Ileorectal anastomosis--friend or foe?

Ileorectal anastomosis is a controversial operation. Its use has been promoted for the management of colonic cancer, familial polyposis, Crohn's disease, ulcerative colitis and in several rarer conditions. In the treatment of ulcerative colitis controversy has centered on the risk of malignant change in the retained rectum and on the long term quality of function. E. S. R. Hughes has been a proponent of this procedure and is one of those able to report a major series with long term follow-up of function and cancer development in ulcerative colitis. Of 364 colitics treated by resection, 43% were selected for this operation. This group showed a success rate of 72% and after 15 years 57% remained functional. The probability of malignant change has reached 14% at 27 years with 8% of the series developing rectal carcinoma. The probability of this development following a diagnosis of moderate or severe mucosal dysplasia reached 42% at 13 years from histological assessment. Ileorectal anastomosis has a high degree of acceptability in appropriately selected ulcerative colitics; its continuing use is dependent on surveillance of sufficient quality to predict cancerous change or to detect it earlier enough to effect cure by proctectomy.

The management of radiation proctitis.

This paper deals with the clinical features, diagnosis and treatment of acute and delayed forms of radiation injury of the rectum. A series of thirty-seven patients with this condition is reported and the current literature is reviewed. Although there have been no major advances in the treatment of this problem, an improvement in results of operative procedures can be expected with a better understanding of the pathology, the use of parenteral nutrition, and the introduction of several new techniques of bowel anastomosis. Aspects of prevention are also discussed.

Operative mortality following excision of the rectum.

Resection of the rectum was performed in 1395 patients. There were 94 (6.7 per cent) operative deaths. The operative mortality was similar in the three types of excision. Mortality was high in the male, in the older age groups and in those having palliative resection. Cardiopulmonary complications and sepsis were the two chief causes of the operative deaths.

Purse string placement for staple anastomosis using the end-to-end anastomosis stapling instrument.

There may be technical difficulties in the use of recommended clamp for the insertion of the purse-string suture during the construction of an end-to-end staple anastomosis. Hand sewing the purse string eliminates some of the problems, but unless the suture is positioned within a few millimetres of the cut edge of the bowel, ischaemic tissue may be included in the staple line. In dogs, this leads to anastomotic dehiscence. The anastomosis may, however, be protected by excising the ischaemic tissue and reinforcing the staple line with sutures. An "over and over" purse-string technique is now preferred to minimize the risk of this occurring.

The management of solitary thyroid nodules under local anaesthesia.

A group of patients with solitary nodules of the thyroid were treated at the University of Malaya by surgery under local anaesthesia. This was done in order to expedite exploration of a potentially malignant condition. This group comprised 43 patients, and four cancers were found. The standard technique used was satisfactory from the viewpoint of both the patient and the surgeon. The pattern of this condition in a Malaysian population is documented, the technique used is described, and thyroidectomy under local aneaesthesia is discussed.