Proceedings of the Annual

Meeting

of

The Royat Australasian College of Surgeons Section of Proctology May 20, 1965 Sydney, Australia EDWARD WILSON, M.D., Chairman Professor Williams responded that he is now concerned with the action of laxatives which cause sigmoidal spasm and which can only be appreciated with cineradiography. Furthermore, he was keen to examine effects of administration of the more refined forms of pharmacology.

Cineradiography of the N o r m a l Colon T h e contribution of Associate Professor H. 13. L. Williams and Dr. B. Billington is based on a cinefihn of a series of normal subjects, designed to establish the origin and transmission of propulsive movements in the colon and at the ileocecal valve. Particular attention had been paid to the trigger areas in the right and left portions of the colon and to conduction of rush waves in response to balloon distention of the rectum and anal canal. An attempt was also made to film, continuously, and by the stop frame technic, the action of the muscles concerned in defecation, notably the levator ani muscle. Discussion. Mr. J. Dixon Hughes said that he had been interested in cineradiography for some time but, as.Professor Williams had said, they are still in the early stages of development of this method. However, in the fihns that were shown, the varied impressions of" the dynamics of the colon are obvious. Usually they do not observe the situation as it actually exists, and it is left to the radiologist to interpret the picture. This type of film has brought this fact very much into focus, particalarty in studies of diverticulitis. An ordinary film may only appear to show an area of minireal change, whereas a dynamic study may show the picture clearly. Probably this medium can be adapted for student teach-, ing. Mr. Hughes wondered it an attempt has been made by Professor Williams to assess the activity caused by administration of purgatives.

Technic of Investigating the Levator #;ni Dr. F. B. M. Phillips had reviewed medical literature on the subject of the levator ani muscle, covering the period from Vesalius to the present day, and said that it reveals divergent opinions and complexities of descriptions. Definitive statements based on small n u m b e r s of observations reveal marked variability. T h e variety of opinions regarding its structure, the small series of observations, the interval since the last complete survey, and demands by clinicians for further information on the structure of" the tevator ani muscle to meet the needs of current surgical practice, justify further investigation. Removal of the pelvic floor to facilitate examination in the fresh state involves mobilization of the bony pelvis in front of each hip joint, splitting the sacrum transversely at the junction of the third and fourth pieces, and deep dissection throagh the ischiorectal ~ossae to provide for final removal of the entire block. Subsequent dissection on a specifically devised stand was described, and further steps involving microsc0pic study yet to be commenced were outlined. T h e merits of a large series of fresh dis85

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sections, all performed by the investigators with careful routine photographic and standard diagrammatic records, and using the above technic, were described. Origin of the Levator Ani Muscle

After a brief review of studies of the origin of the levator ani from other sources, Dr. N. D. Sherson presented a concept which attempts to embody the morphologic variability of the muscle origin. Confusion has arisen due to the description of two white lines of the lateral pelvic wall which the authors, in harmony with Courtney, considered to be part of the same structural and functional unit; namely, the origin of the posterolateral fibers of levator ani. T o rationalize the variability of origins observed in their 20 dissections of fresh material, the authors proposed a spectrmn of origins, the most frequent m e m b e r of which takes the form of a horizontal Y, the limbs being the ~hite lines of the pelvic fascia and the levator ani, which fuse posteriorly to form a dense stem attached to the ischiai spine. T h e attachment of the lower limb (the fascia white line) to the postero-inferior aspect of the pelvis is constant, but the u p p e r levator limb is variably attached to the superior pubic ramus having a variable relationship to the o b t u r a t o r canal. It was said to be noteworthy that the medial muscular fibers arising from the pubis and its superior ramus do not attach to the inferior limb of the horizontal Y as they cross each other. Attention was also given to: 1) T h e incon.sistent, inconclusive lamination of the muscle; 2) t,~e posterolateral defects in the muscle; 8) the interlevator space; 4) the origin of fibers from the inferior pubic ramus, the obturator fascia lateral to the medial part of the muscle and the deep perineat m e m b r a n e ; and 5) the hiatus of Schwalbe. Mr. E. S. R. Hughes asked if the fascia

of Waldeyer exists? If so, how strong is it and what is its relation to the levator ani? Mr. Sherson replied that he has not yet studied the u p p e r sacral arrangements in detail. However, he has f o u n d that there are two divisions of fascia leading from the anterior sacral surfaces to the inferior surface of the rectum. Mr. E. Wilson asked if there is really a hiatus of Schwalbe and Mr. Sherson replied that he had never found the hiatus open. It is created by removing fascia by dissection and exposing the opening. An Anal Retractor

Mr. J. N a y m a n described an anal retractor which was designed to facilitate operative procedures by exposing the whole longitudinal length of any arc of the anal canal and may be used in patients of all ages. A N e w Interpretation of Hemorrhoids

Mr, D. Leslie. said that internal hemorrhoids have been described as varicose veins in the subrauco'us coat of the anal canal, but d o u b t has been cast on this concept. Stelzner suggested that the vascular component of internal hemorrhoids is erectile tissue called corpus cavernosttrn recti. Histologic studies do not support this theory either, and it is probable that vessels taking part in tile formation of internal hemorrhoids are specialized collections of sinusoids with arteriovenous communications. Tile properties and functions of this tissue were discussed. P r i m a r y Closure of P e r i a n a l W o u n d s after H e m o r r h o i d e c t o m y Mr. D. gaiies presented a personal series of 24 cases in which hemorrhoidectomy was :followed by primary suture of the wound. His long-term results were very satisfactory. In the immediate postoperative period, the chief advantages were p r i m a r y healing of the skin wounds and earlier discharge of the patient from the hospital. After operation,

ROYAL A U S T R A L A S I A N COLLEGE O]g SURGEONS

pain did not appear to be significantly different than that of the standard operation.

Primary Suture of Mucosa and Skin after Excision of Hemorrhoids Mr. "W. Stern remarked that objections to p r i m a r y suture of the mucosa and skin after hemorrhoidectomy were theoretical rather than real. Primary suture, he said, had been carried out in over 100 cases with no ill effects. Discussion. Mr. R. C. Bennett stated that the a m o u n t of pain which follows various technics of hemorrhoidectomy should be compared by a method in which emotional factors are excluded, but this is extremely difficult. Such a study was commenced during his experience in Leeds. A variety of technics were used and were assessed by various physicians in the clinic. T h e type of p a i n and the physical findings prior to discharge of the patient were tabulated, and the results have been reported. Mr. J. H. Pry'or drew attention to the fact that hemorrhoids bleed red blood. This is simply owing to a nmcosal tear as the tissues stretch during defecation, and is the same mechanism as that of bleeding from a fissure. Mr. Killingback has been performing alternative operations for hemorrhoids, one with p r i m a r y closure and one by the standard technic. H e has not been able to detect any difference in the degree of postoperative pain, and he was sure it is related to the a m o u n t of perianal skin toss occasioned by the operation. H e also stated that his patients are kept in the hospital ten days during which one is able to determine accurately that there is no problem with the bowels. Certainly, at the end of the operation, when a primary closure is performed, the skin bridges may seem swollen and there may be skin tags. H e thought this is a definite disadvantage of this type of operation. "The patient should be assured of a smooth anat margin after hemorrhoidectomy.

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Mr. D. Failes stated that possibly an average time of 4½ weeks' absence f r o m work was rather long, but he was rather "soft" with his patients. T h e y were completely comfortable after 2 weeks. Mr. Stern replied to Mr. Killingback's statement that his patients have their bowels open twice before they are discharged from the hospital. T w o of the patients operated on for hemorrhoids required removal of skin tags, and others have been left with m i n o r skin tags which caused no trouble. A n u m b e r of his patients return to work within t0 to 14 days.

Refinements in Colostomy a n d Ileostomy M a n a g e m e n t Mr. G. Grove r e m a r k e d that m o d e r n colostomy and ileostomy appliances have been developed to a high degTee of perfection and they meet the needs of most patients admirably, b u t elderly patients and those with grave disabilities of the hands and fingers m a y have embarrassing problems with any appliance. T w o devices designed to help such patients have been developed at the Alfred Hospital, Melbourne. These were described, and one was demonstrated in a short film.

Traumatic Transverse Cotostomy Miss L. Sisety described a patient with a pre-existing incisionai hernia, who fell u p o n a heap of stones, and gangrene of an area of skin resulted within a few days. I n the d~bridement, two ends of the transverse colon presented as a double-barrelled colostomy with complete sloughing of an intermediate portion approximately 6 inches long. This presentation dealt with the subsequent course and management.

Ascaris P e r f o r a t i o n Mr. D. G. McLeish discussed nine cases of ascaris perforation and one of ascaris obstruction, which were encountered by the

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Australian Surgical T e a m during its first 3 months in South Vietnam. H e explained why ascaris infestation is so common in that country. T h e majority of patients live in symbiosis with the ascaris, and the ways in which ascaris could cause disease were outlined. A brief account was given of the clinical features, differential diagnosis and treatment of ascaris perforation of the small bowel. Gangrene of the Colon Mr. R. M. Hollings said that gangrene of the cecum implies generalized or localized ischemia of the bowel wall, resulting in necrosis of mucosa and muscle. Causes are 1) p r i m a ~ arterial or venous occlusion; 2) large bowel obstruction which, if unrelieved, can cause such a rise in intraluminal pressure that the blood supply becomes impaired. (In this respect, the anatomic features peculiar to the cecum make it the most vulnerable part of the gastrointestinal tract.); and 3) Infection within the cecal wall as seen in a variety of conditions. Cases illustrating the causes of cecal gangrene were presented and practical aspects of treatment were discussed. Infarction of the Transverse Colon Mr. D. Lane discussed two patients the first of w h o m was a 46-year-old man, complaining of severe, cramping, generalized abdominal pain for 12 hours. H e was somewhat cyanosed, was in obvious pain, and there was dark blood on the glove after rectal examination. Next day, the pulse rate had risen, the abdomen had become more distended and bowel sounds were con-siderably decreased. X-rays of the a b d o m e n showed slow passage of Gastrografin. T h e i m p o r t a n t finding was really noted in retrospect; namely, a constant lack of gas in the transverse colon. Operation revealed a segmental hemorrhagic infarction of the transverse colon due to thrombosis of the midcLle colic vein. Right hemicolectomy was performed. Afterward a tight, short

stricture appeared at the rectosignnoidal level, which required periodic dilatation. X-ray examination showed a lack of haustration in the colon just behind the ileocolic anastomosis. T h e changes in the remaining portion of the colon no d o u b t were due to vascular disturbances which occurred at the time of the original thrombosis. Experience with this patient emphasizes the need for wide resection in such cases and that one is fortunate if a successful result is obtained. T h e second patient was a 67-year-old m a n with severe hypertension. Otherwise, he was well. T w o days after a routine transurethral prostatectomy, his a b d o m e n became distended. Hematemesis began and recurred at intervals. His general condition was poor and his blood urea was 306. Conservative treatment was continued. A week later his a b d o m e n was m o r e distended and timre were obvious signs of peritonitis. A flat x-ray p l a t e of the a b d o m e n showed gross distention of the transverse portion of the colon, with free gas in the peritoneal cavity. At laparotomy, it was discovered that the transverse colon was perforated in two places along its mesenteric attachment. T h e involved portion of the colon was removed and the condition of the patient improved for several days until another profuse gastric hemorrhage culminated in his death. Autopsy revealed that death was due to bleeding esophageal varices. T h e specimen Of colon showed necrosis at the site of the two perforations and it a p p e a r e d that the segmental ileus of the transverse colon was probably caused by ischemia. T h e latter could be explained on the basis of the fluctuation in blood pressure in a hypertensive patient, accompanied by repeated hematemesis. These cases illustrate the need for intensive consideration of the diagnosis in any acute abdomen, especially in the presence of cardiovascular disease. If in doubt, taparotomy should be performed and a

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS wide resection of the involved portion of the gu~ may be the only solution of the problem. However, as illustrated by the first case, changes in the gut may be much more extensive ttlan was originally appar, ent. In patients who survive operation, the prognosis always must be guarded because the same circumstances may arise in the future and cause further infarction. Posthemorrhoidectomy Hemorrhage Mr. S. Levitt presented a series of 504 patients who underwent ligation and excision for hemorrhoids. In all cases, Xylocaine®. I%, w i t h adrenalin, I in 80,000, was administered: as an anesthetic. T h e types :of :postoperative hemorrhage encountered were described. Hemorrhage WaS Classified as reactionary in all cases where a single change of dressing was insufficient to control bleeding. Twenty-seven such instances were encountered. Pedicle hemorrhage (secondary hemorrhage) was recoi-ded in cases where repeated or severe bleeding occmTed from the pedicles. No cases of early pedicle hemorrhage (less than 5 days) occurred. Twelve late pedicle hemorrhages occurred. Reactionary hemorrhages occurred mainly during the hot months of December, january and February, but pedicle hem0rrhages were evenly distributed throughout the year. In all cases, chromic catgut was used to transfix the pedicle and no hemorrhage was caused by slipping of a ligature. Late cases of pedicle hemorrhage were ControlIed by insertion into the rectum o~ a tube surrounded by gauze. No patient required rehospitalizatiom Reactionary hemorrhages were controlled easily by injection into the offending skin wound of a local anesthetic agent with adrenalin. Many reactionary hemorrhages might 1lave been prevented if operation had not been undertaken during very hot days. Discussion, Mr. E. Dunlop asked Mr. McLeistl if he had encountered any cases of ascaris perforation of the common bile

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duct, and he recounted some of the conditions which he found in Thailand. He encountered many necrotizing lesions of tire large bowel, particularly the cecum, and he related an anecdote concerning country surgery. Mr. A. F. Hun~er asked if Mr. Levitt had encountered any cases of hemorrhage after hemorrhoidectomy in patients who were being ,given cortisone therapy. He said he knew of two such cases. Mr. Levitt replied that none of his patients had been given cortisone therapy, but in three, anticoagulants had been administered, and this was discdntinUed :at least a fortnight before OperatiOn. Mr. McLeish, in answer t0:Mr. Dunlop, stated that he had no case of ascaris perforation o£ the common duct. Granulomatous Lesions of the Anal Canal Mr. A. C. McEachern discussed diagnostic problems concerning granulomatous lesions of the anal canal. Even in a temperate climate; he said, syphilis, tuberculosis, lymphogranuloma inguinale and Cr0hn's disease may be encoumered and fo:reign body reactions are always observed. Difficulty may be experienced in distinguishing between simple nonspecific ulcer o[::the anal canal, nonspecific proctitis and the anal lesions o~ ulcerative_ colitis. Anal lesions frequently have counterparts in the small or large bowel. Reference w a s made to a coloproctectomy for ulcerative colitis in a young woman in whom, 8 years previously, biopsy of the vagiiaal wall had suggested lymphogranuloma ingninale. In another young woman, biopsy of acute anal utcers revealed monocy{ic leukemia. A woman, 69 years old, was seen with a history of bleeding constipation and ex2 tens~ve deep ulceration of the anorectal region. A barium enema x-ray examination suggested diverticulitis or ulcerative colitis. A biopsy report described the giant cell arrangement as typical of tuberculosis,

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and acid-fast bacilli morphologically identical with mycobacterium tuberculosis were discovered. However, these proved not to be tubercle bacilli. During performance of a transverse colostomy and resection of the left colon and rectum, a segmental lesion, 20 cm. long, was found in the pelvic portion of the colon, separated from the area of anorectal ulceration by normal mucosa. Histologic features of the pelvic colon were similar to those of the anal ulcers and the condition was considered to be Crohn's disease. In Gabriei's classical description of fistulas, 16 per cent were tuberculous. Goligher, in t961, implied that about 4 per cent of fistulas are tuberculous and that about 4 per cent were due to foreign body reactions. In the last 10 years at the Royal Adelaide Hospital, 120 patients with fistulain-ano were treated and in none was tuberculosis found. In fact, none has been recorded by the South Australian. Tuberculosis Services in recent years. In Australia, a histologic appearance resembling that of tuberculosis in an anorectal lesion is likely to be Crohn's disease. It is apparent that in the anal area, an acid-fast bacillus, even within the tissues, cannot be accepted as a tubercle bacillus without full bacteriologic proof. T h e r e is an equal chance that it might be mycobacterium stercoris, an acid-fast saprophytic organism which is nonpathogenic except under experimental conditions.

Present Management of Perianal Suppuration Mr. Do Beard presented results of a survey of the records of 100 patients, some of whom were persona1, and others who were encountered a t the Queen Elizabeth Hospital, "Woodvitle. T h e subject was discussed under the following headings: 1) historic; 2) anatomic; 3) etiologic; 4) types of infection; 5) management; and 6) complications. Discussion. Mr. Wright pointed out that the problems of anal granulomas are both

clinical and pathologic. A case was mentioned in which a perianal granuloma had been treated as tuberculosis for 12 months, utilizing streptomycin. T h e r e were no symptoms suggestive of a bowel disorder and the lesion was said to be identified as definitely tuberculosis. However, Mr. Wright was not satisfied with the diagnosis and had the patient admitted to the hospital for investigation. Unfortunately, sigmoidoscopy was not done at that time. T h e abscess was opened and specimens for further microscopic examination were taken. Eventually these were sent to four senior pathologists in Auckland and they suggested the diagnosis of probable tuberculosis, ulcerative colitis, Crohn's disease and threadworms. Shortly after that, sigmoidoscopy revealed bowel changes of ulcerative colitis, and this diagnosis was confirmed subsequently. Colotomy a n d Coloscopy for Polyps Mr. E. S. R. Hughes reviewed the records of a series of 25 patients with polyps in the colon, treated by colotomy and coloscopy from May 1957 to September 1964. T h e n u m b e r of patients with simple polyps of the colon undergoing treatment had increased. He said that diagnosis is di~cult. False-positive and false-negative x-rays were common. T w o patients (exclusive of his series) were thought to have polyps, but none were found; three patients had normal x-rays but polyps were found in the sigmoid flexure. It was common to find a second polyp in the same segment with the one originally found in the rectum. H e believes that coloscopy is useful to detect a second polyp in the colon. Colotomy is a simple procedure and, provided care is taken, has low mortality and morbidity rates. T h r e e polyps with long stalks were thought to be benign. Subsequently invasive carcinoma was reported in some of these polyps. T h e y were removed and they have not recurred.

ROYAL AUSTtI~LASIAN COLLEGE OF SURGEONS

Malignant Polyps of the l~ectum Mr. A. B. Carden said that the main problem in the treatment of apparently benign polyps of the rectum by local removal is the unexpected histoIogic finding of invasive malignancy. T h e significance of this finding was revealed in studies of the records of 65 patients at St. Mark's Hospital, London, over a period of 30 years. T h r e e forms of treatment were used: 1) local removal alone; 2) local removal followed by immediate radical excision of the rectum because inadequate local removal was suspected; and 3) initial radical excision of the rectum. Follow u p of these cases has been complete and review of records of patients suffering from recun'ent cancer has enabled establishment of features requiring further surgery after local removal.

A Technic of Excision of Villous Papilloma of the Rectum Mr. M. Killingback said that villous tumors frequently involve the lower part of the rectum. Usually they are sessile, frequently large, and clinical and biopsy evidence of malignancy is difficult to determine. Excision of the rectum and low anterior resection should be avoided in the m a n a g e m e n t of a benign tumor. Local removal by means of fu!guration, diathermy loop or "piecemeal" excision may increase the difficulties for the pathologist in determining the presence of a small focus of carcinoma. A technic was described in which a t u m o r is prolapsed as far as possible and excision is performed through the anaI canal. T h e operation is more precise titan oLher methods and frequently will allow the t u m o r to remain intact for daorough examination° Also, the risk of perforation of the rectum is lessened. Discussion° Mr. S. G. Koorey stated, with reference to Mr. Killingback's operation, that he has used it on four occasions dur-

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ing the past 2 or 3 years and he could confirm that usually it is a fairly simple procedure. In one case the papilloma was lying directly behind the prostate and could only be partially everted. Despite this, a complete specimen was removed. Mr. S. L. Spencer described the method he uses when searching for multiple polyps. This is done by transilluminating the colon with a lighted retractor. However, the procedure is more satisfactory when the bowel can be lifted from the a b d o m e n and a small spotlight can be used to send its b e a m through the bowel walls. It is possible, by this method, to detect polyps smaller than 1 cm. in diameter. T h e bowel must be prepared properly so that sinai1 flecks of feces can be identified. T r a n s i l l u m i n a t i o n is not submitted as an alternative to coloscopy, but it has value. Mr. H. H. Stewart stated that he had seen a s ~ m o , d polyp" demonstrated .tw:ice radiologically in a patient who was not able to undergo surgical u'eatment for some time afterward. Finally, at operation, no potyp was found. Another patient was m e n t i o n e d in w h o m the lesion was almost on the point of disappearing when the colotomy was performed. Mr. Stewart was surprised that no one had suggested the use of the bivalve vaginal speculum for operating within the lower rectum. T h e a m o u n t of manipulation required to insert it does not i m p a i r sphincter efficiency afterward. By its use, a t u m o r may be r e m o v e d a n d sutures inserted. Mr. D. Leslie pointed out the difficulty of deciding when radical treatment of maligiaant polyps is required. H e described an instance in which anterior resection was performed :for two apparently similar potyps at the rectosi~noidal junction, One was m a l i g n a n t and a iT~mph node was involved. If he had relied on local removal, the l y m p h node would have been left behind.

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Duhamel Operation for Hirschsprung's Disease Mr. P. Grant claimed that the Duhamel operation for Hirschsprung's disease has gained a great deal of popularity among surgeons throughout the world displacing, in many centers, the Swenson operation. It came into being because of problems reported to be associated with the Swenson operation such :as,constipation, viral enteritis, :fecat :incontinence, bladder dysfunction and fear of sexual dysfunction. Many of these complications appear to be due to incorrect surgical technic. Technically, the Duhamel operation has proved to be an easy operation to perform, gives good results and has few complications.

Spontaneous Perforation of the Colon Mr. A. B. Vivian said that the majority of reported cases of spontaneous perforation of the colon have had three features in common: the site of perforation; they are preceded by constipation, and they occur while straining at stool. These features occurred in a patient who was described, evaluated with reference to present-day knowledge of colonic anatomy and physiology, and a theory was advanced to explain the mechanism of the perforation. Discussion. Mr. "W. J. McCann stated that 5 years ago, he reported, in the Medical .Journal of Australia, a case of spontaneous perforation of the colon and, at that time, he had collected eight or nine cases. H e believes that this condition is more common than is generally believed.

Internal Drainage for AnM Fistula Mr. P. Ryan: said that Parks excises an etlipse of mncosa and internal sphincter (with attached infected anal intennuscuIar glands) at the inner end of the fistula, and that the remainder is merely cored o~t. Nine pm>onal cases operated upon by this method have been followed from a m o n t h to more than 5 years, and there was only one failure :in a patient who had six exter-

nal openings a n d still has one. Since these fistulas : are::,probably caused originally by poor drainage of anal intermuscular glands, and since: h a l f of them have no demonstrable inrier opening, the success of this procedure may be due to proper internal drainage rather than to excision of the anal glands.

Emergency Right Hemicotectomy Mr. J. H. Pryor said t h a t there is a surprising variety of acute abdominal disorders which may require emergency right b.emicolectomy, and he presented a personal series of 19 cases in which there were no cleaths and minimal morbidity. Eight ca~uses reported in the 12 patients were obstructing carcinoma of the cecum, five; perf0ra!ed carcinoma of the cecum, one; volvulus :of ttae cecum, one; inflammation of:a So!itary diverticulum of the cecum, one; strangulation of a mobile right colon, one; perforati0n of the cecum secondary to targe"bowel I 0b~truction, one; perforation of the Cecum 8e4ondary to prolonged ileus, one; and:i:!ea'l.fiS:tula secondary to adhesive o b s t r u c t i o n - a t the site of excision of a gangrenous .subhepatic appendix, one. In obstruc:t.ing carcinoma, the operation was tolerated well and patients (including an 86-Yea>old woman) fared better than previous pa:tients treated by a bypass operation. Mobility of the tumor must be assessed carefully before emergency hemicolectomy is undertaken. A decompression procedure (Muir's maneuver) was not used and no ill effect resulted. Mr. Pryor doubted, the vahm of the Muir procedure. In the other cases, w i t h the exception of solitary diverticulum in wb~ich carcinoma could not be excluded, and the ileal fistula where it seemed the best wax, out of a complex problem, the operation was obligatory. T h e following technical features were employed: 1). Large incision. 2) Bowel decompression Performed through an area of lower ileum w h i c h was to be resected. 3) Open anastomosis. T h e bowel was cleared of mesentery and fat for 11~ inches

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS beyond the proposed site of resection. Crushing clamps were applied at this point and the bowel was divided. Application of clamps to the bowel provided accurate placement of sutures so that the bowel at the site of resection had the proper diameter (which cannot be accomplished if crushing clamps are placed close to the line of resection). 4) If the bowel lumina are similar, a two-layer continuous 00 atraumatic catgut closure was performed. If there was marked disparity of bowel lumina, interr u p t e d seromuscular sutures were used with accurate placement based on the relative diameters. This provided a telescope type of anastomosis which appeared to be very safe. In this type of anastomosis, by leaving the end two interrupted seromuscular sutures untied until after the inner alI-coat suture had traversed the corner, a snug closure was provided. 5) Care was always taken to avoid placing the anastomosis across a stercoral ulcer, which is a real hazard :in cases of obstruction.

?V/arsupialization of Pilonidal Sinuses Mr. F. H u b e r recalled that marsupializalion of a pilonidal sinus was first suggested by Buie in 1937. T h e proposed rationale (continuity of squamous epithelium) cannot be substantiated in most cases because only granulation tissue persists. Nevertheless, practically, the operation is satisfactory. U n d e r general or, more recently, local anesthesia, the tract is probed and opened to its full extent. Secondary tracts are sought and managed similarly. H a i r and grumose materiat are removed, and overhanging skin and sinus walls are excised. T h e skin and sinus edges are a p p r o x i m a t e d with interrupted 00 chromic gut, incidentally achieving complete hematemesis. A vaseline gauze dressing, which wilt be changed every three days, is then applied. Bridge formation is preven.ted during dressings. X-ray epilation was carried out in alternate cases, but has been discontinued as no advantage accrued. This series consisted of 56 patients oper-

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ated upon during tile past 6 years, and there was a follow up of 86 per cent. A 1-year m i n i m u m follow up was used. As pilonidat disease is not dang'erous or disabling, the following criteria for a suitable operation a p p e a r important: 1) Simplicity and a m i n i m u m degree of trauma. 2) Minim u m pain. B) Short period of hospitalization. 4) R a p i d return to work. 5) Low recurrence rate. T h e above advantages are revealed by the following statistics: average period of hospitalization, 6.3 days compared with 18.3 days for primary suture (Goodall); average time off work 18.6 days cornpared with 57 days (GoodaII); healing time is l o n g e r - - i l days compared with 10 days (Swinton and Goodall) ; recurrence rate was 6.5 per cent (patients complaining of discharge or l u m p at any time being regarded as a recurrence). Reported results of recurrence rates after p r i m a r y closure were Goodall, 38 per cent; Hamilton, Custer and Kelner, 53 per cent; Palumbo, Larimore and Katz, 21 per cent. Marsupialization is more than satisfactory.

Cysts of the R e c t u m Mr. W. J. McCann reported two instances of cysts associated with the rectum. Postrectal cyst is rare and a submucous cyst arising d e n o v o probably is unique. Search of the literature failed to reveal a similar case. Discussion. Mr. E. S. R. Hughes commented on Mr. Ryan's p a p e r as follows: i. Patients are kept in the hospital about 8 days after simple laying open of a fistula. 2. It is extremely di~cult to understand why it is calted a fistuIa if no external opening is demonstrated. H e then illustrated this point with a case report. 8. T h e type of operation described is experimental. T h e orthodox operation is most reliable. Mr. E. Wilson stated that fistulas must be larger in patients in Sydney. In very few instances is it possible to have patients home in a week. H e considered that time spent in the hospital is tess i m p o r t a n t than the certainty o{ cure.

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PROCEEDINGS OF ANNUAL MEETING

Mr. R. P. S i l v e r t o n r e f e r r e d to a p a t i e n t w h o h a d a p e r i r e c t a t a n d s u b m u c o s a l abscess w i t h a fistula w h i c h d r a i n e d i n t o the r e c t u m at the a n o r e c t a l ring. T h e r e was no extension of the abscess i n t o the ischiorectal fossa, a n d it was p o s s i b l e to i n s t i t u t e d r a i n a g e by i n t e r n a l s p h i n c t e r o t o m y . T h e result was very satisfactory. Mr. A. C. M c E a c h e r n said t h a t we are all g r a t e f u l to Mr, H u b e r for a g a i n drawing o u r a t t e n t i o n to this c o m m o n c o n d i t i o n . " I have f o l l o w e d the l i t e r a t u r e on it for a n u m b e r of years," he said, " a n d the opera t i o n 2[ use is excision of a b l o c k of tissue, p l u s the i n n e r surface of the sinus, s u t u r i n g the tissues to the sacral a p o n e u r o s i s . T h i s r e q u i r e s a p e r i o d of h o s p i t a l i z a t i o n o f a b o u t 14 days. W e m u s t be a b l e to assure the p a t i e n t of a speedy r e t u r n to work. T h e o p e r a t i o n s h o u l d be s i m p l e a n d b l o o d l e s s w i t h m a x i m a l r e t e n t i o n of u n i n v o l v e d skin," Mr. P. J. R y a n asked Mr. H u b e r if t h e r e is a l a y e r of e p i t h e l i u m in the sinus to w h i c h he s u t u r e s the skin. M r . H u b e r said he h a d n o t b e e n ab!e to find any e p i t h e l i u m even in cases w h e r e t h e r e is n o a p p a r e n t gross i n f e c t i o n . H e s i m p l y s u t u r e s the skin edges to fibrous a n d g r a n u l o m a t o u s tissue.

Carcinoma of the A n u s M r . D. G r e e n said t h a t art u n d e r s t a n d i n g of t h e difference i n b e h a v i o r of c a r c i n o m a of the a n a l m a r g i n a n d c a r c i n o m a of the a n a l c a n a l is i m p o r t a n t i n p l a n n i n g m a n a g e m e n t , the o b j e c t of w h i c h is to c o n t r o l the disease a n d , w h e r e possible, to preserve n o r m a l :[unction. Lesions of the a n a l m a r g i n r a r e l y cause i m p a i r m e n t of a n a l f u n c t i o n a n d u s u a l t y can be c o n t r o l I e d b y local excision o r r a d i o t h e r a p y w i t h r e s u l t a n t p r e s e r v a t i o n of a n a l f u n c t i o n . I n contrast, lesions of the a n a l c a n a l often i n v o l v e the s p h i n c t e r c a u s i n g i r r e p a r a b l e d a m a g e a n d this, t o g e t h e r w i t h the r e l a t i v e l y h i g h i n c i d e n c e of metastasis to l y m p h nodes, is an i n d i c a t i o n for r a d i c a l

a b l a t i v e surgery therapy.

in

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Discussion. Mr. N. T . H a m i h o n c o m p l i m e n t e d Mr, G r e e n on his o b j e c t i v e app r o a c h to t h e p r o b l e r a of r a d i o t h e r a p y o[ c a r c i n o m a of t h e anus. Mr. B. P. M o r g a n c o n s i d e r e d t h a t r a d i o t h e r a p y has f a i l e d in the t r e a t m e n t of carc i n o m a of t h e anus. I t does n o t p r o d u c e a f u n c t i o n a l anus. H o w e v e r , t h e m o r t a l i t y rate in this disease has d r o p p e d in the d e c a d e f r o m 1940 to 1950. W e can n o w a p p r o a c h t h e surgical p r o b l e m c o n f i d e n t l y a n d there is a p l a c e for p e r i n e a l e x c i s i o n of the r e c t u m in this c o n d i t i o n . Mr. E. W i l s o n a p p r o v e d t h e use of t h e L o c k h a r t - M u m m e r y p e r i n e a l p r o c e d u r e in some of the cases w h e n t h e g e n e r a l condit i o n of the p a t i e n t is p o o r . L i s t e d in a l p h a b e t i c a l o r d e r a r e the foll o w i n g p a r t i c i p a n t s in t h e m e e t i n g : Mr. D. Beard, Adelaide Mr. R. C. Bennett, Adelaide Dr. B. Billington, Sgdney Mr. A. B. Garden, Melbourne Mr. E. Dunlop, Melbourne Mr. D. Failes, Sydney Mr. P. Grant, Brisbane Mr. 13. Green, Sydney Mr. G. Grove, Melbourne Mr. N. T. Hamilton, Melbourne Mr. R. M. Hollings, Sydney Mr. F. Huber, Sydney Mr, E. S. R. Hughes, Melbourne Mr. J. D. Hughes, Sydney Mr. A. F. Hunter, Auckland Mr. M. Killingback, Sydney Mr. S. G. Koorey, Sydney Mr. D. Lane, Brisbane Mr, D. Leslie, Melbourne Mr. S. Levitt, Perth Mr. W. J. McCann, Melbourne Mr. A. C. McEachern, Adelaide Mr. D. G. McLeish, Melbourne Mr. B. P. Morgan, Sydney Mr. J. Nayman, Melbourne Dr. F. B. M, Phillips, Melbourne Mr. J. H. Pryor, Ballarat Mr, P. J. Ryan, Melbourne Dr, N. D. Sherson, Melbourne Mr. R. P. Silverton, Sydney Miss L. Sisely, Melbourne Mr. S, L. Spencer, Sydney Mr. W. Stern, Melbourne Mr. H, H. Steward, Perth Mr. A. B. Vivian, Perth Mr. H. B. L.Williams, Sydney Mr, E. Wilson, Sydney Mr. Wright, New Zealand