Classic Articles in Colonic and Rectal Surgery MARVIN L . CORMAN, M . D . ,
Editor
Paul Kraske 1851--1930
Paul Kraske was born J u n e 2, 1851, in Berg, near Muskau. He obtained his surgical training in Halle under the tutelage of Richard yon Volkmann, working as his assistant from 1876 t h r o u g h 1883. In 1878 he presented his doctoral dissertation on an "Experimental Investigation Concerning Regeneration of Striated Muscle." For several years Kraske demonstrated a particular interest in colorectal cancer, producing a n u m b e r of publications on this subject. T h i s was the foundation of his fame, so that he was appointed director of the Surgical Clinic in Freiborg at the age of 32 years. In 1885 he presented a lecture at the Fourteenth Congress of the German Society of Surgery on the subject of the transsacral approach to the removal of rectal cancer. His experience was based on cadaver dissection and treatment of two patients. It is for this report that Kraske achieved e p o n y m o u s immortality. Kraske remained faithful to the University of Freiborg until his death. He led the clinic for 36 years and retired in 1919 at the age of 68. Kraske is remembered as a man with a "soft and feeling heart," yet with a clear mind. He was always very critical with respect to the proposition of various scientific ideas. He was not one who immediately accepted change. He was felt to be rather shy and preferred quiet work in the operating room and at the patient's bedside. He was also considered a great patriot, having volunteered as a soldier in the Franco-Prussian war of 1870-1871, and as a medical officer in the beginning of the first world war (1914). His particular interest in later years was in the value of early exploratory laparotomy for abdominal wounds. Kraske died J u n e 15,1930, a the age of 80 years. He is considered one of the great early masters responsible for the development of surgery. Kraske P. Extirpation of high carcinomas of the large bowel. Dis Colon Rectum 1984;27:499-503.
E X T I R P A T I O N OF H I G H C A R C I N O M A S OF T H E L A R G E BOWEL* by Professor Doctor P. Kraske Gentlemen! In spite of gratifying progress that we have accomplished in recent years in operative removal of carcinomas of the large bowel, we cannot deny that there are a n u m b e r of cases in which all modern, improved methods are not satisfactory. In addition to those cases in which extirpation of the carcinoma is impossible because of the spread of tumor and adherence to other tissues or organs, there are mainly very high carcinomas which, because of their position, are considered to be n o l i m e tangere (not to be touched). *Translated by Rudolf Garret, M.D. Director, Department of Pathology, Sansum Medical Clinic, Santa Barbara, California.
Paul Kraske T h e usual suggestion in textbooks is that carcinomas of the large bowel which cannot be completely palpated from above under anesthesia with chloroform, and also if the tumor cannot be moved from the surrounding tissue, should be declared as absolutely inoperable. These cancers are situated, as V o l k m a n n expressed in a cursory way during the conference in Copenhagen, too deep for an operation through laparotomy and too high for an extirpation from the outside. Lack of a method which would make it possible to extirpate the high carcinomas is unfortunate because these carcinomas are not rare. Each average practitioner surely has seen quite a n u m b e r of cases in which the operation had to be abandoned only because the t u m o r was situated too high. O u t of 11 carcinomas of the large bowel that I had the opportunity to examine within the
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last year, there were four cases where the upper end of the tumor could not have been reached even under anesthesia. I was able in two cases to push the tumor down by exerting a strong pressure on the abdomen. The tumor protruded into the rectum; however, I was able in these cases to palpate the lower surface only. I decided in both cases to try an operation under pressure from the patients whose complaints were very significant, in spite of the fact that one patient, in addition to carcinoma of the large bowel, suffered from severe emphysema, and the other patient suffered from massive albuminuria of 12 years duration. T h e difficulties were tremendous. In spite of extensive anterior and posterior raphf incision and in spite of the extirpation of the coccyx, I succeeded with tremendous effort and mostly in the dark and under control of the fingers, to mobilize the tumor and move the bowel forward so that the tumor could be amputated. The peritoneum in both cases was opened in situ, and there was a wall of the bowel free by a small finger width. There was a significant loss of blood during both operations. Both patients died--the only operative deaths that I could complain about within the last year when I performed nine extirpations of the rectum in which only once the peritoneum was not opened. One patient (with emphysema) died from hypostatic pneumonia in spite of good w o u n d healing. The patient died on the sixth postoperative day. T h e other patient died from peritonitis. I have a strong opinion that the peritonitis could have been avoided if the peritoneal incision could have been done not in dark depths and the peritoneum could be handled with greater accuracy and that perhaps the hypostatic p n e u m o n i a could have been avoided if the patient's heart would not be weakened due to blood loss especially, as mentioned before, due to difficulties in controlling the bleeding. T h e difficulties in the operative methods in highly positioned carcinomas of the large bowel, which I became aware of in both cases mentioned above, led me to think if it would not be possible to approach the tumor from the side other than from below and create a better approach to the upper parts of the large bowel. As it appears impossible that those areas can be approached through laparotomy, one can find a way to consider the approach through coccyx and sacral bone. Attempts in this direction were already made. Kocher (reference: Extirpation of the Rectum After Previous Excision of the Sacral Bone, Centralblatt Fur Chirurgie, 1874, #10 and Concerning Radical Treatment of Carcinoma, Deutsche Zeitschrift Fur Chirurgie, Volume 13, Page 161) recommended 10 years ago a way to facilitate an approach to the rectum through excision of the sacral bone, and he repeated his recommendations in 1880. Nevertheless, it appears that the recommendation of Kocher did not create any interest, which, in my opinion, they surely deserve. During the congress in Copenhagen
Dis. Co]t,l~yReCt. 1984
in the previous year, Esmarch (reference: Deutsche Med Wochenschrift, 1884, #39) expressed the opinion that the extirpation of the sacral bone most of the time is not necessary. This applies, in my opinion, only for those rare cases, as far as my experience reaches, in which the cancer is situated at the anus or in the lowest part of the large bowel. In all other cases, one can make the operation much easier, provided that one follows the recommendation of Kocher exactly, and aside from that, with the removal of the sacral bone, the healing of the wound, because of simplicity, is desirable. However, even if the method of Kocher is to be recommended, it is not satisfactory if there is a problem of approach to such tumors which are located in the uppermost part of the large bowel. Kocher himself, as it appears, never operated on high carcinomas. At least, as he reported, he never reached the tumor so far that during the operation the peritoneal cavity was opened. I illustrated in the two cases mentioned above that the difficulties, even after excision of the sacral bone, are not removed in a satisfactory way. Therefore, I decided to try on a cadaver, if it would be possible through partial resection of the sacral bone to pave the way to the highest part of the rectum. I thought that the approach to the large bowel, which in the upper part is situated completely to the left of the midline, by the removal of the lowest part of the left wing of the sacral bone could be made easier. I performed the operation on the cadaver in the following way: I made an incision with the cadaver lying on the right side in the midline from the middle portion of the sacral bone to the anus. I detached the gluteal muscles at their insertion at the lowest portion of the left wing of the sacral bone, cut and excised the sacral bone and separated the lowest part after expanding the outer margin of the wound, the ligaments tuberosacral and the underneath ligament, the spino-sacral close to the attachment of the sacral bone. I was surprised how far I could reach with my finger underneath and from the side of the inner surface of the sacral bone and how easy it was to mobilize the large bowel surrounded by areolar tissue as soon as I transected the ligaments a n d pushed the soft tissues with a sharp hook toward the outside. I became convinced that by transecting the tubero-sacral ligament and spino-sacral there was a lot to be gained for the easier approach to the upper part of the colon. The approach became even easier when I removed the lowest portion of the left wing of the sacral bone with a hollowed chisel in one line which extended from the left margin at the level of the posterior third sacral foramen and extended to the left in a concave arc through the inner and lower margin of the third orifice of the sacral bone and extending to the fourth to the lower horn of the sacral bone (see the figure). I paid no attention to the posterior branches of the sacral nerves. I
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transected the ventral fifth and sixth branches of the sacral nerves; however, the third was saved. After the areolar tissue and muscle of the posterior surface of the free large bowel was transected to the wall with a very smooth surface of the chisel, I p u t the cadaver in lithotomy position with elevated pelvis and became engaged in actual extirpation of the rectum. I discovered that it is very easy to mobilize the whole large bowel u p to the transition to the sigmoid flexure after separation of the anus and also to the base of the sacral bone because these parts became very easily visible. I repeated this operation on the cadaver quite frequently and became convinced that with the help of this operation, one can resect a segment of the large bowel with preservation of the lower segment. In the attempts which I made in this direction, I split the bowel longitudinally posteriorly to the level of the lower m a r g i n of the segment to be resected. T h e n I took the corresponding part of the bowel and I transected it, and the u p p e r part of the bowel could be pulled forward. It is not necessary to split the lower part; one can perform the transection at any place with the bowel closed without any difficulty and without fear of injuring the neighboring organs. After my experience with the results and attempts on the cadaver, I t h o u g h t that it would be possible following the transection of the tuberous and sacro-spinous ligaments to partially resect the sacral bone as an attempt to facilitate the a p p r o a c h to the u p p e r part of the rectum on patients. T h e injury that would result in this operation does not involve such parts which, if traumatized, would do h a r m to the patient. T h e detachment of the most posterior parts of the gluteus muscles from the sacral bone is an indifferent operation as far as later function is concerned and as far as it applies to the transection of the strong tendons extending from the tubercle and the ischial spine I could not imagine that the scarring would result in i m p a i r m e n t of the [unction of the pelvis because of insufficient strength. However, I thought to myself even if the gait and sitting should be disturbed, one must not pay too m u c h attention to it because the advantages of the operation make u p for it to a large degree. Even the important nerve structures are not injured because of the resection of the sacral bone. T h e transection of the posterior branches of the sacral nerves means absolutely nothing. T h e injury of the fifth ventral branch is also fully indifferent and the fourth anterior branch can be transected without any afterthought because the injury involves one side only. T h e third ventral branch should be saved because it participates in the formation of the ischial plexus, and the sacral canal should not be opened. My idea that I should try to perform this operation on a patient after proven operations on the cadaver was still enforced because during this time I had an opportunity to
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FIG. 1.
perform an operation on an elderly m a n who died because of very highly situated carcinoma of the bowel which was adherent to the prostate and bladder and was perforated. I became convinced that after the removal of the lower horn of the left wing of the sacral bone, it was possible to mobilize the t u m o r from behind, in spite of extensive and firm adherence of the tumor to the anterior surface of the sacral bone. It was possible to pull the t u m o r lower so far that if destruction of the anterior parts was not very extensive, the removal could be accomplished in spite of the very high location of the tumor. I had since that time an opportunity to repeat this operation twice on patients, the same operation that I experimented on cadavers. In the first case, there was a weak, small scoliotic woman, 47 years old, w h o complained of bowel problems for two years. T h e complaints: pain, blood, m u c u s and pus in the stool, increased rapidly in recent times, and this weak w o m a n went downhill markedly fast. T h e examination with the finger showed a ring-like ulcerated carcin o m a 4-5 cm p r o x i m a l to the orifice with resultant narrowing of the l u m e n of the bowel. However, the finger could be introduced into the lower part of the stricture for
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about 3-4 cm. From this point the stricture became narrower, so that it was feared that a rupture of the peritoneum could occur if one tried to reach the upper margin of the tumor. Therefore, it was not done. Whatever the case, the tumor reached very high up. During the vaginal examination, one could palpate the tumor at the end of the posterior arch of the septum. The uterus was movable and the mucosa over the tumor was movable everywhere; however, in some areas it was paper thin. T h e tumor was posteriorly quite adherent to the concavity of the sacral bone. I decided to extirpate the tumor because of significant complaints caused by carcinoma in spite of the miserable state of the patient and applied my operation to gain a better approach to the tumor so that fast and exact control of the bleeding could be accomplished and significant loss of blood, which this patient could not have survived, could be avoided. I.performed the operation on December 10, 1884, and followed exactly my experience which I practiced on the cadaver. After l accomplished the resection of the sacral bone through the posterior incision with the patient on her right side, I put the patient in lithotomy position with highly elevated pelvis; I circumcised the anus and mobilized the bowel around the tumor with preservation of the outer sphincter. T h e detachment from the vagina was successful without injury to the mucosa. It was not difficult to mobilize the large bowel posteriorly; however, on the left side, the adhesion was somewhat stronger, and I had to apply more power. T h e whole procedure could be done under visual control so that it was possible to tie each transected blood vessel immediately. Therefore, the loss of blood was extremely limited. Then the peritoneum was opened from the posterior fornix and a moderate a m o u n t of serous fluid escaped from Douglas' pouch. Unfortunately, it was established that the serosa contained small nodules which could not have been anything else but carcinomatous implants. Therefore, the large bowel was pulled downward so that it was surrounded by peritoneum and attached to the mesorectum, so that the tumor protruded from the opening of the lateral peritoneum. T h e n the amputation was performed, and the bowel was sutured with catgut with perirectal tissue of about one finger-breadth from the anal opening. T h e peritoneal wound was cleansed and sprinkled lightly with iodoform. A drain was inserted posteriorly reaching the peritoneal cavity and a tampon with iodoform gauze was inserted into the rectum and also into the vagina. The w o u n d remained open and was also covered with iodoform gauze. T h e course was absolutely afebrile. T h e patient was very little affected by the operation, recovered fast and gained weight. On the fifth day after the operation, the patient had her first abundant stool. T h e patient was discharged home during the fifth week. T h e rectum was
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Dis. Col. ge Rect, July 1984
healed, and the w o u n d was scarred up to the granulation tissue of the posterior corner. T h e patient w h o m I recently saw, can produce a firm stool, looks quite well, enjoys walks, and has no pain. Unfortunately, one can see underneath the mucosa of the rectum suspicious infiltrations, and one can feel some firm movable nodules on the abdomen. However, for the time being, the metastatic tumor does not result in any complaints. The second case concerned a 37-year-old ranger in whose family the cases of large bowel carcinoma occurred quite frequently. He was always in good health, and he noticed within the last two years rectal bleeding with stool from time to time. Soon he started to complain of a feeling of downward pressure and evacuation of blood and purulent mucus. The complaints were recently quite significant and the patient lost weight. The patient was admitted on the 26th of December, 1884, in the clinic with definite wish to undergo surgery. The examination showed a very high positioned ring-form carcinoma. Even if the tumor was pushed down, the finger reached only the lower surface of the tumor which was located 12 to 15 cm proximal to the large bowel orifice. It was impossible to determine the upper margin of the tumor under these circumstances; however, one could establish that the tumor was barely movable against the surrounding tissue. After the patient was prepared with cathartics and frequent enemas, the operation was performed on the 31 st of December, 1884. T h e first step: posterior incision, transection of the tendons of the sacral bone, removal of the coccyx and sacral bone, I performed in the same way as in the previous case. When the large bowel appeared, it was established that the lower margin of the tumor was located exactly at the upper margin of the created defect of the sacral bone. I split the lower healthy segment of the rectum for a distance of 1.5 cm from the lower margin of the tumor and flapped the tube apart after the patient was put on his back. I could not decide whether to remove the 10 cm long lower healthy part, but I separated it at the end of the incision where the intestinal tube was split about 1.5 cm distal to the lower margin of the tumor and transected it. This transverse incision opened the peritoneal cavity. The t u m o r arose on the other side of the anterior part of the margin of the peritoneum. T h e n the peritoneum was opened further to both sides, and a silk suture was inserted into the bowel infiltrated by tumor, and the tumor was pulled downward. T h e mobilization from the anterior surface of the sacral bone was accomplished with the finger and short scissors without special difficulties. The tumor spread approximately 3 to 4 cm upward. The bowel was transected proximal to the tumor. In this area the bowel was surrounded by peritoneum. After the peritoneal cavity in the area of the w o u n d was cleansed and sprinkled with iodoform lightly, the bowel was attached to the stmnp of the rectum with catgut for about two-
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thirds of the circumference. T h e longitudinal suture of the previously cut lower portion of bowel was deferred temporarily because the large w o u n d cavity was to be tamponaded, and this was to be considered later. A drain was inserted into the left peritoneal cavity after the large bowel was closed and compressed with iodoform gauze which pushed the peritoneum together, and the whole w o u n d was also tamponaded with iodoform gauze. T h e blood loss was moderate throughout and did not affect the patient during the operation. In the evening of the fourth day, the patient had a transitional elevation of temperature to 38.7. There was no reaction observed in the wound and there were no signs of peritonitis. O n the ninth day, the patient evacuated the first a b u n d a n t stool after he passed flatus for a few days before. When the patient was discharged at the beginning of February, the large bowel formed a channel opened posteriorly. In the area where the u p w a r d pulled bowel was sutured, there was a slight nick of the bowel with an angle open anteriorly. There was no stricture in this area (the posterior wall of the u p p e r segment of the bowel was in contradistinction pulled posteriorly due to adhesions). However, the nick resulted in the fact that the patient was able to keep a firm stool for some time. At the beginning of March of this year, the patient presented himself again. T h e scar was complete, and at the margins of the channel opened posteriorly the skin and mucosa were fused together in scar tissue. I attempted to perform a plastic operation on this channel to change it again into a tube and followed the identical principle that is established in the operation of Thiersch for epispadias. T h e attempt was successful in a satisfactory way. T h e lower segment of the large bowel to the sphincter was transformed into a tube in which only one area (located approximately at the level of extirpated coccyx) exhibited narrowing with a fistula opened posteriorly. I have no doubt that this fistula will close spontaneously or with additional operation, cauterization, etc. will be easy to close. T h e sphincter functions so well that when the fistula opening is closed by excrement, the patient is able to retain flatus. One cannot find any disturbance related to the transection of the tendons of the sacral bone or partial resection of the sacral bone or injury to the nerves. Gentlemen! These are only two cases in which I could prove my experience with extirpation of the highpositioned cancers of the large bowel. Both cases showed me that this experience is useful and that I followed the right way in my endeavors. I dare to claim that in both of those patients that I reported to you, the very highpositioned carcinomas, beginning on the opposite side of the anterior peritoneal fold, could not have been extirpated with the presently available methods; I believe that the good outcome should be attributed primarily to this new experience. T h e fast and exact control of bleeding,
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which is especially troublesome in this type of patient, could not have been possible with the presently available methods. In addition, I would like to stress that this experience needs i m p r o v e m e n t , a n d I believe that i m p r o v e m e n t is possible. In especially difficult cases, in which, for instance, the adherence of the tumors are very extensive, I would have no objections to resecting more sacral bone to the right and open the sacral canal (see the figure). T h e dural sac does not reach so far to be injured in this procedure, and the transection of the filum terminale would be of no great importance. T h e opening of the sacral canal can be performed without injury to the patient as reported in an i m p o r t a n t case by my distinguished teacher, Volkmann, 9 years ago (Verhandl der Deutschen Gesellschaft Fur Chirurgie V Congr 1876 I $62). H e resected a large part of the sacral bone throughout the whole thickness because of myelogenous sarcoma with the o p e n i n g of the spinal canal; the patient recovered and showed no disturbances. Also with reference to the actual removal of the tumor, some aspects can be altered a n d improved as it happened in both cases reported. For instance, I will attempt in the future in cases of very highly located carcinomas and in which the lower segment of the rectum should be preserved, to perform suturing of the bowel without previous splitting of the lower end of the large bowel and I have no doubt that after my experience with operations on cadavers, I will succeed. Gentlemen, I would like to beg you to attempt the procedure I presented to you to perform for extirpation of the highly positioned carcinomas of the rectum in appropriate cases, and I will be very h a p p y when you yourself will improve the progress in this technique. I was led in my attempts by the idea that especially in the operative treatment of carcinomas of the large bowel, which according to u n a n i m o u s experience of all the surgeons should be most frequently radically cured, even the smallest improvement is of some value. These examples will make it possible to accomplish extirpation of such tumors which were considered inoperable until the present time.
Acknowledgment T h e Editor is most grateful to Miss Elizabeth McChristie, research associate, Reeves Medical Library, Santa Barbara Cottage Hospital, Santa Barbara, California.
Bibliography Kraske P. Zur Exstirpation hochsitzender Mastdarmkrebse. Arch F Klin Chir (Berl) 1886;33:563-573. Biography--Oehler J. Prof. Paul Kraske (Obituary). Zentralbl Chir 1930;57:1777-8.
