Back to basics.

The Society for Surgery of the Alimentary Tract originated as the Society for Colon Surgery. Therefore, it is appropriate that the dramatic developments in colorectal surgery that have occurred during the life of the Society should be emphasized. Major technical advances are identified as ileoanal anastomoses, colonoscopy, and EEA staplers. Although control of cancer remains a major problem, recent trends in the education and agenda of colorectal surgeons promise a bright future.

Occult gastrointestinal bleeding: newer techniques and diagnosis and therapy.

Complex problems occur concerning the diagnosis and treatment of GI bleeding. How often can the exact cause and site of the bleeding be determined? What are the advantages and complications of various forms of treatment? There are no universal answers, applicable to all situations. Nevertheless, certain assumptions seem to be justified. Diagnosis of the cause of severe bleeding, often suggested by the patient's history, is confirmed most effectively by selective angiography, which should give an answer in over 95% of cases. The causes of slow, persistent bleeding, manifested either by gross blood or by positive tests for blood in the stools, are diagnosed in about the same percentage of cases by endoscopy. It is when the bleeding is intermittent and of minimum or moderate severity that determination of the site of origin is the most difficult; angiography cannot help in the majority of cases, and endoscopy can miss tiny lesions that are not bleeding at the time of examination. However, laparotomy, especially when it is combined with intraoperative enteroscopy or angiography, should reduce the number of unsolved diagnoses to under 5% of the total. Surgery is the primary method of therapy in many cases. Primary control of bleeding also can be obtained in approximately 80% of cases of severe bleeding by endoscopy, by the use of coagulation or laser, or by selective arterial infusion of pitressin. Recurrences must be treated by surgery, except in some instances where selective embolization by the angiographer may result in a cure. The surgeon must attempt to cure the hemorrhage and to prevent recurrence at a later date by such measures as gastric resection and vagotomy for bleeding duodenal ulcers to prevent stomal ulcers, or by subtotal rather than segmental colectomy for widespread colonic diverticulosis. There will be an irreducible percentage of lesions that continue to develop in other sections of the GI tract after successful primary treatment of the original cause of bleeding; AVMs, angiodysplasia, and vasculitis are examples. Fortunately, such diseases are relatively rare. It is not unreasonable today to expect that the measures discussed herein will cure bleeding in 95% of cases; if death occurs it rarely is due to hemorrhage, but to some type of organ failure.

A thousand operations for ulcer disease.

A retrospective study of 1068 patients who had operations for peptic ulcer disease in the 12-year period from January 1, 1974, to January 1, 1986, permits these conclusions: The number of patients admitted to the Massachusetts General Hospital (MGH) has declined steadily in the years of this study--1974-1986. The average number of patients admitted with a diagnosis of peptic ulcer disease in precimetidine years--1974, 1975, and 1976--and in recent years--1982, 1983, and 1984--shows a decline of 39.3% in admissions. In the same periods, the average number of operations per year has declined from 92 in precimetidine years to an average of 71 (16.5%) recently. The decline has been greatest in patients operated on electively for duodenal ulcer. Operations for massive hemorrhage and acute perforations and the number of deaths have remained nearly constant. The overall mortality rate was 10.3%. The mortality following elective operations for pain was 0.5%; for urgent operations, including those for obstruction, 4.5%, and for bleeding other than massive, 7.5%; and for emergency operations, including those for acute perforation, 20.9%, and for massive hemorrhage, 22.1%. The main causes of death were organ failure (most commonly of the lungs) and sepsis. Early complications were documented 345 times and were followed by reoperation in 84 cases, or 7.4% of the total. Delayed stomal function was noted in 63 cases and required reoperation in 14. It was most common after Roux anastomoses and required operative intervention most commonly after gastric resection, Billroth I (GRBI). Delay was three times as common when vagotomy (V) was added to GR. Early postoperative hemorrhage was a serious complication when it occurred after operations for acute perforations or massive hemorrhage. The incidence was 3.7% after suture of a perforation; after operations for acute massive hemorrhage, it was 4.3% after pyloroplasty and vagotomy, with or without arterial ligation [PV(L)], and 0.3% after GR, with or without arterial ligation [GR(L)]. Late complications led to reoperation in 66 cases (6.2%). The most important were recurrent ulceration and alkaline gastritis. Recurrence rates after a minimum follow-up of 5 years (based on survivors of initial procedures and a second operation, both in the MGH) were 20.5% after suture of a perforation, 6.2% after PV, 2.3% after GRBII, and 0.4% after GRVBII. These figures are lower than expected; incomplete follow-up and improved medical care are factors.(ABSTRACT TRUNCATED AT 400 WORDS)

Percutaneous drainage of diverticular abscess. An adjunct to surgical therapy.

We undertook this study to determine whether a computed tomography-guided, percutaneous preoperative drainage of a peridiverticular abscess can safely allow a one-stage procedure in patients requiring surgery for acute diverticulitis. In 17 patients evaluated prospectively by computed tomography, thin-needle aspiration demonstrated purulent fluid collection in 11 patients. Percutaneous catheter drainage was undertaken in eight patients. In the three remaining patients, the abscess was either too small to warrant drainage or no safe access route was present. Seven of eight patients had a single-stage resection within one to three weeks of percutaneous catheter drainage. There were no complications. Our studies suggest that a combined radiological-surgical approach has the potential to reduce morbidity and hospital costs without increasing mortality in the management of perforated colon diverticulitis with associated abscess formation.

Failure patterns following curative resection of colonic carcinoma.

To identify patterns of failure following curative resection of colonic (nonrectal) carcinoma, the medical records of 533 patients undergoing resection with curative intent were reviewed. The overall local failure rate was 19% (102/533 patients) with 32 patients having local failure alone and 70 patients having concurrent local failure and distant metastases. The incidence of local failure rose with advancing stage of disease. Tumors staged B3, C2, and C3 had local failure rates in excess of 30%. Local failures occurred predominantly in tumor bed and adjoining structures (82%) and not by regional nodal failure (18%). One hundred thirty-one patients (25%) developed distant metastases. One hundred ten patients (84%) failed in the abdomen-liver, peritoneal seeding, para-aortic, or portahepatic lymph nodes. Patients with Stage B3, C2, and C3 tumors were found to have abdominal failure rates (excluding local failure) of greater than 20%. The highest failure rates in the liver were in Stage C2 and C3 patients in which the subsequent development of liver metastases was 29% and 31%, respectively. In Stage C3, peritoneal seeding and abdominal lymph node failure occurred in 18% and 14% of the patients, respectively.

Changing patterns in the surgical treatment of diverticular disease.

This paper includes a brief historic summary of the surgical aspects of diverticular disease and of corresponding developments in the Massachusetts General Hospital from 1911 to the present. The 350 cases observed in 1974-1983 are compared with 338 seen in the previous decade. Major trends include a decrease in hospital admissions for diverticular disease but a sustained number of operations; increased severity of the disease in hospitalized patients manifested by an increased percentage of patients with immunosuppression or serious other diseases (p less than 0.001), an increased number with sepsis and general peritonitis (p less than 0.001); an increased percentage of cases with one-stage resection and anastomosis (p less than 0.02); in patients with general peritonitis, resection of the perforated segment at the time of the original operation was accompanied by the lowest mortality (p less than 0.02); incidental splenectomy appears to be dangerous, with three deaths in eight cases; and overall mortality in the last decade is 6.4%; for emergency cases 10.2%, for urgent 9.7%, and for elective cases 2.4%.

Adenocarcinoma and lymphoma of the small intestine. Distribution and etiologic associations.

Malignant small-bowel tumors in 171 patients over 64 years included 68 with adenocarcinomas, 41 with primary lymphomas, 50 with carcinoids, and 12 with sarcomas. The distribution of the carcinomas showed approximately 80% preponderance in the duodenum and proximal jejunum. A similar distribution in the upper small bowel in small-bowel carcinomas induced in Fischer and Sprague-Dawley rats by azoxymethane (90-160 mg/kg) suggests defense mechanisms within ileal mucosa. The clinical series from 1958 to 1976 included two Crohn's carcinomas (jejunum, defunctioned ileum), two jejunal cancers (lymphoma, carcinoma) associated with celiac disease, two duodenal carcinomas arising in villous adenomas, and one jejunal lymphoma following exposure to irradiation. Multiple primary malignancies were found in 20 to 25% of enteric cancers. Hemorrhage was more common with carcinoma than lymphoma, but lymphomas predominated considering perforation or a palpable mass. Both carcinoma and lymphoma had 75 to 80% resectability rates and 14 to 15% five-year postoperative survival rates. The prognosis was least poor for carcinoma of the jejunum, one third of patients with "curative" resections surviving five years.