[The role of laparoscopy in the management of prostatic cancer]. / Laparoscopia szerepe a prosztatarák kezelésében.

Laparoscopic lymphadenectomy is a new surgical modality with increasing usage in the staging and management of prostate carcinoma. Since the presence or absence of metastatic disease in the pelvic lymph nodes must be assessed for proper treatment planning, and preoperative staging studies have a high rate of false negative results, histological evaluation of the pelvic lymph nodes should be performed prior to radical prostatectomy. Laparoscopic pelvic lymphadenectomy is a well tolerated, safe, and accurate alternative to the conventional open surgical procedure.

Results of abdominoperineal resections for failures after combination chemotherapy and radiation therapy for anal canal cancers.

Thirty patients treated with combination chemotherapy (CT) and radiation therapy (RT) for anal canal carcinoma were reviewed retrospectively to analyze the results of abdominoperineal resection (APR) for treatment failures. Mean follow-up was 34.9 months. Twenty-four patients had squamous carcinomas, and six had cloacogenic carcinomas. Twenty-five had negative inguinal lymph nodes, and five had positive inguinal lymph nodes. The group received 5-fluorouracil, mitomycin C, and 30 to 50 Gy of RT. Biopsy was obtained at six weeks posttherapy. Seventeen of 22 patients (77 percent) with primary tumors of less than 5 cm and negative nodes were disease free at 37 months post-CT-RT. None of the seven patients with primary tumors of greater than 5 cm or positive nodes were free of disease. APR was done for positive biopsy in eight patients and for local recurrence (disease detected after six months of treatment) in one patient. Eight of nine patients who had APR died of disease (mean, 20 months), and one of nine died of other causes. A review of published series, including our data, reveals 24 cases of APR post-CT-RT for positive biopsy, with 17 of 24 (71 percent) dead of disease within three years. APR for CT-RT failures has a poor prognosis. Future protocols may determine whether further CT-RT will improve survival. APR for palliation should always remain an option.

Endoscopic examination of the colon and rectum distal to a colostomy.

We report results of the endoscopic examination of the colon distal to a colostomy in 85 patients. Almost half had symptoms related to the excluded bowel. Whereas severe colitis or tumor may be asymptomatic, many patients had discomfort, pain, bleeding, and discharge. Endoscopic examination revealed abnormal findings in 80% of the patients. These were as uncomplicated as mucous plugs or as serious as polyps or carcinoma. We found a high incidence of diversion colitis in the excluded colon. Because of these abnormal findings, endoscopy of the bowel distal to a colostomy at regular intervals is recommended. Mucous plugs and scybala should be treated by irrigation, while polyps and carcinoma should be treated as they would in the nondiverted colon. Diversion colitis can be treated medically with local steroids, or surgically. In most cases, even in severe colitis, we recommend closure of the colostomy. Removal of the excluded colon is seldom necessary.

Diversion colitis: a clinicopathologic study of 21 cases.

Inflammation occurring in a defunctionalized portion of bowel, following either ileostomy or colostomy, has long been recognized by endoscopists. However, little has been written about this entity, particularly the histopathologic changes. Glotzer et al in 1981 described 10 cases, and coined the term "diversion colitis". We studied 21 patients without previous history of inflammatory bowel disease who, for reasons including perforated diverticulitis, carcinoma, or trauma, had loop colostomies or Hartmann's procedure performed. Many of these patients became symptomatic with complaints related to the defunctionalized bowel, including rectal discomfort, pain, discharge, and bleeding. Nineteen patients had endoscopic examinations, which revealed a variety of findings including mucous plugs, friability, petechia, erythema, ulcers, exudate, and nodules or polyps. All except one case had tissue from the excluded portions of bowel available for pathologic examination. Most displayed nonspecific changes with mild-to-moderate lymphoplasmacytic infiltrates in the lamina propria, mild architectural alterations of the crypts, and slight decrease in crypt numbers. Ulceration, cryptitis, and crypt abscesses simulating ulcerative colitis were uncommon findings and were observed almost exclusively in more severe cases. Granulomas were observed in two cases, raising the possibility of Crohn's disease.

The fate of the forgotten rectal pouch after Hartmann's procedure without reconstruction.

The rectal pouches of 45 patients who underwent Hartmann's procedure and were not scheduled to have a colostomy closure were examined with an endoscope at least 1 year after operation. Twenty-five patients had no symptoms related to the rectal pouch. The rest had pain, mucous discharge, moderate-to-severe bleeding, or discharge of small bowel contents. Endoscopic findings included moderate-to-severe proctitis in 20 patients, 10 of whom had no symptoms. Polyps were found in four patients (two asymptomatic) and carcinoma in seven (one asymptomatic). Of 24 patients operated upon for diverticulitis, 12 had proctitis and 2 had polyps. Of 14 patients with carcinoma, 4 had proctitis, 1 polyps, and 5 carcinoma. Of two patients with benign polyps, one had polyps and one, carcinoma and of five patients with inflammatory bowel disease, four had proctitis and one, carcinoma. The treatment of polyps and carcinoma is the same as for other patients with these conditions. Proctitis should be treated with reanastomosis. The frequent presence of abnormality in the rectal pouch indicates the need for regular follow-up examinations of these patients.

Malignant transformation of anorectal giant condyloma acuminatum (Buschke-Loewenstein tumor).

Giant condyloma acuminatum, originally described by Buschke and Loewenstein in 1925 as a lesion of the penis, is more rarely seen in the anorectum and is characterized by clinical malignancy in the face of histologic benignity; however, malignant transformation to frankly invasive squamous-cell carcinoma has been described. Malignant transformation has been reported in 15 patients with "ordinary" condylomata acuminata as well. Twenty giant condylomata acuminata have been previously reported, six of which (30 percent) went on to develop squamous-cell carcinoma. The authors report eight cases of giant condylomata acuminata with invasive squamous-cell carcinoma developing in four patients. Light and electron microscopic methods were used to verify the diagnosis of squamous-cell carcinoma and/or giant condyloma acuminatum in our cases. Human papillomavirus (HPV), known to cause condylomata acuminata, is also known to induce these tumors. The authors support the hypothesis that giant condyloma acuminatum represents an intermediate lesion in a pathologic continuum from condyloma acuminatum to squamous-cell carcinoma. These lesions have a propensity for recurrence, likelihood of malignant transformation, and significant mortality. Therefore, early and radical local excision, and in cases of recurrence, invasion, or malignant transformation, abdominoperineal resection, along with vigilant follow-up, provides the only current hope for cure.

A critical evaluation of the Hartmann's procedure.

We reviewed 150 cases of Hartmann's procedure between 1972-86. Indications, rate of colostomy closure, and "diversion colitis" of the rectal pouch are discussed. There were 76 cases performed for diverticulitis. This procedure is easy to perform and carries a low risk. While it removes the diseased bowel segment, it leaves the patient with a colostomy requiring a major operation for closure. When possible, resection with anastomosis is preferable. There are no generally accepted guidelines for performing the Hartmann procedure; it depends on the individual surgeon. Forty three cases were performed for carcinoma. For palliation, it is a good operation; for cure others are preferable. With few exceptions, it is a poor choice for inflammatory bowel disease. In 42 cases of diverticulitis, the colostomy was not closed because of the patient's age, medical or surgical contraindications. Thirteen patients declined the closure. Twelve pouches had to be removed. Mild colitis was found in every pouch examined endoscopically. Severe colitis was found in one patient operated for cancer, in three for diverticulitis, and in 11 for colitis.

Appendicovesical fistula.

Appendicovesical fistula is a rare complication of unrecognized appendicitis. Only 99 previous cases have been reported in the literature. We reviewed these cases and contribute an additional one with hope that increased awareness of this entity may facilitate the correct diagnosis and avoid inappropriate management.

The pathogenesis of hemorrhoids.

The structure of the anal canal was examined in histology slides. Hemorrhoids are normal features of the human anatomy. They are pads that bulge into the lumen. Hemorrhoids have three parts: 1) the lining, which can be mucosa or anoderm; 2) the stroma with blood vessels, smooth muscle, and supporting connective tissue; and 3) the anchoring connective tissue system, which secures the hemorrhoids to the internal sphincter and the conjoined longitudinal coat. The anchoring and supporting connective tissue system deteriorates with aging. The hemorrhoids not only bulge, but descend into the lumen. This becomes observable in the third decade of life, with individual differences. The veins become distended as they lose their support. The descended loose lining becomes more sensitive to pressure from straining and to trauma from the stool. There can be a stasis in the veins, with clot formations and swelling, or erosions of the lining, with bleeding. The hemorrhoids become symptomatic.

The prevalence of hemorrhoids.

The clinical records of 835 patients were reviewed. Five hundred ninety four had symptoms of hemorrhoids (symptomatic group) and 241 had no symptoms (asymptomatic group). Eight-six per cent of the entire group had hemorrhoids, 88 per cent among the symptomatic group and 82 per cent among the asymptomatic group. It was felt that if the prevalence rate of hemorrhoids in the symptomatic and asymptomatic groups is similar or close to similar in every age, it is likely that a certain number of people will have hemorrhoids in every age group irrespective of the presence or absence of symptoms. If the prevalence rate is high, it would seem to support the theory that hemorrhoids are normal parts of the human body, not a disease but a sign of aging. Although the difference in the prevalence rate overall in the symptomatic and asymptomatic groups, 88 versus 82 per cent was mathematically significant, this was due to the large sample size and it was small enough to be without clinical importance. No significant differences in the prevalence rate between symptomatic and asymptomatic patients within age groups were found.

Work in progress: radioisotopic evaluation of gastroplasty patients.

Radioisotopic gastric emptying studies, using technetium-99m-sulfur-colloid-labeled egg, were performed in 14 patients who had undergone gastroplasty. The radioisotopic method was found to be a good quantitative indicator of the amount of solids that empty from the stomach and a useful tool in the longterm follow-up of gastroplasty patients. It was particularly helpful in evaluating the efficacy of surgery in patients with poor postsurgical weight reduction.

Age-related changes and scar formations of perianal connective tissue.

Changes in perianal connective tissue were studied using specimens from juvenile cadavers and resected tissue from adults. The fibers of the anal sphincter muscles lie in a connective tissue mesh which anchors the muscle fibers, the anal mucosa and skin, and the entire anal canal. The connective tissue mesh is present in the newborn and has similar patterns in every age group, but the ratio of the amount of connective tissue/muscle tissue (C/M ratio) increases with age. The increase of the C/M ratio may have a role in the development of weakness of the sphincters and mucosal or rectal prolapse in the elderly. After injuries or operation no pure collagen scar formation was observed in the sphincter muscles, but there was an increase in the C/M ratio. In inflammatory bowel diseases, when severe anal stenosis is present, the connective tissue web and sphincter are intact and the scar formation is confined to the submucosal and subcutaneous layers.