Resection with preservation of the anal sphincters is new widely accepted as providing satisfactory treatment for carcinoma of the upper rectum. However, restorative resection is less widely performed for tumours of the lower rectum because anastomosis can be technically difficult when performed low in the pelvis. Between 1973 and 1980, 76 patients with rectal carcinoma underwent rectal resection and restoration of bowel continuity by means of a sutured anastomosis between colon and anal canal. The pathological characteristics of these tumours were similar to those of all cases of carcinoma of the rectum treated at St. Mark's Hospital between 1948 and 1972. Two patients developed pelvic sepsis following colonic necrosis and anastomotic breakdown. Eight developed pelvic sepsis without major anastomotic breakdown. No patient died as a result of pelvic sepsis. Sixty-nine of the 70 patients who were able to be assessed were either completely normal functionally or had only minor deficiencies of bowel function. Six patients have been observed to develop recurrent pelvic tumour, localized to the pelvis in 4 patients and concurrent with the development of widespread metastases in 2. Twenty-one of 32 patients are alive 3 years and 12 of 19 patients are alive 5 years after a curative operation for rectal carcinoma. These results are comparable with those seen following total excision of the rectum and pelvic floor for similarly sited tumours.
Medullary CRC is more common than previously reported, frequently presents with locally advanced disease, and may be associated with higher mortality at 30 days after resection. Despite this, when strict criteria are used for diagnosis, the overall survival is favorable when compared with CRCs with equivalent demographic and pathological characteristics.
A prospective, manometric trial of anal fissure treated by subcutaneous lateral internal sphincterotomy (SLIS) was designed to elucidate the pathophysiology of this condition. Anorectal manometry with a closed, precalibrated, water-filled microballoon using the station pull-through technique was performed on 13 patients with anal fissure before, and at one and 150 days after SLIS. The results were compared with 13 control subjects, matched for age and sex, who had no history of anal disease. Both resting pressure (RP) and maximum voluntary contraction pressure (MVCP) were measured at centimeter intervals of the anal canal. At all levels RP was significantly higher in the preoperative patients compared with controls (p less than 0.0001). After operation RP fell significantly at all levels with the result that there was no significant difference in RP between postoperative patients and controls, except at 4 cm from the anal verge, where there remained a significant elevation in RP in the postoperative group. There was no significant difference in the two sets of postoperative manometric results. All patients underwent rapid healing and resolution of their symptoms. MVCP did not change significantly after operation, nor did it differ from the control values. This suggests that the increase in RP is due to activity of the internal anal sphincter. This over-activity is present throughout the entire length of the internal anal sphincter and sphincterotomy of its lowest portion returns RP to normal values throughout most of the anal canal.
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