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BACKGROUND: Controlled muscle fiber conversion by electrostimulation makes transformation of fast twitching type II muscle fibers to slow twitching type I fibers possible, which gives skeletal muscles the capacity for tetanic contraction. This phenomenon has been recently applied in the so-called 'dynamic graciloplasty' to restore function of an insufficient or excised anal sphincter. This paper describes our results with this method in patients with fecal incontinence or following an abdomino-perineal resection (APR) of the anorectum. METHODS: From April 1992 through April 1997, 28 patients (12 women and 16 men) were treated by dynamic graciloplasty. The median age was 53.5 years (range 16 to 79). Indications were as follows: APR + synchronous restoration of the excised sphincter by graciloplasty (n = 12); total anorectal reconstruction (TAR) following APR in the past (n = 6); Patients with acquired fecal incontinence (n = 4); and Congenital atresia (n = 6). Muscle transposition, implantation of stimulation electrodes and pulse generator were done as a single-stage procedure, the 'neosphincter' was wrapped in a modified technique (split-sling technique). Muscle transformation was performed by controlled neuromuscular stimulation during 8 weeks (from 1992 to 1995) and 4 weeks (since 1996), respectively. RESULTS: No postoperative mortality (90 days) was observed in either group. In our early experience, rectal injury occurred in 4 patients as the most prominent complication. Evaluation of the functional outcome showed the best results in patients operated either for congenital of acquired incontinence who achieved a continence for solids and liquids or solids alone, respectively (1 or 2 according to Williams' score) in 90%, while patients following APR showed a satisfying outcome (continence for solids and liquids, solids alone or with occasional episodes for liquids) in only 55.5%. In patients following APR, defecation disorders turned out to be the most prominent functional problem and had to be treated by enemas. CONCLUSION: In this series, we have been able to perform dynamic graciloplasty as a one-stage procedure using a modified muscle wrap (split-sling-technique) thus reducing the time period until continence could be achieved to 7 weeks. We found the appropriate tension of the muscle wrap essential to prevent direct injury to the rectum as it was seen in our early experience. For this reason, we have introduced a modified device to perform intraoperative anal manometry and to measure pressures created by the neosphincter objectively. Am J Surg. 1998;175:187-193. [C] 1998 by Excerpta Medica, Inc.

Background. Because of experimental and preliminary clinical evidence that additional modulation of the biochemical pharmacology and cytotoxicity of 5-fluorouracil (5-FU) and leucovorin (LV) may be possible by combination of these agents with cisplatin (CDDP), the authors undertook a prospective randomized trial in patients with colorectal cancer. Methods. Between 1989 and 1992, 138 patients with advanced measurable colorectal cancer previously unexposed to chemotherapy were randomly assigned to treatment with either 5-FU (425 mg/[m.sup.2]) and LV (20 mg/[m.sup.2]) for 5 days, or the combination of 5-FU and LV in the same daily dose plus cisplatin (20 Mg/[m.sup.2]), each drug given for 4 consecutive days. In both treatment arms, courses were administered every 28 days, if toxicity allowed, for a total of 6 months or until evidence of tumor progression. Results. The overall responses (complete and partial response) were 19% and 28% for the 5-FU/LV and the 5-FU/LV/CDDP treatment arms, respectively. Although the three-drug combination appeared superior to 5-FU/ LV for time to progression or death (8.5 versus 5.2 months; P = 0.042), there was no evidence that the adoption of cisplatin will translate into a definite survival advantage. A comparative analysis of the toxicities experienced by the patients in the two treatment groups showed a comparable rate, although severe side effects (P < 0.05), specifically stomatitis (P = 0.013), were noticed more frequently in patients treated with 5-FU/LV for 5 days. Conclusions. These results suggest that the therapeutic index of 5-FU/LV in metastatic colorectal cancer may be improved with the addition of cisplatin. However, the somewhat better therapeutic activity and lower incidence of severe gastrointestinal side effects have to be weighed against additional pharmaceutical charges and the need for a more intense antiemetic regimen. Cancer 1994; 73:1562-8. Key words: colorectal cancer, fluorouracil, leucovorin, cisplatin, biochemical modulation.

Background. To determine the maximum tolerated dose of epirubicin for use in combination with 5-fluorouracil (5-FU) and low-dose leucovorin (LV), a Phase I-II trial was conducted in 37 patients with advanced gastric carcinoma. Methods. The doses of 5-FU (425 mg/[m.sup.2]) and LV (20 Mg/[m.sup.2]), both given intravenously on days 1-5, were held constant while the dose of epirubicin was escalated in cohorts of patients (beginning dose, 50 mg/[m.sup.2] on day 1). Cycles were repeated every 4 weeks. Results. Significant gastrointestinal symptoms and myelosuppression were observed infrequently at the initial dose level. At a dose of 60 Mg/[m.sup.2] of epirubicin on day 1, however, five of eight patients had significant mucosal toxic effects during the first cycle of therapy. In addition, two patients treated at this dose level had Grade 4 granulocytopenia with insufficient recovery to permit a second course by day 28, and one patient each had severe diarrhea and nausea and vomiting. Among 37 patients with assessable disease, there were 3 complete and 11 partial responses (response rate, 38%). Conclusions. LV modulation of 5-FU can be incorporated safely into combination chemotherapy with epirubicin and provides a relatively active regimen for treatment of disseminated gastric cancer. Cancer 1993; 71:2177-80.

'Ferritin-bloeked lymphocytes' or placental ferritin (PLF)-positive T cells have repeatedly been described in the circulation of patients with female breast cancer. Since a monoelonal antibody directed against PLF beeante available, a study was performed to evaluate its usefulness in an easily reprodueile system. One hundred patients with controversial or highly suspicions findings on mammography who subsequently underwent operation entered this trial. Sixty-one healthy blood donors served as controls. Patients with early (lymph-node negative ) stages of breast cancer ( in situ and TINO tumors) revealed significantly higher numbers of PLF-positive eel (9.00% + 4.5% and 6.21% 4- 3.4%) as compared with controls or patients with benign lumps (p Patients with negative lymph nodes differed significantly from node-positive patients ( 9.79% versus 2.55%; p

A major complication of abdominoperineal rectum excision for rectal or anal carcinoma is local wound infection. The main reason for this infection is that systemically administered antibiotic prophylaxis does not reach sufficiently high concentrations of antibiotic in the tissue of the sacroperineal wound. Since gentamicin-polymethylmethacrylate (PMMA) in the form of chains of beads has been confirmed as a useful tool in the treatment of local infection in bone and soft tissue surgery, we have evaluated its effect on the abdominoperineal rectum excision in a prospective, randomized trial. Forty-four patients with rectal or anal carcinoma entered the study. Only patients with stage Dukes D were excluded from the trial. Following randomized selection, the patients were treated either with local gentamicin and drainage (Group A) or drainage alone (Group B), using the Lloyd-Davis procedure. The two groups were comparable regarding age, sex, tumor stage and level, and risk factors predisposing for an infectious complication (anemia, nutritional status, blood transfusion). The postoperative mortality rate was 0% in both series. Analysis of local perineal would healing revealed a statistically significant higher percentage of primary wound healing in Group A than in Group B (87% versus 46%; p, Patients with rectal or anal cancer may require abdominoperineal rectum excision, a procedure in which the anus and rectum are closed off and an artificial intestinal opening is established through the abdominal wall. A major complication of this extensive surgery is the development of local wound infection, particularly in the perineal area (area between the anus and scrotum or vagina). Up to 70 percent of patients who develop perineal wound infection will have secondary wound healing, perineal abscess and even septicemia (blood poisoning). Although the use of preventive antibiotics has reduced the rate of infection for other intestinal surgery, the same improvement has not been achieved for abdominoperineal resection patients. The main reason is that systemically administered antibiotics do not reach high enough concentrations in the wound tissue of the abdominoperineal ares. This is due to the impaired blood supply to the soft tissue of this area. A reduction in infection rate in bone and soft tissue surgery has been achieved using local application of gentamicin (gentamicin-polymethylmethacrylate) in the form of chains of beads placed within the wound. This provides release of high concentrations of antibiotics within the wound area over a period of days and weeks. A report is presented of the effectiveness of administering these gentamicin bead chains to patients who underwent abdominoperineal rectum excision. Patients were studied prospectively and were randomly assigned to receive either gentamicin beads or serve as controls (those who did not receive gentamicin beads). The two patient groups were similar. The group receiving gentamicin had a significantly higher rate of primary wound healing than the controls (87 percent, compared with 46 percent). The gentamicin group also had a significantly shorter postoperative hospital stay than the controls (20 days, compared with 27 days). These results indicate that gentamicin bead chains have a beneficial effect on local wound healing for patients who undergo abdominoperineal rectum excision. (Consumer Summary produced by Reliance Medical Information, Inc.)