Diseases of the Colon & Rectum

Records of 266 patients who had undergone rubber ring ligation for hemorrhoidal complaints from 1969 through 1976 were reviewed to evaluate the long-term results. The minimum follow-up period was 36 months, with a mean of 60 months. Of the patients, 80 per cent were improved, with 69 per cent totally free of all symptoms. A subsequent hemorrhoidectomy was required in 7.5 per cent. Results were similar when either bleeding or prolapse was the primary indication for treatment. Patients who had a single band applied fared as well as those with two or more ligations.

Most long-standing rectal abscesses, difficult to diagnose, are situated in the intermuscular space between the internal and external sphincter muscles. They originate high in an infectious process, extending through the anal ducts and terminating in the glands above the anorectal ring. Treatment is not difficult, but may be tedious. Internal sphincterotomy, which in reality is a fistulostomy, is the procedure of choice and provides for adequate drainage.

The objective of this study was to determine whether initial azathioprine therapy, followed by ileocolic resection if azathioprine fails, or initial ileocolic resection without a trial of azathioprine is the preferred treatment strategy in steroid-dependent, terminal ileal Crohn’s disease. A Markov, decision analytic model was developed to simulate a 36-month course for a patient with steroid-dependent, terminal ileal Crohn’s disease who would initially take azathioprine or have ileocolic resection. Clinically important outcomes in the model included side effects and effectiveness of azathioprine and postoperative complications, mortality, and recurrence following ileocolic resection. The probabilities and utilities for these variables were derived from previously published studies. Initial azathioprine therapy offered a relatively small benefit of 0.45 quality-adjusted life-months over initial ileocolic resection. The model was sensitive to utility for being symptom-free on azathioprine and utility for being symptom-free postoperatively. Initial azathioprine therapy and initial ileocolic resection are both reasonable treatment strategies in this setting. The preferred treatment strategy is highly dependent on the quality of life that can be achieved with each treatment option. Therefore, individual response and symptom control with each treatment must be strongly considered in this treatment decision.

The basic principles of plastic surgery for sliding skin graft have been employed routinely in and about the anal canal. In 2,072 patients operated upon by the authors the infected fissure and crypt-bearing hemorrhoidal tissue was excised and the defect closed primarily with a broad-based sliding skin graft. Any associated disease—hemorrhoids, cryptitis, etc.—was also removed, employing the closed technic. Excision of a chronic fissurein ano and covering of the defect with a sliding-flap broad-based skin graft offers the advantages of: 1) decreased postoperative pain; 2) decreased postoperative wound care, in both hospital and office; 3) decreased incidence of postoperative complications (recurrent anal fissure and stenosis are rare, the diameter of the anus is actually increased and is our procedure of choice for anal stenosis); 4) primaryvs. secondary wound healing,i.e., a) healing more rapid, b) decreased scar and resultant deformity, c) decreased postoperative inflammatory response and infection; 5) the increased operative time is not harmful to the patient under caudal or epidural anesthesia.

PURPOSE: The purpose of this study was to review the clinical presentation and characteristics of primary colorectal lymphoma, analyze the prognostic factors, and assess the results of treatment with adjuvant chemotherapy. METHODS: We identified 37 cases at our institution between 1980 and 1996. They comprised 0.48 percent of all cases of colon malignancies (37/7,658) during this period. The following clinical information was obtained: age, gender, signs and symptoms, tumor site, tumor size, histology grade, pathology, and adjuvant chemotherapy. RESULTS: The most common presenting signs and symptoms were abdominal pain (62 percent), abdominal mass (54 percent), and weight loss (43 percent). The most frequent site of involvement was the cecum (45 percent). Histologically, 29 (78 percent) were classified as high-grade, and 8 (22 percent) as intermediate-grade-to-low-grade lymphoma. Nine (24.3 percent) of the cases were Stage EI, 23 (62.2 percent) were Stage EII, and 5 (13.5 percent) were Stage EIV. Twenty-one (57 percent) cases received adjuvant chemotherapy. The five-year survival rate was 33 percent for all patients and 39 percent for patients treated with combination chemotherapy. Overall median survival time was 24 months and 36 months for those with adjuvant chemotherapy. Only histology grade, among the factors examined, was a significant prognostic factor for survival. The mean survival time of the patients with Stage II disease who received chemotherapy was 117.4 months, and it was 47.9 months for the patients with Stage II disease who did not received chemotherapy. Conclusions: In our retrospective study high-grade lymphoma was the only significant adverse prognostic factor for survival. Receiving adjuvant chemotherapy significantly improved survival in patients with Stage II disease. Patients with diffuse large-cell type had better survival than patients with small noncleaved-cell type in Stage II high-grade lymphoma.

PURPOSE: Aim of this study has been to evaluate natural killer (NK) activity in patients with colorectal tumors before and after curative surgery. METHODS: Forty colorectal cancer patients without distant metastases were stratified according to American Joint Committee on Cancer/International Union Against Cancer staging system into three categories: Stage I (n = 12), Stage II (n = 15), and Stage III (n = 13). All of them underwent curative resection, and there were no major postoperative complications. Venous blood samples were obtained preoperatively, at surgical wound closure, and on the 1st, 7th, and 21st postoperative days. Mononuclear cells were isolated over Ficoll-Hypaque ™ (Lymphoprep, Nycomed Pharma AS, Oslo, Norway) gradients, and NK activity was assayed by evaluation of cytotoxic response against K562 cells. Normal NK activity was achieved from 15 healthy donors. Percentage relative increments in relation to preoperative levels were calculated for every postoperative sample, andt-test was used for statistical evaluation. RESULTS: Before surgery, Stages II and III patients had lower levels of NK activity than healthy people(P< 0.05 andP< 0.001, respectively). NK activity always fell after surgery (Stage I: -18.48±11.42; Stage II: −16.93±13.57; Stage III: −35.29±12.03, at day 1 postsurgery) and appeared to rise slightly by the 21st postoperative day in Stage I patients (+4.87±12.41). Stage II, and especially Stage III, patients did show a significant recovery by the 21st postoperative day (+23.63±9.36 and +43.19±13.34, respectively). At this time, NK activity in these two groups was not significantly lower than in normal subjects(P> 0.05). CONCLUSION: NK activity is depressed in colorectal cancer patients in relation to progression of illness, even at locoregional stages. Curative resection of tumors at Stages II and III has promoted a recovery of NK activity in patients with uneventful postoperative courses.