Search

Background: We evaluated the influence of several clinicopathologic variables on 5-year actuarial survival rate after curative resection of gastric adenocarcinoma., Methods: Clinical characteristics were retrieved from the records of all patients who underwent gastric resection for curative intent between 1965 and 1986 at The University of Chicago Medical Center, and follow-up was obtained from our tumor registry. Pathologic characteristics were determined from a detailed review of all available histopathologic slides., Results: One hundred seventy-eight patients underwent a curative resection during the study period at our institution. Overall 5-year actuarial survival rate was 29%. The relationship between clinicopathologic variables and 5-year survival rate was evaluated by Kaplan-Meier survival curve construction and chi-squared analysis. Lymphatic and/or capillary microinvasion (absent vs present, p < 0.001), tumor location (antrum and body vs gastroesophageal junction, p = 0.05), local extent of disease (limited to the gastric wall versus involving adjacent organs, p = 0.003), stage (absence versus presence of lymph node metastases, p < 0.001), Lauren type (intestinal versus diffuse, p < 0.01), and Ming type (expanding versus infiltrative, p < 0.02) significantly influenced survival. When a multivariate analysis with logistic regression of 5-year survival was performed, lymphatic and/or capillary microinvasion emerged as the only statistically significant, independent prognostic factor associated with long-term survival (p = 0.039). If microinvasion was omitted from the analysis, lymph node metastases (p < 0.05) and the extension to adjacent organs (p < 0.04) became the only statistically significant variables. Multiple correlation analyses suggested that microinvasion is an early histopathologic finding that correlates with a more aggressive natural history., Conclusions: Lymphatic and/or capillary microinvasion is a more powerful predictor of 5-year survival than lymph node metastases or tumor extension to adjacent organs. Correlation among clinicopathologic variables suggests that microinvasion may represent an early finding, serving as a potential marker for a biologically more aggressive tumor.

Purpose: The role of immunoscintigraphy with 111In-satumomab pendetide in the medical and/or surgical management of colorectal cancer patients was evaluated in a multicenter trial., Methods: This 103 patient study population included 46 individuals with rising serum carcinoembryonic antigen levels and otherwise negative diagnostic evaluation, 29 patients with known recurrence, presumed to be isolated and resectable, and 28 patients for whom standard diagnostic tests provided equivocal information., Results: No adverse reactions were noted following intravenous administration of 1 mg of satumomab pendetide radiolabeled with approximately 5 mCi of 111In. Thirty percent of patients developed human anti-mouse antibodies postinfusion. In the 84 patients for whom correlation with histopathologic, diagnostic, and/or clinical findings was available, antibody imaging demonstrated a sensitivity of 73 percent in patients with confirmed tumor (36/49) and negative results for all 35 patients with no evidence of malignancy. Occult disease was detected in 18 patients., Conclusion: 111In-satumomab pendetide immunoscintigraphy was helpful in the medical and/or surgical management of 45 (44 percent) patients and provided information unavailable from other diagnostic modalities.

Objective: The authors review their experience, evaluating the incidence and examining the various modalities employed in the diagnosis and treatment of patients with Crohn's disease complicated by fistulae., Summary Background Data: Although common, internal and external fistulae in Crohn's disease may pose challenging problems to the surgeon., Methods: Of 639 patients who underwent surgical treatment at the University of Chicago between 1970 and 1988 for complications of Crohn's disease, 222 patients (34.7%) were found to have 290 intra-abdominal fistulae., Results: A fistula was diagnosed preoperatively in 154 patients (69.4%), intraoperatively in 60 (27%), and only after examination of the specimen in 8 (3.6%). The fistula represented the primary or single indication for surgical treatment in 14 patients (6.3%) and one of several indications in the remaining patients. Of 165 patients with an abdominal mass or abscess, 69 (41.8%) had a fistula. All patients underwent resection of the diseased intestinal segment; 160 (73.1%) with primary anastomosis and the remaining 62 with a temporary or permanent stoma. The fistula was directly responsible for a stoma in only 16 patients (7.2%) and was never responsible for a permanent stoma. Resection of the diseased bowel achieved en bloc removal of the fistula in 145 cases. Removal of 93 additional fistulae required resection of the diseased bowel segment along with closure of a fistulous opening on the stomach or duodenum (n = 14), bladder (n = 35), or rectosigmoid (n = 44). When the fistula drained through a vaginal cuff (n = 4), the opening was left to close by secondary intention; when the fistula opened through the abdominal wall (n = 46), the fistulous tract was debrided. In the remaining two entero-salpingeal fistulae, en bloc resection of the involved salpinx accomplished complete removal of the fistula. There was a dehiscence of one duodenal and one bladder repair; 14 patients (6%) experienced postoperative septic complications and one patient died., Conclusions: Fistulae are diagnosed preoperatively in 69% of cases and can be suspected in as many as 42% of patients with an abdominal mass. Fistulae are the primary or single indication for surgical treatment and are directly responsible for a stoma only in a few patients. Treatment, based on resection of the diseased bowel and extirpation of the fistula, can be accomplished with minimal morbidity and mortality.

Objective: To document the functional results of 50 consecutive patients who underwent hand-sewn ileal J pouch-anal restorative proctocolectomy for ulcerative colitis between 1988 and 1991 (mean follow-up, 18.1 months; range, 6 to 48 months)., Design: Patients recorded their observations daily over 1 week. The patients completed these weekly diaries every 3 months for the first year and then at 18, 24, 36, and 48 months after ileostomy closure., Study Participants: Fifty patients (mean age, 31 years; 24 males)., Setting: The University of Chicago (Ill)., Results: Stool frequency at 3, 6, 12, and 24 months was 6.3 +/- 2.1, 5.5 +/- 2.4, and 5.1 +/- 1.9, and 5.9 +/- 1.6 per day, respectively, without urgency. Fifty-four percent were perfectly continent; 18% had occasional spotting (one or two leaks per week); 12% had minor leakage (three to seven per week); and 16% had major leakage (more than seven per week). In these three groups, loss of solid feces never occurred in 84%, 88%, and 65% of patients, respectively. Females had more severe incontinence than males, but continence improved over time for both sexes. Twenty-two percent of female patients developed dyspareunia; no males developed impotence, but 19% had retrograde ejaculation. The probability of experiencing pouchitis increased with time from 15% at 6 months to 40% at 12 months, and 50% after 24 months., Conclusions: These results represent an accurate assessment of patient function after ileal J pouch-anal anastomosis. We encourage the use of a prospective, patient-completed protocol to obtain a realistic assessment of functional results.

We report on 14 cases of intestinal adenocarcinoma complicating Crohn's disease, seven occurring in the small bowel and seven in the large bowel. In both locations, two-thirds of patients were male. The average ages at the time of diagnosis of Crohn's disease and of cancer were similar between the two groups of patients: 28 and 48 years, respectively. The diagnosis of cancer was suspected or obtained preoperatively in only four cases of large bowel cancer; in two patients with large bowel cancer and five with small bowel cancer, the diagnosis was made at laparotomy. In the remaining cases, only careful histologic examination revealed the carcinoma. Six small bowel cancers were located in the ileum, and five colonic cancers were distal to the splenic flexure. Two small bowel and one large bowel cancer were multifocal and had surrounding mucosal dysplasia. All tumors, except one small bowel cancer, underwent resection. Survival correlated with stage of tumor at resection; no patient with regional or distant metastasis survived five years, in comparison with an 83 percent five-year actuarial survival rate of patients with tumor confined to the intestinal wall. Mean survival was six months for patients with small bowel cancer in comparison with 65 months for patients with large bowel cancer, reflecting a tendency toward more advanced lesions in the small bowel cancer group.

A stapling technique for construction of an ileal J-pouch is presented. The technique is simple, minimizes the chances for pelvic contamination and avoids midpouch enterotomies. By postponing the performance of the apical enterotomy until after the pouch is in the definitive position, the apical enterotomy is placed exactly where needed to facilitate the subsequent ileoanal anastomosis.

This retrospective study was aimed at defining the morbidity and mortality of a radical resection for adenocarcinoma of the rectum complemented by a wide pelvic lymphadenectomy. Twenty-seven consecutive patients with rectal carcinoma who underwent a surgical resection with conventional (Group I) or wide (Group II) pelvic lymphadenectomy were analyzed. Group I consisted of 10 patients (three women and seven men; mean age, 71 years) with tumors between 6 and 14 cm (mean, 10.6 cm) from the anal verge. Group II consisted of 17 patients (eight women and nine men; mean age, 67 years) with tumors between 3 and 14 cm (mean, 9 cm) from the anal verge. The choice of lymphadenectomy in association with colorectal resection was left at the discretion of the surgeon. There were no deaths within 60 days of operation. Mean intraoperative blood loss was the same in the two groups, although three patients (18 percent) required blood transfusions of over two liters during the performance of a wide pelvic lymphadenectomy in comparison with only one (10 percent) during conventional pelvic lymphadenectomy. The rate of early postoperative complications and the average length of postoperative hospital study were each similar between the two groups. After a wide pelvic lymphadenectomy, three (18 percent) patients developed a neurogenic bladder, requiring intermittent self-catheterization, and they all recovered within one, four, and eight months, respectively. Of the 16 males, three from Group I and four from Group II were sexually active and potent before surgical treatment; after recovering from surgery, only two patients from Group I regained their sexual potency. We conclude that the performance of a wide pelvic lymphadenectomy did not increase the intraoperative or early postoperative complication rate, the mean intraoperative blood loss, or the length of postoperative hospital stay. Technical refinements are currently under study to obviate the neurologic long-term complications.

Thirty-six pancreatic patients with massive gastrointestinal bleeding have now been identified as having pancreaticoduodenal and gastroduodenal artery aneurysms as causative. In the past decade, seven of the patients have been encountered at the authors' institution and seven presented in the literature. Of these 14, there was a predilection for men (85%) with an average age of 48.1 years, who had complications of pancreatitis (75%), that is, abscess or pseudocyst. Eleven of these patients underwent surgery with an 81 per cent survival rate. Previous reports had shown a 47 per cent survival rate in 19 similar patients. Embolization of the aneurysm was attempted in four patients with two successes. The authors believe that early diagnosis by arteriography and early operative intervention were responsible for the improved survival. A high index of suspicion in this patient population is crucial for early diagnosis and improvement in survival.

Between 1970 and 1988, 1379 patients with Crohn's disease were treated at the University of Chicago. Of these, 639 (mean age, 32.5 years; 322 men, 317 women) required at least one surgical procedure. The most common indications for operation were failure of medical treatment (n = 215, 33%), presence of a fistula (n = 154, 24%), and bowel obstruction (n = 141, 22%). A fistula was the most common intraoperative Crohn's-related complication. In 582 patients (92%), a resection was necessary, with primary anastomosis in 416 (65%), a temporary stoma in 124 (20%), and a permanent stoma in 42 (7%). The remaining 57 patients underwent diverse procedures (stricturoplasty, bypass, and so on). Two patients (0.3%) died. Follow-up data was obtained in 95%. One hundred eighteen patients developed recurrence requiring reoperation. The recurrence rate was 20% at 5 years and 34% at 10 years. The recurrence involved a permanent stoma or a previous anastomosis in 62 patients (afferent limb in 46, efferent in 16). In the 391 patients without previous surgery for Crohn's disease, a covariate analysis was performed to determine those variables significantly associated with recurrence. Variables included demographic data, findings at operation, surgical procedures, and histopathologic characteristics. The analysis revealed that the number of sites involved was the only variable that was significantly associated with the intra-abdominal recurrence rate (p less than 0.001). The annualized risk of recurrence was 1.6% for patients with single-site involvement and 4% for those with multiple-site involvement. Perineal disease was associated with a significantly higher risk of local recurrence than any other site (p less than 0.02). A subanalysis of 236 patients with single-site involvement but no previous operation allowed us to study the influence of site on indications for surgery and type of operative procedure. Failure of medical treatment was the most common indication for all sites. In contrast the site involved influenced the procedure: resection and primary anastomosis was feasible in 88% of jejunoileal and terminal ileal cases and a temporary ileostomy was necessary in only 12%. No patients with small bowel localization required a permanent stoma. A resection with primary anastomosis was feasible in only 32% of patients with colonic disease. The remaining two thirds of patients required either a temporary or a permanent stoma. It is concluded that multisite involvement is associated with 2.5 times the rate of recurrence of single-site disease, while the presence of perineal disease has a significantly higher incidence of local recurrence.(ABSTRACT TRUNCATED AT 400 WORDS)

As reported in the Bulletin at various times over the past several years, the American College of Surgeons has frequently been called upon by federal agencies and commissions to provide clinical information and advice on issues that are associated with implementation of the Medicare physician payment system reforms mandated by the Omnibus Budget Reconciliation Act of 1989 (OBRA '89). In doing so, the College has often relied on the expertise of Fellows who are deeply committed both to the practice of general surgery and to the College. The purpose of this article is to provide a review of the College's participation in activities related to implementation of the Medicare reforms, as viewed by some of the general surgeons who shared in those efforts.

Rectal adenocarcinoma is said to have a poorer outcome than colon adenocarcinoma when compared on the basis of Dukes' staging. However a new staging system, determined by a multivariate analysis of 147 patients with rectal adenocarcinoma, has revealed three other variables significantly related to outcome. Therefore this study analyzed the authors' experience with colonic carcinoma during the same time period as they had studied for rectal carcinoma to determine whether the new staging system is valid for colon carcinoma as well, and, if so, to compare the outcome of patients with colon and rectal carcinoma on the basis of this new staging. A total of 603 patients with 611 colonic adenocarcinoma were operated on at the University of Chicago Medical Center between 1965 and 1981. Two hundred seventy-nine adenocarcinomas (45.7%) were located proximal to the splenic flexure and 332 (54.3%) were located between the splenic flexure and the rectosigmoid. Four hundred sixty-two patients underwent segmental colectomy, 46 subtotal colectomy, 26 total colectomy, 18 proctocolectomy, 5 abdominal-perineal resection, 1 appendectomy, while 20 had local excision of the tumor through colotomy and 25 had permanent diverting stoma as the only procedure. The operative mortality rate was 6.1% in the whole group, but was only 2.7% in the group of potentially curable patients. Complete follow-up was obtained in all patients. To validate a previous staging system for Dukes' B and C rectal adenocarcinoma, the authors investigated the correlation between 5-year survival for colonic carcinoma patients and all relevant variables that they had considered potentially meaningful in the previous study with rectal adenocarcinoma. The resulting multivariate analysis using Cox regression showed that the four variables found previously to be significantly related to outcome for rectal adenocarcinoma patients (stage, race, tumor morphology, and vascular and/or lymphatic microinvasion) were the only four variables significantly (p less than 0.05) associated with outcome for colonic adenocarcinoma patients. In addition, by using the results of their previous staging system for rectal adenocarcinoma patients, they 'predicted' the 5-year survival rates of the colon adenocarcinoma patients, divided in 16 staging subgroups. In subgroups of at least 15 patients, the rectal staging system predicted the outcome to within 1 to 6 percentage points of the observed outcome of the colonic adenocarcinoma patients. Thus this study validates this staging system, incorporating stage, race, tumor morphology, and microinvasion to predict 5-year survival rate more accurately than Dukes' staging alone for both colon and rectal adenocarcinoma.(ABSTRACT TRUNCATED AT 400 WORDS)

A total of 853 patients with 861 colorectal adenocarcinomas were operated on at our institution between 1965 and 1981. Complete follow-up information was obtained in all but six patients (99.4%), and all available histologic slides were reviewed to determine pathologic stage and characteristics. Six hundred fifty-one patients (76.3%) underwent a potentially curative procedure, and their operative mortality rate was 2.8%. Of the 627 patients available for analysis, 50 (8%) had a local recurrence. The median time to local recurrence was 18 months, and only 16% of local recurrences were diagnosed 5 years after the original resection. Median survival of patients with a local recurrence was 3 1/2 years from the original resection, and 16 patients (32%) survived 5 years or longer. A multivariate logistic regression analysis was conducted to examine the influence of several clinical and pathologic characteristics on local recurrence among Dukes' stages B and C adenocarcinomas (n = 539) after exclusion of patients with synchronous tumors (n = 8), postoperative deaths (n = 18), loss to follow-up (n = 6), or incomplete data (n = 11). This analysis revealed that the local recurrence rate was significantly related to depth of invasion (B1 + C1 = 0%; B2 + C1 = 10%; p less than 0.01), site of origin (right plus transverse colon = 6%; left plus rectosigmoid colon = 10%; rectum = 12%; p less than 0.05), and lymphatic or capillary microinvasion (absent, 6%; present, 14%; p less than 0.05). This analysis attempts to identify patients at high risk for development of local recurrent disease to select candidates for postoperative adjuvant therapy.

Total parenteral nutrition (TPN) is a well-established means of nutritional support in the critically ill patient who is unable to maintain adequate oral intake. A complication of long-term parenteral nutrition is gallbladder disease. Cholecystitis is often difficult to diagnose in patients with multisystem disease and has a dour prognosis when there is delay in diagnosis and operative treatment. An awareness of the risk factors for cholecystitis, including TPN, in the critically ill patient is the sine qua non of early diagnosis. If cholecystitis is suspected, the diagnosis may be established by ultrasonography, tomography, and scintigraphy. Immediate cholecystectomy is the treatment of choice.

An ileosigmoid fistula complicating Crohn's disease of the small bowel has been considered a perplexing entity, but in practice does not pose a serious operative problem. The presence of such a fistula does not signify that the sigmoid colon is a primary site of Crohn's disease. The operative treatment of this entity is simple and usually does not require resection of the sigmoid colon. Rather the sigmoid colon defect may easily be treated by simple closure, or by minimal partial resection and closure. Temporary diversion of the fecal stream is occasionally indicated because of local inflammation. Forty-four of the 48 patients treated in this manner had successful resolution of their problem. Four patients were found to have primary Crohn's disease of the colon and required further treatments in addition to closure of the fistula.

S-shaped ileal reservoirs (SSRs) and double-barreled ileal reservoirs (DBRs) of equal size were placed 6 or 2 cm from the anus and evaluated over 1 year for their ability to improve the functional incontinence noted after an ileoanal anastomosis (IAA). Compared to straight IAA, both reservoirs prolonged intestinal transit (235 minutes versus 135 minutes, P less than 0.001) and alleviated frequency without causing nutritional abnormalities. The capacity of the reservoirs was greater than that of a comparable length of distal ileum in dogs (n = 6) with straight IAA (304 +/- 16 ml versus 102 +/- 2 ml, P less than 0.001). The SSRs (n = 9), in contrast to the DBRs (n = 10), developed excessive volume capacity (360 +/- 30 ml versus 254 +/- 104 ml, P less than 0.01) and obstructive complications. Reservoirs with 6 cm efferent conduits (n = 13), in contrast to those with a 2 cm efferent conduit (n = 6), underwent marked dilatation (334 +/- 24 ml versus 238 +/- 13 ml, P less than 0.005). Electromyography and manometry revealed the DBRs to be more contractile than the SSRs but less than ileum proximal to the anus in dogs with a straight IAA. Ileal reservoirs improve results after IAA. Reservoirs should be complaint and yet contractile (e.g., DBR) so as to discourage excessive dilatation, which is the harbinger of obstruction. Ileal conduits facilitate reservoir placement, but if longer than 2 cm they excessively impeded reservoir emptying, predisposing to excessive reservoir dilatation and obstruction. A DBR with a 2 cm efferent conduit results in continence without obstructive problems.

The estrogen receptor protein (estrophilin) was determined in specimens from 359 primary breast cancers and from metastatic tumors of 214 patients. Ninety-eight patients were eventually treated by some form of endocrine therapy: 82 patients were treated by ablative therapy, and 16 by hormonal additive treatment. The records of 81 of the 98 patients whose tumors were characterized for estrogen receptor content and who had received some type of endocrine therapy were reviewed by a peer review group that assessed the objective data for these patients regarding objective remission or failure to treatment. A positive estrophilin determination was defined as receptor content greater than 250 fmole per gram of tumor for premenopausal females and greater than 750 fmole per gram of tumor for postmenopausal and previously castrated patients. Estrogen receptor determinations may be made from tumor specimens as small as 200 mg. Sixty-nine patients underwent some form of ablative therapy. Twenty-seven of these patients were found to have significant receptor determinations. Of those patients in whom a definite determination was made of their post-treatment response, roughly two-thirds experienced objective remissions. None of the 42 patients with negative estrogen receptor determination experienced an objective remission to ablative endocrine therapy. Only one of 6 patients with negative determinations benefited from additive hormonal therapy; 4 of 6 patients with positive determinations benefited from additive therapy. Not all women with receptor containing mammary cancer will respond favorably to endocrine therapy, but those patients whose tumors lack a critical amount of estrophilin have little chance of benefit from either endocrine ablation or hormone administration. The estrogen receptor content of the primary tumor indicates the hormonal dependency of the tumor and may be used to predict the response to endocrine treatment when recurrent disease appears.

Thirty-eight patients with incidental thyroid carcinoma were reviewed. Thyroid lobectomy was adequate therapy in 15 to 17 patients. Both patients in whom lobectomy alone was inadequate had received prior irradiation. Five patients had antecedent head and neck irradiation, and in three of them, multicentric foci of tumor developed. Lobectomy alone was inadequate in three of these patients; they required thyroidectomy. A clinical recurrence developed in only two of 38 patients, and both of them had received previous irradiation. Reoperation in previously dissected areas was associated with an increased rate of complications. Lobectomy in nonirradiated and total thyroidectomy in irradiated patients cured the majority of patients suffering from incidental carcinoma of the thyroid.

Eighty-eight consecutive patients with invasive, but potentially curable, carcinoma of the abdominal colon were operated upon between January 1970 through June 1974 at the University of Chicago Medical Center by a small group of senior surgeons, all of whom utilized extensive lymphadenectomy. Pathologic stage of the disease, lymph node involvement, contiguous organ involvement and degree of differentiation of the primary tumor affected survival rates. Five and ten year absolute survival rates were 71.2 and 50.0 per cent, and the relative survival rates were 78.1 and 60.9 per cent. By five years, 30.0 per cent of the patients had recurrence, and by ten years, 33.3 per cent had recurrence. The majority of recurrences occurred within three years of operation. Only 12 per cent of the recurrences were local or regional. We conclude that operation using wide anatomic resection and extended lymphadenectomy improves survival rates and limits local and regional recurrences in patients with carcinoma of the abdominal colon. Furthermore, surveillance of patients after operation for invasive carcinoma of the abdominal colon should be aggressive for at least the first three years because of the frequency of recurrence within this period.

Cancer of the colon and rectum appear to be epidemic in the US, with 150,000 cases expected during 1988. Two thirds of these patients are over age 60, and two thirds also have either full penetration of the bowel wall or metastases to regional lymph nodes. Mass screening via tests for occult blood in the stool is invaluable for detecting early carcinomas of the colon and rectum. Digital examination, endoscopy, and barium contrast radiographs help to confirm the diagnosis. Tumors of the colon and rectum are best treated operatively with appropriate lymphadenectomy and adequate margins, both proximally and distally, to guard against local recurrence. Certain factors, such as mucinous tumors, microinvasion, and non-exophytic tumors of the rectum have been shown to have a propensity for local recurrence. Local treatment by fulguration or electrocoagulation is advocated only for tiny tumors confined to a polyp, or for the extremely elderly or poor-risk patient. Radiation therapy appears to be an appropriate adjuvant to the treatment of rectal cancer either preoperatively or postoperatively.

A 27-year-old woman with cystic fibrosis had a 6-month history of fatty food intolerance and biliary colic. Ultrasonographic studies confirmed the presence of gallstones. A cholecystectomy and appendectomy were performed. An intraoperative cholangiogram showed anomalous drainage of the cystic duct into an accessory right hepatic duct. Patients with cystic fibrosis now commonly survive into adulthood and are at high risk for the development of cholelithiasis. The diagnosis may be obscured by other common gastrointestinal complications of cystic fibrosis. Optimal surgical management includes meticulous preoperative and postoperative pulmonary care. The surgeon must also have a thorough knowledge of the biliary tract anomalies that have been described in patients with cystic fibrosis.

Fifteen pediatric patients have been presented who required operative treatment for Crohn's disease. This disease is associated with severe side-effects in children, especially maturation and growth arrest. There are clear indications for surgical treatment: fistula, chronic obstruction, hemorrhage and perforation. Failure to grow, when associated with obstruction of the small intestine, is an urgent indication for operation. From our observations, we conclude that growth arrest in these patients occurs because of malnutrition. In a majority of patients, chronic obstruction of the small intestine contributes significantly to this malnutrition. Operative treatment is one of conservative resection, and the operative mortality is nil. The majority of patients with growth arrest will grow postoperatively. Operative treatment of Crohn's disease is carried out for its complications, and treatment is quite effective in relieving these complications, although the disease itself may persist.

Convulsions have complicated the surgical management of life-threatening inflammatory bowel disease in five patients. These patients experienced a transient, generalized convulsive disorder and toxic ambylopia. Results of neurological examination were unremarkable. Treatment included metabolic stabilization along with the administration of oxygen and anticonvulsive medication. Various factors, such as hypoxia, fluid overload, cerebral edema, steroid administration, and deficits in calcium, magnesium, and potassium, may have contributed to the cause of this complication.

Four cases of desmiod tumors of the anterior abdominal wall recently treated at the University of Chicago Hospitals and Clinics are presented. From our experience we conclude: 1. Inadequate excision of desmoid tumors results in local recurrence. 2. Adequate excision of desmoid tumors ot the abdominal wall sometimes necessitates creation of an abdominal wall defect too large for primary closure. 3. Marlex mesh has been used successfully in reconstruction of the abdominal wall following adequate excision of desmoid tumors. 4. One patient (Case 4) with an abdominal wall desmoid tumor associated with familial polypisis and mesenteric fibromatosis has benefited greatly following wide excision of abdominal wall and reconstriction using Marlex mesh, despite the fact that the mesenteric fibrous tumor was unresectable.

From 1970 to mid-1975, we have operated on 25 consecutive patients with toxic dilatation of the colon with no mortality. This report deals with the principles of management which we follow; primary emphasis is given to aggressive diagnosis and resuscitation, followed by early operative intervention. We prefer total abdominal colectomy with ileostomy and sigmoid mucous fistula for cases of toxic megacolon not complicated by hemorrhage.

Three adenosquamous carcinomas and 2813 adenocarcinomas of the colon proximal to a line 7 cm craniad to the dentate line were treated between 1946 and 1986. Of these, one adenosquamous carcinoma and 42 adenocarcinomas were associated with ulcerative colitis. Therefore it was calculated that adenosquamous carcinoma occurs 0.07 percent as frequently as adenocarcinoma of the colon in the general hospital population and 2.4 percent as frequently in patients with ulcerative colitis, a 33-fold increase. It is concluded that, although adenosquamous-cell carcinoma of the colon is a rare tumor, its frequency in relation to adenocarcinoma increases in the presence of ulcerative colitis.