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The type of surgery performed for primary transverse colon cancer varies based on tumor characteristics and surgeon perspective. The optimal oncological outcome following different surgical options has not been clearly established, and transverse colectomy has shown oncological equivalence only in small cohort studies.Our aim was to compare long-term oncological outcomes after transverse colectomy versus extended resection for transverse colon cancer.This study is a retrospective review of prospectively collected data.This study was conducted at a tertiary care hospital.All patients treated for transverse colon cancer at the Samsung Medical Center between 1995 and 2013 were included.Oncological outcomes were compared between 2 groups of patients: a transverse colectomy group and an extended colectomy group (which included extended right hemicolectomy and left hemicolectomy).A total of 1066 patients were included, of whom 750 (70.4%) underwent extended right hemicolectomy, 127 (11.9%) underwent transverse colectomy, and 189 (17.7%) underwent left hemicolectomy. According to univariate analysis, surgical approach, histological type, tumor morphology, cancer T and N stage, cancer size, and lymphovascular invasion were significant factors contributing to disease-free survival (DFS). However, as seen in multivariate analysis, only node-positive disease (HR = 2.035 (1.188-3.484)), tumors with ulcerative morphology (HR = 3.643 (1.132-11.725)), and the presence of vascular invasion (HR = 2.569 (1.455-4.538)) were significant factors for DFS. Further analysis with a propensity-matched cohort between the transverse and extended colectomy groups demonstrated no significant differences in DFS and overall survival.This study was limited because it was performed at a single institution and it was retrospective in nature.In terms of perioperative and oncological outcomes, transverse colectomy and extended colectomy did not differ despite a shorter specimen length and fewer lymph nodes harvested in the transverse colectomy group. Independent prognostic factors for DFS were node-positive disease, the presence of vascular invasion, and ulcerative morphology.

This study was undertaken to assess the incidence of 1) metachronous colorectal cancer and 2) subsequent extracolonic cancers, in relation to the location (proximal or distal to the splenic flexure) of the first primary colorectal tumor. In this population-based study, a cancer registry database was used to identify patients diagnosed with colorectal adenocarcinoma between 1970 and 1999. Patients with familial adenomatous polyposis and those with hereditary nonpolyposis colorectal cancer syndrome were excluded from the study, as were patients with nonepithelial tumors. Location of the first tumor was established according to International Classification of Diseases-Oncology-02 classification. The registry covers a population of 500,000 residents. A total of 5,006 patients had sporadic adenocarcinoma of the colon or rectum during this period of time, with 1,703 first primary tumors (34 percent) being located proximal to the splenic flexure. One hundred twenty occurrences of second primary colorectal cancer were observed in this population (2.39 percent). The risk for developing a second incidence of primary colorectal cancer was higher in patients whose initial tumor was located in the proximal colon (3.4 percent vs. 1.8 percent; odds ratio, 1.92; 95 percent confidence interval, 1.33–2.77; P < 0.001). The risk for each segment of the large bowel was as follows: cecum, 3.4 percent; right colon, 3 percent; transverse colon, 3.8 percent; left colon, 2.8 percent; sigmoid colon, 1.7 percent; and rectum, 1.8 percent. By contrast, the risk for developing a second, extracolonic tumor did not differ between patients with proximal and distal tumors (13.7 percent vs. 13.4 percent, P = 0.73). Patients with a first tumor located within the proximal colon are at twice the risk for developing metachronous colorectal cancer. From an epidemiologic standpoint, these data are in accordance with 1) the increasing incidence and 2) the better prognosis of proximal colon cancer in various populations. Our results confirm that proximal colon cancer is a distinct entity, which justifies the reporting of cases of colon cancer according to their location proximal or distal to the splenic flexure.

Purpose: The aim of this experimental study was to investigate whether covering the colonic anastomoses with fibrin glue can protect the colonic healing from the adverse effects of 5-fluorouracil (5-FU), when it is injected intraperitoneally immediately after colon resection. Methods: Sixty-four rats were randomized to one of four groups. After resection of a 1-cm segment of the transverse colon, an end-to-end sutured anastomosis was performed. Rats of the control group and the fibrin glue group were injected with 6 ml of solution 0.9 percent NaCl intraperitoneally. Rats in the 5-FU and the 5-FU + fibrin glue groups received 5-FU intraperitoneally. The colonic anastomoses of the rats in the fibrin glue group and in the 5-FU + fibrin glue group were covered with fibrin glue. All rats were killed on the 8th postoperative day and the anastomoses were examined macroscopically. The bursting pressure measurements were recorded and the anastomoses were graded histologically. Results: The leakage rate of the anastomoses was significantly higher in the rats of the 5-FU group than in those of the fibrin glue group and those of the 5-FU + fibrin glue group (37.5 percent vs. 0 percent, P = 0.020). The adhesion formation score was significantly higher in rats of the 5-FU group than in the other groups. Bursting pressures were also significantly lower in the 5-FUgroup than in the other groups (P < 0.001). Rats in the 5-FU + fibrin glue group developed significantly more marked neoagiogenesis than rats in the other groups. Rats in the 5-FU + fibrin glue group also presented significantly more fibroblast activity than those in the 5-FU group. (P = 0.004) Conclusions: The immediate postoperative, intraperitoneal administration of 5-FU inhibited wound healing. However, when the colonic anastomoses were covered with fibrin glue, the injection of 5-FU had no adverse effects on the healing of the anastomoses

Metastasis of a malignant neoplasm to a benign tumor is an infrequent event. Adenomatous polyps of the colon have only been reported on three occasions acting as host tumors. We report the first case where a malignant melanoma metastasizing to a tubular adenoma in the colon was detected during colonoscopy. METHODS: An 85-yearold male with dementia and right hemiparesis presented to the hospital with change of bowel habits, signs and symptoms of anal incontinence, and a perianal ulcer. On physical examination, multiple subcutaneous nodules over his chest and abdominal wall were detected, and laboratory data revealed iron deficiency anemia. A colonoscopy was performed. RESULTS: During colonoscopy, a pedunculated, greenish-brown–colored polyp measuring 2 cm in greatest dimension located in the transverse colon was identified and snared. Pathology of this polyp was consistent with a malignant melanoma infiltrating into a tubular adenoma. Subsequently, one of the subcutaneous lesions was biopsied and this revealed malignant melanoma cells metastatic in soft tissue. The primary site of the malignant melanoma could not be identified. CONCLUSION: Polyp-cancer sequence is well documented in colorectal cancer. The vast majority of malignant lesions found in adenomatous polyps in the colon are the consequences of malignant transformation from benign neoplastic colonic adenomatous tissue. The possibility that colonic adenomatous polyps could harbor metastatic tumors should also be entertained. This could change the treatment and may require an appropriate workup.

PURPOSE: The aim of this retrospective study was to determine which aspects of tumor morphology and histology influenced the incidence of local recurrence after curative resection of colonic adenocarcinoma. METHODS: Patients who had a curative resection for a primary colonic adenocarcinoma between 1980 and 1993 (inclusive) were identified from the colorectal cancer database in the Department of Colorectal Surgery. The charts of patients diagnosed with a local recurrence were then reviewed and their findings at operation and histologic assessment analyzed. Patients were followed up for at least five years or until death. RESULTS: Over the period of study, 1,031 patients had a curative resection for colonic adenocarcinoma. Local recurrences were detected in 32 patients (3.1 percent). The gender distribution of patients with local recurrence was 18 males (56.3 percent) and 14 females (43.7 percent) with a mean age of 63.4 years. The median time to local recurrence was 13 (range, 2–71) months. The distribution of primary tumors that recurred locally favored the cecum (n = 9; 28.1 percent) and sigmoid colon (n = 14; 43.7 percent) over other locations; these were, however, the most common sites of primary lesions. Less common sites included the ascending colon (n = 0; 0 percent), hepatic flexure (n = 2; 6.3 percent), transverse colon (n = 1; 3.1 percent), splenic flexure (n = 3; 9.4 percent), and descending colon (n = 3; 9.4 percent). Of the total number of tumors, 101 were found to be adherent to at least 1 other intra-abdominal viscus, and 12 (11.9 percent) recurred locally. Other factors associated with local recurrence were tumor perforation and fistulation. Overall, 30 tumors (2.9 percent) were perforated, and 6 (20 percent) recurred locally. Four tumors (0.4 percent) were fistulating; of these, 2 (50 percent) recurred locally. Advanced tumor stage was also associated with an increased rate of local recurrence (Stage I, 0 percent; Stage II, 2.05 percent; Stage III, 7.0 percent; and Stage IV, 6.1 percent). Similarly, tumor differentiation was related to local recurrence, with no instances in well-differentiated tumors, 2.8 percent in moderately differentiated tumors, and 6.8 percent in poorly differentiated tumors. CONCLUSIONS: The location of the primary tumor is not a factor in producing local recurrence. Fixity to another viscus, perforation or fistulation, advanced stage of disease, and differentiation of tumor appear to increase the chances of recurrence of curatively resected colonic carcinoma. Although the recurrence rate is higher in these groups than for tumors overall, definitive oncologic surgery prevents recurrence in the majority of cases. No colonic tumor that was T1 or T2 (N0, N1, or N2) or that was well differentiated recurred locally.

On occasion, the left colon is not available for rectal or low pelvic anastomosis either because of synchronous pathology, previous resections, or inadequate blood supply. The short middle colic pedicle prevents use of the transverse colon for this purpose. In this situation, the right colon is a good anastomotic conduit. The aim of this video is to demonstrate the right colonic transposition technique.Intraoperative footage was filmed and edited in a multimedia format. Operative details were as follows: the diseased left colon and transverse colon are excised; the right colon is fully mobilized and transposed 180 degrees anticlockwise around the axis of the ileocolic pedicle, so the hepatic flexure reaches into the pelvis without tension. The hepatic flexure is then used for anastomosis within the pelvis either to the residual rectum or anus (see Supplemental Digital Content, Videos 1-3, http://links.lww.com/DCR/A46, http://links.lww.com/DCR/A47, and http://links.lww.com/DCR/A48). Case notes were reviewed to analyze clinical outcome and bowel function.Three patients underwent the technique, 2 females and 1 male (median age, 45 (range, 30-55) years). Median operating time was 98 (range, 95-114) minutes. There were no anastomotic failures or other major complications. One patient had a superficial wound infection. The median in-hospital stay was 7 (range, 7-8) days. The median time to first bowel movement was 3 (range, 3-4) days; the median daily stool frequency was 4 (range, 3-4) on discharge, decreasing to 2 daily stools 12 months after surgery. Stoma formation and total colectomy were successfully avoided in each patient.Right colonic transposition is a useful technique to enable the construction of a tension-free rectal anastomosis with a good blood supply. The use of the right colon in these clinicopathological situations can be achieved with low morbidity and results in good short- and long-term bowel function in these patients. Careful preservation of the ileocolic pedicle and division of the right colic vessels are essential to facilitate successful anastomosis.

BACKGROUND: Because proximal colorectal cancers have a tendency to present at a more advanced stage and thus have a poorer prognosis, it is important to understand the factors associated with the development of proximal colorectal cancer. We hypothesized that older age, female gender, and the presence of comorbid illness would be associated with proximal cancers. METHODS: Incident cases of colorectal cancer (n=9,550) occurring in 1994 were identified from Florida's population-based statewide cancer registry. We categorized colorectal cancers as either proximal (cecum, ascending colon, and transverse colon) or distal (descending colon, sigmoid colon, rectosigmoid, and rectum). Multiple logistic regression analysis was used to determine the multivariable relationship between clinical characteristics and the odds of a proximal-occurring lesion. RESULTS: Four characteristics emerged as independent predictors of a proximal lesion. Each year of increasing age was associated with a 2.2 percent increase in the odds of a proximal lesion, whereas female gender was associated with a 38 percent increase in the odds of a proximal lesion. The presence of a comorbid condition was associated with a 28 percent greater odds of a proximal lesion, and, finally, black, non-Hispanic race was associated with a 24 percent greater odds of a proximal lesion. CONCLUSIONS: We found that increasing age, female gender, black, non-Hispanic race, and the presence of comorbid illnesses were factors associated with a greater likelihood of developing colorectal cancer in a proximal location. Further studies will be required to confirm these findings and to establish the mechanism by which comorbidity influences the site of colorectal cancer development.

A 64-year-old male in May 1997 was diagnosed by colonoscopy and a barium enema examination as having an invasive cancer in the transverse colon. Pathologic study of the resected surgical specimen revealed a well-differentiated adenocarcinoma invading the muscularis propria. He had a colonoscopic examination in 1991 and was diagnosed as having multiple adenomas, which were endoscopically removed. After that he had annual colonoscopy or barium enema examination follow-ups. At endoscopy in February 1994, a superficial depressed cancer 6 mm in diameter had been detected. However, the cancer was not seen again in several endoscopic examinations until one in 1997. Because the location of the lesion detected in 1994 and that of the invasive carcinoma detected in 1997 were identical, it was considered that the superficial depressed cancer developed, 40 months later, to an advanced cancer. Doubling time was calculated as 8.4 months.

INTRODUCTION: This study sought to determine whether dietary arginine influences colonic anastomotic healing in the rat model. METHODS: Three groups of 42 Sprague-Dawley rats were fed 0, 1, and 3 percent arginine diets for three preoperative and three postoperative days. Animals underwent transection of the transverse colon with handsewn anastomosis. Subgroups of 14 animals in each dietary group were killed on postoperative Days 6, 10, or 14, and bursting pressures, histologic inflammation, and collagen content were compared. RESULTS: Mean anastomotic bursting pressures on postoperative Day 6 were lower for the 0 percent arginine group than the 1 and 3 percent arginine groups (mean ± standard error of the mean =134±6 mmHg, 164±7 mmHg, and 166±7 mmHg, respectively;P

PURPOSE: The aim of this study was to assess the clinical features and management of fistulas involving the stomach and duodenum (gastroduodenal fistulas) in patients with Crohn's disease. METHODS: The medical records of 14 patients with a gastroduodenal fistula complicating Crohn's disease treated in this unit between 1958 and 1997 were reviewed. RESULTS: In six patients a gastroduodenal fistula was diagnosed before surgery, whereas eight gastroduodenal fistulas were discovered during surgery for distal Crohn's disease. In six patients, the fistula originated from Crohn's disease in the transverse colon, and in six patients, it originated from a recurrent disease at an ileocolonic anastomosis; these patients had no gross evidence of gastroduodenal Crohn's disease. In one patient, the ileocolonic-duodenal fistula closed on medical treatment. The other 11 patients underwent resection of the diseased bowel and closure of the gastric or duodenal fistulas. The two remaining fistulas were from the duodenum to the abdominal wall; both had primary Crohn's duodenitis. One duodenocutaneous fistula was treated by debridement of the duodenal fistula and simple closure of the defect; the other was treated by limited duodenal excision around the fistula and by duodenojejunostomy. In all patients, gastroduodenal fistulas were cured, and there have been no fistula recurrences. CONCLUSIONS: Simple closure of the gastroduodenal component of the fistula is generally advised for gastroduodenal fistulas. However, when the duodenal defect after excision around the fistula is large, duodenojejunostomy is recommended, provided there is no evidence of jejunal Crohn's disease.

Patients from a hereditary nonpolyposis colorectal cancer (HNPCC) kindred (Lynch Type 1 and Type 2) have an increased risk of developing large-bowel cancer. Tumors occur at a young age and are characteristically right-sided. Colonic mucosal proliferation is known to be increased in several groups of patients at risk of colorectal cancer. PURPOSE: This study was performed to assess the pattern of mucosal proliferation at different sites in the colon of patients at risk of HNPCC and to determine whether this pattern differs from normal patients. METHODS: Mucosal biopsies were obtained at colonoscopy from 21 patients at risk for HNPCC (16 females; mean age, 42 years) and from 7 normal patients (4 females; mean age, 38 years), and mucosal proliferation was quantified using the whole crypt mitotic count (WCMC) technique. RESULTS: In patients from HNPCC families, WCMC and crypt area were significantly greater in the cecum than in the transverse colon and left colon (P< 0.001). Compared with normal patients, WCMC in HNPCC patients was significantly greater in the cecum only (P< 0.05). A significant right-to-left shift was also observed in normal patients, but the percentage increase from right to left was two-fold greater in HNPCC patients. CONCLUSIONS: These results confirm a proximalto-distal proliferative gradient in the human colon and suggest that this may be exaggerated in HNPCC. This increased proximal proliferative rate may be a factor in the development of right-sided cancer in these patients.

PURPOSE : This study was undertaken to elucidate characteristic findings of tuberculous (TB) colitis at double-contrast barium enema examination (DCBE). MATERIALS AND METHODS : Twenty-five patients with TB colitis diagnosed by biopsy (n = 13) or therapeutic trial (n = 12) were included. DCBE findings were retrospectively analyzed, with special emphasis on distribution of lesions and mucosal changes. RESULTS : Involvement was asymmetric in 12. The lesion was noted more commonly in the ascending colon (n = 23), cecum (n = 21), and terminal ileum (n = 19) compared with the transverse colon (n = 15) and descending and sigmoid colon (n = 9). Skipped lesions were seen in 13 patients. Sixteen patients had multiple ulcers that were mostly transverse or circumferential in alignment (n = 11). Depth of ulcers was superficial (

PURPOSE: This study was developed to compare median and actuarial survival after left hemicolectomyvs.left segmental colectomy. METHODS: Between January 1980 and January 1985, 270 consecutive patients (133 males and 137 females; mean age, 64±12 (range, 18–91) years with left colonic carcinoma located between the left third of the transverse colon and (but not, including) the colorectal juncture were randomly allotted to undergo either left hemicolectomy or left segmental colectomy. Left hemicolectomy removed the entire left colon along with the origin of the inferior mesenteric artery and the dependent lymphatic territory. Left segmentai colectomy removed a more restricted segment of the colon and left the origin of the inferior mesenteric artery unmolested. RESULTS: After elimination of 10 patients for protocol violation, 131 patients with left hemicolectomy and 129 with left segmental colectomy were analyzed. Both groups were similar with regard to preoperative risk factors (age, sex, obesity, weight loss, anemia, diabetes, cirrhosis, kidney failure, steroid therapy or radiation therapy performed for any cause other than cancer), pathology findings (size, degree of differentiation, Dukes stage, invasion of lymph nodes at the origin of the inferior mesenteric artery), and associated lesions. Only the length of tumor-free margins of colon removed was significantly longer in left hemicolectomy. The number of early postoperative abdominal and extra-abdominal complications was similar in both groups. Overall, early postoperative mortality was 4 percent higher, but not significantly in left hemicolectomy (eight deaths, 6 percent) than in left segmental colectomy (three deaths, 2 percent). Median survival was 10 years and nearly equivalent in both groups. The two actuarial survivai curves were similar. Bowel movement frequency was significantly increased after left hemicolectomy during the first postoperative year. Our results suggest that survival after left segmental colectomy is equivalent to that of left hemicolectomy. Notwithstanding the observation of other carcinologic rules, left segmental colectomy rather than left hemicolectomy may theoretically be performed under laparoscopy without compromising the carcinologic outcome.

To study the possible alteration of mucosal-submucosal somatostatin-containing cells in inflammatory bowel diseases (IBD), the total numbers of somatostatin-containing endocrine cells (SCEC) and submucosal ganglion cells (SGC) were counted in Crohn's disease (CD) and ulcerative colitis (UC). Tissue specimens from 25 CD and 25 UC patients were fixed in Hollande's fixative immediately after resection and were investigated by immunohistochemical staining. A single specimen was collected from 25 colorectal cancer patients, the control group. There was a significant difference in the number of SCEC between the tissues taken from the proximal colon (ascending and transverse colon) and the distal colon (descending and sigmoid colon). The distal colon tended to contain more somatostatin-immunoreactive cells than did the proximal colon. In IBD, SCEC were decreased in number compared with the controls. This decrease was related to the degree of inflammation in CD; the higher the grade of inflammation, the lower the number of SCEC. The number of SGC was decreased in IBD: however, a significant decrease was noticed only in CD. The anatomic origin and the degree of inflammation did not affect the number of SGC. In the present study, the decrease of somatostatin-containing cells was noticed in both CD and UC, but there was no significant difference between CD and UC. Therefore, it was assumed that this decrease was secondary to inflammation. However, the decrease of somatostatin, which works as an inhibitory peptide for inflammation, might have some role in the pathogenesis of IBD.

Leiomyosarcoma of the transverse colon is uncommon. A case report involving a 68-year-old man is presented. Included is a discussion of the characteristics of this rare entity based upon a review of the literature. The potential role of colonoscopy and indium-111 antimyosin in the diagnosis of this tumor is addressed.

PURPOSE: The increased mortality of emergencyvs.elective colonic surgery applies equally to the right and left colon. Recent interest has surrounded the application of expandable metal stenting in acute obstruction but has been confined to the left colon. We describe successful application of stenting in the right colon, allowing postponement of a particularly high-risk laparotomy. METHODS: A patient with acute bilateral iliofemoral thromboses simultaneously developed complete obstruction of the proximal transverse colon. After heparinization and under fluoroscopic control, a 10-cm-long, self-expanding Wallstent®(Schneider, Bulach, Switzerland), 22 mm in diameter, was manipulated across the obstruction. RESULTS: Immediate decompression with symptomatic relief ensued. The stent prevented obstruction during a 10-week period of anticoagulation, and repeat duplex scanning showed resolution of iliac thrombus. An elective right hemicolectomy was then performed. Postoperative course was uncomplicated, and histopathology confirmed a Dukes B carcinoma. CONCLUSIONS: This case, in which a potentially hazardous laparotomy was delayed until the operative risk improved, defines a new role for stenting in colonic obstruction and demonstrates an extension of its applicability to the right colon. Literature review found no other report of stent application in the right colon.

Laparcoscopic curative left hemicolectomy requires the takedown of colonic splenic flexure and has been challenging. The present study aims to examine if the technical advantages of medial-to-lateral dissection method, as shown in our previous laparoscopic rectosigmoid resection, can be extrapolated to the laparoscopic left hemicolectomy. A total of 24 consecutive patients (from October 2004 to March 2005) with left-sided colon cancer requiring the takedown of colonic splenic flexure to facilitate a curative left hemicolectomy were subjected to this laparoscopic procedure that included initial incision on the mesentery medial to inferior mesenteric vein, ligation of vessels in no-touch isolation fashion, subsequent medial-to-lateral extension of retroperitoneal dissection along Gerota fascia, opening of lesser sac by transection of gastrocolic ligament, dissection of mesenteric root of distal transverse colon, and the final separation of splenocolic ligament and lateral attachments of descending colon. The technical efficiency, the number of cleared lymph node, and functional recovery of patients were prospectively evaluated. The laparoscopic medial-to-lateral approach is considered as highly efficient because it was preformed with acceptable operation time (214.4 ± 54.4 minutes, mean±standard deviation) and little blood loss (40.0 ± 14.0 ml) through a small wound (5.5 ± 0.6 cm). The number of dissected lymph nodes was 14.0 ± 3.0. There were no major complications. Moderate morbidity represented 8 percent of all cases, including minor leakage in 1 case (4 percent) and wound infection in 1 case (4 percent). The patients have quick functional recovery, as evaluated by the length of postoperative ileus (48.0 ± 12.0 hours), hospitalization (9.0 ± 1.0 days), and degree of postoperative pain (3.5 ± 0.5, visual analog scale). The overall costs were NT$194,000.0 ± 3200.0 (1.0 US dollar = 32.0 NT$). By medial-to-lateral dissection method, the laparoscopic takedown of colonic splenic flexure can be performed with highly technical efficiency, acceptable number of cleared lymph node, and short convalescence. We therefore recommend this dissection method to the expert surgeons, endeavoring to define a standard technique to curative surgery in the left-sided colon cancers, and especially to the beginners, seeking to shorten their learning curve of laparoscopic left hemicolectomy.

Total colectomy is the preferred surgical option in proven slow-transit constipation. With advances in technology and instrumentation, laparoscopic total colectomy has become feasible. After a mechanical bowel preparation, the patient is placed in a modified lithotomy position and pneumoperitoneum is established. Using a subumbilical 12-mm trocar the camera is inserted. Two further 12-mm and 5-mm trocars, each, are used for access to the peritoneal cavity. In an approach from medial to lateral, ileocolic, middle colic vessels and the inferior mesenteric artery are divided. Medial mobilization is completed before the sigmoid is freed up laterally. The lateral mobilization continues orally to the descending, transverse, and ascending colon with the omentum being separated from the transverse colon completely. The mesorectum is divided using the harmonic scalpel, and the upper rectum is transected with either one or two passes of the endoscopic linear cutting stapler. The colon is exteriorized through a 5-cm Pfannenstiel incision. The terminal ileum is transected extracorporeally. After pneumoperitoneum has been reestablished, the ileorectal anastomosis is performed laparoscopically using a double-stapling technique. The video reports about a 56-year-old lady who had been suffering from chronic constipation since childhood and had become dependent on laxatives. A dolichocolon had been found in barium enema. A prolonged colonic passage was proven in an x-ray transit study. There were no intraoperative or postoperative complications. After surgery, first bowel movements occurred on the second day and the patient was discharged from the hospital on the sixth postoperative day. Laparoscopic total colectomy is a safe, feasible operation for slow transit constipation. With fast recovery and short length of stay it may become an attractive surgical approach.

Yersinia enterocolitica abscess of the bowel is a rare entity. Only five cases have previously been reported--none in the surgical literature. A unique presentation for Yersinia infection, abscess of the transverse colon, is described, and the literature of Y. enterocolitica intestinal perforation and abscess is reviewed.

Primary linitis plastica of the colon and rectum is an uncommon entity. Sixty-six cases have been reported in the English literature. Two new cases are reported, one of the transverse colon with widespread metastases and the other of the right colon extending from the appendix to the distal resection margin of the transverse colon. Some clinical and pathologic characteristics of the tumor are discussed, based on a review of the literature.

The posterior surface of the proximal transverse colon and the anterior surface of the descending duodenum are intimately related. The clinical importance of this apposition is re-emphasized with presentation of two cases which had the uncommon phenomenon of benign duodenocolic fistula. These two rare cases of duodenocolic fistulas secondary to Crohn's disease are added to the literature. It is also suggested that in some cases, duodenal mucosal alterations with adjacent Crohn's disease of the colon might be the result of reactive inflammatory changes, and do not necessarily indicate continuous extension of the granulomatous disease.

Thirty male Sprague-Dawley rats received weekly injections of dimethylhydrazine for three months. They were subsequently laparotomized and tumors were palpated in 21 rats. The colonic tumor was removed and a fraction was autotransplanted into the wall of the transverse colon and a second fraction into the subcapsular space of the left kidney. The results demonstrated successful autotransplantation of colonic tumors in 13 of 21 rats (i.e., 62 percent). In 11 of the 21 rats (52 percent) the tumor grew in the left kidney. Of the various experimental methods proposed for the study of tumor metastases, the one described herein appears to be the first in which primary and secondary tumors were studied in the same individual, since dimethylhydrazine-treated rats usually develop more than one colonic tumor per individual. The model may be useful to monitor the effect of various drugs known to affect tumor growth, not only at the primary site, but also at the site of metastasis.

Fifty-eight cases of colonic volvulus were reviewed including 30 cases of sigmoid volvulus, 27 cases of cecal volvulus, and 1 of transverse colon volvulus. Decompression procedures were attempted in 31 instances of sigmoid volvulus in 27 patients and were successful 25 times (81 percent). Seven patients with sigmoid volvulus did not undergo surgery and of those, two died of unrelated causes, one was lost to follow-up, one was well, and three had recurrent volvulus. Twenty-four operations were performed on 23 patients and there were three deaths (13 percent mortality). There was one recurrence in two patients who underwent simple detorsion. Chronic large-bowel motility disturbances were a persistent problem in 9 of 20 (45 percent) surgical survivors. Among 27 instances of cecal volvulus, one was reduced by contrast enema and ten endoscopic attempts at decompression were unsuccessful. Twenty-six operations were done and there were four operative deaths (15 percent mortality). There were no recurrences. Large-bowel motility disorders were noted in follow-up in 3 of 22 patients (14 percent). Overall there were 10 deaths in 58 patients for a 17 percent mortality rate. These data support the importance of endoscopic decompression for sigmoid volvulus but not for cecal volvulus. Definitive treatment of both forms of volvulus should include assessment of colonic motility.

A case is described of a patient found, at operation, to have two infiltrating leiomyosarcomas in the transverse colon. Study indicated them to be two separate primary lesions. Literature on leiomyosarcoma is reviewed.

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.

In the ten-year period between 1975 and 1986, 367 patients underwent colonic resection with subsequent anastomosis using intraoperative colonic irrigation with 10 percent povidone iodine. One hundred thirty three patients underwent resection of the right or transverse colon, whereas 233 patients had left hemicolectomy with low anterior anastomosis or reanastomosis. Twenty individuals underwent emergency resection for perforation and temporary end colostomy. Nineteen of these patients returned for definitive reanastomosis as part of a two-stage procedure. The rate of wound infection, and/or intra-abdominal abscess formation was retrospectively reviewed and found to be completely nonexistent in these patients. This study examines the various techniques used to reduce the rate of wound infection after colonic surgery and addresses the concept of intraoperative povidone iodine irrigation.

A fistula between the greater curvature of the stomach and the midportion of the transverse colon usually is an ominous condition. If there is no history of previous surgery, it is likely that a diagnosis will be made of a gastrocolic fistula secondary to a primary carcinoma of either the stomach or the colon. However, as shown in this paper, a spontaneous fistula may develop between the stomach and the transverse colon in a patient with a benign unoperated gastric ulcer.

Rapid improvement in the safety with which intestinal resection and anastomoses can be done make it desirable to delineate the extent to which dissection should be carried out for carcinoma of the various segments of the bowel. This should be done on a basis of what is known of the anatomy of lymphatic drainage and the physiopathologic characteristics of the tumor, rather than upon technical feasibility alone.

Among lipomas of the colon, mixed submucous-subserous lipomas are rare. The etiology is obscure. Diagnosis is difficult and rarely made without radiologic study of the colon with double-contrast technic and air insufflation.

A review has been presented of the historical background and pathogenesis of acute fulminating ulcerative colitis with distention of the colon. A personal series of ten cases has been summarized and symptomatology, physical findings, diagnosis and treatment have been discussed. Opinions have been expressed regarding problems involved in the management of this severe complication and recommendations have been made concerning the optimum surg cal procedure.

A rare case of severe rectal bleeding beginning in adult life is reported. A diffuse, cavernous hemangioma of the right transverse colon was visualized by superior mesenteric arteriography and the diagnosis was confirmed by peroperative colonoscopy carried out through a colotomy. The patient was treated by right hemicolectomy. The diagnostic value of selective abdominal arteriography in patients who have severe rectal bleeding is demonstrated.

For three months 65 male Sprague-Dawley rats received subcutaneous 1,2-dimethylhydrazine (DMH) weekly. Of the 65 animals, 45 were subjected to resection of the transverse colon, which subsequently was stitched to the abdominal wall. The remaining 20 animals were sham-operated controls. Fifty-four per cent of the tumors occurred either at the anastomotic site in the functioning colon (31 per cent) or at the anastomotic site of the isolated and defunctionalized colonic loop (23 per cent). On the other hand, only 10 per cent of the tumors occurred in the transverse colon of sham-operated controls. The difference was significant (P less than 0.001).

A case report of sclerosing mesocolitis is presented. This is an unusual and poorly understood entity. A 49-year-old woman presented with episodic abdominal pain and a palpable abdominal mass. A fibrotic mass causing extensive compression of her cecum and transverse colon was found at laparotomy. The pathologic findings and treatment of sclerosing mesocolitis are discussed.

In an attempt to know the exact retrograde spread of high-dosage 5-aminosalicylic acid enemas, we have studied eight patients with active left-sided colitis, by adding a small amount of barium sulfate to the enemas and by checking the spread radiologically after 15 minutes, 1 hour, and 6 hours. Four grams of 5-aminosalicylic acid in 100-ml enemas and 4 gm in 200-ml enemas were used. The same experiment was repeated in a subsequent attack, with enemas labeled with technetium-99m and checked by scintiscans in five of these patients. We always have observed a volume-dependent spread of enemas but, interestingly, in the patients studied with technetium-99m there was always a wider spread than that which was detected with barium enemas. In all five patients, 100-ml enemas reached the splenic flexure. In two patients with total colitis, a progression of 100-ml technetium-99m enemas was performed in the transverse colon, but the maximum opacity remained in the left side. We can conclude that 4 gm of 5-aminosalicylic acid in 100-ml enemas can be suitable for treating patients with left-sided colitis, and will represent a valid addition for patients with more extensive colitis.