Faculty Bibliography

Abdominosacral resection is the most reliable radical sphincter-saving operation for midrectal cancers which are too low for anterior resection. The posterior incision provides maximum exposure for wide resection of the tumor, a measured distal margin, and an accurate anastomosis. The procedure can be carried out consistently to the pelvic floor without disrupting the anal sphincters and their innervation. Sphincter function is consistently preserved. Mortality rate is no higher than for other radical rectal resections. Morbidity can be limited by the selective use of protective colostomy. The use of mechanical retractors and the end-to-end stapler facilitates the operation and should encourage its wider application. The transsacral approach allows mobilization of the rectum to the levators in every case, and resection is limited only by the distance of the tumor from the sphincter, and not by poor exposure due to obesity or a narrow pelvis. In the treatment of 926 consecutive patients with rectal cancer, sphincter-saving resection was possible in 79%. In our experience, abdominosacral resection extends the range of sphincter-saving resection beyond that which is possible by the abdominal approach alone, with no compromise in safety and no increased risk of local recurrence or death from cancer

Open autologous adrenal medullary to caudate nucleus transplantation was performed in 12 patients with advanced Parkinson's disease (PD). Ten of these patients had diurnal response fluctuations including 'wearing off' and 'on/off' phenomena. All of the patients were no longer satisfactorily responding to levodopa/carbidopa and dopamine agonists. The mean age of the patients was 55.1 years (range 37-65 yrs); mean duration of PD was 11.7 years (range 4-40 yrs); mean stage 'on' was 3.3 (range 2-4); mean stage 'off' was 4.8 (range 4-5). Mean duration of follow up from surgery was 10.4 months (range 2-17 months). Three patients improved dramatically with major changes in their lifestyle. The course of improvement in these 3 patients was different in each, implying that different mechanisms were responsible for the improvement. One of the patients died unexpectedly. In this patient, there were no surviving adrenal cells. Three patients improved moderately. Patients reported that they were 'on' longer and had to take medication less often and were less dependent on individual doses of levodopa/carbidopa. The improvement has been sustained in two patients. However, in one of these patients there had to be frequent changes in scheduling to maintain the improvement. Two patients after technically successful implants did not improve. One of these patients subsequently died. In this patient there were a few surviving adrenal medullary cells. Four patients suffered major complications. One patient had a cerebral infarction and two had cerebral hemorrhages. One of these patients has shown a good recovery. One patient with autonomic insufficiency had a cardiac arrest with cerebral anoxia one week after surgery. This patient has shown a partial recovery.(ABSTRACT TRUNCATED AT 250 WORDS)

During a 24-month period, 350 patients were prospectively studied in an effort to determine the perioperative factors in the development of infections after colon and rectal resections. All patients received standard mechanical bowel preparation; perioperative parenteral cefoxitin (group A) or preoperative oral neomycin and erythromycin, in addition to perioperative cefoxitin (Group B), were also given. Both groups were comparable with respect to age, sex, associated diseases, and primary diagnosis. Wound infections developed in nine of 169 (5%) group B patients and in 15 of 141 (11%) group A patients. Stratification by type of operative procedure revealed that the rectal resections involved the highest rate of infection in group A (22%) and in group B (11%). In patients requiring intraperitoneal colon resection, the rates of wound sepsis were similar (3% in both groups). Analysis of length of operation revealed that in operations lasting 215 minutes or more the infection rate was 12%; in those lasting less than 215 minutes the rate was 4%. Patients with rectal resection and operative times of 215 minutes or more had a wound infection rate of 19% compared to 2% (p less than 0.05) in those with shorter nonrectal operations. Group B patients with the longer rectal operations had lower infection rates (11%) than group A patients (27%), while there was no difference among those who had shorter operations. Intra-abdominal abscesses (p less than 0.01) and anastomotic dehiscence (p less than 0.05) were also significantly reduced in group B patients. Postoperative wound infection is associated with length of operation and location of colon resection and can be significantly lowered by a combination of oral and parenteral antibiotics

The presence of ectopic fallopian tube epithelium (endosalpingosis) in postmenopausal women is rare and usually asymptomatic. A case is presented of symptomatic endosalpingosis in a postmenopausal woman who had none of the previously described predisposing factors

Abdominosacral resection is the most reliable radical sphincter saving operation for midrectal cancers which are too low for anterior resection. The posterior incision provides maximum exposure for wide resection of the tumor, a measured distal margin, and an accurate anastomosis. The procedure can be carried out consistently to the pelvic floor without disrupting the anal sphincters and their innervation. Sphincter function is consistently preserved. The risk of abdominosacral resection is comparable to that incurred for anterior resection or abdominoperineal resection. Mortality rate is 2%. Morbidity can be limited by the selective use of a protective colostomy. The use of abdominosacral resection has extended sphincter saving resection to include 77% of 646 consecutive patients with rectal cancer. Abdominosacral resection provides the maximum clearance around the tumor and long term follow up has revealed no greater risk of local recurrence or death from cancer

Hepatic resection for metastatic colorectal cancer has been reported in over 700 patients. However, approximately 5000 patients each year are candidates for surgical excision. Since 1972, 25 patients have undergone hepatic resection for colorectal metastases at New York University. Potentially curable synchronous lesions were detected by preoperative liver chemistries and operative palpation. Patients were screened for metachronous lesions by serial liver chemistries and carcinoembryonic antigen (CEA) determinations; when clinical findings or laboratory findings were either positive or equivocal, then scanning techniques were used. Most patients had solitary lesions (20). Thirteen of 25 lesions were synchronous; 12 were metachronous. Anatomic lobectomy was performed in 13 patients (6 extended resections); and wedge resection was performed in 12. The operative mortality rate was four per cent; the 2-year survival rate, 65%; the 5-year survival rate, 25%. Hypertonic dextrose solutions were administered during and after operation. Post-operative albumin requirements ranged from 200 to 300 grams/day. Coagulation factors II, V, VII, and fibrinogen decreased after surgery to 30 to 50% of their preoperative levels. Subsequent elevation of these factors correlated with increased bile production and improvement in liver chemistries 10 to 14 days after operation. At present, hepatic resection for colorectal metastases provides the only potential method of salvage, offering a 20 to 25% long-term survival rate

Operative approaches which attempt to spare the rectal sphincter mechanism in patients with diffuse cavernous hemangioma of the sigmoid colon, rectum and anal canal have associated high morbidity and have failed to provide continence in at least 2 per cent of the patients. Sphincter-saving operations should be reserved for the rarer lesions which spares the lower part of the rectum and anal canal. Abdominoperineal resection by the combined synchronous approach with temporary vascular control of the hypogastric vessels provides a safe effective method of managing patients with diffuse cavernous hemangioma of the sigmoid colon, rectum and anus

From 1966 to 1981, 646 patients underwent resection for primary adenocarcinoma of the rectum by one surgeon (S.A.L.) in one hospital. The operation, selected by preoperative sigmoidoscopic measurement, was anterior resection (ASR) in 320 patients, abdominosacral resection (ASR) in 175 patients, and abdominoperineal resection (APR) in 151 patients. The operative mortality rate was 2% following each of the operations. Anastomotic complications occurred in less than 2% after AR and in 9.7% after ASR. All patients were completely continent of stool and flatus after AR and ASR. Follow-up is complete in 419 of 427 patients treated from 1966 to 1976. Five-year survival for curative resection (no distant metastases) was 66.2% after AR (129/195), 62.9% after ASR (56/89), and 43.4% after APR (33/76). For patients with no tumor in lymph nodes, survival rates were 73.9% in AR, 75% for ASR, and 59.5% for APR. With involvement of regional lymph nodes, survival fell to 45.2% in AR, 37.9% for ASR, and 17.7% for APR. Pelvic recurrence was detected in 13.3% after AR, 14.6% after ASR, and 13.2% after APR. The authors believe that for midrectal cancer, ASR is the most reliable sphincter-saving procedure. It affords maximum exposure for wide resection of the tumor and safe anastomosis without disrupting the anal sphincters and their innervation. Sphincter preservation can be consistently preserved with no apparent increase in the risk of local recurrence or death from cancer