Sitting a transverse colostomy.

Traditional teaching suggests that a transverse colostomy should be sited in the right upper quadrant. This study of 67 colostomies (26 right upper quadrant and 41 right iliac fossa) indicates that they should be placed in the optimum position for each patient, which is usually the right iliac fossa.

Management of the chronic perineal sinus: not a problem to sit on.

It is our belief that the majority of cases of perineal sinus are curable if certain principles of wound management are followed. The causes and management of perineal sinus are reviewed. Four cases which illustrate the difficulties of achieving healing are reported, and from these important aspects of treatment are highlighted.

Stapling or suturing for anastomoses of the left side of the large intestine.

Two hundred and fifty patients undergoing elective surgical treatment involving anastomoses of the left side of the colon or colon and rectum have been studied in a randomized trial in which the EEA (U. S. Surgical Corp.) circular stapler has been compared with single layer sutured anastomoses. Only patients in whom either technique was feasible were included in the analysis. The operative techniques were largely standardized. Patients were studied by means of a limited barium enema on the ninth or tenth postoperative day. The data have been analyzed for leakage rate (clinical and roentgenologic), other complications and degree of experience of the surgeon. Eleven patients were excluded from the analysis because the selected technique could not be carried out; of these, eight were in the stapled group in which it was possible to perform a sutured anastomosis. There were no instances in which it was possible to staple but not possible to suture. The remaining three exclusions were patients in whom either a coloanal anastomosis or a Hartmann procedure was performed. There was no over-all difference in the leakage rate--roentgenologic, clinical or total--between the two groups. However, when analyzed by the surgeon, the clinical leakage rate for surgeons in training was greater for sutured anastomoses than for stapled anastomoses (p = 0.053). Thus, it appears that the benefits of experience are more pronounced for sutured anastomoses but that, in experienced hands, neither technique is superior.

Clips or sutures for herniorrhaphy wounds?

This study compares the pain experienced by fifty patients following bilateral herniorrhaphy using two different methods of wound closure. No significant difference was found between the use of Michel clips and interrupted monofilament nylon sutures. Clips were preferred by a significant majority of patients, probably because they cause less pain on removal. The use of Michel clips should not be limited by the belief that they cause more pain than conventional sutures.

Occult blood loss from small bowel tumours. Case report.

We report 4 patients who presented with occult blood loss, from a small bowel adenocarcinoma, in whom there was considerable delay in diagnosis. The difficulty in diagnosis and the role of CT scanning is discussed. We recommend a careful laparotomy when endoscopic and radiological investigations fail to reveal the source of blood loss.

A retrospective study of colostomies, leaks and strictures after colorectal anastomosis.

A review was undertaken of 360 patients undergoing elective left-sided colonic or rectal resections with primary anastomosis, under the care of one surgeon, over a nineteen year period. The incidence, aetiology and management of anastomotic leaks and strictures was studied and the role of proximal diverting colostomy considered. Perioperative mortality was 2.7%. The incidence of anastomotic leaks was 24.4%. Leaks were more common when anastomoses were low, were sutured or were constructed by trainees. Strictures developed in 5.8%. Local recurrence of tumour was the cause of 25% of these strictures. Anastomotic leakage was the principal cause of benign strictures; those developing in association with leaks were more likely to require surgical intervention. There was no evidence that delay in colostomy closure contributed to the development of benign anastomotic strictures. It was not possible to determine whether the presence of a colostomy affected the incidence of leaks but the local effects of such leaks were mitigated in patients with colostomies. Where a minor leak had occurred it was not necessary to wait for complete anastomotic healing before closing the colostomy. After major leaks, colostomy closure before complete healing was associated with further anastomotic problems in 16.0% of cases.

Surgery for recurrent colorectal carcinoma--is it worthwhile?

A series of 45 patients undergoing a second operation for recurrent colorectal cancer is reported. The majority developed recurrence within 2 years of their initial surgery. Despite regular follow-up, in only 27% of patients submitted to further surgery was the recurrence detected at routine review, and only three of these were asymptomatic at the time of diagnosis. A potentially curative second procedure was undertaken in 47% of cases, with a 2-year survival of 71% and a 5-year survival of 29%. Of those undergoing palliative surgery, this was worthwhile in 64%, providing palliation for more than 6 months. Mean survival following a palliative procedure was 10 months. Palliation was better, and operative mortality lower, when the bulk of the tumour could be removed. In obstructed patients the outcome following palliative resection was better than for palliative bypass procedures. Following resection of metastases there is the prospect of long-term survival, but it is difficult to predict those patients who will do well.

The functional result of pelvic ileal reservoir in 10 patients with familial adenomatous polyposis.

Ten patients with familial adenomatous polyposis (FAP) were treated by total colectomy, mucosal protectomy and ileoanal anastomosis with a pelvic ileal reservoir. The functional results were assessed by means of a patient questionnaire and suggested that this operation may represent the ideal treatment for the condition, irradicating disease-bearing mucosa, avoiding an ileostomy and providing acceptable function.

Experience of restorative proctocolectomy with ileal reservoir.

The experience gained with restorative proctocolectomy and ileal reservoir in 60 patients is presented. Fifty-two patients had W reservoirs and the operative technique of the procedure is described in detail. Forty patients had a defunctioning ileostomy and 20 had a single stage procedure. There was no perioperative mortality. The main complications were sepsis (28 per cent), intestinal obstruction (18 per cent) and reservoir ileitis (20 per cent). There was a significant improvement in sepsis rate (from 20 to 4 per cent) and hospital stay (from 31.8 to 15.6 days) with increased experience. The functional results of 48 patients with W reservoirs was assessed. The mean number of evacuations per 24 h (+/- s.d.) was 3.8 +/- 0.2. Sixty-five per cent of patients did not evacuate at all, or rarely, at night and none evacuated more than once at night. Forty-four per cent of patients took antidiarrhoeal agents. Continence was normal in 50 per cent of patients. Minor leakage occurred in 46 per cent of cases, frequent leakage in 4 per cent and incontinence in none. Sexual function in 29 men was normal. Ninety-four per cent of patients considered the results of their operation to be good or excellent.

Endometriosis of the recto-vaginal septum treated by anterior resection.

Two young nulliparous females with severe symptomatic recto-vaginal endometriosis that had not responded to medical treatment were considered for surgery. Pre-operatively they were investigated by laparoscopy and Magnetic Resonance Imaging (M.R.I.) which demonstrated that the lesions were confined to the recto-vaginal septum with no intraperitoneal involvement. Both patients underwent resection of the middle third of the rectum and part of the posterior wall of the vagina with preservation of the ovaries, uterus and fallopian tubes. In one patient a J-colonic pouch with colo-anal anastomosis was fashioned and in the other patient a stapled colo-rectal anastomosis. Both patients are now asymptomatic with normal bowel function six months post-operatively. Radical surgery is indicated very rarely. We believe it should be considered in young nulliparous women who wish to conceive, in whom the diagnosis has been confirmed histologically and who have severe symptoms. M.R.I. is a useful pre-operative investigation to delineate the extent of the disease.

Villous tumours of the large bowel.

A series of 110 patients with villous tumours of the colon and rectum treated by a single surgeon over an 18-year period is reported. Multiple lesions were present in 15 per cent of patients and 24 per cent of cases contained invasive malignancy, of which 83 per cent were Dukes' A. The major lesion was in the rectum in 84 per cent of patients and in the sigmoid colon in 12 per cent. Rectal bleeding and diarrhoea were the most common presenting symptoms; 6 per cent of patients were asymptomatic. Digital assessment proved a more reliable indicator of the presence of malignancy than either random biopsy or barium enema. In all, 70 of 76 (92 per cent) benign rectal lesions and 15 of 22 (68 per cent) malignant rectal lesions were successfully removed by peranal submucous excision or snaring and none of the malignancies so treated has developed a recurrence to date. Benign recurrence has developed in 13 per cent of all patients; the majority appeared within 4 years and were at the same level as the initial lesion. Of the 79 patients with benign tumours 7.6 per cent have subsequently developed large bowel carcinomas, after 2-16 years; all were symptomatic, half were at the same level as the previous benign lesion, and half were suitable for peranal removal.

Colovesical fistula.

The experience of 66 cases of colovesical fistula is reported. The most common cause was diverticular disease (71%), the remainder being due to malignancy, Crohn's disease, radiotherapy, appendicitis and trauma. The most sensitive investigation was barium enema, which was abnormal in 98% and actually showed the fistula in 57%. In 32 patients a single stage resection was performed, without mortality or significant morbidity and we would advocate this form of treatment for fistulae which are not complicated by gross sepsis or obstruction.

The value and significance of the limited barium enema examination following restorative resection for carcinoma of the rectum.

The results of limited barium enema examinations from a consecutive series of 143 patients who underwent restorative resections for carcinoma of the rectum were studied. An assessment was made of the value of the investigation both in terms of clinical management decisions and also to see whether radiologically detected anastomotic leakage was associated with a higher incidence of tumour recurrence. A study was also made of the incidence of leakage with respect to tumour size, length of the distal resection margin, Dukes' grading and histological differentiation. Results showed that there was a greater incidence of tumour recurrence following anastomoses which leaked, although due to small numbers the figures did not reach statistical significance. There was no relationship between tumour size, grade, differentiation, or length of the distal resection margin, and radiological leakage. We consider that the limited ten day barium enema examination does not contribute significantly to surgical management of these patients, except to define the extent of a leak and in the assessment of new anastomotic techniques. However, we suggest that a larger series may demonstrate a statistically significant increase in pelvic recurrence in patients who developed leakage from the anastomosis. This could dramatically alter the application of the postoperative limited barium enema.