinence have b e e n r a n d o m i z e d to treatment by anterior (n = 8), posterior (n = 10), or total repair (n = 11). All patients have b e e n studied by anal manometry, mucosal electrosensitivity, and videoproctography. Preliminary clinical results indicate that c o m p l e t e continence to flatus and feces was achieved in 3/8 after anterior repair, 2/10 after posterior repair, and 8/11 after total repair. These data support that total pelvic floor repair is the o p t i m u m operation for w o m e n with postobstetric fecal incontinence.

Dynamic Graciloplasty for Fecal Incontinence (18) C. Baeten} J. Konsten, F. Spaans, P. Soeters,

25 6.0

Dis Colon Rectum, April 1991

A. Habets . . . . . . . . . . . . . . . 5.0

4.0

3.0

c m from a n a l v e r g e

2.0

1.0

Maastricht, The Netherlands

Complete fecal incontinence is a debilitating and distressing disorder, which can often not be treated suc-

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MEETING ABSTRACTS

cessfully. In the past, plastic operations have b e e n developed. The gracilis muscle transportation was rarely successful due to its fatiguability and contraction on volition. In experimental cardiac surgery it has b e e n demonstrated that a skeletal muscle can be reprog r a m m e d by continuous neurostimulation to b e c o m e infatiguable by a change in fiber pattern and to b e c o m e i n d e p e n d e n t of volition. In this study we investigated the effect of neurostimulation of a transposed gracilis muscle in nine patients on their otherwise untreatable incontinence. Leads were implanted in the transposed gracilis and connected to a neurostimulator that was implanted in the abdominal wall. All patients underwent the same training program with the neurostimulator. In the follow-up (mean 32 weeks, range 20-200 weeks) seven patients b e c a m e c o m p l e t e l y continent. One patient had bad results due to nondistention of the rectum in a frozen pelvis, and one patient had an infection leading to removal of neurostimulator and leads. This last patient had promising results after recent reimplantation. All patients were evaluated with anal m a n o m e t r y (74 percent pressure rise) and with an e n e m a test (increase of retention time from 27 to 312 seconds). Defecography showed perfect continence and voluntary defecation when stimulation was disconnected with the help of a magnet. Dynamic graciloplasty gives a continuous contraction i n d e p e n d e n t of volition and leads to satisfactory fecal continence.

Ileal Bacteriology and Pouchitis: An Experimental Study (19) W. R. Schouten, J. G. H. Ruseler van Embden, J. J. A. Auwerda . . . . . . . . . Rotterdam, The Netherlands To investigate the role of bacteria and their metabolites in the pathogenesis of pouchitis, an experimental study was conducted in 15 beagle dogs. After subtotal colectomy an ileostomy was constructed with (n = 5) and without (n = 10) prestomal reservoir. Before and after a 6-week period of progressive, intermittent stoma occlusion in five dogs with conventional ileostomy (Group II) and in five dogs with reservoir (Group III), ileal effluent, bacterial flora, and mucosal m o r p h o l o g y were analyzed. Group I (n = 5, no reservoir, no occlusion) served as control group. Ileostomy occlusion in Group II did not alter bacterial flora, whereas in Group III an increasing numbers of anaerobes were found. After the occlusion period, mucosal m o r p h o l o g y in Group II did not differ from that in Group I. In contrast, all reservoirs showed chronic inflammation with slight mucosal atrophy. In Group II, ileostomy occlusion did not alter blood-group antigenicity of intestinal glycoproteins, whereas in Group III this antigenicity c o m p l e t e l y disappeared, indicating breakdown of the glycoprotein layer. This p h e n o m e n o n was associated with a significant increase in glycosidase activity in Group III. Six weeks after ileostomy construction proteolytic activity (trypsin, chymotrypsin, elastase) was r e d u c e d in Group I and II. In Group Ill, however, this activity did not alter.

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Based on these findings we conclude that chronic inflammation of ileal reservoirs is caused by overgrowth of anaerobes. These organisms p r o d u c e an increased amount of glycosidase-enzymes, resulting in breakdown of protecting mucosal glycoproteins. Further damage is caused by persistent activity of proteolytic enzymes.

Ileal Ecology After Ileoanal Anastomosis with Myectomy (20) P. M. Sagar, P. Goodwin, P. J. Holdsworth, D. Johnston . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Leeds, UK

Ileoanal anastomosis with m y e c t o m y has b e e n advocated as an alternative form of restorative proctocolectomy that eliminates the n e e d to construct an ileal pouch. We have investigated the effect of this p r o c e d u r e on fecal bacteriology, fecal volatile fatty acids, ileal mucosal morphology, and the efficiency of emptying of the "neorecrum." Thirty female adult beagles underwent proctocolectomy with one of four operative p r o c e d u r e s - - s t r a i g h t ileoanal anastomosis (IAA) (n = 7), IAA with myectomy (m) (n = 8), IAA + M + ileal valve (V) (n -- 7), or IAA with J-pouch (P) (n = 8). IAA was associated with a lower ratio of anaerobes to aerobes ( P < 0.01) and lower levels of fecal volatile fatty acids, particularly acetic and propionic acids ( P < 0.05), c o m p a r e d with each of the other operative groups. Mucosal inflammation and the degree of villous atrophy ( P < 0.01) were more marked in the J-pouch group c o m p a r e d with the other procedures. The percentage of stool retained after defecation was greater in the J-pouch group ( P < 0.05). These findings suggest important differences in the ecology of ileal pouches c o m p a r e d with single lumen ileum with and without myectomy. This study lends further support to the concept of ileoanal anastomosis with myectomy.

Comparison of Colorectal Anastomotic Bursting Pressures (ABP) Using Sutured, Stapled, and Biodegradable Auastomotic Ring (BAR) Technique

(21) C. A. Bundy, D. M. Jacobs, M. P. Bubrick Minneapolis, MN Previous comparative studies of sutured, stapled, and BAR colorectal anastomoses have failed to show consistent differences in healing. Although ABP of colorectal anastomoses may be an important determinant of healing, comparative studies of the three techniques have not b e e n performed. The following study was undertaken to compare ABP of colorectal canine anastomoses. Methods: BAR, stapled, and sutured colon anastomoses were sequentially placed in each of the 48 dogs following division of the colon at three equally spaced sites. Four groups of 12 dogs were sacrificed either on day 0, 3, 7, or 28. ABP was measured using a waterbath with colored saline infused into the bowel segment and ABP was r e c o r d e d when colored saline leaked from the bowel. From previous studies, normal canine colonic burst pressure is 434 --+ 89 (range 323-520).

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Day

BAR

0 3 7 28

233 • 63"t 135 + 88* 346 • 58 310 • 87*4

Mean ABP (mm Hg) Suture (SU)

167 + 43# 273 +- 118# 340 • 75 446 -4-83#

Stapled (ST) 69 -4-26 181 + 61 298 + 82 373 +--105

* P< 0.05 BAR vs. SU; + P< 0.05 BAR vs. ST; # P< 0.05 SU vs. ST. Conclusion: BAR anastomoses have the greatest strength on the day of surgery, sutured anastomoses are strongest on the third day, and all are comparable by the seventh day. Bursting pressures for all groups by day 28 approach normal colonic burst pressure, with differences likely reflecting variance in anastomotic fibrosis and luminal area.

Lower Limit of Tissue Blood Flow for Safe Colonic A n a s t o m o s i s ~ A n Experimental Study Using Laser Doppler Flowmetry

Dis Colon Rectum, April 1991

tively. Sixty-nine Sprague-Dawley rats were studied to determine whether fibrin glue improves healing of small intestine anastomoses irradiated intraoperatively with a single dose of 2,000 rads. These rats were divided into three study groups. Group I; ileal anastomosis without radiation, without fibrin glue; Group 2: ileal anastomosis with radiation, without fibrin glue; Group 3: ileal anastomosis with radiation, with fibrin glue. Seven days postoperatively, the rats were sacrificed and the anastomotic segment was tested for breaking (tensile) strength. Anastomotic collagen content was evaluated using a hydroxyproline assay. Tensile strength results demonstrated that Group 2 was significantly weaker than Groups t and 3 and that the hydroxyproline content of Group 3 was significantly greater than Group 2. The results show that the addition of fibrin glue to an intraoperatively irradiated small bowel anastomosis improves healing, demonstrated by both tensile strength and collagen content studies.

Group

N

Tens. Streng. mg (SD)

HydroxyprolineCont. t~g/mg dry wt. (SD)

1 2 3

23 23 23

60.6 (23.7) 38.2 (21.3) 60.7 (23.7)

13.3 (4.7) 11.4 (4,0) 15.6 (6.7)

(22) H. Kashiwagi, F. Konishi, K. Kanazawa Tochigiken, Japan Laser doppler flowmetry was used to clarify the lower limit of colonic tissue blood flow for safe anastomosis of the colon in an experimental study. A preliminary study showed a good correlation between laser doppler flowmerry and hydrogen gas clearance method with the r value of 0.91; 22 dogs were divided into three groups according to the length of devascularization at the coIonic end for anastomosis; i.e., Group A, 2 cm; Group B, 4 cm; and Group C, 6 cm. The mean laser doppler values at the devascularized e n d of the colon measured from the serosal side in the three groups were, 1.0, 0.8, 0.6. The leakage rate in the three groups were 0 percent (0/ 7), 15 percent (1/6), and 78 percent (7/9). There was a significant difference in laser doppler value between the dogs with leakage and those without. The dogs with leakage showed the laser doppler value lower than 0.8. It is concluded that the lower limit of colonic blood flow for safe anastomosis measured from the serosal side is considered to be slightly higher than 0.8 in laser doppler value. Based on this result the application of this method for the intraoperative measurement of colonic tissue blood flow in colorectal surgery will become possible.

Fibrin Glue Improves Healing of Irradiated Bowel Anastomoses

(23) D. O. Woodland, T. J. Saclarides, M, S. Bapna Chicago, IL Many surgeons have concern when dealing with irradiated bowel anastomoses. Previous studies have demonstrated diminished tensile strength of small bowel anastomoses which have b e e n irradiated intraopera-

1 vs. 3 tensile str. not significant. Hydroxyproline content Group 3 significantly greater than Groups 1, 2. Local Immunity and Metastasis of Colorectal Carcinoma (24)

Y. Kubota, K. Sunouchi, M. Ono, T. Muto Tokyo, Japan The spread of tumor cells from a primary neoplasm to distant organs and the production of metastasis is the most devastating aspect of cancer. The outcome of the process has b e e n shown to d e p e n d on host defense mechanism. Therefore, we investigated the local immunity in metastasis of colorectal carcinoma. The subsets of tumor infiltrating lymphocytes (TIL) and prostaglandin (PG) E2 was measured in the resected tissues of 20 colorectal cancers without metastases and 11 with metastases. Subsets of TIL (Leu 1, Leu 2a, Leu 3a, Leu 10, Leu 11; Becton-Dickinson Co.) were detected by immunohistochemical staining of frozen tissues. The n u m b e r of positive cells were counted and expressed as n u m b e r positive per 250 x 250/~m 2. The n u m b e r of T cells (Leu 1) and natural killer cells (Leu 11) were larger in early (mucosal and submucosal) cancers and decreased in parallel with the presence of metastasis (control n = 9: 89 + 28, 6 -+ 4; early cancers n = 9 : 2 6 9 + 112,* 76 + 56*; advanced cancers without metastases n = 11:182 --80,* 56 + 59*; advanced cancers with metastases n = 11: 76 +__ 42,* 26 -4- 21,* P < 0.05 ANOVA). The level of PGE2 from the draining vein was higher than those from both feeding artery and the periphery vein. The V/A ratio of cancers with metastases was significantly higher than those of cancers without metastases. (13.2 +-- 2.4 vs. 5.6

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Vol. 34, No. 4

-4- 0.8). TIL was decreased in parallel with the increase of PGE2 V/A ratio. We conclude that TIL and PGE2 may play an important role in metastasis of colorectal carcinoma and that PGE2 have adverse effect in suppressing local immunity.

Preoperative studies of pelvic floor physiology should be considered investigational at this time.

DNA Ploidy Pattern of Colonic Flat Adenoma

S. D. Wexner, N. Daniel, D. G. Jagelman Ft. Lauderdale, FL

(25) T. Muto, T. Masaki, K, Suzuki, M. Adachi Tokyo, Japan In an attempt to clarify the nature of "fiat adenoma," DNA content was measured by means of microspectrophotometry. Thirty-nine fiat a d e n o m a s (FA). 13 with mild, 22 with moderate, and 4 with severe atypia were collected for this study. In FA, diploidy, polyploidy, and a n e u p l o i d y was found 100, 0, 0 percent in mild atypia, 41.9, 4.5, 54.5 percent in moderate atypia, and 0, 0, and 100 percent in severe atypia, respectively. FA seems to have much higher malignant potential than previously expected, because in particular FA with moderate atypia more than 5 mm showed a n e u p l o i d y in 93 percent. These data suggest that flat adenomas with moderate atypia play an important role in the pathogenesis of small colonic carcinomas.

Assessment of Anorectal Physiology Prior to Subtotal Colectomy for Chronic Constipation (26) J. A. Heine, W. D. Wong, S. M. G o l d b e r g Minneapolis, MN Anorectal physiologic assessment was carried out on 18 patients (16 females, mean age 44.4 years) with chronic constipation prior to subtotal c o l e c t o m y in an attempt to define the role of these studies in the selection of patients for surgical management. Preoperative stool frequency ranged from every 7 to 30 days. Six patients strained at stool for longer than 30 minutes. Eight patients had abnormalities of anorectal physiology including high resting anal pressure (2), d i m i n i s h e d rectal sensation (2), and non-relaxation of the puborectalis (5). There was no mortality. Small b o w e l obstruction occurred in five patients (28 percent) and two required laparotomy. Functional outcome was assessed at a mean of 29 months (8-54). Sixteen patients (89 percent) had at least one bowel m o v e m e n t daily. Two patients with intractable constipation required ileostomies and difficult defecation persisted in four. Three of these six patients with suboptimal outcome had a rion-relaxing puborectalis although this abnormality was not predictive of poor outcome at a statistically significant level (chbsquare, P > 0.05). We conclude that subtotal colectomy for constipation results in an acceptable outcome for most patients. Caution should be observed before submitting patients with abnormal pelvic floor physiology to surgical treatment, even though some will benefit.

Colectomy for Constipation: Preoperative Physiologic Investigation Is the Key to Success (27)

The results of total abdominal colectomy with ileorectal anastomosis (TAC) as a treatment for colonic inertia (CI) were prospectively assessed. 112 patients were evaluated for chronic constipation b e t w e e n July 1988 and March 1990. Patients underwent pancolonic transit times, anorectal manometry, cinedefecography (CD), and electromyography (EMG). CI was defined as diffuse marker delay on transit study without evidence for paradoxical puborectalis contraction on CD or EMG. 13 patients (10.7 percent; 12 females and 1 male) of a mean age of 49 (range 24-75) years with CI underwent TAC. Preoperative bowel frequency ranged from three p e r w e e k to one per month; all 13 patients evacuated only with high doses of laxatives, enemas, or both. TAC was p e r f o r m e d with no postoperative mortality or major morbidity; two patients were readmitted 3 and 4 weeks after surgery, respectively, and both underwent successful conservative treatment for partial small bowel obstruction. At a mean follow-up of 14 (range 5-26) months, these 13 patients reported a mean frequency of spontaneous daily bowel evacuation of 3.0 (range 1-7). No patients continued to use laxatives or enemas, and patient satisfaction with the operation was "excellent" or "good" in 12 patients (92 percent) and satisfactory in one patient. No patient r e p o r t e d worsening of symptoms. Thorough preoperative physiologic evaluation permits the selection of a small group of patients with colonic inertia who may benefit t r e m e n d o u s l y from total abdominal colectomy with ileorectal anastomosis.

Internal Rectal Intussusception--Cause or Effect of Obstructed Defecation: Results of Surgical Treatment

(28) J. Christiansen, O. Rasmussen, B.-W. Zhu Copenhagen, Denmark Twenty-one patients with obstructed defecation and defecography demonstrating internal rectal intussusception were treated surgically. None were incontinent, and anorectal m a n o m e t r y and electromyography studies were normal. Median rectal compliance were lower although not significantly so than in an age- and sexmatched control group. The patients were treated by abdomino-rectopexy, 14 by Ivalon sponge technique, and seven by Orr's fascia sling method. Follow-up after 6 months to 4 years showed that 19 patients were cured of the rectal intussusception as demonstrated by defecography. Only 10 were improved and nine were unchanged. These results suggest that internal rectal intus-

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susception may not be the cause, but rather an effect of obstructed defecation of otherwise unknown etiology. The intussusception may aggravate defecation disorders as shown by the improvement obtained in half of the patients, but defecographically demonstrable intussusception should not necessarily be an indication for surgical treatment.

Treatment of Rectal Prolapse in the Elderly by Perineal Rectosigmoidectomy (29) J. G. Williams, D. A. Rothenberger, J. L. Schottler, S. M. G o l d b e r g . . . . . . . . . . . . . . . . . . . Minneapolis, MN Many patients with rectal prolapse are not suitable candidates for abdominal repair, and a variety of perineal approaches have b e e n described. Of these, we favor perineal rectosigmoidectomy, which we p e r f o r m e d on 114 patients during the last 10 years. Their ages ranged from 21-100 years; 80 percent were aged over 70 years. Preexisting medical p r o b l e m s were present in 81 patients (71 percent), Cardiac disease was present in 68 (60 percent) and 21 (18 percent) suffered with dementia. Median hospital stay was 4 days (range 2-25 days). There were no deaths and complications d e v e l o p e d in only 14 patients (12 percent). Bleeding from the suture line occurred in three patients and there were no anastomotic leaks. Ten patients were lost to follow-up. Median follow up of the remaining patients was 12 months (interquartile range 4-36). Eleven patients (10 percent) d e v e l o p e d a recurrent rectal prolapse 3-48 months after surgery. Six patients underwent repeat rectosigmoidectomy. Sixty-six patients (64 percent) had varying degrees of incontinence prior to surgery. Sixteen (24 percent) regained full continence and a further 19 (29 percent) improved. Twenty-six patients (39 percent) r e m a i n e d the same, and in five patients (8 percent) the d e g r e e of incontinence deteriorated further. These results show that perineal rectosigmoidectomy is an effective operation for rectal prolapse in the elderly high risk patient. Morbidity, length of hospital stay, and recurrence rates are low. Improvement in continence is less than following an abdominal procedure.

A Prospective Assessment of Biofeedback for the Treatment of Paradoxical Puborectalis Contraction

(30) S. D. Wexner, S. Heyman, F. Marchetti, D. G. Jagelman . . . . . . . . . . . . . . . . . Fort Lauderdale, FL One hundred consecutive patients were prospectively evaluated for chronic constipation. All patients underwent colonic transit study, anal manometry, cinedefecography (CD), and concentric n e e d l e electromyography (EMG). Fourteen patients (11 females and 3 males) of a mean a g e o f 62 (range 10-84) years who had paradoxical puborectalis contraction (PPC) identified as the etiology for the constipation were referred for biofeedback. Prior t o biofeedback, none of these 14 patients had any unassisted bowel movements (BMs). Twelve patients had

Dis Colon Rectum, April 1991

laxative-assisted BMs a mean of 4.3 (range 1 7) times weekly. Seven patients had enema-assisted BMs a mean of 2.0 (range 1-3) times weekly. Patient underwent a mean of 9.8 (range 5-19) 1-hour computer assisted biofeedback sessions using an intra-anal EMG sensor. After biofeedback retraining, these 14 patients had a mean of 8.2 (range 1-21) unassisted w e e k l y BMs. Two patients continued to take laxatives less than once each week, and two patients took one and three w e e k l y enemas, respectively. These latter two patients considered the treatment to have b e e n a failure. The other 12 patients rated their i m p r o v e m e n t as "excellent" for an overall success rate of 86 percent at a mean length of follow-up of 8.2 (range 1 to 15) months. No biofeedback-associated complications were identified. EMG-based anal biofeedback is a valuable and relatively noninvasive technique associated with an 86 percent success rate in the treatment of PPC.

Mucinous Carcinoma: Just Another Colon Cancer?

(3i) J. B. Green, A. E. Timmcke, T. C. Hicks, J. E. Ray, J. B. Gathright . . . . . . . . . . . . . . . . . . . New Orleans, LA The significance of mucinous carcinoma has b e e n controversial since first described by Parham in 1923. Previous reports have suggested mucinous tumors affect younger patients, involve more proximal colon, are more advanced at the time of diagnosis, and have a poorer prognosis than non-mucinous colon carcinoma. More recent reports have refuted these results. In an effort to clarify the significance of mucinous histology, a retrospective review of patients with invasive colon cancer treated at the Ochsner Clinic b e t w e e n 1982 and 1985 was undertaken. Mucinous adenocarcinoma, as defined by _> 50 percent mucin, was found in 57 patients. During the same time period, 407 non-mucinous adenocarcinomas were resected. The mean age, distribution within the colon, stage at diagnosis, and survival of mucinous carcinoma patients were c o m p a r e d with those with nonmucinous tumors. Mucinous tumors p r e s e n t e d at a statistically significant more advanced stage (38 percent vs . 21 percent Dukes' C lesions, P < 0.01). No significant differences were seen in age at presentation, distribution within the colon, or stage for stage survival. In our experience, mucinous adenocarcinoma presents at more advanced stage, but otherwise acts similarly to nonmucinous adenocarcinoma.

Colorectal Cancer and Pregnancy

(32) M. A. Bernstein, R. D. Madoff, P. F. Caushaj Worcester, MA Colorectal cancer presenting in pregnancy is an unc o m m o n disease that is r e p o r t e d to be associated with an extremely p o o r prognosis. Because of the rarity of this condition, only small series have b e e n reported in the literature. In order to better characterize this disease, we mailed 1,529 questionnaires to the m e m b e r s h i p of

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MEETING ABSTRACTS

the ASCRS. Thirty-four w o m e n with large b o w e l cancer who presented during pregnancy or in the i m m e d i a t e postpartum period were identified. The mean age at presentation was 30.4 years. Tumor distribution was as follows: right colon 3, transverse colon 1, descending colon 2, sigmoid 4, rectosigmoid 3, and rectum 21. Dukes' stage at presentation was A - - 0 , B - - 1 1 , C--15. Eight patients p r e s e n t e d with hepatic metastases. Mean survival was 41 months. Patient status was: alive, no evidence of disease, 13 (mean follow-up 72 months); alive with disease, 5 (mean follow-up 26 months); d i e d of disease, 16 (mean survival 17 months). Our data demonstrate that large bowel cancer associated with pregnancy presents in a distal distribution with 24 of 34 (71 percent) lesions located in the rectum or rectosigmoid. The disease presents an advanced stage with 22 of 34 (65 percent) patients having nodal a n d / o r hepatic metasases at the time of diagnosis. Our data confirm the poor prognosis associated with this lesion.

DNA Flow Cytometry in Colorectal Cancer: Clinicopathologic Correlations with Ploidy Status in 100 Patients

Pll

edly falls short of the true risk of d e v e l o p i n g a metachronous lesion over time because it does not account for patient death due to other causes. To d e t e r m i n e a more accurate estimate of the true risk of metachronous lesions, 2,118 patients with colorectal cancer were studied. To minimize the influence of synchronous lesions, metachronous lesions were defined as those occurring greater than 2 years after the primary colon cancer. Metachronous cancers were identified in 33 patients, for a crude rate of 1.5 percent. The cumulative risk for d e v e l o p i n g a metachronous lesion was calculated by summing the rates for the population at risk each year after the diagnosis of the primary lesion. At the end of 15 years, the cumulative risk was five times that of the crude rate (7.5 percent). Therefore, the true, cumulative risk of metachronous colorectal cancers is higher than that c o m m o n l y reported. This emphasizes the increased risk that patients with colorectal primaries have for developing a metachronous lesion.

The Prognostic Significance of Location of Lymph Node Metastases in Colorectal Cancer

(33)

(35)

Detroit, MI

H. Shida, T. Yamamoto, T. Machida, T. Imanari Tokyo, Japan

R. Zelnick, R. J. Zarbo, C. K. Ma, T. Fox Jr. DNA flow cytometry was p e r f o r m e d using a 2-color multiparametric technique, d e v e l o p e d at our institution, on 100 fresh mechanically dissociated tumors from patients undergoing colon and rectal cancer resections b e t w e e n 1988 to 1989. Thirty-five tumors were diploid and 65 were aneuploid, with mean age at resection of 67 years (range 33-90 years). There was no statistical correlation (Student t-test) b e t w e e n p l o i d y status and clinicopathologic parameters such as age ( P > 0.85), sex ( P > 0.63), size ( P > 0.15), depth of invasion ( P > 0.62), grade ( P > 0.2), lymph node status ( P > 0.79, vascular invasion ( P > 0.46), lymphocytic infiltrate ( P > 0.66), fibrosis ( P > 0.76), and tumor peripheral b o r d e r ( P > 0.62). The Dukes' stage distribution of this series was comparable to historical colorectal controls. Ploidy status did not correlate with individual Dukes' stages or comb i n e d Dukes' A + B v s. Dukes' C + D stages. The incidence of a n e u p l o i d y was Dukes' A - - 7 9 percent, Dukes' B - - 5 7 percent, Dukes' C - - 6 6 percent, and Dukes' D - - 6 8 percent. Ploidy status appears to be unrelated to the other numerous clinicopathologic parameters traditionally considered in the assessment of colon and rectal cancers.

The True Incidence of Metachronous Colorectal Cancer (34) R. L. Cali, G. J. Blatchford, A. G. Thorson, M. A. Christenson, R. M. Pitsch . . . . . . . . . . . Omaha, NE The benefit of lifelong colonic surveillance to detect metachronous lesions has b e e n well established. The crude rate of developing a metachronous lesion has b e e n variably estimated from 0.6 to 3.6%. This figure undoubt-

The prognostic value of stage of nodal metastases was evaluated for 357 patients who underwent curative resection for colorectal cancer. Cumulative 5-year disease-free survival rate (5DFSR) was 63 percent in Dukes' C patients. Subdivision of Dukes' C patients according to n u m b e r of positive nodes revealed that 5DFSR was 66 percent for patients with 1-3 nodes and 53 percent in those with 4 or more nodes. Division according to location revealed that 5DFSR was 72 percent in those who had only local node metastases, c o m p a r e d with 39 percent in those who had distant nodal metastases along the major vessels. Although the n u m b e r and location were correlated, there were 12 patients who had only one positive distant n o d e with no local n o d e involvement. Their 5DFSR was lower than those who had 4 or more positive local nodes (27 v s . 59 percent). Lymph node dissection had b e e n performed with either high or low ligation of the major vessel. In the case of distant n o d e metastases, higher 5DFSR was noted in patients with high ligation than in those with low ligation (45 v s . 28 percent). We conclude that the location, rather than the number, of nodal metastases has a higher impact on prognosis in colorectal cancer.

Postoperative Adjuvant Radiotherapy in Astler-Coller B2 and C Rectal Cancer (36) J. Y. Wang, Y. T. You, R. P. Tang, J. S. Chen, C. R. Chang-Chien . . . . . . . . . ......... Taipei, Taiwan Between 1979 and 1983, 127 patients (RT-group) with and 122 (S~group) without postoperative and adjuvant

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radiotherapy were c o m p a r e d to d e t e r m i n e the effect of postoperative radiotherapy on the survival and disease failure. Each group was stratified into subgroups according to substage and tumor differentiation: subgroup BW (stage B2 and well differentiated tumor), BM (stage B2 and moderately differentiated), CW (stage C and well differentiated), CM (stage C and moderately differentiated), and P (all poorly differentiated). About 95 percent of living patients were followed for a m i n i m u m of 5 years. Postoperative radiotherapy led to a r e d u c e d 5year survival rate in subgroup BW (87 vs. 67 percent, P = 0.02). In the remaining subgroups, there was a trend the RT-group had worse survival rate (65 vs. 56 percent, 64 vs. 47 percent, and 46 vs. 41 percent for subgroup BM, CW, and CM respectively). The local failure rates were 10 vs. 23 percent, P = 0.15 in subgroup BW; 32 vs. 21 percent, P = 0.4 in subgroup BM, for S-group and RTgroup, respectively. Nine percent had severe or lifethreatening radiation-related complications. Postoperative adjuvant radiotherapy alone did not improve the survivals of patients with stage B2 or C rectal cancers. It even led to worse prognosis in those patients with well differentiated and stage B2 rectal cancer.

Recurrence Pattern After Hepatic Resection for Colorectal Metastases. (37) K. Sugihara, K. Hojo, Y. Moriya, H. Hasegawa Tokyo, Japan A total of 159 patients with hepatic metastases from colorectal cancers underwent hepatic resection b e t w e e n 1978 and 1989 at National Cancer Center Hospital in Japan. Of them, 109 had curative hepatic resection, excluding 6 with non-curative resection of primary tumors, 19 with extrahepatic metastases, 7 with residual tumors in the liver, and 18 with cancer positive surgical margin. All 107 except 2 hospital deaths were followed by periodical examinations including CEA assay, abdominal ultrasound, c o m p u t e d tomography, and chest x-ray. The 3year and 5-year survival rate was 56.6 and 37.2 percent, respectively (by Kaplan-Meier test). Patients with metachronous metastases showed the better survival rate than those with synchronous ones with statistical signiL icance (by generalized Wilcoxson test). Other possible determinants of prognosis failed to show the differences in a survival rate among the subgroups. During the average follow-up of 30.6 months, 58 were found to have recurrent diseases; hepatic recurrence in 33, pulmonary in 17 and local in 9. Hepatic recurrent tumors were d e v e l o p e d at the initial resection region in 10, the other segment of the same hepatic lobe in 9, the other hepatic lobe in 6, and the both lobes with multiple tumors in 8. Of 10 developing recurrent tumors at the resection region, two could not have d e v e l o p e d them if initial resection was more extensive. They were only 2.5 percent of 81 who had limited partial hepatic resection.

Dis Colon Rectum, April 1991

Thoracotomy for Colorectal Cancer Metastases

(38) B. Krueger, T. J. Saclarides, W. Warren, L. P. Faber Chicago, IL We reviewed the charts of 91 patients with colorectal metastases to the lung. Since 1978, 23 patients underwent a total of 35 thoracotomies to eradicate metastases, which were synchronous in two cases and metachronous in 21. The synchronous metastases were resected 1 and 30 months after b o w e l resection. Identification and resection of the metachronous metastases followed colorectal resection by an average of 33 months. Sex distribution was equal; average patient age was 57 (22-69) years at the initial diagnosis of cancer. The primary site was colonic in 65 percent, rectal in 35 percent. Available pathology revealed that 13 percent were Duke's A (modified), 25 percent were Duke's B, 44 percent were Duke's C, and 19 percent were Duke's D. Adjuvant therapy was given to 35 percent prior to thoracotomy and to 26 percent following pulmonary resection. Average survival following initial diagnosis of the colorectal primary was 47 (9-197) months in the thoracotomy patients vs. 33 months for those with n o n r e s e c t e d thoracic metastatic disease. Forty-one percent of patients with resected pulmonary disease survived 5 years from the initial diagnosis of colorectal cancer. Comparisons will be p r e s e n t e d in patient demographics and survival data for groups with and without thoracotomy for metastatic disease. We conclude that, for selected patients with thoracic colorectal metastases, thoracotomy should be p e r f o r m e d even if multiple procedures are required. Physician Performance Profiles: Utilization and Quality Monitoring (39) M. E. Abel, Y. S. Y. Chiu, T. R. Russell, P. A. Volpe San Francisco, CA During the 1980s physicians and hospitals were pressured to reduce length of stay by government as well as private insurers. The e n d of the decade brought a shift from intensive utilization review to quality care monitoring. The approach for the 1990s has b e c o m e outcome assessment and establishment of practice parameters. In the selection of providers, outcome is b e i n g assessed more critically by employers and third party payors. An institutional experience in the establishment of departmental and physician performance profiles is presented. Data were derived from quality and utilization monitoring in caring for surgical patients. Colorectal procedures were p e r f o r m e d on 483 patients over a 2year period. Large b o w e l resection was d o n e on 197 of these patients. The average length of stay for patients u n d e r g o i n g colorectal resection was 12.34 days in 1988 and decreased to 11.7 days in 1989. Utilization of ancillary services demonstrated the following patterns, expressed as percent of charges, from 1988 to 1989 respectively: imaging 3 and 2 percent, pharmacy 15 and 14 percent, and laboratory 13 and 12 percent.

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Quality assurance department review revealed a mortality of 1.3 percent (1988) and 0 percent (1989). The morbidity was 7.2 percent in 1988 and 4.0 percent in 1989. Departmental and physician performance profiles have b e e n established at our institution and will be p r e s e n t e d in substance. Such information will allow for comparative outcome analysis of surgical specialists.

A Prospective Randomized Trial of Impatient v s . Outpatient Bowel Preparation for Elective Colorectal Surgery (4O) R. C. Frazee, J. Roberts, S. Symmonds, S. Snyder, J. Hendricks, R. Smith . . . . . . . . . . . . . . . . . Temple, TX A prospective randomized trial of inpatient v s. outpatient bowel preparation for elective colorectal surgery was performed in 100 consecutive patients. Bowel preparation was standardized for both groups and consisted of 4 liters of Colyte and oral n e o m y c i n and flagyl the day before surgery. The patients were r a n d o m i z e d within four subcategories: ileocolostomy, colocolostomy, abdominal perineal resection, and other. Tap water enemas were administered on the morning of surgery to assure an adequate mechanical prep. Ninety-six percent of the inpatient group and 97 percent of the outpatient group were able to drink 3/4 or more of the oral lavage p r e p ( P - - 0.789, Fischer's exact test). A mean of 2.26 tap water enemas was required to achieve clear returns for the inpatient group c o m p a r e d with 2.28 tap water enemas for the outpatient group ( P = 0.221, Fischer's exact test). The adequacy of the bowel p r e p as graded by the primary surgeon was g o o d 93 percent, fair 4 percent, and p o o r 4 percent for the inpatient group and g o o d 84 percent, fair 13 percent, and p o o r 3 percent in the outpatient group (p -- 0.673, Fischer's exact test). W o u n d infection develo p e d in 4 percent of the inpatient group and 4 percent of the outpatient group ( P = 1.0, Fischer's exact test). Anastomotic leak or intra-abdominal abscess was seen in one patient in each group ( P = 1.0, Fischer's exact test). We conclude that outpatient bowel preparation is equally effective to inpatient for elective colorectal surgery and offers the advantage of cost savings and shorter hospitalization.

The Safety of Primary Closure in the Management of Penetrating Colon Trauma

(41) N. Merchant, H. Hashmi, T. Scalea, R. Whelan Brooklyn, NY A retrospective review of 157 consecutive patients who sustained penetrating colon injuries was undertaken. Eighty-seven percent of the patients had gun shot wounds and 13 percent had stab wounds. Operative treatment included: 1) primary closure in 89 patients (56 percent), 2) colostomy and mucus fistula or Hartmann's

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pouch in 60 patients (38 percent), 3) exteriorized repair in 4 (3 percent), 4) primary repair with proximal diversion in 3 (3 percent). The severity of injury was assessed by determining the presence of hypotension (BP <80 systolic), the transfusion requirements, and the n u m b e r of associated injuries. For the primary closure group (n = 89), 20 percent were hypotensive, 14 percent required 3 or more units of blood, and 50 percent of patients had 2 or more associated visceral injuries. For those requiring colostomy, 45 percent p r e s e n t e d with hypotension, 55 percent received 3 or more units of blood, and 59 percent had two or more associated injuries. Intra-abdominal infections, including abscesses, anastomotic leaks, and fistulas, occurred in three patients (3 percent) of the primary closure group and in 13 (22 percent) of those who had colostomies. Seventy-seven percent of those patients with colostomies who develo p e d intra-abdominal infections required 7 or more units of b l o o d and had two or more associated injuries. The overall mortality was 4 percent (6 patients). All six patients had colostomies, four received greater than 20 units of blood, and five had three or more associated injuries. These results suggest that the d e v e l o p m e n t of intraabdominal infections in patients with penetrating colon trauma is related more to the overall severity of injury than to the m e t h o d of colon w o u n d management. Furthermore, primary closure is a safe alternative and appears to be the p r o c e d u r e of choice in the majority of patients with colon injuries. The precise criteria for patient selection for primary closure have yet to be identified.

Small Bowel Obstruction (SBO) After Colon Resection (42) C. N. Ellis, H. W. Boggs, G. W. Slagle, P. A. Cole Shreveport, LA To d e t e r m i n e the etiology and outcome of patients with SBO following a colon resection for benign and malignant diseases, the medical records of 118 patients who underwent 120 laparotomies for small bowel obstruction occurring over 30 days after a colon resection were reviewed. Contrary to other reports, benign adhesions were the most c o m m o n etiology, causing the obstruction in all patients with a history of benign colon disease, 82.6 percent of patients with a history of adenocarcinoma of the colon, and 30.1 percent of patients with known recurrent malignancy. The morbidity and mortality was 36.9 and 0 percent for those with a benign obstruction, and 53.8 and 23.1 percent, respectively, for those with a malignant etiology ( P < 0.008). Gangrenous bowel was not found in any patient with a malignant obstruction but was present in 6.5 percent of patients with adhesive SBO ( P < 0.008). In patients with SBO the outcome is more related to the etiology of the obstruction. Considering the high likelihood of adhesive obstruction in patients with a history of, or known, metastatic colorectal carcinoma, and the increased risk of

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MEETING ABSTRACTS

intestinal gangrene with adhesive SBO, it is suggested that a history of colorectal malignancy not deter surgeons from aggressive early surgical intervention in these patients who develop SBO.

Ischemic Colitis: Patients and Prognosis (43) W. E. Longo, B. J. Gusberg, G. H. Ballantyne New Haven, CT Although segmental ischemic injury to the large intestine is often a self-limited event, it can lead to fulminant necrosis and death. We reviewed 47 patients from 19781985. The mean age at presentation was 56.2 years with a 2.2:1 male predominance. In 32, symptoms occurred without a prior h e m o d y n a m i c event. Ten d e v e l o p e d ischemic colitis in the hospital and an additional six after aortic surgery. Associated diseases were: diabetes (17 percent), renal failure (5 percent), and hematological disorders (5 percent). Sixty-one p e r c e n t were d i a g n o s e d at the time of exploratory laparotomy. The mean delay in diagnosis was 1.8 days (range 3 hours to 23 days). In 21 patients the right colon was ischemic, and 19 had rectosigmoid involvement; 15/16 patients were successfully treated nonoperatively with antibiotics and bowel rest. Among the 31 requiring intestinal resection, enteric continuity was reestablished in 14; second-look laparoto m y (8 patients) revealed further ischemia in two (20 percent). Overall, operative mortality was 29 percent (9/ 31). No patient has d e v e l o p e d recurrent ischemia (mean follow-up 5.3 years). Ischemic colitis often occurs without an obvious predisposing event, it can involve all segments of the large intestine, and frequently requires surgery. Although its course may be self-limited, elderly and diabetic patients and those d e v e l o p i n g ischemia following aortic surgery or hypotension, continue to have a poor prognosis.

Dis Colon Rectum, April 1991

one case where laparotomy was normal and in the other the patient was in the agonal stage of AIDS. Survival was 89 percent at 1 month and 48 percent at 6 months from laparotomy. Carefully selected AIDS patients can survive surgery for major intra-abdominal sepsis and necrosis. The perioperative mortality of e m e r g e n c y laparotomy is lower than previously suggested. The Clinical Conundrum of Solitary Rectal Ulcer (45) J. Tjandra, V. W. Fazio, I. C. Lavery, J. M. Church, J. R. Oakley, J. W. Milsom . . . . . . . . . . . . Cleveland, OH A retrospective study of 80 patients with biopsy-proven SRU was conducted to review its clinical spectrum. The median follow-up was 25 months. The F:M ratio was 1.4:1 and the mean age was 48.7 years. Principal symptoms were rectal b l e e d i n g (56 percent), constipation (35 percent), and excessive straining at defecation (28 percent). Twenty-one patients (26 percent) were asymptomatic and required no treatment. A previous "wrong" diagnosis was made in 25 percent. Rectal prolapse was identified in 26 percent (overt 15 percent, occult 11 percent). Proctoscopy revealed ulcerated lesion in 29 percent (always symptomatic), a p o l y p o i d mass in 44 percent (which p r e d o m i n a t e d in the asymptomatic group), and edematous hyperemic mucosa in 27 percent. Management by bulk laxatives and bowel retraining led to symptomatic i m p r o v e m e n t in 19 percent of cases (Table 1). In 30 percent of cases, symptOms persisted despite healing of the lesion. Intractability led to surgery in 27 (34 percent) patients. Conclusions: The macroscopic appearance of SRU has a significant bearing on the clinical course. The p o l y p o i d variety tends to be asymptomatic and w h e n symptomatic, tends to r e s p o n d to therapy more favorably than nonTable 1. Treatment in Symptomatic Patients

Emergency Laparotomy in AIDS (44) T. Davidson, T. G. Allen-Mersh, B. Gazzard, A . J . G . Miles, C. Wastell, M. Viponde, A. Stotter, R. F. Miller, N. Fieldman, W. W. Slack London, UK We have reviewed experience with e m e r g e n c y laparotomy in AIDS (Centers for Disease Control Grade 4) patients over a 3-year p e r i o d from three inner city hospitals whose HIV units treat >2,000 AIDS patients/year. Twenty-eight patients underwent e m e r g e n c y laparotomy. The c o m m o n e s t indication was acute colitis (seven patients) complicated by toxic m e g a c o l o n in five and colonic perforation in two patients. Treatment was by total colectomy and ileostomy. Intestinal lymphoma producing perforation or obstruction occurred in five patients, appendicitis in five patients, and mycobacterial (MAI) infection in four patients. Overall, 22 patients were treated by resection or perforation closure, and four underwent lymph node biopsy for MAI. Surgery was inappropriate in two patients, in

Symptomatic Improvement

Macroscopic Lesion

Nonoperative (%)

Surgery (%)*

Ulcer Polypoid Hyperemic

2/24 (8) 6/18 (33) 3/17 (18)

7/13 (54) 10/12 (83) 3/6 (50)

* Thirty-one procedures in 27 patients: local excision (n = 6), rectopexy (n = 10). resection (n = 10), diversion (n = 2), and miscellaneous (n = 3). polypoid varieties. Most cases do not require surgery and the optimal surgical p r o c e d u r e remains unclear. Colonic Carcinoids in Connecticut: Incidence, Distribution, and Survival (46) P. E. Savoca, G. H. Ballantyne, J. T. Flannery, I. M. Modlin . . . . . . . . . . . . . . . . . . . . . . New Haven, CT Population based studies of colonic carcinoids have not previously b e e n reported. Consequently, the aims of

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MEETING ABSTRACTS

this study were threefold: first to d e t e r m i n e the true incidence of colonic carcinoids in Connecticut from 1975-1986, second to compare the site distribution of these lesions with that of ordinary colon cancer in the same population, and finally to examine survival and cause of death in these patients. Age-specific incidence and percent distribution were calculated based on 1970 census data, while survival was calculated using the Kapplan-Meyer method. Carcinoids of the a p p e n d i x were excluded. Complete follow-up was a c c o m p l i s h e d in 96 percent of cases. A total of 54 cases of either benign or malignant carcinoids of the colon were reported: 23 males and 31 females. Average age was 64.1 ___8.7 years (mean + SEM) with a range of 12-83 years. This is nearly identical to that of adenocarcinoma. The age adjusted incidence of carcinoids was 1.21/100,000 p o p u l a t i o n / year about 1/33 that of colonic adenocarcinoma. Although adenocarcinoma of the colon is still predominantly left-sided (67 percent), 50 percent of carcinoids were located in the cecum, and only 27 percent occurred in the left colon. The n u m b e r of carcinoids occurring in the ascending colon (16 percent), transverse colon (6 percent), and left colon (10 percent) were comparable to adenocarcinoma. Two-year survival of all patients with colonic carcinoids was 63 percent as c o m p a r e d with 80 percent of adenocarcinoma, whereas five-year survival was 37 percent. Almost 20 percent of patients survived more than 5 years, and death due to carcinoids was observed in this population up to 7 years after the time of diagnosis. In addition, there was a high incidence of metachronous gastrointestinal malignancies (19 percent). These data indicate that colonic carcinoids result in a high mortality and are associated with a high rate of metachronous gastrointestinal malignancies. We therefore r e c o m m e n d that these patients should u n d e r g o an e x t e n d e d p e r i o d of follow-up and that vigorous surveillance of the entire GI tract should be initiated seeking evidence of synchronous or metachronous malignancies. Peristomal Skin pH: Is There a Correlation with the Status of the Peristomal Skin? (47) K. Tsukada, J. M. Church, K. Tazawa, V. W. Fazio, E. C. Lavery, J. R. Oakley . . . . . . . . . . . . . Cleveland, OH Normal skin has a pH of 5.5, which prevents bacterial growth and inhibits digestive enzyme activity. Rises in the pH of peristomal skin may therefore p r e d i s p o s e towards peristomal skin infection and excoriation. A prospective study was d e s i g n e d to measure skin pH around ileostomies and to investigate any association b e t w e e n this and the skin appearance. Methods: The pH of clean, dry peristomal skin was measured using the Beckman pH Meter in 43 Brooke ileostomy and 11 Kock ileostomy patients. All patients had previously had ulcerative colitis. Patients were classified according to the condition of their peristomal skin. Results: All Kock ileostomy patients had normal appearing skin. All, however, wore pads to control mucus, leading to a skin pH of 8.5 ---+0.4 (mean + SD). Results in Brooke ileostomy patients are shown in Table 1.

P15 Table 1. PeristomalSkinAppearance Normal

pH

5.5 +-- 0.4

Erythematous 6.2 + 0.4

Ulcerated 7.6 + 0.5

The pH of the skin barrier was 5.5. Conclusions: Peri-ileostomy skin damage is associated with a high skin pH. The skin barrier has a protective effect on skin pH. Mucous leakage from the ileum produces a marked rise in skin pH. Acidifying agents may have a role in the treatment of resistant peristomal skin irritation.

A Reevaluation of the Radionuclide Scan in Patients with Lower Gastrointestinal Bleeding (48) G. R. Voeller, G. Bunch, L. G. Britt . . . . .

Memphis, TN

The efficacy of technetium 99 l a b e l e d red cell scintigraphy in localizing hemorrhage, directing surgical intervention, and in screening patients for arteriography was d e t e r m i n e d in patients with lower gastrointestinal bleeding. The b l e e d i n g scan in 56 patients was c o m p a r e d with the definitive b l e e d i n g site d e t e r m i n e d at surgery, endoscopy, or arteriography; 59 radionuclide b l e e d i n g scans were p e r f o r m e d in 56 patients; only 15 scans were positive for hemorrhage, three of which incorrectly localized the site of bleeding; 74% of the patients with lower gastrointestinal b l e e d i n g had negative b l e e d i n g scans yet had confirmation of a b l e e d i n g site at endoscopy, arteriography, or surgery. Overall, the radionuclide scan sensitivity was 20 percent. Surgical intervention for lower gastrointestinal b l e e d i n g was required in 13 patients; seven of these requiring surgery had negative scans and six had positive scans. In the six patients with positive scans requiring surgery, in no instance did the b l e e d i n g scan direct the surgical intervention; deteriorating clinical condition, b l o o d loss, and other diagnostic procedures directed surgery. In 12 patients with both scintigraphy and arteriography, half of those with positive scans had negative arteriograms; conversely, of those patients with negative arteriograms, half had positive arteriograms for active hemorrhage. In conclusion, scintigraphy failed to localize hemorrhage in 80 percent of the patients. Technetium 99 l a b e l e d red cell scintigraphy did not direct surgical intervention nor did it adequately screen patients who n e e d e d arteriography for localization of hemorrhage.

Ambulatory Treatment of Hemorrhoids: A Prospective Random Trial (49) J. A. Reis Neto, F. A. Quilici, F. Cordeiro, J. A. Reis Jr . . . . . . . . . . . . . . . . . . . . . . Campinas, Brazil A total of 228 patients with internal hemorrhoids were randomly allocated into three groups: A, B, and C. Each group was treated by a different technique: Group A was submitted to rubber band ligature, group B to cryother-

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MEETING ABSTRACTS

apy, and Group C to infrared-photo-coagulation. Only patients with second degree internal hemorrhoids were admitted to this trial, with no distinction of age, sex, and race. All patients had a follow-up of, at least, 1 year. Symptoms before the treatment were noted and evaluated 1 year later. Localization and number of piles of each patient, number of piles treated, symptoms referred to during treatment, and the results obtained were registered and compared. The analysis of the results permitted the following conclusions: 1) all methods were considered efficient; 2) rubber band ligature was the painless treatment during application, the most easily performed and the most effective for prolapse; 3) cryotherapy created a painless post-treatment period with quick normalization of the bowel habit, but it took longer than the other methods for each application and also originated a greater incidence of anal margin edema; 4) infrared-photo-coagulation, c o n t r o l l e d h e m o r r h a g e more efficiently, it was easily performed, but painful during application and responsible for the most serious complications.

Pelvic Sepsis as a Result of Hemorrhoidal Banding: Incidence and Sequelae (50) J. B. Wojcik, S. R. Banerjee, D. L. Waiters, D. A. Cherry Hartford, CT Case reports have established that pelvic sepsis may be a complication of rubber band ligation of internal hemorrhoids. No study has reported the incidence of septic complications and the clinical outcome in a large series of patients. A questionnaire was developed and sent to the membership of the ASCRS. The questionnaire was designed to ascertain the relative frequency of rubber band ligation, the technique used, the frequency and severity of complications, any potential predisposing factors of pelvic sepsis, therapy, clinical outcome, and the role of informed consent. A total of 549 questionnaires were returned, of which 534 were complete and suitable for analysis. Patients with symptomatic internal hemorrhoids were treated by rubber band ligation in 53 percent. The Barron technique was used by 86 percent, whereas suction or a combination of both techniques were used by 14 percent of responders. Bands were placed in a single site by 80 percent and multiple sites in 20 percent of responders. Thirty-four physicians reported 54 patients with pelvic sepsis as a result of rubber band ligation. Hospitalized patients with pelvic sepsis received IV antibiotics, 53 percent had the band removed, 44 percent underwent debridement of the site, and 6 percent underwent proximal fecal diversion. Six patients expired of uncontrolled sepsis. As a result of the complications encountered, 44 percent of responders stated that they had altered their technique for treating symptomatic internal hemorrhoids. Technique and possible etiologies are discussed. In conclusion, septic complications as a result of rubber band ligation poses a rare but real risk and despite

Dis Colon Rectum, April 1991

aggressive therapy can lead to significant morbidity or even mortality.

Symptomatic Hemorrhoids: Current Incidence and Complications of Operative Therapy

(51) R. Bleday, J. P. Pena, S. M. Goldberg, J. G. Buls Minneapolis, MN Operative treatment of symptomatic hemorrhoids is common, but there is a paucity of information on its frequency and complications. We reviewed the experience from our large colorectal group practice from January 1985 to July 1990. There were a total of 21,439 visits for symptomatic hemorrhoids (excluding thrombosed external hemorrhoids): 24.5 percent were treated with banding, 1 percent were injected or sclerosed, and 9.3 percent underwent surgical treatment. The operative experience of one office was reviewed for the same time period. There were a total of 214 patients: 59 percent men and 41 percent women. The mean age was 47.4 years; 23 percent of patients underwent urgent surgery for acute symptoms; 3.3 percent of cases were in the postpartum period; 80 percent of patients had either Grade III or IV rectal mucosal prolapse; 20 percent of patients had an associated anal fissure. A closed technique was used in all patients; 39.5 percent had simultaneous internal sphincterotomies, 17.1 percent had urinary retention, 2.4 percent had major delayed bleeding, 2.4 percent had fecal impaction, and 2 percent had errors in diagnosis. Only one patient had an abscess (0.5 percent). Median length of stay (LOS) was 2.5 days; 6.5 percent were done as outpatients. We conclude that only a minority of patients require surgery (9.3 percent). There is a higher complication rate compared with our previous analysis from 1978, but this is probably due to more advanced disease at the time of surgery. Even with the higher rate, LOS has decreased about 2 days in the past decade.

Laser Hemorrhoidectomy: are the Claims Justified?

(52) R. Pascual, G. Tripodi, A. Padmanabhan Waterbury, CT Laser hemorrhoidectomy has been advocated as being superior to surgical excision because of its claimed advantage diminishing postoperative pain, but there have been few well-controlled studies on this subject. Two modalities of treatment performed on 109 patients at one institution between January 1, 1988, and June 30, 1990, were reviewed retrospectively. Because laser hemorrhoidectomy was performed by one surgeon, these patients (Group 1, n = 28) have been compared with two other groups, namely surgical hemorrhoidectomy by the surgeon carrying out the laser method (Group 2, n = 23) and the surgical hemorrhoidectomies carried out by the other general surgeons during the same period (Group 3, n = 50).

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MEETING ABSTRACTS

The extent of surgery, type of anesthesia, assessment of postoperative pain, clinical complications, length of hospital stay, number of days before return to work, and estimates of costs and charges for the operations have been compared. Preliminary analysis of the data indicates no significant differences for the parameters in the three groups for clinical items, particularly pain and pain medication requirements. There is a substantially higher cost and charges for laser hemorrhoidectomy, raising questions about its value in clinical practice.

Ultra Slow Wave Pressure Variations in the Anal Canal Before and After Lateral Internal Sphincterotomy

(53) W. R. Schouter, J. D. Blankensteijn Rotterdam, The Netherlands Ultra slow waves (USW) in the anal canal are discrete, regular pressure fluctuations with a low frequency ( 1 - 2 / minute) and high amplitude (10 percent above or below baseline resting pressure). Between May 1987 and March 1989, we performed anorectal manometry, using a microtranducer, in order to study USW in 20 control subjects (mean age: 45 years, male/female ratio 1:1) and 58 patients with anal fissure of hemorrhoids before and 2 weeks after lateral internal sphincterotomy (LIS) (mean age: 40 years, range 15-70 years, male/female ratio 1:1). USW could be demonstrated in two control subjects (10 percent) and in 29 patients (50 percent). The mean maximum anal resting pressure (MARP) in the two control subjects was higher than the MARP in the 18 control subjects without USW (160 + 1 v s. 103 +-- 35 cm H202, P < 0.0005 Mann-Whitney). The same difference was found between MARP in patients with and without USW (166 --- 26 vs. 143 --- 28 cm H20, P < 0.05, Mann-Whitney). Two weeks after LIS, USW disappeared in 50 percent of the patients. The pressure reduction in these patients was statistically significantly higher than the pressure reduction after LIS in patients with persistent USW (40 v s. 15 percent, P < 0.02, Mann-Whitney). The results of this present study demonstrate that USW are associated with high MARP and disappear when such a high anal canal resting pressure is reduced by LIS to a level found in control subjects without USW. These findings indicate that USW are the manifestation of increased activity of the internal anal sphincter.

Prediction of Morbidity by T4 Lymphocyte Count in the HIV Positive or AIDS Anorectal Outpatient (54) S. Moenning, P. Huber, C. Simonton, C. Odom, E. Kaplan, S. Nightengale . . . . . . . . . . . . . . . . Dallas, TX A retrospective chart review of 39 ambulatory anorectal HIV+/AIDS patients was performed to establish a method of predicting morbidity in the HIV+/AIDS patients. All 39 patients had known T4 lymphocyte counts and HIV+/AIDS status and form the basis for this study.

P17

The authors defined morbidity as a complication occurring within 1 month of treatment. Morbidity was correlated with T4 lymphocyte counts and the diagnosis of HIV+/AIDS. All the 39 patients were followed for an average of 4 months. The T4 counts were separated into two groups, Group 1 (n = 23) had T4 counts of <200 and Group 2 (n = 16) had T4 counts of >200. Group 1 experienced a 65 percent morbidity, while group two had a 7 percent morbidity following conservative (n = 29) or surgical treatment (n = 10). Those patients with AIDS (n = 14) experienced a 78 percent morbidity, while the HIV+ patients (n = 25) had a 20 percent morbidity. Comparison between the groups was investigated using the two tailed Fisher's exact test and found to be statistically significant ( P < 0.001). The authors conclude: 1) a T4 count of <200 may be used to predict the treatment associated morbidity, and thus influence the degree of aggressiveness in treating the ambulatory anorectal HIV+/AIDS patient; 2) the treatment of ambulatory AIDS patients is associated with a significantly higher surgical anorectal morbidity than HIV+ patients; 3) in high risk ambulatory individuals with anorectal complaints and unknown HIV status, the T4 count of <200 may be used to predict treatment morbidity.

Imperforate Anus: Results of Surgical Correction

(55) P. C. Shah, H. F. Hashami, P. Kottmeier, F. Velcek, D. Klotz, R. L. Whelan . . . . . . . . . . . . . . . . Brooklyn, NY A retrospective review of 65 patients who underwent surgical treatment for imperforate anus during the period of 1965 to 1986 was performed. High anomalies (above the levator) were found in 44 patients (68 percent), while 21 patients (32 percent), had low anomalies. Fifty two patients (80 percent) required surgery within the first 48 hours of life, 8 had definitive repair, and 44 had colostomies constructed. Fifty-seven patients underwent definitive procedures at a mean age of 15 months. The following combined operative approaches were used: abdomino-perineal in 55 percent, sacroperineal in 8 percent, and abdomino-sacroperineal in 5 percent. A perineal approach was used in 32 percent. In 48 patients, of whom 38 had high anomalies, a poor result necessitated a total of 73 additional major operative procedures. These operations were Nixon flaps in 41 percent, levatorplasty in 12 percent, and gracilis sling in 4 percent. A permanent colostomy was eventually necessary in three patients. The mean age of the patient population at last follow-up was 6 years. Of the 21 patients with low anomalies, seven reported incontinence to solid or liquid stool at last follow-up. Only one of these patients had frequent incontinence (>1 episode/month). Five of the 21 patients reported soiling. At last followup, 38 of the 44 patients (86 percent) with high anomalies reported episodes of incontinence to solid or liquid stool; of these, 24 patients were incontinent at least once per week. Thirty-two patients reported soiling. Irrespective of the type of definitive procedure originally performed,

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MEETING ABSTRACTS

all but 14 percent of the patients with high anomalies required at least one additional re-operation. The average rate of severe incontinence for all patients undergoing c o m b i n e d procedures was 58 percent. There was no significant difference in functional results b e t w e e n the various operative approaches. Low anomalies are associated with substantially better functional results than those with high anomalies. The majority of patients with high anomalies will have poor functional results regardless of the operative approach used or the n u m b e r of operations performed.

Low Hartman Procedure for Severe Anorectal Crohn's Disease

(56) M. E. Sher, J. J. Bauer, I. Gelernt . . . . . . .

New York, NY

Perineal wounds often fail to heal following proctectomy for Crohn's disease. Twenty-five patients with severe anorectal Crohn's disease and perineal fistula, necessitating excisionary surgery, underwent a low Hartmann p r o c e d u r e in lieu of the standard proctectomy. Fifteen of the 25 (60 percent) patients had a c o m p l e t e l y healed p e r i n e u m and required no further surgical therapy. Perineal disease persisted in the other 10 patients; however, their p e r i n e u m was much improved c o m p a r e d with the initial presentation. Following a low Hartmann procedure, the rectal stump b e c o m e s atrophic and anoperineal disease "cools down," thereby permitting subsequent perineal p r o t e c t o m y in less inflamed tissues. Because only a 3-4 cm cuff of rectum was retained from the initial surgery, a p e r i n e a l intersphincteric approach could be employed a n d no abdominal dissection was necessary. Of the 10 patients who subsequently underwent perineal proctectomies, three patients still have an u n h e a l e d perineum. Eighty-eight percent (22 of 25) of patients have a c o m p l e t e l y healed p e r i n e u m (mean follow-up period 69.1 months). No attempt was made to establish intestinal continuity in any of the 25 patients. We conclude that the p r o b l e m of the u n h e a l e d perineal w o u n d can be averted with this approach, and therefore, reduce the long-term morbidity to the patient.

nipple valve is maintained by the application of four custom-made, TA-55, 4.8 m m staple lines, the fourth of which incorporates the anterior wall of the reservoir. The outflow/inflow tracts are secured to the reservoir with 40 Prolene (before 1986) and 4-0 Vicryl (after 1986). Eighty patients (42 m) received continent ileostomies for ulceractive colitis (26 percent) or conversion from Brooke ileostomies (25 percent). There was no mortality. Fourteen patients (18 percent) required surgical revision because of fistula (5), valve prolapse (4), incontinence (3), valve slippage (1), and valve necrosis (1). Pouchitis occurred in 10 patients (13 percent). All are now continent to gas and liquid. Twenty patients (11 m) underwent continent urostomies. Indications for surgery include patient request (40 percent) and b l a d d e r cancer (30 percent). There were no deaths and only one (5 percent) required revision. All remain c o m p l e t e l y continent. The Kock p o u c h has evolved into an excellent alternative to conventional ileostomy and urostomy. Attention to detail is paramount in order to maintain a low revision rate.

The Double Staple Technique for Colorectal Anastomosis

(58) J.J. Nogueras, R. L. Whelan, A. C. Lowry, W. D. Wong, C. O. Finne . . . . . . . . . . . . . . . . . . . . . . Minneapolis, MN This is a retrospective review of 110 patients who underwent a "double-stapled" colorectal anastomosis. With this method, a circular EEA stapler is passed per anum through a linear rectal staple line. All anastomoses were inspected intraoperatively, and the level of the anastomosis from the anal verge was recorded. The indications for surgery were: 1) adenocarcinoma (84 percent), 2) diverticular disease (8 percent), and 3) miscellaneous (8 percent). The clinical leak rate for ultra-low anastomosis (<4 cm) was:

<4 crn >4 cm

The Kock Pouch: Historical Curiosity or Valued Alternative?

(57) D. P. Launer, A. Gerber . . . . . . . . . . . . . . . . .

La Jolla, CA

After Kock introduced his idea of an internal reservoir in 1967, his technique was a d o p t e d and m o d i f i e d by many surgeons. From 1985 until 1989, 100 Kock pouches have been created by us e m p l o y i n g a single technique. The reservoir is constructed in an "S" configuration. Three limbs of ileum measuring 12-15 cm are mobilized. Fifteen cm are used to construct the continence valve (multiple valves for urostomies). The serosa of the ileum used for the nipple valve is scarified and the p e r i t o n e u m covering its mesentery is stripped. The position of the

Dis Colon Rectum, April 1991

No. of Patients

Leak Rate (%)

26 84

15 7

Both groups were matched for age, sex, and intraoperative b l o o d loss. The overall clinical leak rate for the study was 9 percent. There was one perioperative cardiac death. Morbidity occurred in 30 patients. Elective proximal diversion was performed in 16 patients (12 ileostomies, 4 transverse colostomies), and there were no clinical leaks in this group. Eleven patients received preoperative RT (one leak), and 5 patients were steroid d e p e n d e n t (3 leaks). Functional results will be examined. Based on our observed leak rates, elective proximal diversion for double-stapled colorectal danastomoses at 4 cm from the anal verge can be justified. Our preferred m e t h o d of diversion is loop ileostomy.

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MEETING ABSTRACTS

Anal Dilatation Revisited; Successful Treatment of Anal Fissures Employing a Precise, Reproducible Method of Dilatation (59) N. Sohn, M. A. Weinstein, R. N. Lugo, M. M. Eisenberg New York, NY Until the early 1970s, the standard operation for anal fissure incorporated an anal dilatation. At that time this p r o c e d u r e was supplanted by the internal anal sphincterotomy. The latter p r o c e d u r e was felt to be more precise, less traumatic, and associated with fewer complications and a higher cure rate. The technique of dilatation was not standardized, varied from author to author, and often from case to case. The authors, in an effort to minimize the potential for complications inherent to this technique, e m p l o y e d a precise and reproducible technique of dilatation, utilizing a Parks retractor o p e n e d a standard measured distance for a measured amount of time; 107 p r o c e d u r e s were performed with fissures being totally eradicated in 93 percent. Except for two cases of temporary and spontaneously corrected incontinence to flatus, there were no complications. More recently an even simpler technique of balloon dilatation has b e e n developed; 75 cases are in that group, with the fissure being eradicated in 96 percent and with no cases of incontinence. In both techniques, a precise, reproducible, and constant d e g r e e of dilatation is performed for a measured amount of time. Thus the variability of technique with inconstant results are eliminated. Anal dilatation, thus performed, is associated with a high cure rate, rapid pain relief, nearly i m m e d i a t e return to work and virtually no important complications. It should be considered as an alternative treatment in patients with anal fissures, when operation is indicated.

Pouchogram: A Predictor of Clinical Outcome Following Ileal Pouch-Anal Anastomosis (IPAA) (60) J. Tsao, S. Galandiuk, J. H. P e m b e r t o n . . Rochester, MN After IPPA, an ileostomy diverts the fecal stream for two months to facilitate healing of the pouch and anastomosis. Among 914 patients u n d e r g o i n g IPAA b e t w e e n January 1981 and June 1989, 463 (51 percent) had a "pouchogram" ( m e g l u m i n e diatrizoate (Gastrografin | enema) to assess anastomosis and ileal p o u c h integrity before closure of the ileostomy. Our a i m was to determine whether a pouchogram was useful to predicting clinical outcome. Results: Abnormal findings were present in 74 patients (16 percent). These included anastomotic and p o u c h leaks and anastomotic strictures. Pouchograms were normal in the remaining 389 patients (84 percent). The incidence of subsequent complications in both the normal and abnormal p o u c h o g r a m groups is shown in the table. The incidence of significant anastomotic stricture requiring dilatation under anesthesia was

much higher in the abnormal than in the normal pouchogram group. More significantly, an abnormal pouchogram was associated with an overall long term failure rate of 23 percent c o m p a r e d with 6 percent for a normal pouchogram ( P < 0.001). Conclusion: Abnormal findings in a pouchogram prior to ileostomy closure indicated those patients at high risk of long-term complications of IPAA. Pouchogram Complications

Abnormal (% of pts)

Normal (% of pts)

P

Significant stricture Failure

33

4

<0.001

23

6

<0.001

Fate of Preserved Anal Mucosa Following TPC and Stapled IPAA for MUC

(61) W. B. Tuckson, I. C. Lavery, S. Strong, V. W. Fazio, J. R. Oakey, J. M. Church, J. w. Milsom Cleveland, OH The potential for persistent MUC or cancer in the preserved and transition zone (ATZ) following total p r o c t o c o l e c t o m y (TPC) and stapled ileal pouch-anal anastomisis (IPAA) has b e e n controversial. Of the 131 patients who had ATZ preservation, MUC was present at the distal margin of resection in 97, absent in 17, and not stated in 17. Seventy-eight of these patients subsequently had anal canal mucosal biopsies a mean of (+95 percent CI) 12 (+1.7) months following IPAA (Table 1). Table 1. Results of Anal Canal Biopsy Following IPAA

Type Mucosa

MUC Present

MUC Absent

Total No. Patients

Rectal Anal ATZ Rectal + Anal Rectal + ATZ Anal + ATZ Ileal + ATZ Ileal N/S*

16 0 1 0 2 0 0 0 14

6 13 1 3 1 1 1 10 9

22 13 2 3 3 1 1 10 23

Total

33

45

78

* N/S = not specified.

Excluding the 10 patients who had ileal mucosa only, MUC was found in 33 patients and absent in 35. None of the anal mucosal biopsies had evidence of MUC. MUC was noted in 73 percent of the patients who had positive distal margins and in 50 percent who had negative margins when either rectal or ATZ mucosa was biopsied. One patient, with unspecified mucosa, had findings of MUC and low grade dysplasia. After 1 year, ATZ preservation appears to be safe, but because of persistent MUC these patients should have regular surveillance.

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MEETING ABSTRACTS

Does Retaining the Anal Transition Zone (ATZ) Fail to Extirpate Chronic Ulcerative Colitis (CUC) After Ileal Pouch-Anal Anastomosis (IPPA) ? (62) W. L. Ambroze, J. H. Pemberton, R. R. Dozois, H. A. Carpenter . . . . . . . . . . . . . . . . . . . . Rochester, MN The anal transition (ATZ) c o m p o s e d in part by transitional epithelium (TE), is b o r d e r e d by rectal epithelium above and squamous epithelium (dentate line) below. Whether to preserve the ATZ during IPAA in order to enhance continence is controversial. Our aims were to characterize the histology of the ATZ, measure its length, and determine whether it was involved by CUC. Methods: Proctocolectomy specimens from 50 CUC patients and from 50 control patients with rectal cancer were stained with alcian-blue (0.5 percent; pH 2.5) to define the ATZ visually. Four biopsies from each s p e c i m e n (2 from the TE and 2 from the rectal mucosa) were scored for the degree of inflammation (0 = none; 4 = severe). Results: Rectalmucosa e x t e n d e d through 89 of the length of the ATZ in 75 percent of the specimens, through 6 of the length in 46 percent, was within 1 cm of the dentate line in 89 percent and actually approximated the dentate line in 9 percent. The length of TE varied about the circumference of the anal canal; the mean maximum and m i n i m u m lengths were 1.3 --- 0.6 cm and 0.4 _+ 0.3 cm, respectively. The mean TE inflammation score in controls and in patients with CUC was 0.4 and 0.5, respectively (ns). The inflammation score of the rectal mucosa, however, was 0.2 cm in controls and 2.6 in CUC ( P < 0.0001). Conclusion: The ATZ is c o m p o s e d of TE a n d rectal mucosa. Although the TE is free of inflammation in CUC, the rectal mucosa is inflamed. Moreover, the proximal border of the ATZ is variegated and ill-defined. Preserving the ATZ w o u l d preserve the disease in most patients with CUC and, therefore, should be excised during IPPA.

Complications and Risk Factors After Ileal Pouch-Anal Anastomosis (IPAA) for Ulcerative Colitis (UC) Associated with Primary Sclerosing Cholangitis (PSC)

(63)

Dis Colon Rectum, April 1991

operative h e m o g l o b i n and albumin levels, and a high PSC risk score (1). Remote IPAA-related complications were 55 percent. The estimated risk of pouchitis at 4 years was 67 percent and correlated ( P < 0.05) directly with advanced hepatic histology and inversely with age. Remote liver-related complications occurred in 25 percent and was associated ( P < 0.05) with advanced hepatic histology, low h e m o g l o b i n and albumin levels, and a high PSC risk score. No patient e x p e r i e n c e d perianastomotic varices or anal bleeding. The estimated survival was 80 percent at 6 years after IPAA. We conclude that in patients with both UC and PSC, IPPA is safe, is not associated with perianastomotic bleeding, but has a high complication rate related primarily to the extent of liver disease.

Treatment of Fistulas Following Ileal Pouch-Anal Anastomosis (64) W. Ambroze, R. Beart, R. Dozois, B. Wolff, J. Pemberton, K. Kelly, R. Devine, S. Nivatvongs, P. Metzger Scottsdale, AZ Among 52 patients with postoperative fistulas from an IPAA, eight were found to be due to Crohn's disease. In spite of routine preclosure radiographic studies, 32 percent were d e t e c t e d prior to ileostomy closure and multiple fistulas were identified in 16 percent. Fistula origin was the anastomosis 55 percent and p o u c h 45 percent. Various techniques of closure were used and repair was successful in 48 percent. Multiple p r o c e d u r e s were required in 44 percent of successfully treated patients. Conclusion: Fistula complicating the IPAA p r o c e d u r e can be successfully treated in about 50 percent of patients. The origin of the fistula or prior operative treatment did not affect the success rate while multiple fistulae and abscess association had a p o o r e r treatment outcome.

Role of Oxygen Free Radicals in the Etiology of Pouchitis

(65)

A. H. Kartheuser, R. R. Dozois, N. F. LaRusso, R. H. Wiesner, D. M. Ilstrup, C. D. Schleck Rochester, MN

K. E. Levin, J. H. Pemberton, S. F. Phillips, A. R. Zinmeister, M. E. Pezim . . . . . . . . . Rochester, MN

Patients with UC and PSC treated by colectomy and ileostomy are at high risk of troublesome b l e e d i n g from peristomal varices. To d e t e r m i n e predictive factors for postoperative complications and outcome in patients with UC and PSC, we evaluated 40 such patients after IPAA between 1/81 and 2/90. No intra- or immediate postoperative deaths occurred. Overall, postoperative complications after IPAA was 43 percent and 26 percent after takedown of ileostomy; 19 patients (47 percent) required b l o o d transfusions (mean, 4.8 units; range, 113 units). The n e e d for transfusion was associated ( P < 0.05) with advanced hepatic histology for PSC, low pre-

The hypothesis was that transient mucosal ischemia, resulting in oxygen-derived free radical production by xanthine oxidase, contributes to the clinical syndrome of "pouchitis" in ileo-anal pelvic reservoirs. We therefore evaluated the effect of allopurinol, a xanthine oxidase inhibitor, in patients with acute and chronic pouchitis. Acute pouchitis was defined by increased frequency and decreased viscosity of stools with fever, malaise, and pelvic pain. The syndrome usually responds to metronidazole. Chronic pouchitis was characterized by persistent pouchitis controlled by antibiotics which recurred within 1 w e e k of discontinuation of therapy. Methods:

Vol. 34, No. 4

MEETING ABSTRACTS

14 patients (10M, 4F) with chronic pouchitis had chronic antibiotic therapy discontinued; they were then given allopurinol (300 mg PO b.i.d.) for 28 days. Eight patients (6M, 2F) with acute pouchitis were treated with allopurinol (300 mg PO b.i.d.) during the episode. Results: Seven of the 14 patients with chronic pouchitis responded completely with no recurrence of symptoms during the 28-day period. The seven remaining patients failed, prompting return to standard therapy. Acute pouchitis resolved promptly in four of eight patients. The other four with acute pouchitis failed; they were then treated with their usual regimen. Three patients had transient side effects (headaches, joint pains, and skin rash). Conclusions: The allopurinol is effective in 50 percent of patients with pouchitis. This appears, therefore, to be a role for mucosal ischemia and oxygen free radical production in the etiology of pouchitis.

Avoidance of a Temporary Ileostomy in Restorative Proctocolectomy

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ence with acute diverticulitis in patients aged -<50 years. Forty patients were hospitalized between 1980-85. The diagnosis was based on findings of fever (57 percent), abdominal pain (98 percent), WBC >10,000 (69 percent), and barium enema or operative findings consistent with diverticulitis. Age ranged from 21-50 years (mean = 44) and there was an equal sex distribution. Surgery was required on initial admission in 10 patients (25 percent) for acute abdomen or failure to improve with antibiotics. Thirty patients (75 percent) improved and were discharged after treatment with bowel rest and antibiotics. Five to 9-year follow-up was obtained of patients treated medically. Ten patients (33 percent) required readmission for diverticulitis, eight of whom (27 percent) underwent surgery, all elective; 73 percent of patients -<50 years old who resolved their initial episode of acute diverticulitis with medical treatment did not require surgery over the follow-up period. Although we agree that diverticulitis in young patients is a serious illness, we cannot r e c o m m e n d surgery after a single episode that resolves with medical treatment.

(66) P. M. Sagar, P.J. Holdsworth, D. Johnston .. Leeds, UK A temporary ileostomy has been employed routinely by most centers to defunction the ileal reservoir after restorative proctocolectomy. The aim of this pilot study was to compare the early postoperative results in patients undergoing restorative proctocolectomy with and without the use of a temporary stoma. A consecutive series of 34 patients was studied. Each patient underwent restorative proctocolectomy with quadruplicated ileal reservoir and stapled pouch-anal anastomosis; 17 with defunctioning ileostomy and 17 without. The two groups of patients were similar in age and sex distribution. There was a reduced incidence of pelvic sepsis, anastomotic stricture, and intestinal obstruction (n.s.) in patients without an ileostomy compared with patients with an ileostomy. The overall complication rate (P < 0.05) and the total length of stay in hospital after operation ( P < 0.01) were both significantly reduced in the group of patients without an ileostomy. The avoidance of a temporary ileostomy does not lead to an increase in postoperative complications and is associated with a shorter length of stay in hospital after restorative proctocolectomy.

Management of Diverticulitis in Patients -< 50 Years Old: 50-Year Follow-up of Medical Management P. Vignati, J. Cohen . . . . . . . . . . . . . . . . . . .

(67) Hartford, CT

Controversy exists regarding management of the initial episode of diverticulitis in young patients. Several authors recommend surgery after one episode requiring hospitalization, whereas others feel this is too aggressive. To help resolve this conflict, we reviewed our experi-

Crohn's Colitis and Cancer: Increasing Justification for Surveillance? (68) T. J. Stahl, P. L. Roberts, D. J. Schoetz Jr., J. J. Murray, J. A. Coller, M. C. Veidenheimer . . . . . . Burlington, MA Colon cancer arising in patients (pts) with Crohn's colitis (CC) is reported with increasing frequency and is often diagnosed at a late and incurable stage. To clarify the clinical course of pts with cancer and CC, we reviewed 18 pts from 1957-1989. The incidence of colon cancer for all cases of Crohn's disease seen during this 32-year period was 18/3,290 (0.55 percent). There were 12 females and 6 males with a mean age of diagnosis of Crohn's colitis of 40.4 years (15-68), and a mean age of diagnosis of colon cancer of 51.6 years (32-70). The mean duration of CC before diagnosis of colon cancer was 11.2 years (0.2-27). Eight patients had CC for over 10 years. Thirteen patients had ileocolitis and 5 pts had left-sided colitis. Cancers arose in colitic segments with the most severe disease in 15, and away from such areas in 3. Five patients had associated dysplasia adjacent to the cancer. The diagnosis was not suspected preoperatively in five pts; cancer was detected in nine pts during evaluation of a presumed flare of CC after a period of relative quiescence, and was found in four pts during routine follow-up. There were two Dukes' A lesions, five Dukes' B lesions, five Dukes' C lesions, and six Dukes' D lesions. The majority of patients (7/8) with greater than 10 years duration of CC presented with Dukes' C or D lesions. Conclusion: All pts with longstanding Crohn's colitis who present with a flare of disease deserve thorough evaluation to exclude a concomitant cancer. A surveillance program may be justified particularly in patients with longstanding quiescent Crohn's colitis.

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MEETING ABSTRACTS

Malignant Colorectal Strictures in Crohn's Disease (69) Y. Yamazaki, M. B. Ribeiro, D. Sachar, T. M. Heimann, A. H. Aufses, A. J. Greenstein . . . . . . . . . . New York, NY In this study we examined the clinical features and outcome of Crohn's disease patients who develop malignant colorectal strictures. One h u n d r e d thirty-two of 980 patients (13.5 percent) with Crohn's disease (CD) involving the colon, admitted to The Mount Sinai Hospital b e t w e e n 1959 and 1985, d e v e l o p e d 175 colonic strictures. Ten malignant strictures were identified in nine patients (3 ileocolitis, 6 colitis). The frequency of cancer in patients with stricture (6.8 percent) was higher than in those without stricture (0.7 percent, 6 of 848, P < 0.001). Seventeen of 165 benign strictures (10.3 percent) were long, extending over more than one anatomical segment of colon, but all 10 malignant strictures were short ( P < 0.0001). The proportion of malignant strictures increased with duration of disease from 3.3 percent with less than 20 years of CD, to 11 percent with CD of 20 years or more. All nine patients with malignant stricture were treated surgically, and four of the nine d i e d of colon cancer during a mean follow-up of 4.3 years. Prognosis was worse in six other nonstricture cancers in this series, with five colon cancer deaths during mean follow-up of 1.6 years. In view of the high rate of malignancy, 6.8 percent in this series, colonoscopy with biopsy is essential in Crohn's disease patients with colonic strictures, and surgery is mandatory when a stricture cannot be fully assessed during colonoscopy.

Coagulation Paremeters and Thrombosis in Patients with Inflammatory Bowel Disease (70) S.J. Stryker, D. Green . . . . . . . . . . . . . . . . . .

Chicago, IL

Patients with inflammatory bowel disease (IBD) have frequent thrombotic/thromboembolic complications. The risk appears greatest during periods of increased disease activity. To investigate the mechanisms that might predispose to thrombosis, we prospectively studied coagulation parameters in 52 consecutive hospitalized IBD patients seen by one consulting surgeon. Detailed history was obtained concerning previous IBD illness and thrombotic events. Prothrombin time (PT), partial thromboplastin time (PTT), b l e e d i n g time (BT), platelet count (PLT), fibrinogen (FIB), antithrombin III (AT3), protein C (PRC), and protein S (PRS) were assessed. Follow-up for thrombosis was continued for >30 days. Results: PT, PTT, and BT were normal in all patients, but 31 of 52 (60 percent) had other abnormal values suggesting a hypercoagulable state, including six of seven with previous or current thrombosis. For specific abnormalities see the table. Two of 21 (10 percent) with ~'PLT, 1 of 10 (10 percent) with ~'FIB, 1 of 11 (9 percent) with ,~AT3, 3 of 5 (60 percent) with ,LPRC, and 2 of 8 (25 percent) with ~PRS had venous thrombosis. Conclusions: Parameters suggesting hypercoagulability were c o m m o n in hospitalized IBD patients. All but one patient with thrombosis had at least one detectable co-

Dis Colon Rectum, April 1991

agulation abnormality. An optimal benefit/risk ratio might entail aggressive thrombosis prophylaxis in those patients with laboratory parameters indicating a hypercoagulable state, especially PRC or PRS deficiency.

PLT ~' FIB J, AT3 PRC J, PRS

All IBD (n = 52)

IBD + T h r o m b o s i s (n ----7)

2I 10 11 5 S

2 1 1 3 2

Natural History of Crohn's Disease (CD) Following Surgical Resection: Interim Report of the Postoperative Crohn's Disease Trial (71) R. C. B. K.

S. McLeod, Z. Cohen, J. Cullen, G. R. Greenberg, S. Ho, R. Reznick, H. Stern . . . . . . . Toronto, Ontario G. Wolff, J. Cangemi, R. Beart, P. Carryer, N. Jeejeebhoy, R. MacCarty, L. Weilland Rochester, MN

A r a n d o m i z e d controlled trial was initiated in 1986 to d e t e r m i n e the effectiveness of mesalamine (Rowasa I) in preventing or delaying the recurrence of CD following a bowel resection (BR) in patients in w h o m there is no macroscopic residual disease. During the first 40 months, 514 patients have had BR of w h o m 296 (56 percent) met entry criteria. One h u n d r e d seventeen of these (39 percent) were entered (70 males, 47 females, mean age 38 years). Forty-nine had SB, 29 had LB, and 39 had both SB and LB disease. The mean n u m b e r of previous BR was 1.6. The mean length of SB resected in 70 patients was 42 cm. All patients have b e e n followed with yearly colonoscopies or small bowel enemas. Patients with symptomatic CD had radiological or e n d o s c o p i c confirmation. After mean follow-up of 16 months, 27 patients (23 percent) have d e v e l o p e d symptomatic recurrent disease (17 percent) overall recurrence rate at 12 months; 37 percent at 24 months). In all but two patients, the recurrence was preanastomotic. Asymptomatic recurrent CD has b e e n docu m e n t e d in 25 patients (8.5 percent at 12 months, 13 percent at 24 months). After a further mean follow-up of 13 months, only seven of these patients (2.8 percent) have d e v e l o p e d symptoms requiring treatment. From this prospective study we conclude that recurrence of CD following BR may be higher than previously reported in retrospective reviews. In addition, many patients may have recurrent CD endoscopically without having symptoms. Hidradenitis and Crohn's Disease---A Significant Association (72) J. M. Church, V. W. Fazio, I. C. Lavery, J. R. Oakley, J. W. Milsom . . . . . . . . . . . . . . . . . . . . . . . Cleveland, OH Over the last 7 years, 55 patients with hidradenitis suppurativa (HS) have b e e n treated in this department.

MEETING ABSTRACTS

Vol. 34, No. 4

Eighteen of these patients (33 percent) also had Crohn's disease. The association is e x a m i n e d in detail in this retrospective review. There were nine male and nine female patients. Their median age was 35 years (range 19-75). All but four had already b e e n diagnosed as having Crohn's disease before their HS presented, this being colonic in 14, ileocolic in 3, and ileal in 1. Twelve patients had u n d e r g o n e b o w e l resection prior to presenting with HS, and 11 had stomas. By the end of the study, all had had b o w e l resections, 17 had stomas, and 14 had lost their rectum. HS occurred in multiple sites ( p e r i n e u m in 18, groin in 9, scotum/vulva in 7, axillae in 4, and buttocks in 7). Seven patients underwent wide excision and split thickness skirl grafting, and 13 had local excision with or without closure. Granulomas were found in excised skin in six patients, but this finding did not adversely affect outcome. At a mean follow-up of 3.3 years (95 percent C.L. 2-5 from their last procedure, 10 patients were asymptomatic for HS, 7 were symptomatic, and 1 patient had died. These data show that patients with Crohn's colitis may develop HS in multiple sites. This complicates both the diagnosis and m a n a g e m e n t of perineal sepsis in such patients.

A Randomized Prospective Assessment of the Treatment of Nonspecific Proctosigmoiditis Using Hydrocortisone Enemas, 5-ASA Enemas, and Short Chain Fatty Acid Enemas (73) A.J. Senagore, J. M. MacKeigan . . . . .

Grand Rapids, MI

The gold standard for treatment of idiopathic ulcerative proctitis has b e e n hydrocortisone (HCT) enemas. Recently, two additional treatment options have b e c o m e available, 5-aminosalicylic (5-ASA) enemas and short chain fatty acid enemas (SCFA). This project represents the first direct comparison of these three treatment options in terms of efficacy, side effects, and cost-effectiveness in a randomized, d o u b l e b l i n d e d study design. All patients diagnosed with ulcerative proctosigmoiditis were eligible for study (N = 19). Diagnosis was based on history, with endoscopic and histologic confirmation. Patients were randomly allocated to one of three treatment groups: hydrocortisone (100 mg/60 cc pr qhs + Azulfidine 500 mg po qid); 5-ASA (4 gin/60 cc pr qhs); or SCFA (50 ml per bid). Treatment was continued for 6 weeks with clinical evaluation p e r f o r m e d at 2-week intervals. Data evaluated i n c l u d e d presence of hematochezia (B), mucus in the stool (M), e n d o s c o p i c grade (G) (1-4), and successful resolution (R) of the inflammatory process.

Initial

IICT (n = 6) 5-ASA (n = 7) SCFA (n = 6)

6 Week

B

M

G

B

M

G

6 7 6

6 6 6

2.7+.5 2.7 -+ .8 3 + .6

1 1 1

1 0 1

1.6+1 0.5 "4" .2 1.3 + .6

5 6 5

P23

There were no treatment related side effects. The cost for 6 weeks of treatment for each group were: HCT: $31.08; 5-ASA: $246.96; SCFA: $21.00. The results indicate no difference in symptomatic and e n d o s c o p i c response rates, incidence of side effects, or treatment failure. 5-ASA preparations were significantly more expensive without significant clinical advantage c o m p a r e d with the other regimens. Therefore, we r e c o m m e n d the use of SCFA enemas for the treatment of idiopathic ulcerative proctosigmoiditis, as a cost-effective treatment that avoids potential 5-ASA and corticosteroids for resistant cases.

Factors Predictive of Recurrent or Persistent Crohn's Disease in the Excluded Rectal Segment

(74) J. Guillem, P. L. Roberts, J. J. Murray, J. A. Coller, M. C. Veidenheimer, D. J. Schoetz J r . . . Burlington, MA The m a n a g e m e n t of the e x c l u d e d rectal segment following excisional surgery for Crohn's disease remains poorly defined. To d e t e r m i n e prognostic factors relating to the fate of the rectal segment, 47 patients (pts) who underwent excisional surgery and creation of an exc l u d e d rectal segment (ERS) were studied. Thirty-three pts (70 percent) had d e v e l o p e d disease in the ERS by 5 years, 24 had a c o m p l e t i o n proctectomy (CP) by 2.4 years and, 9 retained a rectum with disease (W) at a mean follow-up of 4.9 years. Fourteen were without (WO) clinical disease at a mean follow-up of 7.5 years. The three groups were equivalent with respect to sex, duration of preoperative disease, indication for surgery, extent of colonic involvement, and histologic involvement of the proximal margin. The mean age of diagnosis of the CP group t e n d e d to be younger than those with a retained ERS (24, 39, and 37 years for CP, WO and W, respectively). Neither initial involvement of the terminal ileum nor inflammatory changes of the rectum predicted eventual ERS disease. However, initial perirectal fistula, found in 70 percent of pts with disease in the retained rectum and 36 percent of patients without disease, was d e t e r m i n e d to be predictive of persistent ERS disease ( P < .05). Conclusion: Since the presence of perirectal fistula disease in the face of Crohn's colitis predicts persistent or recurrent ERS disease, a primary total proctocolectomy or early c o m p l e t i o n p r o c t o c o l e c t o m y may be indicated in this subgroup of pts.

Outcome of Ileorectal Anastomosis for Crohn's Colitis

(75) W. E. Longo, J. R. Oakley, I. C. Lavery, V. W. Fazio Cleveland, OH Ileorectal anastomosis (IRA) as treatment for Crohn's colitis remains controversial. We reviewed 131 consecutive patients from 1965-1988. Preoperatively, 63 percent were found to have mild or moderate proctitis and 37 percent had rectal sparing macroscopically. Fifty-two percent had associated small b o w e l disease and 15 percent had perianal disease. Sixty-five IRAs were per-

P24

MEETING ABSTRACTS

formed at the time of subtotal colectomy, while 56 were done as a staged procedure. There were no operative deaths. Anastomotic leaks occurred in 3 percent. Thirteen (10 percent) with ileostomies and intact IRAs never had stomal closure. Among the remaining 118 patients, 30 (23 percent) required proctectomy, while 16 (13 percent) required proximal diversion. However, these 46 IRAs functioned a mean of 4.1 years. An additional 13 patients required pre-anastomotic resection and neoIRA, while 11 others required proximal small bowel resection. Seventy-two patients (72/118 or 61 percent of those whose IRA currently functions) retained a functioning IRA after a mean of 9.2 years. Forty-four are free of disease, while 28 are being treated with steroids or antidiarrheals. The average stool frequency is 5.9/day. In this study, the results of IRA for Crohn's colitis are better than generally reported and suggest the operation should b e considered as an alternative to p r o c t o c o l e c t o m y in selected patients.

Multifactorial Index of Preoperative Risk Factors in Colon Resections (76) D. P. Ondrula, M. L. Prasad, R. L. Nelson, H. Abcarian . . . . . . . . . . . . . . . . . . . . . . . . . . .

Chicago, IL

We analyzed the negative predictive value of a variety of preoperative risk factors on operative outcomes. We reviewed all colorectal resections p e r f o r m e d in a single hospital b e t w e e n January 1985 and May 1990; 972 resections were p e r f o r m e d on 825 patients. We studied 17 preoperative risk factors generated from various medical risk categories. Using the multivariate discriminant function analysis we calculated that 11 of the 17 risks were of significance in predicting outcomes (all with P _< 0.031). These factors included e m e r g e n t operation, age ->75, CHF, radiation, steroid use, alb. <2.7, COPD, previous MI, diabetes, cirrhosis, and renal insufficiency. The discriminant analysis was used to categorize patients into 1 of 4 risk groups by d e v e l o p i n g a "risk score." The index used to develop each patient's "risk score" ranged from 6 points for an e m e r g e n c y operation to 1 point for diabetes. The mortality rates for the various risk groups were: I, 0-4 points 1 percent; II, 5-8 points 10 percent; III, 9-13 points 19 percent; IV, >13 points 33 percent. In contrast to previous reports, we s h o w e d that age ->75 alone is not a major preoperative risk factor, but rather acts as a modifier for the other predictors of postoperative complications. We then assessed clinical questions concerning specific preoperative risks such as steroid use, obesity, IBD, COPD, and prior laparotomy and their associated specific postoperative complications. Through the use of this risk index we also were able to assess an individual patient's operative risk more accurately and have d e v e l o p e d prevention strategies based on these findings.

Dis Colon Rectum, April 1991

Total Abdominal Colectomy with Ileorectal Anastomosis: The Preferred Mternative (77) R.J. Coughlin, M. L. Corman, E. D. Prager Santa Barbara, CA The indications for total abdominal c o l e c t o m y with ileorectal anastomosis are debatable. Most surgeons agree that synchronous malignant lesions in different parts of the colon, colonic b l e e d i n g without an identified source, and familial adenomatosis with relative rectal sparing are appropriate indications. With left-sided colonic obstruction, many believe that abdominal colectomy with ileorectal anastomosis is preferred to limited resection and colostomy. It eliminates the n e e d for subsequent colostomy closure with its attendant complications. Two surgeons p e r f o r m e d 50 total abdominal colectomies with ileorectal anastomoses over a 10-year p e r i o d (1980-1989) for synchronous lesions, for bleeding, and for obstruction. The mean age was 65. The mean operating time was 120 minutes. This includes 14 patients (28 percent) who required concomitant procedures. At 6 months follow-up, the average n u m b e r of bowel movements p e r day was 2.6. There were two anastomotic leaks (4 percent) which required a diverting loop ileostomy. These were subsequently closed. There was one death by respiratory failure (2 percent), not related to an anastomotic problem. We find that total abdominal colectomy is safe, expeditious, and results in satisfactory bowel function. This should be the preferred alternative to limited resection if a stoma w o u l d otherwise be required. Treatment of Entero- and Colocutaneous Fistulae with Early Surgery or Somatostatin Analog

(78) D. I. Borison, A. D. Bloom, T. J. Pritchard Cleveland, OH Traditional therapy of enterocutaneous (EC) and colocutaneous (CC) fistulae has consisted of "conservative" m a n a g e m e n t with surgery reserved for failure of maximal medical treatment. We conducted a 5-year retrospective review of 27 patients with EC and CC low output fistulae in order to d e t e r m i n e the outcome of early surgical and nonsurgical treatment of these conditions. Twelve men and 15 w o m e n with a median age of 67 years p r e s e n t e d with 21 EC and 6 CC. Seven patients had early operative intervention in an attempt to close their fistulae, while the remaining 20 patients were treated without surgery. In addition, four of the nonsurgical group received parenteral somatostatin analog (SA). None of the surgical patients was septic preoperatively (median WBC = 9.7), median preoperative hospital stay was 11 days, and no patient required a proximal diverting stoma. All of the surgical group r e s u m e d normal GI function within 2 weeks, and six of the seven (86 percent) demonstrated no recurrence of the fistulae at a median follow-up of 1 year. Of the 20 medically treated patients, three of the four who received SA healed their fistulae within 2

Vol. 34, No. 4

MEETING ABSTRACTS

weeks. Only two of the other 16 medically treated patients (12.5 percent) healed their fistulae. Early surgery or the use of SA should be c o n s i d e r e d in the treatment of patients with low output intestinal fistulae.

Gastroduodenal Polyps in Patients with Familial Adenaomatous Polyposis (79) J. M. Church, E. McGannon, D. G. Jagelman, M. V. Sivak, R. van Stolk, S. Hull-Boiner . . . . . . . . . . . Cleveland, OH In 1986 we reported on the prevalence of u p p e r gastrointestinal polyps in patients with familial adenomatous polyposis (FAP). As a result, esophago-gastro-duo d e n o s c o p y (EGD) has b e c o m e a routine part of our work-up of FAP patients. In this paper we provide a follow-up report on the results of the initial EGD in FAP patients treated at this institution. Methods: A review of the e n d o s c o p y reports and pathology results from the initial EGD of all FAP patients u n d e r g o i n g such an examination was performed.

P25

Results: 224 patients were identified (108 male, 116 female). Before 1986

EGD normal Gastric polyps Duodenal polyps Total Patients

After 1986

Total

n

%

n

%

n

%

54 28 33 100

54 28 33

49 57 53 124

40 46 43

103 85 86 224

46 38 38

After 1986, routine biopsies of "normal" duodenal papilla on initial EGD have shown adenomatous change in three. In follow-up EGDs, a "normal-appearing" papilla was adenomatous in a further 33 patients. Conclusions: Routine EGD is indicated for patients with FAP. There is a trend towards an increasing prevalence of both gastric and d u o d e n a l polyps. A normal appearing d u o d e n a l papilla may not be histologically normal.

POSTER PRESENTATIONS Poster presentations will be on display in Salons H through K beginning 10 a.m., Monday, May 13, and during all open exhibit hours. Authors have been requested to be present at their posters during all intermission breaks on the days their posters will be discussed.

Does Fecal Diversion Affect Resting Anal Pressure in Patients with Ulcerative Colitis:

Booth P1 W, B. Tuckson, V. W. Fazio, I. C. Lavery, J. R. Oakley, J. M. Church, J. w. Milson . . . . . . . . . . . . Cleveland, OH Following fecal diversion maximum anal s q u e e z e pressure (MSP) decreases, but returns to normal values after restoration of bowel continuity. To d e t e r m i n e the effect of fecal diversion on anal sphincter resting tone, the maximum anal resting pressures (MRP) from 20 patients with mucosal ulcerative colitis (MUC), who had a subtotal colectomy and ileostomy at least 12 months before manometry, were c o m p a r e d with the MRP from 20 age and sex matched controls with MUC, who had no previous surgery. Anal pressures were measured using a radially oriented four-port water perfused catheter and the station pull through technique. The results are listed in the table below.

Computerized Defogram Analysis: An Objective Assessment

Booth P3 P. Durdey, M.J. Kennedy, M. Oster, J. Murray, P. L. Roberts, D. J. Schoetz Jr . . . . . . . . . . Burlington, MA Defecography is an unpopular examination with surgeons and radiologists. Interpretation is open to subjective bias. We have d e v e l o p e d a computer aided drawing (CAD) program to objectively assess data from defograms. Anorectal angle (ARA), perineal descent, and pelvic floor m o v e m e n t were c o m p u t e d in 20 patients with constipation (10 slow transit, 10 anismus) and 25 with incontinence. Anorectal angle (ARA) was similar at rest and strain. Mean ARA was more acute on squeeze and evacuation in constipated patients (107 vs. 115, P = 0.04*: 118 vs. 137, P = 0.002*). Position of the pelvic floor was defined as distance from sacral promontory, which is easy to identify, to the ARA. There was no difference in pelvic floor position at rest, strain, and evacuation. On squeeze the incontinent group had a significantly lower position ( P = 0.04*). Contribution of puborectalis to pelvic floor m o v e m e n t was d e t e r m i n e d by comparing the ratio of distance from the inferior border of the pubis to the puborectalis impression at the ARA and from coccyx to ARA. The ratio significantly increased on squeeze in patients with slow transit (0.940.67, P = 0.002*) and to a greater extent with anismus (0.94-0.55, P = 0.001"). The ratio did not alter in incontinents (0.96-0.98, P = NS*), indicating loss of puborectalis function. On strain and evacuation the ratio increased equally in all groups including those with anismus, indicating puborectalis relaxation. These data suggest that pelvic floor m o v e m e n t is achieved primarily by puborectalis. Computer analysis improves data collection, removes subjective assessment, and may improve acceptability of the examination. (*Student's t-test)

Table 1. Effect of Diversion on Anal T o n e

Months diverted ( m e a n / median) MRP (ram Hg) MSP ( m m Hg)

Not Diverted

Diverted

N/A

67/26

87 + 7 216 + 41

underwent both CD and BP. Radiographs were made with the patient at rest and during both squeeze and evacuation. Measurement of the ARA was then undertaken. Between 2 and 12 months later the same interpretation process was repeated. At rest and during squeeze there were highly significant differences b e t w e e n CD and BP ( P < 0.01). The mean difference at rest ranged from 12.6 ~ to 16.9 ~. The differences were noted in all three CD measurements when the same interpreter's sets of data were c o m p a r e d (5.2-7.5 ~ P < 0.01). Although more reproducible measurements were noted with BP, in a significant n u m b e r of patients at least one of the three views was uninterpretable due to the balloon's configuration in the rectum. In conclusion there was p o o r correlation b e t w e e n CD and BP and poor reproducibility of ARA measurement; BP was consistently more difficult to interpret. Neither of the currently available techniques of ARA m e a s u r e m e n t is consistently reliable.

74 + 7 200 + 37

Manometry data reported as mean -+ 95% confidence limits. P = N.S.

There were no significant differences b e t w e e n the MRP or MSP values. MRP values were equal even after p r o l o n g e d fecal diversion. Prolonged fecal diversion alone does not appear to represent a contraindication to sphincter preserving surgery or to attempts at reestablishing bowel continuity.

H o w Reliable Are Currently Available Methods of

Measuring the Anorectal Angle? Booth P2 S. D. Wexner, F. Marchetti, M. Sullivan, G. O. Rosato, J. M. Jorge, D. G. Jagelman . . . . . . . Fort Lauderdale, FL This prospective evaluation was d e s i g n e d to compare two different methods of measuring the anorectal angle (ARA): cinedefecography (CD) and balloon proctography (BP). The aims of the study were to assess the correlation b e t w e e n these two methods as well as the reproductibility of ARA measurement; 74 consecutive patients with either constipation (43 patients), fecal incontinence (17 patients), or rectal pain (14 patients) P26

Vol. 34, No. 4

MEETING ABSTRACTS

"Goodsall's R u l e ' - - I s It Accurate in Predicting the Course of Anal Fistulae?

Booth P4 W. C. Cirocco, L. C. Rusin, A. C. Brown, J. C. Reilly Erie, PA Goodsall's original observations on anal fistulae (ca. 1900) have b e e n c o n d e n s e d and h a n d e d clown over time as "Goodsall's Rule." The rule attempts to forecast the course of fistula-in-ano based on the relation of its external (secondary) o p e n i n g to a hypothetical transverse anal line. External openings posterior to this line are said to predict a curved course to a midline posterior internal (primary) o p e n i n g while external openings anterior to this line predict tracking radially inward to an internal opening. Our data call the predictive accuracy of this time-honored rule into question. Of 303 patients undergoing fistula surgery over an 8year period (1982-89), 63 were e x c l u d e d on the basis of previous surgery, indeterminate findings and Crohn's disease. Of the 240 patients (174 male and 66 female) reviewed, 24 were subcutaneous and 216 were transsphincteric; 124 transsphincteric fistulae had secondary openings posterior to the transverse anal line. In this group the fistulae coursed to the midline posterior 90 percent of the time in accordance with Goodsall's Rule. Of the 92 transsphincteric fistulae with secondary openings anterior to the transverse anal line, only 49 percent o b e y e d Goodsall's Rule. Anterior fistulae in w o m e n were more likely to violate the rule (69 percent) than those in males (43 percent). Goodsall's original observations will be discussed as well as the implications of the present study for the clinician.

Intrarectal Ultrasound in the Evaluation of Perirectal Abscesses

Booth P5 P. Cataldo, A. J. Senagore, M. A. Luchtefeld, J. M. MacKeigan, W. P. Mazier . . . . . . Grand Rapids, MI Experience with intrarectal ultrasonography (IRUS) is limited for the evaluation of perianal sepsis. The p u r p o s e of this paper is to report our experience with IRUS in evaluating perianal abscess and fistula. Twenty-four consecutive cases were reviewed. All IRUS was performed intraoperatively under epidural anesthesia or with intravenous sedation. The patients were e x a m i n e d in the left lateral decubitus position. A Bruel and Kjaer (Model #1846, Denmark) endoanal ultrasound with a 7-mHertz transducer was used. An abscess a p p e a r e d as a hypoechoic area. Internal openings of fistulous tracts a p p e a r e d as breaks in the normally smooth balloon-mucosal interface a n d / o r disruption of the integrity of the internal sphincter. After c o m p l e t i o n of the IRUS, careful bimanual and anoscopic exams were performed. Subsequently the patient u n d e r w e n t appropriate surgical therapy. At surgery, 19/24 patients were found to have perirectal abscesses. In all 19 cases the

P27

abscess was identified correctly preoperatively by IRUS. In 12 (63 percent) cases the relationship b e t w e e n the abscesses and sphincters was noted by IRUS corresponding to the Parks classification. In all 12 cases the relationship p r e d i c t e d by IRUS was identical to surgical findings. At surgery, internal openings of fistulous tracts were found in 14/19 cases. IRUS correctly identified 4/19 internal openings. In 6/24 cases IRUS failed to demonstrate a perirectal abscess. Subsequent careful exam under anesthesia revealed no abscess in any of these patients. In summary, we retrospectively reviewed 24 cases of IRUS for suspected perirectal abscess. IRUS correctly identified the abscess in all cases and correctly identified the relationship of the abscess to the sphincters in 12 cases. The internal o p e n i n g could only be identified by IRUS in 4/14 cases. The role of IRUS in the evaluation of perirectal abscess is evolving. Certainly uncomplicated abscesses can be managed without ultrasonography; however, IRUS can be an adjunct to careful evaluation of c o m p l e x perianal suppurative disease to assess adequate drainage.

Surgery for Symptomatic Hemorrhoids and Anal Ulcers in Patients w i t h Crohn's Disease

Booth P6 A. F. Wolkomir . . . . . . . . . . . . . . . . . . . . . . M. A. Luchtefeld . . . . . . . . . . . . . . . . . .

Red Bank, NJ Grand Rapids, MI

The literature states that anal surgery in patients with Crohn's disease is fraught with danger. Recent papers indicate that select patients with Crohn's can undergo fistulotomy with minimal morbidity. This stimulated review of our experience with surgical treatment of hemorrhoids and anal fissures in the Crohn's patient. A retrospective chart review was done of all Crohn's patients u n d e r g o i n g h e m o r r h o i d e c t o m y and fissure surgery from 1961 to 1989. Seventeen patients with known Crohn's disease (9 colonic, 6 small bowel) underwent hemorrhoidectomy. On mean follow-up of 11.5 years, 15/17 healed without complication, one patient required a proctectomy 15 years later for causes apparently unrelated to the hemorrhoidectomy. Twenty-five patients with known Crohn's (7 rectal, 6 colonic, 1 colorectal, 11 small bowel) underwent 27 operations for anal fissure and ulcer. Twentytwo patients had u n c o m p l i c a t e d healing by 2 months, while two required up to 2 years for healing. One patient was lost to follow-up at 4 months and had an u n h e a l e d w o u n d at that time. Two patients ultimately underwent proctectomy (at 5 months and 7 years), and nine others eventually d e v e l o p e d other perianal disease on longterm follow-up (mean 7.5 years). In summary, 15/17 patients with Crohn's disease had routine w o u n d healing after h e m o r r h o i d e c t o m y and 22/25 patients had w o u n d healing as e x p e c t e d following anal fissure surgery. We conclude that patients with severe symptoms secondary to anal fissures/ulcers and hemorrhoids in known Crohn's disease who cannot be

P28

MEETING ABSTRACTS

controlled with conservative medical m a n a g e m e n t may u n d e r g o surgery on a highly selective basis when the disease is in a quiescent state. Proctectomy is n o t an inevitable outcome.

Dis Colon Rectum, April 1991

clinical information to the surgeon and to the patient in identifying primary and affiliated disorders. CT obviates the n e e d for IVP, permits superior staging and provides a more accurate comparison for postoperative follow-up in these patients.

Perineal Endometriosis--Report of 12 Cases

Booth P7 F. Ruiz-Moreno, R. Alvarado-Cerna, U. Rodriguez, J. Amaro . . . . . . . . . . . . . . . . . . . . . Mexico City, Mexico

P-Glycoprotein as a Novel Tumor Marker in Human Colon Carcinoma Booth P9

Endometriosis is the ectopic location of endometrial tissue under cyclic hormonal influence. There are two clinical forms: 1) e n d o m e t r i o m a w h e n the tissue becomes fibrous and nodular, into a well located mass and 2) diffuse form is badly d e l i m i t e d with dissemination to the surrounding structures. Various theories try to explain the pathogenesis of endometriosis. The perineal location is best explained by the implantation theory. We present 12 cases seen from 1978 to 1990. Eight are endometriomas; four b e l o n g to the diffuse type. All are localized at an episiotomy scar, forming a painful mass with inflammation which b e c o m e s larger and more painful at the time of menstruation. The ages ranged from 24 to 36 years. The symptoms a p p e a r e d from 12 months to 9 years from the date of the e p i s i o t o m y or vaginal surgery. Three to 18 months lapsed from the b e g i n n i n g of symptoms to the surgical treatment. All the e n d o m e triomas were easily resected with no recurrence, whereas the surgical treatment was difficult in the diffuse forms, specially when the anal sphincters were involved; hormonal adyuvant treatment was instituted. We do not r e c o m m e n d anorectal surgery during menstruation.

J. M. Dominguez, T. J. Saclarides . . . . . . . . . J. S. Coon, R. S. Weinstein . . . . . . . . . . . . . . .

Chicago, IL Tucson, AZ

The Preoperative Use of Computerized Tomography in Patients with Colorectal Carcinoma Booth P8

The Level of Serum Gastrin as a Predictive Indicator of Liver Metastasis in Colorectal Cancer Booth P10

B. A. K e r n e l G. C. Oliver, T. E. Eisenstat, R. J. Rubin, E. P. Salvati . . . . . . . . . . . . . . . . . . . . . . . . . Plainfield, NJ

M. Kameyama, I. Fukuda, S. Imaoka, T. Iwanga Osaka, Japan

Controversy exists over the appropriate preoperative evaluation of colorectal cancer patients. Most surgeons agree that basic laboratory studies are indicated. Computerized tomography of the a b d o m e n and pelvis has b e e n used in our practice to augment the preoperative evaluation of these patients. This report represents a 2-year review of 158 patients with primary colorectal carcinoma who underwent a preoperative CT of the abdomen. In 70 patients, CT scans revealed no additional information. In the remaining patients there were 120 additional findings. Of this number, 35 percent were clinically significant and altered the p r o p o s e d operative procedure or a d d e d additional technical information for consideration preoperatively. These findings included liver metastasis, unilateral atrophic kidney, and abdominal wall or contiguous organ invasion. In addition, other solid organ carcinomas were detected. We have c o n c l u d e d that c o m p u t e r i z e d tomography is an effective aid in the preoperative evaluation of individuals with a colorectal carcinoma. CT offers important

It has b e e n demonstrated that gastrin has a t r o p h i c effect on colorectal cancer in animal, but it has never b e e n shown that serum gastrin is associated with the liver metastasis of human colorectal cancer. The aim of this study was to investigate the relationship b e t w e e n serum gastrin and liver metastasis. There were 140 patients with colorectal cancer (T2, T3) who underwent surgery, and for w h o m the fasting serum gastrin concentration was d e t e r m i n e d prior to the surgery. Liver metastasis was d e t e c t e d in 12 of 102 (12 percent) patients with serum gastrin level of less than 150 p g / m l , and in 14 of 38 (37 percent) patients with a serum gastrin level of 150 p g / m l or more. Venous invasion was d e t e c t e d in 55 of 102 (54 percent) patients with a serum gastrin level of less than 150 pg/ml, and in 19 of 38 (50 percent) patients with a serum gastrin level of 150 p g / m l or more. In the patients with venous invasion (v+), liver metastasis was d e t e c t e d in 11 of 55 (20 percent) patients with a serum gastrin level of less than 150 p g / m l , but in 11 of 19 (58 percent) patients with a serum gastrin level of 150 p g / m l or more ( P < 0.01). Our results indicate that

P-glycoprotein (P-Gp) mediates multidrug resistance by functioning as an efflux p u m p that excretes "natural" lipophilic drugs from cancer cells. Whereas the focus of attention has b e e n on the role of P-Gp in anticancer drug resistance, we have n o w e x a m i n e d the influence of Pglycoprotein on the biological behavior of colon cancers in vivo. In an immunohistochemical study using monoclonal antibody C219, we d e t e c t e d immunoreactivity in 65 of 95 primary colon carcinomas, Astler-Coller stage B1 or greater. Solitary invading carcinoma cells and invading cell nests were present at the edge of the tumors. This subpopulation of invading cells expressed P-Gp in 47 cases. There was a higher incidence of lymph node metastases in cases with P-Gp+ invasive cells ( P < 0.01). P-Gp status in invading cells did not influence tumor grade, stage, size or mucin production. In some cases with P-Gp negative primary tumors, invasive cells and lymph nodes were P-Gp+. These findings indicate that P-Gp may be a useful novel marker for colon carcinomas with high metastatic potential.

Vol. 34, No. 4

P29

MEETING ABSTRACTS

serum gastrin is a risk factor, and in combination with venous invasion, it is possible to predict liver metastasis of human colorectal cancer.

Proliferative Activity of Colonic Mucosa at Different Distances from Primary Adenocarcinoma as Determined b y $44; A Nonproliferation-Specific Nuclear Protein Booth P l l S. Kyzer, B. Mitmaker, P. H. Gordon, E. Wang Montreal, Q u e b e c The field change is one hypothesis concerning the d e v e l o p m e n t of colorectal carcinoma. Removal of a carcinoma without its entire surrounding altered mucosa may result in the d e v e l o p m e n t of a recurrence. $44, a monoclonal antibody directed against statin, a nuclear protein expressed in quiescent cells, was used to determine the proliferative rate of colorectal mucosa at different distances from carcinomas. The s p e c i m e n s of 18 patients undergoing resection of colorectal carcinoma were immediately o p e n e d after operation and strips of mucosa were taken at distances of 1, 5, and 10 cm from the carcinoma. For each location, 10 longitudinally orie n t e d crypts were evaluated for Statin-positive cells identified by the presence of a dark brown reaction product. The average percentage of statin-positive cells p e r crypt were significantly lower at a 1 cm distance from the carcinoma c o m p a r e d with the mucosa located 5 and 10 cm from the carcinoma (20.89 + 4.33 at 1 cm, 32.41 +-5.27 at 5 cm, and 34.23 --- 6.45 at 10 cm). None of the calculated parameters showed any significant difference b e t w e e n the 5 and 10 cm locations. The increase in mucosal proliferation rate disappears s o m e w h e r e between 1 and 5 cm from the margin of the carcinoma. We conclude that failure to remove this transitional highly proliferative mucosa may result in subsequent development of anastomotic or perianastomotic recurrences.

The Fat Clearance Technique: Dukes' B to Dukes' C - Does It Matter? Primary Rectal Cancer Booth P12 R. H. Grace, P. Gibbons, K. M. W. Scott Wolverhampton, UK Dukes' staging remains the best single indicator of prognosis in large bowel cancer. It has b e e n shown that the fat clearance technique identifies a larger n u m b e r of nodes than the standard dissection technique. A further study, using the fat clearance technique has shown that, along with the identification of extra nodes, 10 percent of apparent Dukes' B tumors were actually Dukes' C tumors. The 5-year survival rate of these patients has n o w b e e n studied. Four of five of the patients converted by fat clearance from Dukes' B to Dukes' C subsequently d i e d of malignant disease; this does not statistically alter survival figures for the original standard dissection of Dukes' B and Dukes' C tumors, but it is obviously clinically significant in relation to the patients converted from Dukes' B to Dukes' C in that their potential prognosis

was more poorer than originally suggested by the standard dissection technique. It is suggested that in any therapeutic trial, accurate establishment of Dukes' staging is essential because faulty Dukes' staging will negate the conclusions.

Classification

Dukes B Dukes C Dukes B + C

5-Year Survival Standard Dissection (%)

5-Year Survival Standard Dissection with Added Fat Clearance

25/42 (59.5) 12/33 (36.4)

(%)

25/37 (69.6) 13/38 (34.2) 1/5 (20)

Is Endoscopic Nd-YAG Lasercoagulation with 192Ir-HDR Afterloading Radiation in Palliation of Rectal Cancer More Effective? Booth P13

A. Berger, H.J. Mischinger, K. Arian-Schad Graz, Austria Introduction: Advanced disease, including local unresectability, w i d e s p r e a d distant metastases, and the presence of medical conditions that preclude major surgery are the major indications for laser therapy of rectal cancer. Symptoms which can be palliated by Nd-YAG laser tumor ablation are obstruction, bleeding, and mucous discharge. Patient and results: From 1983 to 1987, 63 patients (40 males, 23 females, 70.1 years) with rectal cancer had b e e n treated by Nd-YAG lasercoagulation alone. For desobliteration 5.20 (2-12) laser procedures were necessary. Adequate reeanalization could be achieved in 62/ 63 p a t i e n t s - - o n e required a colostomy; 5.30 (2-12) subsequent laserprocedures were necessary with an interval of 8.4-10.1 weeks. Control of b l e e d i n g was possible in 53 patients (10 of 63 rebled). In a prospective study (since 1988), nine patients have b e e n treated (5f, 4m age 78.7 years) after initial laser-therapywith Ir-192 HDR remote afterloading therapy; 5-7 Gy Ir-192 were a p p l i e d through an inserted rectal tube. Each patient underwent four sessions within 2 months. Control of b l e e d i n g and recanalization could be achieved in all patients (100 percent). Restenosis occurred in one patient and required one additional laser session. Summary: These preliminary results of our prospective c o m b i n e d modality treatment showed a control of bleeding in 100 percent vs. 10/63 and control of stenosis in 1/ 9 vs. 9/63 with laser treatment alone. The effect of palliation seems to be encouraging but controlled rand o m i z e d trials have to be done.

Monoclonal Antibodies to Detect Lymph Node Metastases in Colorectal Cancer: An Expanded Study

Booth P14 M. Davis, D. Miller, L. P. Fielding . . . . .

Waterbury, CT

The presence of local lymph node metastases in patients with eolorectal adenocarcinoma is the single most

P30

MEETING ABSTRACTS

important factor in all studies which have used multivariate analysis to d e t e r m i n e the relative importance of prognostic indices after "curative" resection. Traditionally, hematoxylin and eosin staining has b e e n used to study lymph nodes until n e w techniques using monoclonal antibodies have b e e n reported recently. Our preliminary report using a monoclonal antibody raised against cytokeratin (Pankeratin AEI:AE3, avidinbiotin-immunoperoxidase technique) to better evaluate lymph node status involved 144 patients and results using the Dukes' classification (Astler Coller modification) s h o w e d that McAb usage led to a reduction (17.9 percent) in B2 tumor classification with a reciprocal rise (38.7 percent) in the C2 category (chi-square test for B2, C2 lesion distribution differences: 0.1 < P > 0.05). Furthermore, preliminary data show that reassignment of specimens to a lymph node positive category changes the prognosis of the group in numeric terms; however, the data concerning 5-year survival were not statistically significant because of the small sample size. Using an appropriate mathematical m o d e l for statistical significance (Ipsen e t al., 1970; Cochran e t al., 1957; Fryer 1966), the required n u m b e r of patients to address the question of lymph node tumor involvement was calculated to be 600. The patients have b e e n identified through the Connecticut State Tumor Registry with the collaboration of three additional institutions (Yale, Norwalk, and Bridgeport Hospitals). At the present time, data has b e e n received from the CSTR and s p e c i m e n blocks are being sectioned by collaborating institutions for final staining. Comparison of the reassignment of these specimens with survival data will d e t e r m i n e whether the change in tumor stage associated with a higher yield of lymph node positive specimens b y using the McAb technique has prognostic significance in terms of 5-year survival for patients with large bowel cancer and will be presented. Lymph node status in specimens of patients with colorectal cancer has h e l p e d physicians advise patients about estimates of prognosis. A recent m e m o r a n d u m b y the National Cancer Institute (NCI) has advised physicians to i m p l e m e n t adjuvant c h e m o t h e r a p y for patients with positive lymph node status using a r e g i m e n of 5-FU and levamisole. Thus the NCI has changed the n e e d to evaluate lymph n o d e status from an interest in patients' prognosis to an important evaluation for clinical decision-making to select optimal treatment in colorectal cancer patients.

The Value of Nuclear Morphometry in the Management of Patients with Colorectal Polyps Which Contain Invasive Adenocarcinoma Booth P15 B. Mitmaker, S. Kyzer, L. R. Begin, P. H. Gordon Montreal, Q u e b e c The management of a patient who has u n d e r g o n e colonoscopic p o l y p e c t o m y for a large bowel polyp which contains invasive adenocarcinoma is controversial. Haggitt's classification is a useful guide in that patients in

Dis Colon Rectum, April 1991

Levels 1 to 3 require no operation. Using Level 4 as an indicator for operation, approximately 75 percent of patients will exhibit no residual. Nuclear m o r p h o m e t r y is a useful prognostic discriminant for patients who suffer from invasive carcinoma of the large bowel. We studied the nuclear shape factor of 44 polyps with invasive carcinoma to d e t e r m i n e whether this parameter was of value to define those patients with Haggitt Level 4 who should have a resection. The shape factor of 50 interphase nuclei was obtained through the use of image analysis by tracing the nuclear profiles as digitized on a video screen. The nuclear shape factor was defined as the degree of circularity of the nucleus, a perfect circle r e c o r d e d as 1.0. Our previous experience showed a nuclear shape factor greater than 0.84 was associated with a poor outcome. The overall mean shape factor was 0.71 (0.59 to 0.85). Fifteen of the 17 patients with Level 4 underwent operation and 4 were found to have residual disease or lymph node metastases. There was a t e n d e n c y for the patients with residual disease to have values in the u p p e r range, but the small numbers limited statistical assessment. Our findings suggest that nuclear m o r p h o m e t r y fails to add valuable information in this clinical situation.

Decreased Rectal Wall Contractility in Chronic Severe Constipation Booth P16 K. E. Levin, J. H. Pemberton, A. M. Bell, R. B. Hanson . . . . . . . . . . . . . . . . . . . . . . . Rochester, MN The rectal barostat quantifies the volume of air within an infinitely complaint intrarectal bag maintained at a constant pressure; decreases in intrarectal volume reflect increases in rectal muscular contractility while increases in volume reflect decreased contractility. Aim: To identify differences in rectal wall contractility b e t w e e n healthy volunteers and patients with chronic severe constipation. Method: 15 healthy volunteers (10W, 5M, mean 36 years), and 8 patients (7W, 1M, mean 44 years) were studied. The barostat bag was positioned in the rectum just above the anal canal. Recordings were made for 1 hour prior to and 1 hour after a meal (750 Kcal). Neostigmine (0.5 mg) was then given IV, followed in 1 hour by glucagon (IU) IV. Comparisons were made using unpaired t-tests. Results: Fasting rectal volumes were similar; patients 113 - 7 ml (SEM) vs. control, 103 - 4 ml. P > 0.05. However, constipated patients had significantly less decrease in rectal volume after a meal and after neostigmine than did controls (Table). Moreover, patients had a smaller increase in rectal volume after glucagon then did controls (Table).

Intrarectal V o l u m e Fed Group Controls Constip.

* P < .05.

(%

decrease) 65 + 7 35 - 8*

Neostigmine

Glucagon

(% decrease)

(% increase)

58 + 6 39 --- 6*

64 + 18 28 --+-6*

Vol. 34, NO. 4

MEETING ABSTRACTS

Conclusion: Changes in rectal wall contractility in response to feeding, to a cholinergic agonist and to a smooth muscle relaxant were decreased significantly in patients with profound constipation. These findings suggest that an abnormality of rectal muscular wall contractility is present in constipated patients.

Fecoflowmetry, A New Parameter Assessing Rectal Function in Normal and Constipated Subjects Booth P17 A. Shafik, K. Abdel-Moneim, A. Khalid . . . .

Cairo, Egypt

Fecoflowmetry is a n e w technique by which the fecal flow rate is studied through r e c o r d e d curves representing the changes occurring in the rate against time. Fecal flow rate is the product of rectal detrusor action against outlet resistance. The technique was p e r f o r m e d on 36 normal volunteers and 88 chronically constipated patients. A lliter water e n e m a was given to the individual. Upon feeling the desire to defecate, s h e / h e was placed on the c o m o d e of a fecoflowmeter and was asked to defecate. Evaluation of the obtained defecation flow curve comprises reporting on the defecated volume, flow time, maximum and mean flow rates, and the shape of the curve. D e v e l o p e d to simulate natural defecation, the technique assesses all objective parameters in one test; it provides quantitative and qualitative data concerning the act of defecation. In the 88 constipated patients, two fecoflowmetric patterns were recognized: nonobstructive (intertia) and obstructive. They differ from each other in parameters and curve configuration. The evacuated volume and maxi m u m and mean flow rates were smaller in outlet obstruction than in the intertia type, whereas flow time and time to maximum flow were more prolonged. The ascending limb in the obstructive type curve rose less steeply than in inertia; the curve had a long plateau and the d e s c e n d i n g limb s l o p e d more gradually. To conclude, fecoflowmetric studies could differentiate b e t w e e n defecation of normal and constipated subjects, and in the latter b e t w e e n the obstructive and the inertia type of constipation, The p r o c e d u r e is simple, non-invasive and useful in screening defecation and rectal disorders.

The Changing Incidence of Diverticulitis in Rochester, Minnesota Booth P18 R. M. Devine, R. W. Beart Jr., L. J. Melton, D. M. Ilstrup, B. G. Wolff . . . . . . . . . . . . Rochester, MN Reports suggest that the incidence of diverticular disease has increased in the d e v e l o p e d countries during this century. This population-based study l o o k e d at the incidence of hospitalization and surgery for diverticular disease in a relatively stable North American c o m m u n i t y b e t w e e n 1946 and 1979. All patients living in Rochester, Minnesota, who were admitted with diverticular disease

P31

b e t w e e n 1946 and 1979 were identified and their charts reviewed; 403 patients were hospitalized 598 times for diverticulitis, and 228 surgical procedures were done. Using the n u m b e r of hospitalizations and operative procedures b e t w e e n 1946 and 1979, and the population statistics for the community, the incidence of hospitalization and surgery was calculated. Between 1946-50 and 1976-79, the age- and sex-adjusted incidence of hospitalization increased from 9 to 54 per 100,000 per year, and the incidence of surgery from 3 to 18 per 100,000 per year. The female to male ratio has grown smaller from 4.5:1 in 1946-50 to 0.85:1 in 1976-79. This study provides evidence for an increase in the incidence of diverticulitis in the United States over the last four decades.

The Surgical Management of Right-Sided Colonic Diverticulitis in Singapore Booth P19 S. S. Ngoi, J. Chia, P. Goh, E. Sire . . . . . . . . . .

Singapore

Cecal diverticulitis is an u n c o m m o n surgical entity especially in Western countries in contrast to oriental communities. This may be due to the higher incidence of right sided colonic diverticulosis in oriental populations. We reviewed 68 patients who were treated surgically for cecal diverticulitis over a 10-year p e r i o d from January 1981 to January 1990. There were 36 males and 32 females with an average age of 37.9 years (range 20 to 85 years). All of our patients had clinical presentations that were indistinguishable from acute appendicitis and were thus operated upon. Apart from three cases of e m e r g e n c y right h e m i c o l e c t o m y that were done for a cecal mass, the rest had an appendicectomy. Diverticulectomy for an inflamed and perforated diverticulum was carried out in 25 patients. All had high-close antibiotics both intra- and postoperatively. In the follow-up of these patients, only one patient required an elective right h e m i c o l e c t o m y for repeated diverticulitis. There was no mortality in our series. The morbidity was contributed by a liver abscess in one patient, cecal fistula in another (both treated conservatively) and w o u n d infection in eight. Our results suggest that cecal diverticulitis may be self-limiting and managed by a conservative surgical approach. A more radical surgical resection is indicated mainly for repeated attacks.

The Influence of Design of the Pelvic Reservoir on Ileal Ecology Booth P20 P. M. Sagar, P. Godwin, P. Quirke, D. Johnston Leeds, UK The influence of ileal reservoir design on bacterial content of reservoir effluent, volatile fatty acid concentration, efficiency of evacuation, and mucosal inflammation was assessed. Thirty patients were studied after restorative p r o t o c o l e c t o m y for ulcerative colitis. A triplicated (S) reservoir was used in 10 patients and a quad-

P32

MEETING ABSTRACTS

ruplicated (W) reservoir in 20. Fresh fecal samples were collected and processed promptly. Efficiency of evacuation was determined by the use of radiolabeled synthetic stool. Mucosal changes in reservoir biopsies were scored by one pathologist. The effluent from S reservoirs had significantly greater numbers of bacteroides [12 x 107 cfu/ml (0.083250-18.7) v s. 0.0125 x 10 cfu/ml (0.00111.75)] (P < 0.05) and concentrations of acetic [231.7 # m o l / g (119.3-368.4) v s. 94.93 #mol/g (33.4-211.9)] and propionic acids [60.1 /,mol/g (23.75-91.2) v s . 16.7 #mol/g (10.2-46.2)] (P < 0.05) than effluent from W reservoirs. Efficiency of evacuation was reduced in patients with S reservoirs [59.5 percent (38-68.5) v s . 97.4 percent (91.8-98)] ( P < 0.05). There were no significant differences between the two groups in ratio of anaerobes to aerobes, percentage of water content of the stool, or mucosal changes. In conclusion the ileal ecology of S and W reservoirs is different, and this may be related to stasis. *Median (interquartile range).

Dis Colon Rectum, April 1991

Increased Bowel Permeability After Ileal Pouch-Anal Anastomosis

Booth P22 W. A. Koltun, R. J. Smith, D. Loehner, P. Durdey, J. A. Coller, J. Murray, P. Roberts, M. Veidenheimer, D. Schoetz . . . . . . . . . . . . . . . . . . . . . . . . Burlington, MA Poorly understood are the physiologic changes that occur when small bowel is used as a reservoir, as in the ileal pouch-anal anastomosis (IPAA). The present study examined whole bowel permeability (WBP) in patients undergoing IPAA. WBP was assessed by measuring the urinary lactulose to mannitol excretion ratio (L/M) in a 5-hour urine collection after an oral dose of the test sugars. Five patient groups were studied: 1) normal healthy volunteers (nls), 2) unoperated patients with ulcerative colitis (uCUC), 3) colectomized patients with CUC and ileal stomas (sCUC), and patients with functioning IPAA done for 4) CUC, or 5) familial polyposis (FP)

L/M ratio (mean +

his.

uCUC

sCUC

IPAA-CUC

IPAA-FP

10 1.7 --- 4

5 1.8 + 5

6 1.5 -4- 2

17 3.6 --+-5*

7 5.1 + 7*

SE) Reduction of Resting Anal Pressure in Neurogenic Fecal Incontinence is due to Denervation of the Internal Sphincter Booth P21 P. Durdey, J. A. Coller, R. C. Barrett, J. J. Murray, P. L. Roberts, D.J. Schoetz Jr . . . . . . . . . . Burlington, MA Pudendal nerve damage in patients with neurogenic fecal incontinence cannot explain internal sphincter (IAS) dysfunction, reflected by low resting pressure (RP). Similar reduction in RP is present after ileal pouchanal anastomosis (IPAA), possibly due to denervation of the IAS on rectal transection. We have, therefore, compared manometric data from 45 patients after IPAA with 52 incontinent patients and 21 constipated patients with normal anal sphincters. Median RP (mm Hg) was similar in incontinent patients and after IPAA (34.3 v s. 44.1, P = NS*), both lower than the constipated group (median RP 87.3, P < 0.001"). Squeeze pressures were lower in incontinent patients compared with both IPAA and constipated groups (52.5 v s. 125.0 and 126.3, respectively, P < 0.001"). Thirty-two (71 percent) of 45 after IPAA demonstrated large amplitude (16.5 mm Hg, 6-44 t) low frequency (7c/minute, 5-9) waves. Similar waves (amplitude 12, 4-25, frequency 6.5, 4 - 9 t were present in 38 of 52 (71 percent) incontinent patients. These "intermediate waves" were not present in constipated patients ( P < 0.001+). The data suggest a similar etiology of damage to the IAS in incontinent patients and after IPAA. "Intermediate waves" may represent intrinsic activity of the 1AS independent of autonomic regulation, and implies that low resting pressure is due to denervation of the IAS. (*Mann-Whitney, fmedian and range, +chisquared).

* P< 0.5 compared with nls and sCUCand uCUCby ANOVA. There was no difference in WBP between normals and patients with CUC even after colectomy and ileostomy. The formation of an ileal reservoir, however, significantly increased WBP in both CUC and FP patients. We conclude: 1) patients with IPAA have significant alterations in bowel permeability and 2) this alteration is not due to the underlying pathologic diagnosis. The exact site, cause, and consequence of this abnormality is unclear but may represent compromised gut mucosal barrier function and may relate to local and systemic complications of the IPAA.

Do anal Sphincter Pressures Improve with Time Following Total Proctocolectomy and Ileal Pouch-anal Anastomosis?

Booth P23 W. B. Tuckson, V. W. Fazio, I. C. Lavery, J. R. Oakley, J. M. Church, J. W. Milsom . . . . . . . . . . . Cleveland, OH Following total proctocolectomy (TPC) and ileal pouch-anal anastomosis (IPAA) incontinent patients have been found to have lower maximum anal resting pressures (MRP) than continent patients. There have been reports of a return to preoperative values in the postoperative period, but this has not been universally noted. Anal sphincter pressures from 26 patients, evaluated before and after TPC, IPAA, and ileostomy closure were compared for changes in MRP. The results are listed.

MEETING ABSTRACTS

Vot. 34, No. 4 Table 1. Pressure Changes with Time

MRP (inm Hg) MSP ( m m Hg) Pouch to Manometry (months)

Preop Exam

Initial Exam

Follow-Up Exam

83 + 10" 193 -4- 30

55 -----8 175 + 30 6 -----.5

53 --+ 7 186 + 25 18 + 2

All resuhs mean + 95% confidence interval; * ( P < 0.01).

After 1 year there was no significant change in either the MRP or MSP. Anal sphincter injury, when it occurs, appears to be permanent. Efforts should be made at the time of surgery to minimize anal sphincter injury.

The Ileal Pouch pH: A Regulatory Mechanism for Evacuation Booth P24 M. R. B. Keighley, G. Chattopadhyay, D. Kumar, M. Oya . . . . . . . . . . . . . . . . . . . . . . . . . . Birmingham, UK The role of pouch pH in the regulation of pouch evacuation following a restorative proctocolectomy is not known. To investigate the mechanism of ileal pouch evacuation, we have studied pouch pH for 240 hours (24 hours in each subject) in 10 patients who have had restorative proctocolectomy for chronic ulcerative colitis. pH was measured using a radiotelemetry capsule (Oxford Medical System 1000) tied to the end of a tether and positioned in the pouch. The tether was taped to the buttock. The signal was recorded continuously for 24 hours in a portable solid stage pH data logger. The mean pouch pH was 6.08 --- 0.64 (mean ___SEM). There was no difference between the daytime pH (6.11 + 0.64) and that during sleep (6.13 --- 0.98). We recorded 53 episodes of pouch evacuation (mean of 5.3 per subject). The pouch pH exhibited a significant fall (P < 0.05) in the 30 minutes prior to evacuation (5.71 +_ 0.68) when compared with the 30 minutes immediately postevacuation (6.57 --- 0.71). Meals on the other hand had the opposite effect on pouch pH. There was a significant rise (P < 0.05) in pouch pH approximately 2 hours after a meal (5.99 + 0.66 v s, 7.08 -+- 0.74). These data suggest that pouch pH may be important in the regulation of pouch evacuation and may have significant implications on pouch function following restorative proctocolectomy. The exact role of pH in the regulation of pouch emptying needs further evaluation.

Gastric Emptying of a Solid Meal Following Restorative Proctocolectomy Booth P25 M. R. B. Keighley, K. Hosie, W. Kmiot, A. Mostaf, N. Tultey, I. Harding . . . . . . . . . . . . . . Birmingham, UK The functional results following restoration proctocolectomy are variable. The frequency of defecation is likely to be related to the speed which food residue passes through the gastrointestinal tract. We have as-

P33

sessed the effect of pouch formation on gastric emptying and its relationship with functional result at a mean of 8 months (range 6-24) after surgery. Following an overnight fast, 15 pouch patients and 6 ileostomy controls ate a standard test meal labeled with 99mTc DTPA. Anterior scintigraphic imaging of the abdomen began immediately, and following complete ingestion alternate 2-minute anterior and posterior images were obtained at 15-minute intervals for a minimum of 6 hours. Images were corrected for movement scatter and decay. The geometric mean of the anterior and posterior images were calculated and stomach emptying (T1/2) was defined. The frequency of defecation was recorded for a total of 24 hours from ingestion of the meal during which time the subjects ate a standardized diet There was no significant difference between T1/2 in historical normal controls 40 minutes (range 28-80), ileostomy 57 minutes (range 25-144), and pouch patients 52 minutes (range 29-100), P > 0.05 (Mann-Whitney). There was no correlation between gastric emptying and frequency (P > 0.05) (Spearman rank). Gastric emptying is not affected by restorative proctocolectomy and is not related to frequency of defecation.

Colorectal Trauma: Primary Repair with Intracolonic Bipass v s . Ostomy, A Preliminary Report Booth P26 R. E. Falcone, S. Wanamaker, S. A. Santanello, L. C. Carey . . . . . . . . . . . . . . . . . . . . . . . . Colurnbus, OH Introduction: This is a preliminary report of an ongoing prospective randomized controlled study of primary repair using intracolonic bypass v s . ostomy for severe colorectal injury. Methods: After confirmation of severe colorectal injury at celiotomy, 16 patients were randomized to primary repair with intracolonic bypass (Group i) v s . ostomy (Group 2). Data gathered included: demographics, Trauma Score (TS), Injury Severity Score (ISS), Penetrating Abdominal Trauma Index (PATI), day bowel function returned (BM), hospital stay in days (LOS), hospital charges, and outcome. Statistical analysis was with a variety o f tools, significance established at P < 0.05. Results:

Group 1 Group 2

N

Age

TS

ISS

PATI

BM

LOS

Charge

9 7

24 32

14 14

31 22

39 37

6 6

13 17

$29,663 $28,715

Only age was statistically significantly different (P = 0.047). Additionally, Group 2 charges did not include the cost of subsequent readmission for colostomy closure. Complications were also similar:

Group 1 Group 2

Wound

Abscess

Pneumonia

Sepsis

2/9 3/7

0/9 1/7

1/9 3/7

0/9 1/7

P34

MEETING ABSTRACTS

There were no intra-abdominal complications as a result of primary repair. One patient died (Group 1) from associated injuries. Conclusions: Preliminary study suggests primary anastomosis with intracolonic bypass may be a safe and costeffective alternative to ostomy; ongoing study is warranted.

Anal Sphincteroplasty (AS): A Comparison of Functional (F) and Manometric Results

Booth P27 D. E. Rivera, J. w. Milsom, V. W. Fazio, I. C. Lavery, J. M. Church, J. R. Oakley . . . . . . . . . . . . Cleveland, OH The purpose of this study is to determine if (F) results correlate with anorectal manometric (ARM) testing before and after AS for traumatic sphincter injuries. Twentyeight patients (27 F:I M), mean age of 37, were categorized as to: 1) Grade (G) of incontinence (GO: noneG3: > 1 episode/week); 2) an (F) score determined by impairment of life-style (FO: none-F5: Homebound); 3) ARM to determine maximum resting pressure (MRP), maximum squeeze pressure (MSP), and anal canal length (ACL). As was done in all cases with median follow-up of 12.5 months. G, F score and ARM were reassessed postop:

G F ACL** MRP* MSP*

Preop (-SE)

Postop (--+SE)

P

2.78+0.11 3.04 + 0.22 1.8i + 0.26 30.21 -- 2.60 60.69 _+ 5.12

1.22+0.28 1.08 + 0.29 1.86 + 0.24 33.24 + 2.86 64.58 + 5.87

<0.01 <0.01 ns ns ns

Note: R-squared = 0.133: p o s t o p - p r e o p MRP

vs.

F; * m m Hg; ** cm.

Postop, 13 had no incontinence, 13 had minor incontinence (flatus and leakage), and 2 had major incontinence. Although AS remains an extremely satisfactory method of improving continence in traumatic sphincter injuries, there was no correlation between functional and manometric results. ARM results did not improve postop compared to preop, although function (G and F) did. The value of ARM in managing traumatic sphincter injuries must be questioned.

Can Manometry Predict the Outcome of Patients Undergoing Surgery for Fecal Incontinence

Booth P28 P. Durdey, J. A. Coller, J. J. Murray, P. L. Roberts, D. J. Schoetz Jr . . . . . . . . . . . . . . . . . . . . . Burlington, MA Results of surgery for fecal incontinence are unpredictable. We have performed comprehensive anal manometry in 21 patients before and after repair, to determine if manometry can predict outcome. Initial diagno-

Dis Colon Rectum, April 1991

sis was obstetric or surgical trauma in 13 and neurogenic in 8. Sixteen patients had a direct sphincter repair, and 5 postanal repair. Thirteen of 21 patients (62 percent) improved symptomatically (Group A). In 11/13 (84 percent) the diagnosis was trauma. In 8/21 (38 percent) not improved (Group B); 6 (74 percent) had neurogenic incontinence (P = 0.003*). Group A was significantly younger ( P < 0.01+). Preoperative resting pressures (RP) (mm Hg, median) were similar (A: 32.5, B:32.1). Squeeze pressure and resting and squeeze pressure volume (PV, mm Hg3,) were higher (P = 0.001 +) preoperatively in those improved:

Squeeze

Pressure

Resting PV

Squeeze PV

A B

56.2 43.6

47,259 39,915

124,127 94,224

Preoperative asymmetry, a measure of segmental sphincter loss was higher in Group A (P < 0.05+). RP, squeeze pressure, and PV increased in 11/13 (85 percent) improved after repair. All eight not improved had significant reduction (P = 0.002*) in these parameters indicating further damage to the sphincter. Thus, older patients with neurogenic damage and global sphincter loss are unlikely to benefit from surgical repair. (+MannWhitney U test) (* Fisher's exact test).

Are the Poor Results of Surgery in Neurogenic Fecal Incontinence due to the Pathology or Operation?

Booth P29 P. Durdley, P. T. Gross, M. Oster, J. A. Coller, J.J. Murray, P. L. Roberts, D. J. Schoetz Jr. Burlington, MA Neurogenic fecal incontinence is associated with denervation and re-innervation of the external anal sphincter (EAS). It is unclear whether poor results after surgical repair are due to the procedure or progressive damage to the EAS. We have measured neuromuscular jitter, an indicator of progressive nerve damage, in the EAS of 29 patients presenting with incontinence (13 traumatic, 16 neurogenic etiology) and a matched group of 14 controis. Mean jitter (microseconds) was calculated by measurement of 100 discharges from a minimum of 10 fiber pairs. Mean fiber density (MFD) was determined concurrently. Mean jitter (+SD) was similar in controls [24.2 (4.9)] and patients with traumatic incontinence [27.8 (9.1)] (P = NS*). No control patient had a jitter of >35 microseconds. Jitter was significantly increased in neurogenic incontinence [39.9 (10.7)] ( p < 0.01"). Mean jitter in 10/16 (62 percent) with neurogenic etiology was >35 microseconds indicating active re-innervation. Jitter correlated with MFD (P = 0.01), but not with perineal descent. These data suggest that denervation is progressive in some patients with neurogenic incontinence, and this may explain a poor operative result. Measurement

Vol. 34, No. 4

MEETING ABSTRACTS

P35

of jitter may be valuable in selecting patients for surgery, (* Student's t-test for unpaired data),

to greatly facilitate the evaluation and differentiation of inflammatory large bowel diseases.

Sphincter Repair Without Overlapping for Fecal Incontinence Booth P30

Endoluminal Ultrasound Defines Anatomy of the Anal Canal and Pelvic Floor Booth P32

J. C. Sarles, A. Arnaud, I. Sielezneff, P. Orsoni, A. Joly Marseille, France

J. Tjandra, V. M. Stolfi, J. W. Milson, I. Lavery, J. Oakley, J. Church, V. Fazio . . . . . . . . . Cleveland, OH

Forty patients who had sphincter repair by one surgeon over the last 15 years were reviewed. The etiology of sphincter trauma was previous surgery (22), childbirth (14), and accidental trauma (4). Eleven patients had u n d e r g o n e at least one previous attempt at repair. Prior to operation 12 patients were incontinent of liquid stool and 28 of formed stool. A technique of sphincter repair without overlapping was used. An associated diverting colostomy was made in seven patients who all had a previous failed repair. Follow-up was an average of 17 months after operation (range 2-96 months). After operation, 25 patients were c o m p l e t e l y continent, 6 had occasional leakage for liquid stool, 4 were only continent for solid stool, and 5 did not show any improvement. Neither diverting colostomy nor overlapping sutures appear to be mandatory for successful repair of anal sphincter after trauma.

Accurate delineation of wall layers by endoluminal ultrasound (ELUS) in staging rectal cancers has led to interest in whether it can visualize structures of the anal canal and pelvic floor. The p u r p o s e of this study is to define the sonographic appearance of these structures and their anatomic relationships. Methods: Bruel and Kjaer ultrasound e q u i p m e n t with a 7.0 mHz transducer was used to obtain images of the anal canal and pelvic floor of three human cadavers in the transverse plane. Anatomical layers of one half of anal canal and pelvic floor were sequentially removed and images were obtained and correlated with the opposite side. Results: Coincident ultrasound images and anatomical photographs demonstrate (to be displayed) anal sphincters, puborectalis, and surrounding structures (anococcygeal ligament, perineal body, levators, vagina, urethral sphincter). The focal length (2-5 cm) of 7.0 mHz ELUS does not allow accurate visualization of the internal sphincter. Conclusions: 1) ELUS can visualize anatomical structures in the pelvis and may have potential to define pathological processes in relation to them. 2) Higher frequency ELUS p r o b e s (shorter focal length) may be necessary to visualize the internal anal sphincter. 3) Further effort is n e e d e d to define the role of ELUS in pelvic floor diseases.

Diagnosis of Inflammatory Large Bowel Diseases by Transabdominal Hydrocolonic-Sonography Booth P31 B. Limberg . . . . . . . . . . . . . . . . . . . . . . .

Darmstadt, FRG

In diseases of the large intestine, the diagnostic value of conventional abdominal sonography is limited. We have therefore studied if the instillation of fluid into the colon would improve the diagnostic value of transabdominal sonography in evaluating inflammatory diseases of the colon. In 96 percent of patients the entire length of the colon starting at the recto-sigmoid junction and ending at the cecum could be visualized with rectal instillation of water. The sonographic views obtained using this technique show the echo-free intestinal lumen and the five individual layers of the colon wall. In acute colonic Crohn's disease the normal stratified appearance of the colonic wall is no longer in evidence and the wall appears visibly thickened. In contrast, patients with active ulcerative colitis will maintain the normal sonographic stratified appearance of the colonic wall. In our prospective study in 300 patients severe active colonic Crohn's disease and ulcerative colitis could be d e t e c t e d by colonic sonography with a sensitivity of 91 and 89 percent, respectively. Pathological changes were subsequently confirmed by colonoscopy. In addition, the colonic resections of four patients with acute Crohn's disease were examined in vitro. The sonographic findings demonstrated in vitro agreed within the scope of colonic sonography with those demonstrated in vivo. Colonic sonography is a n e w diagnostic p r o c e d u r e that promises

Sigmoid Volvulus in the High Altitude of the Andes: A Review of 230 Cases Booth P33 H. J. Asbun, H. Castellanos . . . . . . . . . . . J. Asbun . . . . . . . . . . . . . . . . . . . . . . . . . . .

La Paz, Bolivia Bakersfield, CA

Sigmoid volvulus (SV) is a rare cause of intestinal obstruction in the United States. The etiology is unclear. Little has b e e n p u b l i s h e d in the English literature about the high incidence of SV among rural areas of the Bolivian and Peruvian Andes at 13,000 feet above sea level. A review of 230 cases of SV in a Bolivian hospital is presented. SV accounted for 79 percent of all intestinal obstructions. In all patients, nonoperative reduction was initially attempted, except for those with peritonitis. Nonoperative reduction alone was p e r f o r m e d in 31 percent of the patients and 69 percent underwent surgical intervention, 66 percent as an e m e r g e n c y and 3 percent electively. Surgical treatment consisted of sigmoidectomy and primary anastomosis (50 percent), Hartmann's p r o c e d u r e (12 percent), and reduction with sigmoid

P36

MEETING ABSTRACTS

plication (38 percent). Overall mortality was 13 percent. Fifty seven (36 percent) of the surgically treated patients d e v e l o p e d significant complications. High altitude, along with other etiologic factors, may play an important role in SV. Intraluminal gas volume relates inversely with atmospheric pressure which at 13,000 feet is decreased by 483 mm Hg, thus contributing to a chronic distention of the redundant sigmoid. To our knowledge, these series represent the highest incidence of SV in b o w e l obstruction.

Combined Penetrating Rectal and Genitourinary Injuries: A Challenge

in Management

Dis Colon Rectum, April 1991

metastases are present at diagnosis in 13.5 percent; - - metastases may be inquinal, pelvic, or hepatic; - - 7 7 percent are eventually treated by abdominoperineal resection; - - adjuvant therapy was used in 54 percent; - - survival without evidence of disease after 3 years usually signals cure. --

Adenocarcinoma of the Anal Glands Symptoms

%

Location

%

Anal pain Bleeding Perianal mass

58 40 37

Posterior Lateral Anterior

37 29 15

Booth P34 Associated Fistula

E. R. Franko, R, R. Ivatury, D. Schwalb New York, NY Combined rectal and genitourinary (GU) injuries are e x c e e d i n g l y u n c o m m o n , which may be the reason that this has not b e e n previously studied. Seventeen patients were treated for this at a major trauma center. All rectal exams revealed frank b l o o d and 70 percent had positive proctologic exams. Gross hematuria was observed in 82 percent of patients. Only 64 percent of urologic contrast studies were accurate. Operative findings included injuries to the extraperitoneal (15) and intraperitoneal (2) rectum, bladder (13), urethra (3), and distal ureter (1). Treatment consisted of e n d or loop colostomy (17); presacral drainage, PSD (14); distal rectal washout, DRWO (13); rectal w o u n d repair (5) d e b r i d e m e n t a n d / or suprapubic drainage for bladder and urethral injuries (16); and distal ureter reimplantation (1). One mortality occurred secondary to associated injuries. Patients not receiving PSD or DRWO had septic complications (25 percent). GU complications included two rectovesical fistulas, two rectourethral fistulas, three chronic UTIs (two with bladder stones), and two urethral stenoses. All fistulas occurred in patients without rectal w o u n d repair. The complication rate was greater for c o m b i n e d injuries than for rectal injuries alone. It was found that PSD, DRWO, rectal w o u n d repair, and perhaps omental interposition were essential in reducing the morbidity of c o m b i n e d rectal and GU injuries.

Adenocarcinoma of the Anal Glands Booth P35 M. E. Abel, Y. S. Y. Chiu, T. R. Russell, P. A. Volpe . . . . . . . . . . . . . . . . . . . . . . San Francisco, CA Anal gland adenocarcinoma is rare, and information about this lesion is c o m m u n i c a t e d mostly as case reports. A survey of ASCRS m e m b e r s h i p revealed that most colorectal surgeons have not treated this malignancy. In 52 cases, sufficient data are available for analysis. The following are important in evaluation and treatment of this tumor: - - 54 percent will present with a fistula; - - the incidence of fistula is significantly higher in males;

Present Absent

Total (%)

Male (%)

Female (%)

28 (54) 24 (46)

20 (67) 10 (33)

8 (36) 14 (64)

Surgical Treatment Abdominoperineal Local excision Local excision and APR No resection Total

34 9 6 3 52

The Effect of Proctectomy with Colo-Ana Anastomosis on Anal Sphincter Function: A Manometric Study Booth P36 R. Saad, J. M. Church, V. W. Fazio, I. C. Lavery, J. R. Oakley, J. W. Milsom, T. Schroeder Cleveland, OH Proctectomy with coloanal anastomosis (CAA) is an attractive alternative to colostomy in selected patients with low rectal cancer. Its functional results are sometimes unsatisfactory. The aim of this study was to examine the effect of CAA on objective indices of anal sphincter function. Methods: Anal canal length (ACL), maxim u m anal resting (MRP), and squeeze (MSP) pressures were measured before CAA and after subsequent ileostomy closure in 14 patients operated on for rectal cancer (median interval 10.5 months). Results: There were 8 males and 6 females, median age 52 years (range 3069). Postoperatively, 10 patients were continent of solid and liquid stool while five patients had some leakage of liquid stool (three at night).

Technique All Pts

Change -26 MRP - - 4 5 t o - - 7 Change -11 MSP - - 2 3 t o + 7

Hand Sewn

Stapled

-30 -22 --54 to --4 - 6 4 t o + 2 1 -10 -13 --23to+4 --42to+15

Incontinence to Liquid None

Stool Only

-22 --51to+7 -8 --21to+6

-33 -65to-1 -18 --51to+15

Vol. 34, No. 4

P37

MEETING ABSTRACTS

(Data = m m Hg, mean and 95 percent confidence limits). There was a highly significant relationship between preoperative MRP and the change in MRP with CAA ( r = 0.87). A low preoperative MRP is, therefore, not necessarily a contraindication to CAA. Conclusions: Proctectomy and CAA leads to a significant fall in MRP that is associated with nocturnal incontinence. MSP is not affected.

1 POD

AI

CEEA

ACB

HS

CEEA

ACB

0.59

0.63

--

0.65

0.73

--

_+0.06 _+0.06 _+0.03 _+0.04 BP m m Hg 148 + 9 110 • 63 218 -+ 13" 280 - 30 131 • 19" 41 + 25* CCg% 18-+3 2 1 - + 2 28 -+ 5 t 20_+4 20+2 24-+6 7 POD HS

Mid-Rectal Cancer: Pull-Through or Staples? A Prospective Random Trial

AI

Booth P37 J. A. Reis Neto, F. A. Quilici, F. Cordeiro, J. A. Reis Jr. Campinas, Brazil The choice of a surgical technique in low rectum anastomosis has b e e n a controversial subject. A 5-year prospective randomized trial was undertaken to determine tumor recurrence, per and postoperative complications, and long-term survival rates in patients undergoing surgery for mid-rectum cancer, comparing stapled anastomosis with pull-through procedure. Only patients with adenocarcinoma situated between 6 and 12 cm from the pectinate line were admitted to this study; 39 patients underwent a pull-through technique (Group A) and 43 a mechanical anastomosis (Group B). The groups were similar as to age and sex. Level of the tumor, distal margin of resection, and Dukes' anatomopathological classification were noted in all the patients. A total of 61.5 percent of patients of Group A and 69.7 percent of Group B were submitted to preoperative radiotherapy. As to intra-operative complications, there was no significant difference between both groups. However, intraoperative colostomy was performed in 11.7 percent of patients of Group B against n o n e in group A. Postoperative dehiscence was observed in 4.65 percent of patients of Group B and in n o n e of group A. Anastomotic recurrence occurred in 4.65 percent patients of Group B. Long-term survival rates were similar in both groups: 61.5 percent in Group A and 60.5 percent in Group B.

Comparison of Three Techniques in Bowel Anastomoses Booth P38 A. J. Dziki, M. D. Duncan, J. W. Harmon, N. Saini, R. A. Malthaner, M. T. Fernicola, F. Z. Hakki, K. S. Trad, R. M. Ugarte . . . . . . . . . . . . . Washington, DC The ideal bowel anastomosis would be safely and easily performed and would produce a secure, wellhealed closure without stenosis. To this end, the anastomotic compression button (ACB) has b e e n reintroduced. We compared indices of healing and tissue cohesion in 12 dogs u n d e r g o i n g ACB anastomoses to our previous series of standard two-layer handsewn anastomoses (HS) and stapled anastomoses with p r e m i u m CEEA. The largest ACB or CEEA that the bowel could accommodate was utilized. Burst pressure (BP), anastomotic index, the ratio of the diameter of the anastomosis to adjacent normal bowel (AI), and collagen content (CC) were measured and histologic sections evaluated.

4 POD

HS

CEEA

0.60 0.68 9 +0.05 +0.05 B P m m H g 2 0 8 - + 3 4 198_+2 CCg% 21-+ 1 2 8 •

28 POD ACB 0.76 +0.4 t 165+29 24•

Mean + SD; * P < 0.01; ~ P < 0.05

vs.

HS 0.85 "+0.04 303• 25• 1

CEEA

ACB

0.56 0.83 -+0.04* -+0.08 16 t 288-+40 25+2 27• 1

HS.

All handsewn and ACB anastomoses by POD 28 had larger diameters than the widest CEEA anastomosis. HS and ACB showed more complete epithelialization and less inflammation on POD 28. Burst pressure was highest at all intervals in HS anastomoses except POD 1, while the ACB group had a markedly low BP on POD 4. One ACB animal not included above died POD 4 from an anastomotic disruption. Collagen content tended to be high in CEEA on POD 7, perhaps related to the increased incidence of strictures (lower AI). The handsewn technique remains superior to current ACB and CEEA methods.

Laser Closure of Experimental Colotomies Booth P39 P. Ryan, S. Kuramoto . . . . . . . . . . .

Melbourne, Australia

Low level laser energy has b e e n used to anastomose various tubes (Fallopian tube, artery, vas deferens, ureter, urethra, and small bowel). Tissue welding occurs at lower energy levels than required to cut or vaporize, but the mechanism of b o n d i n g is unknown. Advantages of laser anastomosis include avoidance of foreign material and needle trauma, with minimal inflammatory and imm u n e response. Guy sutures were used to appose the edges of transverse colotomy wounds in rabbits. The anastomotic seam was lased using a neodymium-YAG laser, supplied through a hand-held 600-f,m gas-cooled noncontact optical fiber. An 0.5-watt wave of power was applied to the Indian-ink marked bowel edges, moving the laser light up and down the seam several times until tissue blanching indicated a satisfactory weld. A control one-layer anastomosis was performed in the same animal with 5/0 maxon sutures. Lased colotomy wounds up to two-thirds of the bowel circumference were successfully welded in 12 rabbits, with long-term survival. In 14 short-term experiments, there were three leaks ( n o n e of the controls). Eleven explored at 1 week showed an almost invisible seam without adhesions and, at 7 days, normal bursting pressure.

MEETING ABSTRACTS

P38

Carcinoma Specific Human Monoclonal Antibody Mediated Target Cell-Cytotoxicity Booth P40

H. R, Chang, B. Chavoshan . . . . . . . . . . .

San Diego, CA

SK1 has b e e n shown to be a carcinoma specific h u m a n IgM monoclonal antibody (HuMAb). In this study, the c o m p l e m e n t d e p e n d e n t cytotoxicity (CDC) mediated by HuMAb SK1 was examined. Chromium-51 (51Cr) release assay was used to measure the specific lysis of target cells in CDC assay. In that, 100#l of supernatent containing SK1 and 25#l of h u m a n serum containing c o m p l e m e n t were added to 20,000 ~Cr labeled target cells. The maximal release (MR) of radioactivity from lysed cells was obtained from NP40 treated cells. The spontaneous release (SR) of radioactivity was measured from cells growing in the medium. The specific cytotoxicity (SC) mediated by antibody is shown by: SC% = 100 x (CDC~xp~- S R ) / ( M R - SR). The target cells examined were two cells lines: HT-29, a colon cancer cell line; PANC-1, a pancreatic cancer cell line and also fresh tumor cells derived from a surgically removed colon cancer specimen. Our study showed that carcinoma specific HuMAb SK1 kills gastrointestinal (GI) cancer cells including both cell lines and fresh cancer cells.

Target Cells

CDC%

HT-29 PANC 1 Fresh tumor cells

103 83 81

In the serial dilution study SK1 retains significant cytotoxicity at a dilution of 1:16. Fifty percent of fresh tumor cells were killed and diluted SK1. Specific target cell-lysis mediated by SK1 shows promise as a clinical application.

The Influence of Calcium Supplementation and Small Bowel Resection on Ileo-Colonic Cellular Proliferation and Hydrazine Induced Neoplasia in the Rat Booth P41

M. R. B. Keighley, G. Barsoum . . . . . .

Birmingham, UK

This study assessed the effect of 75 percent SBR resection and calcium supplementation (25 Ca lactate/i/24 hours) on ileal (I), cecal (Ca), and colonic (Co) cellular proliferation (CCPR) and tumor formation in Wistar rats after 30 weeks DMH administration (40 mg/kg body wt/ wk for 5 weeks. CCPR was assessed by an i n v i v o stathmokinetic method. CCPR was different at all 3 sites (I = 9.1 - 0.6, Ca = 4.7 _ 0.5, Co = 3.9 -+ 0.6, P < 0.01 ANOVA). SBR (I = 16.3 + 13, Ca = 6.6 - 1.1, Co = 11.2 4- 1.9, p < 0.01), DMH (I = 16.6 + 1.8, Ca = 9.6 + 1.6, Co = 9.3 -- 1.1, P < 0.01) and SBR + DMH (I = 21.1 -1.3, Ca = 12.0 --+ 1.0 Co = 9.4 --- 1.0, P < 0.01) increased CCPR at all three sites. The effect of SBR + DMH was

Dis Colon Rectum, April 1991

not cumulative. Calcium reduced the ileal ( P < 0.02), cecal ( P < 0.01), and colonic ( P < 0.01), CCPR of the SBR, DMH and SBR + DMH group but not controls. It also reduced tumor yield in the DMH group (13 vs. 5, P < 0.05) but not the SBR + DMH group (9 vs. 14). The inability of SBR to c o m p o u n d the effect of DMH and ability of calcium to reduce CCPR without affecting tumor yield confirms that hyperplasia alone does not increase susceptibility to malignancy. The influence of calcium in the DMH model is likely to be a direct action on mucosal cell membrane.

Effect of Glutamine Supplementation on Anastomotic Bursting Strength in Rats Booth P42

D. M. Jacobs, C. A. Bundy, M. P. Bubrick Minneapolis, MN Glutamine is essential for the maintenance of small intestine mucosal structure and function. Enteral glutamine supplementation has b e e n shown to preserve mucosal integrity and function in stress models. Standard enteral and parenteral feeding formulae provide little or no glutamine, and this may contribute to anastomotic dehiscence in critically ill patients. We postulate that glutamine supplementation may improve small bowel anastomotic healing as determined by bursting strength measurement. Model: Using Sprague-Dawley rats (400600 g) we placed a feeding gastrostomy and divided the ileum 3 cm proximal to the cecum. The small bowel was reanastomosed with 6-0 chromic suture. Animals were kept NPO for 24 hours, given water a d lib and randomized into four groups: U = unfed, RC = rat chow, E-GIy = enteral formula (EN) + 2% glycine, E-Glu = EN + 2% glutamine. Enterally fed animals were given 230 Kcal/ kg/day and 1.2 g nitrogen/kg/day. All animals were sacrificed at 6 days and bursting strength (mmHg) determined. Villous height was assessed histologically.

U RC E-GIy E-GIu

Burst Strength

Villous Ht

168 4- 78 228 4- 46* 218 4- 57 248 4- 59*

0.62 4- 0.07 0.62 4- 0.07 0.60 + 0.12 0.59 4- 0.06

* P< 0.05 vs. unfed. Conclusion: Supplementation of a standard enteral feeding formula with glutamine improves anastomotic bursting strength at 6 days.

Evaluation of Colonic Microcirculation Pattern Booth P43

R. Bonardi, A. Scaramelo, A. Possebon, C. Peres, C. R6hrig . . . . . . . . . . . . . . . . . . . . . . . . . . Curitiba, Brazil Etiology of microcirculation abnormalities in the colon are still unknown. The present study establishes a numerical pattern related to age, of mucosal and sub-

MEETING ABSTRACTS

Vol. 34, No. 4

mucosal vessels, and tries to explain the behavior of the b l e e d i n g vessels. Thirty colons either from autopsies or surgical specimens were studied. The age range varying from 0 to 96 years ( m e d i u m 57.7 years). In four cases the colon was resected from male patients with history of lower G.I. bleeding. Segments of the mesenteric border were cut 5 cm apart from the cecum to the distal sigmoid colon, stained with H.E., and studied under optical microscopy. The internal and external diameter of the vessels of the mucosa and submucosa were measured on each specimen. The results in Table 1 are the average measurements on the different age groups (micron).

Age

Mucosa

Group

0 40 41-60 >61

Submucosa

Int.

Ext.

Int.

Ext.

14.5 16.8 21.9

17.4 20.7 28.0

15.9 18.7 22.3

19.9 23,4 28.8

There was a progressive increase in the vessels' diameter with aging, but no significant difference in the diameter of these vessels on the several colonic segments, showing that the dilatation occurs in an equal manner throughout the colon. On the other hand the "index of resistance" (R = e/D; e = thickness of the wall; D = external diameter) progressively decreases with aging as shown in Table 2.

Age G r o u p

Mucosa

Submucosa

0-40 41-60 >61

2.50 2.15 1.79

2.14 1.98 1.71

P39

Pelvic Peritoneal Reconstruction to Prevent Radiation Enteritis in Rectal Cancer Booth P45

J. S. Chen, H. A. Fan, J. Y. Wang . . . . . . .

Taipei, Taiwan

Some patients with rectal cancer who undergo exenterative surgery require radiation therapy for recurrent or residual disease as adjuvant treatment. A devastating side effect of this treatment is radiation-associated small bowel injury. The prevention of radiation enteritis is the c o m m o n goal of the surgeon and the radiation oncologist. We used a new technique in 18 patients with rectal cancer. After removal of the rectal lesion (eight APR, nine Hartmann's procedure, one LAR), the pelvic peritoneum, transversalis abdominis fascia, and posterior rectal sheath were dissected out. Reconstruction of these structures partitioned the abdominal cavity at the level of the umbilicus to the sacral promontary. The small bowel was kept out of the pelvic cavity. X-ray films of the small bowel were p e r f o r m e d before radiation therapy and 7 months and 1 year postoperation. Most patients showed the small bowel remaining in the abdominal cavity. During the follow-up p e r i o d of 4 months to 2 years (average 14.8 months), one early complication and three late complications of pelvic p e r i t o n e u m breakdown were noted. Two of these required laparotomy for intestinal obstruction, and radiation enteritis was noted in both. The follow-up p e r i o d is still short, but the results encourage us to perform this n e w technique for advanced rectal cancer.

A Newly Designed Occluder Pin for Presacral Hemorrhage Booth P46 V. M. Stolfi, J. Milsom, V. Fazio, I. Lavery, J. Oakley, J. Church . . . . . . . . . . . . . . . . . . . . . . . . . . Cleveland, OH

Experimental Prevention of Adhesion Formation Booth P44

M. R. B. Keighley, A. M. Kappas, J. Ortiz, G. Barsoum . . . . . . . . . . . . . . . . . . . . . . Birmingham, UK Post-ischemic release of oxygen radicals has b e e n implicated in adhesiogenesis. We studied three drugs that may interfere with the production and release of free oxygen radicals (verapamil, corticosteroid, and phosphatiodylcholine) and may modify adhesion formation. An adhesiogenic m o d e l (laparotomy and intraperitoneal irrigation with saline at 40~ was used to assess these agents. Eighty rats were allocated into four groups: irrigation and verapamil (Gv), irrigation and hydrocortisone sodium succinate (Gh), irrigation nad phosphatidylcholine (Gp), and irrigation alone: controls (Gc). All animals were sacrificed at 2 weeks. Adhesions were found in: 13/19 control animals c o m p a r e d with 7/ 20 of Gv ( P = 0.056, Fisher's exact test), 6/20 of Gh ( P = 0.025) and 3/20 of Gp ( P = 0.001). These data suggest that in this m o d e l postoperative adhesions can be significantly r e d u c e d by phosphatidylcholine.

Inadvertent entry into the presacral fascia during mobilization of the rectum from its sacral attachments may result in massive b l e e d i n g from the presacral venous plexous and the sacral basivertebral veins. Suture and electrocautery as hemostatic measures are often unsatisfactory in this instance. We have d e s i g n e d a n e w type of titanium hemorrhage occluder pin that may be rapidly p l a c e d into the sacrum to control bleeding. The aim of

this study is to measure the forces n e e d e d to pull this new occluder pin out of human sacrum c o m p a r e d with conventionally d e s i g n e d titanium thumb tacks. Methods: Four fresh human cadaveric pelvises were isolated and

P40

MEETING ABSTRACTS

cut on a sagittal m e d i u m plane ancl the thickness of each vertebral body was measured. Titanium pins, both ridged (R) and smooth (S) were used. A 12-ram shaft pin was used for $1, $2, a 7 m m for $3, $4, $5. Pins were inserted in each sacral vertebra and the m a x i m u m load necessary to extract pins was measured by c o m p u t e r i z e d dynamometry. Results: Measured sacral widths indicate 7-mm pins can be used in all sacral vertebrae to avoid entry in the sacral canal: " S1 mm_+SE

27•

S2

S3

S4

$5

18+ 1

12_+ 1

9_+ 1

8+ 1

Significantly more force is required to extract R pins, both with 12-'and 7-mm shafts ( P < 0.01).

12 mm R

Newtons -+ SE

'"

33 + 4

vs, S

7 mm S

R

S

13 -+ 2

29 -- 4

12 + 2

A newly designed ridged hemorrhage occluder pin is more secure in sacrum than a smooth pin and may be an improved method of controlling presacral hemorrhage. Abdomino-Pelvic O m e n t o p e x y (APO)-Preparatory Procedure for Radiotherapy in Rectal Cancer Booth P47 P. Lechner, K. Arian-Schad, P. Lind, H. Cesnik Graz, Austria Adjuvant RT in adenocarcinoma of the rectum requires the application of b e t w e e n 5,500 and 6,600 cGy. On the other hand, the small bowel does not tolerate doses b e y o n d 4,200 cGy without d e v e l o p i n g complications like enteritis, perforation, and stenosis. Several attempts to form an artificial diaphragm b e t w e e n the abdominal cavity and the true pelvis were b u r d e n e d with various sequels. So we d e v e l o p e d a simple technique to retain the small bowel outside of the RT target volume: From tile greater o m e n t u m we form a bag that houses the intestinal loops. The lower margin of the o m e n t u m is attached to the parietal p e r i t o n e u m of the posterior abdominal wall b e y o n d the promontorium. The lateral edges are sutured to the ascending and d e s c e n d i n g colon. RT starts immediately after laparotomy has healed. With the help of APO we have p e r f o r m e d high dose RT following tumor resection in 43 patients. RT was free of complications, and there is no evidence of local recurrence in all patients after mean 26 months by now. Triangulating Stapling T e c h n i q u e ~ A n Alternate Approach to, Low Anterior Anastomosis Booth P48 K. S. Venkatesh, D. M. Larson, D. N. Morrison, P.J. Ramanujam . . . . . . . . . . . . . . . . . . . . . . . . . Mesa, AZ Over 259 patients underwent triangulating stapling technique for low anterior anastomosis. The results w h e n

Dis Colon Rectum, April 199'1

c o m p a r e d with EEA and hand-sewn anastamosis showed this m e t h o d equally effective and advantageous. The age of patients range from 33 to 86, the average being 68. The follow-up range from 6 months to 8 years, the average being 48 months. The average hospital stay was 6 days postoperatively. The average level of anastomosis is approximately 6 to 6.5 cm from the anal verge; 85 percent of the patients represent anastomosis of the non-peritonealized upper and mid-rectum; 58 percent of the patients had carcinoma of the distal rectal sigmoid, upper mid-rectum; 38 percent of the patients had diverticular stricture and diverticular abscess. Complications: Two patients had clinical leak from the anastamosis requiring diversion. One patient had a fecal fistula, which was controlled with he!p of a drain, closing spontaneously over a p e r i o d of 8 weeks. Two patients had anastamotic narrowing without any clinical symptoms. Anastamotic recurrence of cancer is the same as with EEA for u p p e r and mid-rectal carcinoma. From our experience this technique is simple to use and the short and long term results c o m p a r e d very favorably with the EEA stapling technique.

Mechanical v s . Pressure (BAR) Intestinal Anastomoses: A Comparison Booth P49 M. Rubbini, F. Mascoli, C. Mari, V. Bresadola, I. Donini . . . . . . . . . . . . . . . . . . . . . . . . . . . Ferrara, Italy, Staplers significantly improved the quality of intestinal anastomoses by reducing complications like dehiscence and hemorrage, and by improving functionality, o n e limitation of staplers is the possibility of stenosis due to the foreign b o d y reaction favored by metal clips and by the smaller diameter of the stenosis with respect to the adjacent intestine, corresponding to the diameter of the inner blade of the stapler. The VALTRAC pressure biofragmentable suture system seems to avoid this p r o b l e m performing a sutureless anastomosis with a diameter equal to that of the intestine. Methods: We considered 40 patients with colorectal cancer divided in two h o m o g e n e o u s series of 20. In the first series we e m p l o y e d ILS, EEA, and CEEA staplers, in the s e c o n d one, we used the BARs. Endoscopic, radiologic, and clinical exams were p e r f o r m e d 30, 90, and 180 days after surgery to evaluate the diameter, state, and distensibility of the anastomoses. Results: In the mechanical series there were three stenosis, two substenosis, and one Rx dehiscence. Furthermore, a diaphragm r e d u c e d the lumen caliber and distensibility in all patients, s o m e t i m e to clinical evident level. The BAR series i n c l u d e d only one clinical dehiscence whereas the repair process of the anastomosis was slower. Conclusions: BAR anastomoses are generally superior in the long run, with fewer complications, virtually free of stenosis and functional limitations. The slower healing conceivably due to the pressure mechanism e m p l o y e d is not a serious drawback and is amply balanced by the more physiologic anastomoses obtained.