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The technique of pullthrough resection with delayed anastomosis for carcinoma of the rectum as performed at the Cleveland Clinic is described. A series of 84 cases of rectal cancer treated in this way is reported. The average tumour diameter was 4.5 cm, the average margin of resection was 4.1 cm and the average distance of the tumour from the anus was 7.6 cm. The incidence of necrosis of the pullthrough was 1.2 per cent. The overall 5-year survival was 63 per cent with 100 per cent, 57 per cent and 53 per cent for Dukes' A, B and C tumours respectively. The quality of bowel function following surgery is described in detail. It is felt that this procedure has an important place in sphincter conservation in carcinoma of the middle third of the rectum.

The Kock pouch has three major limitations at the present time: The efferent nipple valve remains by far the weakest link in the procedure. A 10 to 20 per cent failure rate is too high, and it remains to be seen whether further modifications will be successful in the long run. The long-term function is unproven, and it is possible that deleterious effects may be seen as additional follow-up is obtained. Theoretically, the low-pressure system afforded by the Kock pouch may be superior in long-term safety to that provided by reservoirs made from other bowel segments. A stoma is still necessary. In spite of the above, there is a need for this type of procedure. We cannot remain content with the ileal conduit and should continue to search for better functional diversions. It is a debatable issue relative to the superiority of an internal functional reservoir to the urethra, which may lead to night-time incontinence, versus a Kock pouch with a stoma, which must be intubated. Improvement in overall survival from bladder cancer may be hard to come by, unless effective systemic chemotherapy is available; one means is to perform the surgery without delay in patients with potentially lethal cancers. To do this on a large scale, we must make the surgery as safe as possible and provide the least disruption of lifestyle. In some patients an internal intestinal reservoir attached to the urethra will be possible. Other patients may elect for a Kock pouch, whereas others may even be best served by standard ileal conduit. The growth pains of the Kock pouch have been significant but not without a reward.

Records of 32 patients with 34 villous and tubulovillous adenomas of the duodenum, treated at the Cleveland Clinic over the past 21 years, were reviewed. Twenty-two patients (69%) had complete resection of the adenoma; the incidence of malignancy was 47%. Five patients underwent a Whipple procedure; 4 patients had segmental resection of the duodenum; 12 had wide local excision of the adenoma; 1 had both a segmental resection and a local excision for two separate adenomas; and 5 patients had endoscopic excision alone. The remaining five patients underwent exploratory laparotomy alone or with palliative bypass procedures. A 28% recurrence rate was observed, all of these after segmental resection, local excision, or endoscopic excision. The highest recurrence rate was associated with local excision. The 2- and 5-year survival rates for patients with adenomas containing invasive cancer were 22% and 0%, respectively, compared to 87% and 87%, respectively, for benign adenomas (including those with carcinoma in situ). Twenty-two per cent of patients had intestinal polyposis syndromes. Duodenal adenomas were diagnosed a mean of 17 years after colectomy for polyposis, indicating the need for continued surveillance in these patients.

A review of 2,368 patients with Crohn's disease identified 45 patients with hydroureteronephrosis treated with various medical and surgical regimens. Twenty-six of 30 patients undergoing both pre- and post-treatment intravenous pyelography showed resolution of the obstructed ureter, even though ureterolysis was rarely used.

Colon perforation in renal transplant recipients is a potentially lethal condition that is amenable to appropriate medical and surgical treatment. The 11 cases seen at the Cleveland Clinic (incidence 1.1% of all renal transplant patients) and previous reports in the literature have been reviewed. The pathogenesis is related to a high incidence of diverticular disease in patients with polycystic kidneys and/or chronic renal failure, the effects of long-term immunosuppression, and the transplant procedure itself. The high mortality of this condition (61% overall) is related to the effects of immunosuppression on the response to sepsis and the surgical procedure used. Mortality has fallen from 88% (1970-1974) to 53% (1975-1979), and there are indications that it is continuing to fall. All four cases operated on here since 1980 have survived, giving a total operative mortality of 2/6, and all have maintained excellent allograft function. A high clinical index of suspicion, prompt exteriorization of the perforated colon, reduction of immunosuppression to minimal levels, and effective antibiotic coverage have all contributed to the declining mortality.

Patients with colorectal cancer respond poorly to in vivo immunotherapy with lymphokine-activated killer (LAK) cells generated from peripheral blood mononuclear cells (PBMC). We postulated that gut-derived immune cells could be a more relevant source of LAK cells directed against colorectal cancer. Intestinal lamina propria mononuclear cells (LPMC) and colonic adenocarcinoma cells were isolated from operative specimens by combination of mechanical and enzymatic dissociation methods. LAK cells were generated by culturing PBMC and LPMC with recombinant interleukin 2 (IL2), with and without OKT3 monoclonal antibody, in short- (4 days) and long-term (21 days) cultures. Other cultured tumor cells, normal intestinal fibroblasts, and hapten-modified autologous LPMC were used as control targets. Cytotoxicity was measured by a 4-hr 51Cr release assay. Short-term cultured LAK cells exhibited a strong to moderate degree of killing against normal intestinal fibroblasts, hapten-modified self cells, and four different tumor cell lines. Instead, fresh colon cancer cells were resistant to cytotoxicity, regardless of their degree of histologic differentiation and the autologous or allogeneic nature of the LAK cells. Long-term culture with IL2 remarkably increased LAK cell activity against all tumor targets, but not against colonic adenocarcinoma cells. The results of this study, showing that freshly isolated colon cancer cells are intrinsically resistant in vitro to highly activated cytotoxic effector cells, may explain the poor clinical results observed in human trials with in vivo administration of IL2 or LAK cells.

A retrospective study was undertaken, evaluating 54 patients who underwent 57 Ripstein procedures at the Cleveland Clinic Foundation during the years 1963-1978. The patients were evaluated for their preoperative characteristics as well as early and late postoperative results. Patients who experience procidentia are generally middle-aged women who have had previous gynecologic and anorectal surgery and who generally had significant disorders of bowel function. Although the operative mortality was zero, and the majority of patients were satisfied with the results of their Ripstein procedure, there was significant operative morbidity (26 per cent). Twelve and one-half per cent of patients had recurrent rectal prolapse, and 18 per cent of patients had significant long-term obstructive symptoms. The Ripstein procedure still remains the treatment of choice for rectal prolapse.

The clinical courses of 114 patients with positive Clostridium difficile cultures or toxin assays performed between 1981 and 1984 were reviewed to determine the relationship between outcome of treatment and quantitative bacteriologic test results. C. difficile culture was positive in 60 of 91 patients while toxin assay was positive in 99 of 114. One third of the patients received supportive therapy only, and 30 percent of these failed to resolve their symptoms. Ninety-one percent of the patients treated with vancomycin resolved, although 11 percent of these suffered relapse. Patients with high toxin titers receiving supportive treatment alone showed a lower response rate than patients with lower toxin titers. This effect was not seen in patients treated with specific therapy nor with different culture quantities. C. difficile colitis has a range of clinical and microbiologic manifestations. Endoscopy is not always diagnostic, both culture and toxin assays are needed for diagnosis, and toxin titer may help in planning treatment. Patients with low toxin titers may be treated supportively, but high toxin titers are an indication for specific therapy. Quantitative culture results have little diagnostic or therapeutic value.

In a retrospective review, 62 patients treated for rectal cancer by contact (endocavitary) irradiation at The Cleveland Clinic Foundation were analyzed. This treatment modality delivers high dose, low penetration irradiation to a rectal cancer by direct contact of a 50 KV x-ray source through a special proctoscope. Cancers selected for this treatment include small (3 cm or less), mobile tumors without presacral lymphadenopathy that are within reach of digital examination and are well- or moderately well-differentiated adenocarcinomas. Between 1973 and 1984, 62 patients (37 males, 25 females) were treated--46 by contact irradiation alone and 16 by contact irradiation after excisional biopsy. The median tumor dose was 12,000 rads administered in four fractions at monthly intervals. Mean follow-up was 31 months. Fifty-six patients (90 percent) were disease-free at the time of review or death (ten died from unrelated causes). Eleven patients (18 percent) developed local recurrence but eight of these without distant metastases were rendered disease-free by other treatment--six by surgical resection and two by further radiotherapy. Mean time since secondary treatment is 20 months. Three patients are alive with incurable disease and three have died from cancer--in three of these six patients there was no evidence of local disease. Ulcerated tumors developed local recurrence in five of 17 cases (29 percent) while polypoid tumors recurred locally in six cases (14 percent). Morbidity from the treatment was minor in nature. It is suggested that contact (endocavitary) irradiation is effective treatment for carefully selected cases of rectal cancer.

Polyethylene glycol electrolyte lavage solution was compared with a 10 percent mannitol solution for preoperative colonic cleansing. Eighty patients were prepared randomly with one of these solutions on the afternoon prior to surgery. Colonic cleansing was better with polyethylene glycol electrolyte lavage (90 percent optimal cleansing vs. 75 percent). Analysis of hematologic, biochemical, and weight changes before and after the bowel preparation, demonstrated a mild subclinical dehydration with the use of mannitol. Evaluation of patient tolerance demonstrated more nausea, cramps, and abdominal pain with mannitol. Other symptoms were similar with both preparations. Colonic hydrogen gas was sampled during surgery, and two patients in the mannitol group had combustible levels. This study confirms that both 10 percent mannitol and polyethylene glycol electrolyte lavage are safe, effective methods of preoperative bowel cleansing. Better cleansing, patient tolerance, and lower hydrogen gas level make polyethylene glycol electrolyte lavage the preferred method.

From a review of the literature and detailed study of 16 cases, the authors believe that ureteral obstruction in diverticulitis is more common than is apparent from the literature. They suggest that urograms be performed preoperatively in patients destined to undergo intestinal surgery. Management of the intestinal disease need not be altered from that initially planned for treatment of diverticulitis except with the proviso that the retroperitoneum be examined for the presence of a fibrotic inflammatory reaction. If this is found, they suggest that ureterolysis of the involved ureter be performed to allow relief of this obstruction.

The authors reviewed their experience with diagnosis and treatment of lower gastrointestinal bleeding secondary to colonic arteriovenous malformations (AVM). A diagnosis was established exclusively by endoscopy in 80 percent of the patients. Twenty-eight patients were treated by endoscopic coagulation; bleeding stopped after one or more treatments in 67.9 percent of these patients. There were no complications or mortality as a consequence of endoscopic treatment. Surgery controlled the recurrent bleeding in six of seven cases of failed endoscopic coagulation, and in 13 of 17 cases where surgery only was undertaken, for an overall success rate 79.2 percent. It is concluded that colonoscopy can accurately establish the diagnosis of colonic AVMs in chronic lower gastrointestinal bleeding. Endoscopic coagulation is a useful adjunct in the treatment of this condition, and is safe, effective, and leaves other options open.

Desmoid tumors are locally invasive, nonmetastasizing fibrous tumors most frequently seen in patients with familial polyposis coli (FPC). Of 325 patients with FPC treated at the Cleveland Clinic, 29 (8.9%) were found to have a total of 36 desmoid tumors. These tumors occur in young patients (mean age: 29.8 years), particularly women (ratio 3:1), and most appeared after previous colectomy (86%). The majority (72% of all desmoids, 90% of patients) were located within the abdomen, specifically within the mesentery of the small intestine. In most cases, attempts at surgical resection were followed by recurrence, and other previous treatments were similarly ineffective. Six of the 29 patients (21%) died from the desmoid and three died from other causes. The recent use of sulindac (Clinoril) has produced some early encouraging results in four patients with these tumors that have proven so difficult to treat in the past.

Twenty-one patients with pseudomembranous enterocolitis were seen over a 17 year period. Major inciting factors appeared to be an antecedent operation or a serious medical illness. The most common symptoms were fever, diarrhea and abdominal pain. The most commonly involved organ was the colon. The diagnosis was missed in the majority of patients. Neither conservative treatment or surgical treatment were successful. Awareness of the disease and its course will lead to earlier diagnosis and hopefully to a higher cure rate.

The records of 1,040 patients with 1,440 villous and tubulovillous adenomas of the colon and rectum treated at the Cleveland Clinic over a 21 year period were reviewed. The incidence of invasive adenocarcinoma was higher in patients with multiple adenomas at the time of presentation, in patients with a family history of colorectal cancer, and in those with adenomas greater than 4 cm in diameter. Eighty percent of the adenocarcinomas were Dukes' A or B, 15 percent were Dukes' C, and 5 percent presented with distant metastases. Clinical impression on examination was more accurate than biopsy in assessing the presence of malignancy in these tumors. Recurrence after local treatment of both benign and malignant tumors was high. Recurrence was significantly related to the size of the adenoma (more common when the tumor was more than 4 cm in diameter), location (more common when it was located in the rectum), and the type of treatment. Only 4 percent of the patients had died from colorectal cancer at the time of follow-up. The overall 5 year actuarial survival rate was 85 percent.

Actinomycosis is a chronic, suppurative, mycotic infection, which tends to form abscesses and fistulas. The organism is a saprophyte of the human mouth. When a break in the normal contiguity of the gastrointestinal tract occurs, the organism may gain access to the surrounding tissues and become almost impossible to eradicate without surgical extirpation and administration of a long course of antibiotics. The diagnosis of actinomycosis should be considered for any patient in whom persistent or unusual enterocutaneous fistulas develop, when there is a recent history of perforated viscus or surgical intervention involving the gastrointestinal tract, such as appendectomy. The diagnosis is confirmed by the presence of "sulfur granules" in the fistulous tracts.

Patients with carcinoma involving chronic fistulizing Crohn's disease may have developed the malignancy due to chronic epithelial irritation at either end of the fistula tract. Alternatively, the carcinoma may be the cause of the fistula. Examples of each type of relationship are presented in the reports of four patients from our institution and supported by a review of the literature. The diagnoses of such carcinomas are often delayed due to lack of specificity of symptoms and signs. A high index of suspicion and regular surveillance of high-risk patients are recommended.

To assess the long-term results of surgery for duodenal Crohn's disease, 11 patients, ten surgically treated, have been followed an average of 13.9 years to assess 1) the need for further treatment of duodenal disease; 2) the activity of Crohn's disease in other areas of the gastrointestinal tract; and 3) their functional status based on the Karnofsky Performance Scale (KPS). Follow-up indicates that seven patients have required a total of ten further operations directly related to duodenal Crohn's disease. The indications for subsequent operations were 1) marginal ulceration; 2) obstruction at or in one limb of the gastrojejunostomy due to recurrent jejunal Crohn's disease or stricturing at the gastrojejunostomy; and 3) duodenal fistula. Eight of these 11 patients also required surgery for Crohn's disease in other areas of the gastrointestinal tract. Despite a high reoperative rate for Crohn's disease in both the duodenum and other areas of the gastrointestinal tract, functional results, as tested by the KPS, can be satisfactory if appropriate reoperative surgery is done.

Between 1965 and 1975, 27 patients underwent surgical treatment for ileosigmoidal fistulas complicating Crohn's disease at the Cleveland Clinic. There was no death and no anastomotic leak. The preferred procedure is resection of the ileocecal area involved by Crohn's disease with ileocolic anastomosis and a separate segmental resection of the sigmoid colon with colocolic anastomosis. A covering temporary loop ileostomy is used when there is associated pelvic sepsis or small-bowel obstruction.

The temporary skin-level loop transverse colostomy has been described. Proof of its ability to divert the fecal stream totally is illustrated by complete diversion in 25 patients ingesting a postcolostomy barium meal. There was no postoperative complication.

Rectourethral fistula is an uncommon complication of Crohn's disease. When the rectum is apparently spared of active Crohn's disease, repair by an advancement flap of the rectum may be used, with or without temporary fecal diversion. Three such fistulas were reported successfully using this technique.

Thirty-three patients with perianal Bowen's disease were treated at the Cleveland Clinic Foundation from 1954 to 1986. Twenty-one patients were women and 12 were men, ranging in age from 30 to 69 years (mean, 48 years). Twenty patients (61 percent) presented with symptomatic perianal disease, while 13 patients (39 percent) were noted as having perianal Bowen's disease upon pathologic examination of routine hemorrhoidectomy specimens. Ten of the patients (30 percent) had prior histories of unrelated cancer. Twenty-seven patients were managed by wide local excision, three patients by simple excision, three patients by fulguration, and one patient by an abdominoperineal resection. During a follow-up period averaging 3.7 years (range, 0.3 to 10 years), one patient developed a new invasive skin cancer while a second patient experienced a recurrence of perianal Bowen's disease. The characteristic gross appearance of this lesion and its failure to respond to conventional therapy should prompt the performance of a biopsy, which readily establishes the diagnosis. This experience confirms that wide local excision is adequate therapy for perianal Bowen's disease and that close clinical follow-up is necessary to identify disease recurrence or the development of a malignancy.

This is a retrospective review of 58 patients undergoing surgery for anal incontinence at the Cleveland Clinic. Forty-four patients had overlapping sphincter repairs, nine had postanal repairs, three had a combination of overlapping repair and postanal repair and two had Silastic slings. An associated loop colostomy or ileostomy was performed in 19 patients (33%). Satisfactory continence was attained in 86% of patients with direct sphincter injury (overlapping sphincter repairs) and this is comparable with the experience of others. These results with the postanal repair for patients with neurogenic incontinence were poor, however, as four of the nine were complete failures. Poor results were directly related to the age of the patient (P less than 0.0001) and the duration of incontinence (P less than 0.02). It was concluded that direct sphincter injury (obstetric, operative or traumatic) is effectively treated by an overlapping sphincter repair. Incontinence secondary to a degenerative neuropathy affecting the anal sphincter mechanism, however, whether it occurs in conjunction with a pre-existing sphincter injury or alone, is often not cured by surgery, that is, by postanal repair.

Over the past 11 years (1974 to 1985) ten patients with perianal Paget's disease were treated. The average age was 64 years and half were male. Two patients were diagnosed as an incidental finding after hemorrhoidectomy and the remainder presented with a symptomatic perianal rash (itching and moisture) that averaged two years in duration. Physical examination in these patients demonstrated characteristic lesions (seven with erythematous or ulcerated, whitish gray lesions and one with a papillary lesion). Three patients presented with invasive carcinomas and, despite aggressive therapy, all developed metastatic disease. Two patients had local excisions with minimal margins and developed associated invasive cancers at four and ten years after diagnosis. The remaining five patients were treated by wide local excision and skin grafts. At present all are free of disease. The characteristic appearance of this lesion and its failure to respond quickly to conventional therapy should lead the clinician to obtain a biopsy which readily establishes the diagnosis. Experience confirms that wide local excision is adequate therapy, but adequate initial evaluation and close follow-up are necessary to identify other malignancies that may develop.

Extramedullary plasmacytoma (EMP) of the small bowel is a rare entity previously reported as a cause of intestinal obstruction or bleeding. A case report of this disease entity presenting as an ileocolic fistula is reported. EMP is diagnosed by the following criteria: 1) absence of paraproteinemia; 2) absence of Bence Jones proteinuria; 3) normal skeletal survey; and 4) normal bone marrow biopsy specimen. Gastrointestinal plasmacytoma often occurs as a manifestation of multiple myeloma. EMP of the gastrointestinal tract is a rare manifestation of the disease, accounting for 13 per cent of all cases of EMP. It is a slow-spreading, radiosensitive tumor with a high tendency toward local recurrence. Surgical excision combined with radiotherapy is the treatment of choice for EMP of the gastrointestinal tract.

Five patients who would have been unable to survive because of intestinal complications of radiation therapy were able to lead an otherwise normal life with the use of parenteral nutrition administered at home. One patient died of recurrent carcinoma of the cervix after 14 months. Another patient died as the result of a totally avoidable pharmaceutical error after 2 1/2 years. The remaining three are still disease free without morbidity relating to the parenteral nutrition.

The results of two prospective, randomized trials, comparing single dose piperacillin with multidose cefoxitin prophylaxis in elective surgical procedures of the gastrointestinal tract were combined to examine some basic aspects of clinically, applied antibiotic prophylaxis. As there was no difference in the efficacy of prophylaxis between the groups, data from both centers and both drug groups were combined for analysis. Patients whose ages were greater than 40 years, the presence of cancer and the administration of an antibiotic for longer than 60 minutes preoperatively were associated with a higher rate of infectious complications. Duration of operation was also related to subsequent infection, ranging from 6 per cent in procedures lasting less than two hours to 27 per cent in operations lasting more than four hours. There was a greater failure of prophylaxis in patients undergoing rectal procedures, with a 29 per cent rate of infectious complications compared with 14 per cent in patients undergoing operations upon the colon. This difference was present even when duration of operation was taken into account.

Fifty patients with fibrotic small bowel strictures secondary to long-standing Crohn's disease underwent a total of 225 strictureplasties during the period from June 1984 to July 1988. Forty-two patients (84%) presented with obstructive symptoms. Patients had a 1- to 30-year history of Crohn's disease (mean, 14 years). Sixty-two per cent of patients were taking steroids at the time of admission, and 70% had had previous small bowel resections. All patients had one or more areas of small bowel affected with a fibrotic stricture and partial obstruction. Short strictures were treated by Heinecke-Mikulicz strictureplasties, and longer strictures by Finney side-to-side strictureplasties. In 30 patients (60%), 6- to 65-cm segments of small bowel were also resected due to acute inflammation with phlegmon or fistulae. Patients were discharged from the hospital 5 to 20 days after operation (mean, 10 days). After operation all patients with obstructive symptoms reported relief of symptoms and weight gain. Steroid doses could be tapered and nutritional parameters, such as total lymphocyte count, and serum albumin improved. Strictureplasty had 0% mortality and 16% morbidity rates. Complications included 3 enterocutaneous fistulae, 2 intra-abdominal abscesses, 2 hemorrhages requiring transfusion, 1 prolonged postoperative ileus that could be treated conservatively in 2 patients, and 1 restricture of a strictureplasty. Patients were followed for 1 to 40 months after operation (mean, 8 months). Resection of small bowel disease, especially that associated with perforation, is usually required in Crohn's disease. However, strictureplasty minimizes the need for bowel resection in patients with short fibrotic strictures resulting in recurrent small bowel obstruction.

Premalignant lesions of the anal margin include Bowen's disease (intraepithelial squamous cell carcinoma) and Paget's disease (intraepithelial adenocarcinoma). Our experience includes 11 patients with perianal Paget's disease and 37 patients with perianal Bowen's disease treated from 1957 to 1986. The patients with perianal Paget's disease were older, had a higher incidence of invasive cancer, and had a worse prognosis than those with perianal Bowen's disease. The characteristic appearance of these lesions and their failure to respond to conventional therapy should lead the clinician to obtain a biopsy, which readily establishes the diagnosis. Our experience confirms that adequate evaluation followed by wide local excision is the appropriate therapy. Close follow-up is recommended to identify recurrence of the perianal disease or development of other malignancies.

Hepatodiaphragmatic interposition of the colon is a rare anomaly described by Chilaiditi in 1910. Usually this syndrome presents as an asymptomatic roentgen finding, although occasionally it is associated with a broad range of gastrointestinal symptoms. The hallmark of therapy is conservative, and rarely has surgical intervention been indicated. This is the only case report of the Chilaiditi syndrome associated with colonic volvulus. It also illustrates the rare progression of colonic interposition from mild abdominal discomfort to intermittent bowel obstruction requiring surgical intervention.

Two cases of pneumatosis cystoides intestinalis in patients with Crohn's disease are reported. These cases illustrate both benign and fulminant forms of pneumatosis cystoides intestinalis, and highlight the diagnostic and therapeutic dilemma of patients in whom pneumatosis cystoides intestinalis and Crohn's disease coexist. While therapy is seldom indicated in benign forms of pneumatosis cystoides intestinalis, mortality rates with fulminant pneumatosis cystoides intestinalis are high, regardless of the type of therapy.

Ileorectal anastomosis is a safe operation with low mortality and morbidity and offers a good prospect for success in many patients with ulcerative colitis. The functional results are good in the majority of patients, and there is a high level of patient acceptance. There is a low cancer risk with regular surveillance, but there is a relative contraindication for ileorectal anastomosis in patients with colon cancer or dysplasia present at the time of colectomy. For many patients, especially children and adolescents in their formative years and for young adults, it avoids or delays an ileostomy and avoids the risk of postoperative sexual dysfunction, while at the same time still permits the elective use of some other continence-preserving operation at a later date.

A retrospective study of 174 patients with small intestine cutaneous fistulas was carried out. Cause, location of fistula, amount of output, presence of inflammation, intestinal obstruction, presence of malnutrition and anemia are associated wih an increased mortality. The results of various modes of treatment indicate that intestinal resection with primary anastomosis, carried out six weeks or later after the onset of the fistula, was associated with the lowest mortality and the highest success rate.

To evaluate the outcome of surgery for ulcerative colitis in pediatric and adolescent patients, the experience at the Cleveland Clinic Foundation was reviewed retrospectively. Fifty-nine percent of the patients presented with acute toxic colitis and sepsis; 94 percent underwent staged procedures with creation of a temporary or permanent ileostomy. Sepsis was the most frequent postoperative complication (38 percent), and accounted for all three deaths (5 percent). Long-term disability was minimal, and 90 percent of the patients were fully active at the time of follow-up.

Complex anal fistulas challenge the judgment and operative skills of the surgeon in effecting a cure without compromise of anorectal function. This chapter outlines the classification, pathogenesis, methods of investigation and alternatives of management of a variety of complex fistulas. Also reviewed are the advantages and disadvantages of both traditional and newer methods of management, with special reference to staged fistulotomy and advancement rectal flap procedures.

Retrospective evaluation of twelve patients treated at the Cleveland Clinic for perianal Bowen's disease showed that these patients can be cured by wide local excision with skin grafting when necessary. No recurrence or metastasis was found during the follow-up period when the systematic technic was used. Only involved anal mucosa was removed, and normal mucosa was preserved; this aids in controlling anal continence. The margins of the resected skin must be subjected to frozen section study to be sure that total excision has been achieved. In this study a diagnosis of perianal Bowen's disease was made incidentally in six of the twelve patients during histologic examination of anorectal tissue removed for other reasons. Seven of the twelve either had had a systemic or cutaneous cancer previously or another systemic or cutaneous cancer subsequently developed, indicating the high association between Bowen's disease and other cancers. Therefore, it is important that all excised skin from anal or perianal operations be submitted for histologic examination, and if the diagnosis is Bowen's disease, the lesion must be completely removed using wide local excision. These patients should be evaluated and followed up because other malignancies may be present or evolve at a later time.

The incidence of several forms of liver disease associated with inflammatory bowel disease has been putatively ascribed to a toxic effect on the liver of portal vein bile acids abnormal in type or amount. To examine this possibility, total bile acid concentrations (sulphated and non-sulphated) were measured by gas-liquid chromatography in inferior mesentric vein serum of 19 patients undergoing colectomy for severe inflammatory bowel disease (IBD). Similar determinations were obtained on a control group of eight patients requiring colectomy for other non-inflammatory conditions. Mean values for mesenteric vein serum bile acid concentrations (muM/1) were 19.6+/-1.8 in controls and 16.3+/-2.0 in IBD. The mean sulphated bile acid fraction did not exceed 10% of total, although there was considerable variability (up to 40% of total). Lithocholic acid levels (entirely sulphated in all patients) were low. Although the IBD group showed a more than two-fold increase in mean lithocholate concentration (0.54+/-0.15 muM/1) over controls (0.21 +/- muM/1), this difference was not statistically significant. No significant intra-group difference was noted in the non-sulphated and sulphated fractions for cholic, chenodeoxycholic, and deoxycholic acid species, respectively. No unidentified or unusual bile acids were observed. There was no correlation between bile acid measurements and liver histology. These findings fail to support the hypothesis that liver disease often found in association with severe inflammatory bowel disease represents a form of bile acid toxicity. The invariable finding of total sulphation of the lithocholic acid fraction even in the presence of severe mucosal disease was unexpected.

Pneumatosis cystoides intestinalis is a condition in which submucosal or subserosal gas cysts are found in the wall of the small or large bowel. Both fulminant and benign forms exist. Fulminant pneumatosis cystoides intestinalis is associated with an acute bacterial process, sepsis, and necrosis of the bowel, while benign pneumatosis cystoides intestinalis can be totally asymptomatic and observed as an incidental finding at laparotomy. Many different causes of pneumatosis cystoides intestinalis have been proposed, including mechanical and bacterial causes. A review of the literature is presented with emphasis on the etiology of pneumatosis cystoides intestinalis, which probably can be attributed to bacterial and mechanical factors. Diagnosis and different forms of therapy and their efficacy are also discussed.