Preoperative "chemoradiation" for stages II and III rectal carcinoma.

OBJECTIVE: To determine whether preoperative administration of combination chemotherapy and external beam irradiation ("chemoradiation") for patients with stage II or stage III rectal carcinoma had an impact on perioperative morbidity on oncologic outcome, as compared with patients not receiving preoperative chemoradiation. DESIGN: A group of patients with stage II or stage III rectal carcinoma receiving preoperative chemoradiation were followed up prospectively and compared in a nonrandomized fashion with an inception cohort group of similar patients. SETTING: Northwestern Memorial Hospital, Chicago, Ill, a tertiary care academic medical center. PATIENTS: Thirty patients with rectal carcinoma undergoing preoperative chemoradiation were compared with 56 patients not undergoing preoperative chemoradiation, and also with a subset group of 24 patients who received standard postoperative adjuvant chemoradiation. INTERVENTION: External beam radiation, 45 to 50 Gy, was delivered concurrently with fluorouracil and mitomycin 4 to 8 weeks prior to surgical resection. MAIN OUTCOME MEASURES: Patients were followed up at regular intervals for either tumor recurrence or death. In addition, the group receiving preoperative chemoradiation was evaluated for major preoperative morbidity. RESULTS: All patients agreeing to preoperative chemoradiation completed therapy. Perioperative major morbidity in this group (13%) was comparable to previously published results. Of the 56 patients with stage II or stage III rectal carcinoma not receiving preoperative chemoradiation, only 24 (43%) completed standard postoperative adjuvant chemoradiation. Patients receiving preoperative chemoradiation (n = 30), patients not receiving preoperative chemoradiation (n = 56), and the subset of the group not receiving preoperative chemoradiation who completed standard postoperative chemoradiation (n = 24) were followed up for a mean of 39 months, 31 months, and 32 months, respectively. Five-year actuarial local control rates were 96%, 83%, and 88%, respectively. Disease-free-survival rates were 80%, 57%, and 47%, respectively. Overall survival rates were 85%, 48%, and 78%, respectively. CONCLUSIONS: Preoperative chemoradiation in the treatment of stage II or stage III rectal carcinoma is well tolerated and not associated with an increase in subsequent perioperative major morbidity. In addition, local control, disease-free survival, and overall survival compare favorably with a nonrandomized inception cohort group of patients receiving standard postoperative adjuvant chemoradiation.

A comparison of general versus local anesthesia during inguinal herniorrhaphy.

The current study was done to compare the hemodynamic changes, recovery events and economic impact of elective inguinal herniorrhaphy performed with general anesthesia (GA) or regional field block (RB) in 20 patients (American Society of Anesthesiology class I). In the GA group, anesthesia was induced with thiopental and the trachea was intubated after intravenous administration of 0.08 milligrams per kilogram of vecuronium. GA was maintained with 1.2 +/- 0.25 per cent enflurane in 50 per cent nitrous oxide and oxygen, and ventilation was controlled to keep PECO2 at 36 +/- 2 millimeters of mercury. Anesthesia in the RB group was accomplished by local injection of 3.5 +/- 0.5 milligrams per kilogram of 0.5 per cent bupivacaine. In each patient, a suprasternal ultrasonic Doppler probe was used to measure cardiac output before induction of anesthesia, during and after operation. Total peripheral resistance was calculated from mean arterial pressure and cardiac output. There were no statistically significant differences between cardiac output, mean arterial pressure, total peripheral resistance and heart rate in the two groups at any time period during the study. Patients in the RB group did not require parenteral medication for relief of postoperative pain, whereas all those in the GA group did. Significant cost benefits were realized by the RB group because of elimination of general anesthetic and reduction of recovery room fees.

Gastrointestinal endometriosis. Incidence and indications for resection.

Of 1573 consecutive patients with endometriosis diagnosed at laparoscopy or celiotomy, 85 patients (5.4%) had gastrointestinal involvement and 11 patients (0.7%) required bowel resection due to recurrent gastrointestinal symptoms (usually obstructive in nature) and/or suspicion of malignancy. Of 63 patients with gastrointestinal involvement at sites other than the appendix, who did not undergo bowel resection, only two patients had gastrointestinal symptoms at the time of diagnosis (neither patient had obstructive symptoms); follow-up has revealed that only one patient subsequently developed significant gastrointestinal symptoms. Fifteen patients had appendiceal endometriosis, but none had symptoms suggestive of appendicitis. Indications for resection of gastrointestinal endometriosis include the presence of clear-cut obstructive symptoms or the inability to exclude malignancy. The absence of gastrointestinal symptoms appears to be predictive of the absence of clinically significant intestinal endometriosis, and bowel resection is not indicated in the asymptomatic patient. Appendiceal endometriosis appears to be an incidental finding and one that is not clinically important.

Percutaneous biliary drainage as an initial therapy in sepsis of the biliary tract.

Percutaneous biliary drainage offers a rapid, low-risk, effective method of decompressing the biliary tract in the patient with cholangitis and sepsis. A definite surgical procedure can be delayed until the patient is stabilized. The procedure provides anatomic detail that can be used to plan surgical treatment. In some patients who do not have surgically correctable lesions, operation can be avoided altogether.

Carcinoma of the colon and rectum in patients less than 40 years of age.

Thirty-one patients less than 40 years of age with carcinoma of the colon were treated at this hospital during the ten years between 1968 and 1978. This accounted for 3.6 per cent of the total number of patients with carcinoma of the colon and rectum seen during this period. Pain, rectal bleeding, change in intestinal habits and weight loss were the most common presenting symptoms. The average delay between the onset of symptoms and treatment was 6.4 months. Mucin-producing and poorly differentiated adenocarcinomas were present in 49 per cent of the patients in this study. Metastases to the ovaries occurred in 23 per cent of the female patients. The five year survival rate was only 22 per cent. The importance of early diagnosis and treatment and, in the female patient, of oophorectomy is emphasized.

Intraoperative angiography in intestinal angiodysplasia.

Intraoperative angiography is quite useful in locating the site of bleeding in patients with angiodysplasia of the small intestine. We recommend the placement preoperatively of an angiographic catheter in these patients. We have described a technique that complements this procedure with metallic clip labeling to locate precisely the area of bleeding. This method of treatment is illustrated in the present study by reports of patients bleeding from vascular malformations of the ileum, duodenum and the head of the pancreas.

Mesenteric tumefactions.

Mesenteric tumefactions comprise a group of non-neoplastic conditions that present as an intra-abdominal mass. Symptoms vary from none to obstruction of the gastrointestinal tract. Histologic examination reveals dystrophy, fibrosis, or inflammation of the mesenteric fat. Despite a large number of descriptive terms currently in use, this study suggests that all these lesions are part of a single clinical and histologic continuum.

Healing of the perineal wound.

The operative management of the perineal wound of 100 consecutive patients undergoing abdominoperineal resection or total proctocolectomy was readily divided into four categories: (1) left open with simple packing, (2) closed primarily with simple drainage (Penrose or red rubber), (3) closed primarily with suction drainage (airtight and watertight), or (4) closed primarily with suction drainage plus continuous irrigation. At three weeks, none of the open wounds, 11% of those closed with simple drainage, 48% closed with suction, and 60% of those closed with suction plus irrigation were healed. By three months, the cumulative figures were 20%, 44%, 88%, and 87%, respectively, and at one year, 92%, 77%, 95%, and 97%. No difference was found between the wounds closed with suction and those closed with suction plus irrigation. There was a highly significant difference in the rate of wound healing when the wounds closed with suction alone or with irrigation were compared with those left open or closed with simple drainage. At three months, the former wounds were healed in 88% of the patients, and the latter in only 30%. The method of choice of management of the perineal wound appears to be that of primary closure with immediate suction drainage with or without concomitant irrigation.

Internal hernia with gastric outlet obstruction.

A patient with an unusual type of internal hernia was treated successfully. To our knowledge, this is the first reported case of a hernia emanating through the gastrohepatic ligament that resulted in gastric outlet obstruction. It is even more remarkable because, although the small bowel was the herniated viscus, the symptoms were due to obstruction of the stomach rather than obstruction of the small bowel.

Late occurrence of perineal wound abscess years after total colectomy.

Seven patients presented with a large perineal abscess eight months to seven years after complete healing of the perineal wound following proctocolectomy. Six patients had had total proctocolectomies for ulcerative colitis and a seventh had undergone abdominoperineal resection for cancer. A typical clinical picture of perineal pain, fever, urinary tract complaints (including retention), and minimal local perineal findings was present. Prostatitis or a urinary tract infection was considered in five patients, but none of them responded to antibiotics. Ultrasound examination of the perineum may confirm the diagnosis; however, diagnostic and therapeutic surgical exploration of the healed perineum is recommended when this diagnosis is unclear.

Carcinoma obstructing the left side of the colon.

The clinical course, operative treatment, and results of 129 patients with carcinoma obstructing the left side of the colon were reviewed. There were 64 cases of incomplete obstruction, all secondary to primary adenocarcinoma of the colon. Sixty-five patients had complete obstruction; 37 of these had primary adenocarcinoma of the colon, and the rest, cancer from other primary sites, largely the genitourinary tract. The operations involving colostomy only or colostomy as part of a staged resection resulted in high operative mortality and low long-term survival, in addition to a high rate of postoperative sepsis. Results of operations involving primary resection of obstructing tumor were superior in all the above factors studied.

The primary treatment of breast carcinoma.

The major contribution in the surgical management of carcinoma of the breast have been reviewed. Deficits in our current knowledge have been pointed out in an effort to separate fact from theory and so help the surgeon in choosing the best operation for a patient with breast cancer.

Metastatic tumors of spermatic cord.

A case of metastatic carcinoma to the spermatic cord is presented. The previous 12 cases documented in the literature are reveiwed. In the majority of cases the primary tumor occurred in the gastrointestinal tract with metastasis to the spermatic cord by retrograde lymphatic flow.