Transanal local excision of rectal cancer.

Twenty-five patients with invasive rectal cancer treated by transanal excision between 1978-1989 are presented. Two patients had poorly differentiated tumours and were converted to abdominoperineal resection and one patient had extensive liver metastases documented preoperatively. The remaining twenty-two, mean age 64 years, fulfilled the criteria for local treatment. Eighty-two percent of tumours were T1 or T2 stage. There was no operative mortality. Six complications in five patients occurred, none requiring surgical intervention. Five patients died of unrelated causes without evidence of recurrence at 4, 4, 14, 26 and 58 months. The length of follow-up for the surviving group (17 patients) was 16 to 115 months (mean 63 months). Two patients developed local recurrence at 32 and 60 months. Transanal excision can be curative for selected rectal cancers.

The role of internal sphincter in chronic anal fissures.

Changes in anal sphincteric manometric pressures in response to rectal distention were measured in eight patients with chronic anal fissures and were compared with those of ten controls. No statistically different resting pressures were noted between the two groups. Overshoot phenomenon was more commonly seen in patients with fissure. There were no differences in the anal sphincteric pressures after lateral internal sphincterotomy (LIS) or fissurectomy midline sphincterotomy (FMS). All fissures healed postoperatively, irrespective of the surgical technique (LIS or FMS) or the pressure readings. It can be concluded that the therapeutic effect of sphincterotomies might at least in part be due to anatomic widening of the anal canal rather than to decreased resting pressures of the internal sphincter.

Supralevator abscess: diagnosis and treatment.

Anorectal suppurations are quite common. Supralevator abscesses, previously regarded as a rare subgroup, were seen in 9.1 per cent of 506 patients admitted to Cook County Hospital in a two-year period. Aggressive supportive management was followed by early, adequate drainage through the rectum whenever indicated. When fistulas were identified, either a primary fistulotomy or a two-stage fistulotomy using a seton was performed in the majority of cases. Important factors in the prevention of morbidity and mortality included debridement of all necrotic tissue, careful bacteriologic studies and judicious use of antibiotics, close postoperative observation, and long-term follow-up of the patients.

Hepatic abscesses in diverticulitis.

Liver abscess is an uncommon but potentially lethal complication of diverticulitis. Either may be present in an occult form. We present two cases to illustrate the diagnostic and therapeutic problems created by these occult presentations. A high index of suspicion and an aggressive diagnostic approach are necessary to ensure early diagnosis and proper treatment. Barium enema should be done in patients with liver abscesses when there is no obvious source for the abscess. Intraoperative evaluation of the liver, including needle aspiration of any suggestive areas, should be done in all patients operated upon for complicated diverticulitis. Patients with diverticulitis and abnormal results of liver function tests should have liver scan or abdominal sonography.

A prospective survey of 474 patients with anorectal abscess.

A prospective survey of patients with anorectal abscesses treated at Cook County Hospital over a 35-month period produced data on 474 patients. The peak incidence was in the third decade of life. Males were affected 1.76 times more frequently than females. Perianal abscess was the most common anatomic type (42 per cent), with ischiorectal abscess (20 per cent) being second. The supralevator space was involved in 7 per cent of the abscesses. Primary fistulotomy was performed when an anal fistula could be demonstrated (34 per cent). Our standardized method of treatment, utilizing radial incisions for drainage, produced satisfactory results with a complication rate of 3 per cent, an in-hospital reoperation rate of 0.6 per cent, and an average hospital stay of 5.7 days.

A rare cause of ischemic colitis: polyarteritis nodosa.

This paper details the first case report of a patient with fulminant, gangrenous, ischemic colitis caused by polyarteritis nodosa which was successfully treated surgically. Ischemic colitis is a rare complication of polyarteritis nodosa. It should be suspected in patients with a past history of polyarteritis nodosa who develop abdominal pain and rectal bleeding. The identification of cutaneous lesions preoperatively and or mesenteric or serosal vascular beading at operation are helpful in establishing this diagnosis. Prognosis is generally determined by the extent of systemic involvement by polyarteritis nodosa, and death is generally associated with renal failure.

The preoperative diagnosis of hepatic metastases in cases of colorectal carcinoma.

Preoperative LDH, CPK, alkaline phosphatase and liver scan results were compared with the presence or absence of hepatic metastases at operation in 124 laparotomies in 123 patients with colorectal carcinomas during a three-year period. The overall accurcy rates for the four tests ranged from 74 to 84 per cent. The false-negative rates were acceptably low (9-13 per cent) for all but the CPK determination. The false-positive rates were unacceptably high for all four tests (38 to 60 per cent). A 'metastatic score' for reducing the high false-positive rate is described. In view of the high false-positive rates of preoperative screening tests, laparotomy is presently the most accurate method of diagnosing hepatic metastases.