The argon beam coagulator: a more effective and expeditious way to address presacral bleeding.

Presacral bleeding is a dreaded complication of pelvic surgery. Rapid and effective control of such bleeding is important to avoid potentially life-threatening outcomes. Various methods for controlling presacral bleeding, all with only limited success, have been described in the literature. We report the alternative technique of using the argon beam coagulator (ABC) to control presacral bleeding. We demonstrate its efficacious use in both open surgery and a laparoscopic case. Our approach involved applying an argon beam at bone setting directly to the bleeders and using a "point and shoot" technique. We found that ABC is a simpler, equally effective and expeditious way of addressing presacral bleeding. To the best of our knowledge, there has been only one previously reported case in the literature of the use of ABC to control presacral bleeding.

The safe and effective use of postoperative radiation therapy in modified Astler Coller Stage C3 rectal cancer.

Locoregional recurrence in patients with Stage C3 (adjacent organ invasion) rectal carcinoma approaches 100% when surgery is not followed by adjuvant radiation therapy. The advent of the intestinal sling procedure (use of an absorbable polyglycolic acid mesh to suspend the small bowel out of the pelvis) has allowed tumoricidal doses (5000 cGy) of radiation therapy to be delivered to the pelvis without incurring radiation associated small bowel injury (RASBI). This surgical technique has allowed us to readdress the question, "what is the effectiveness of postoperative radiation therapy when tumoricidal doses can be safely administered to patients with Stage C3 rectal cancer?" Nineteen consecutive patients with Stage C3 rectal carcinoma underwent resective procedures and simultaneous use of the intestinal sling procedure. Postoperatively, all patients underwent contrast simulation studies that documented the small bowel above the sacral promentory. Tumoricidal doses ranging from 5200 to 5800 cGy (mean, 5600 cGy) were administered in fractionated doses. No patient demonstrated obstruction, infection, nausea, vomiting, cramps, diarrhea, or acute RASBI. There have been two locoregional recurrences in a mean follow-up period of 33 months (range, 12 to 54 months) in patients evaluated by physical examination, carcinoembryonic antigen (CEA) levels, computed axial tomography (CAT) scans, endoscopy, and reoperation or autopsy (P = 0.01). There have been ten distant recurrences (eight liver, one brain, and one lung). Three patients were reoperated on to rule out recurrence at 16, 17, and 24 months. All mesh was resorbed and there were no adhesions and no recurrent tumor. When the intestinal sling procedure is used, tumoricidal doses of radiation therapy can be safely administered without incurring RASBI. Postoperative high-dose radiation therapy can suppress locoregional recurrences in Stage C3 rectal carcinomas over and above what would be expected.

Efficacy of an absorbable mesh in keeping the small bowel out of the human pelvis following surgery.

Patients with pelvic malignancies frequently require postoperative radiation therapy either as adjunctive or palliative treatment. Tumoricidal doses, however, are frequently associated with small-bowel damage. Animal experiments demonstrated tolerance to high-dose radiation therapy and protection from radiation enteritis by use of an absorbable polymer polyglycolic acid (PGA) that is used as an intestinal sling to elevate the small bowel away from the operated site. Sixty patients (42 with rectal carcinomas and 18 with gynecologic malignancies) underwent surgical treatment that included the intestinal sling procedure. Postoperative radiation was begun within three weeks following surgery and patients received a mean approximating 5500 rads in fractionated doses. A mean follow-up time of 28 months has not revealed a single case of radiation enteritis (by either contrast studies or physiologic studies) or PGA mesh-related complications. The authors believe that this surgical technique should be employed in patients who may require postoperative radiation treatment for pelvic malignancy.

Button colopexy for colostomy prolapse.

Prolapse of a colostomy is a common problem. Although rarely a significant risk to life, it does present serious problems for patient care and stomal function. Button colopexy can be done easily as an outpatient procedure and is best suited for those patients who are not candidates for more extensive revisions.

Herniation of the cecum through the foramen of Winslow.

A case of cecal herniation through the foramen of Winslow is presented. Although rare in occurrence, it carries a high mortality risk when diagnosis and treatment are delayed. A better understanding of the nature of this hernia and appreciation of the classic radiographic findings will allow for earlier recognition and treatment.

Adenocarcinoma in Crohn's colitis.

A case of Crohn's disease with carcinoma of the rectum is reported, bringing the number of reported cases to 44. Although the exact incidence of carcinoma arising in a segment of Crohn's disease is not known, a review of the literature emphasizes that there does seem to be a definite increased risk.

Volvulus of the transverse colon: report of case and review of the literature.

A case of transverse colon volvulus is reported, bringing the total number of collected cases in the English language medical literature to 45. Although this type of volvulus is rare, a definite pattern can be appreciated. Patients tend to be young, female, and give a history of chronic or recurrent difficulty in having bowel movements. A triad of underlying factors predisposes to the development of the volvulus: a distal impediment (either organic or functional) to the evacuation of the bowel, a redundant bowel and mesocolon and a fixed point around which the bowel can twist. The best treatment is resection with either anastomosis or exteriorization, depending on bowel viability.

A method of palliation for obstructive carcinoma of the rectum.

The use of the resectoscope has several advantages in treating the patient with inoperable obstructive carcinoma of the rectum, particularly when compared with fulguration. It is immediate in its results, as often testified to by the sudden outpouring of blockaded feces. It is also safer in allowing greater amounts of tissue to be resected with less depth of tissue injury by the electrical output. It does, however, require the skills of someone able to handle the instrument, and the procedure should be a joint effort by the surgeon and urologist. The use of the urologic resectoscope should prove to be a useful addition in the surgeon's armamentarium in a selected number of patients.