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In January 1989 the patient was investigated for heavy rectal bleeding. A fungating carcinoma of the rectum was diagnosed 10cm from the anal verge. The lumen at this level only just permitted examination by the colonoscope. Computerized tomography (CT) examination showed no evidence of perirectal spread, but both lobes of the liver appeared to contain numerous small metastases. The patient was informed that her life expectancy was approximately 12 months. A course of “palliative” radiotherapy (45Gy) was administered to the rectal tumour followed by a further treatment (6Gy) 1 month later. Sigmoidoscopy 3 months after treatment revealed no visible tumor, but subsequently recurrence occurred. Further radiotherapy (8Gy) and local excision with a urological resectoscope failed to control the lesion, and the patient was referred in July 1990.

The patient presented with a 4-month history of urinary symptoms (frequency and dysuria) associated with noncolicky abdominal pain. There were no bowel symptoms. On abdominal examination, there was a large, smooth suprapubic mass that reached the level of the umbilicus. A urologist made a diagnosis of urinary retention, but investigations were normal. A barium enema showed a distorted sigmoid colon “stretched” over the abdominal mass. Rigid sigmoidoscopy revealed 2 small polyps in the rectum.

For 2 months the patient had noticed an “abscess” in the right buttock associated with rectal bleeding, constipation, and loss of weight. There was a large rectal cancer found at the 7 cm level, and biopsy of ulcerating nodules on the surface of the buttock also revealed adenocarcinoma. The buttock mass measured 8cm × 15cm (Figure 33.1). Laparotomy and colostomy were performed. The surgeon considered the tumor to be nonresectable. The patient was referred for further opinion and management. Examination under anesthesia revealed a subepithelial cord of hard tissue extending from the distal edge of the rectal cancer into the buttock mass. The rectal lesion appeared fixed. Investigations revealed no evidence of other metastases. The patient was treated with two courses of 5 fluorouracil and Lomustine administered by regional perfusion via the right common iliac artery. Preoperative radiotherapy was considered but not given.

In February 1976 the patient underwent a curative resection of a moderately well differentiated adenocarcinoma of the lower third of the sigmoid colon. The vascular ligation was immediately below the upper left colic artery. The distal margin of the tumor clearance was 5cm. A 2-layer anastomosis was performed which was later measured at 13cm from the anus. At operation, the uterus was noted to be enlarged and retroverted with a large fibroid on the upper part of the posterior surface. The carcinoma involved 2/3 of the lumen for a distance of 45mm and “partly infiltrated” the muscularis propria. One mesenteric lymph node 2cm from the colon contained adenocarcinoma, 12 other lymph nodes were negative (Dukes C, T N M). One year after operation, clinical examination and examination under anesthetic revealed a mass in the “pouch of Douglas” (PD), attached to the uterus and the wall of the bowel at the level of the anastomosis. Investigations for metastatic disease elsewhere were negative. [Computerized tomography (CT) and transrectal ultrasound (TRUS) assessment of the pelvis were not available for this patient in 1976].

The patient developed ulcerative colitis (UC) at the age of 14 years (1948) and was referred for a surgical opinion in 1966 with a history of UC for 17 years. He had recently noticed intermittent pain in the left lumbar region and pain under the left costal margin on deep inspiration. Sigmoidoscopy showed minimal active colitis. A barium enema demonstrated total colitis, a large polypoid lesion of the splenic flexure, and a stricture of the upper descending colon 9cm in length regarded as malignant (Figure 35.1).

In August 1994 the patient was admitted to the hospital with severe pain and tenderness in the left iliac fossa accompanied by fever and vomiting. A pelvic ultrasound suggested a possible left-sided pelvic mass. Laparoscopy by a gynecologist revealed normal ovaries and “extensive diverticular disease.” Antibiotics were administered and the symptoms settled. A subsequent barium enema confirmed the diagnosis of sigmoid diverticular disease. Nine months later, a series of similar episodes occurred over a period of 12 weeks, resulting in a further admission to hospital for 7 days. Elective operation was advised for recurring diverticulitis.

The patient was referred after an urgent laparotomy during which a transverse colostomy was performed for an inflammatory mass in the lower sigmoid and rectum. Subsequent colonoscopy was limited to the distal sigmoid, where a 10-mm polyp was removed (villous adenoma). Anterograde colonoscopy via the colostomy revealed marked narrowing of the sigmoid colon due to diverticular disease and a large polyp with a broad pedicle which could not be snared with safety.

One year prior to emergency admission to the hospital, the patient had an attack of abdominal pain that was diagnosed as diverticulitis. At the time of this urgent admission, he complained of left iliac fossa pain, vomiting, and diarrhea. There was lower abdominal tenderness maximal on the left. A computerized tomography (CT) examination showed diffuse induration surrounding the sigmoid colon with bubbles of gas beyond the lumen. Some free fluid was present but no loculated collection suitable for catheter drainage. Over a period of 4 days, there was no significant improvement and operation was advised.

In 1977 the patient underwent laparotomy for a suspected carcinoma of the sigmoid colon. The surgeon found a large fixed mass firmly adherent to the pelvic structures, which he considered to be inoperable. A left-sided loop colostomy was performed. The patient was subsequently informed that her disease was incurable cancer. After a 5-year period, by which time no deterioration in her health had occurred, the patient was referred for a second opinion. Clinical examination revealed a pelvic mass. Flexible sigmoidoscopy was possible only to 25cm, at which level no malignancy was identified. Review of the barium enema films performed prior to the laparotomy in 1977 showed a stricture of the sigmoid with mucosal continuity throughout (Figure 39.1). The diagnosis was now considered to be diverticulitis.

The patient presented with a 1-month history of lower abdominal pain and narrow frequent stools. Previous, less severe attacks had been diagnosed as diverticulitis, which had responded to antibiotic treatment. There was abdominal tenderness in the suprapubic region. Rectal examination revealed a fixed, hard mass involving the anterior pelvis. Flexible sigmoidoscopy was not possible beyond 20cm due to marked narrowing of the lumen. A barium enema demonstrated a stricture of the sigmoid colon consistent with diverticular disease. There was no significant concern regarding the possibility of carcinoma.