Internal fistulas in diverticular disease are uncommon and have a reputation of being difficult to treat. Eighty four patients treated from 1960 to April 1986, representing 20.4 percent (84 of 412) of the surgically treated diverticular disease patients, were reviewed. Eight patients had multiple fistulas. Sixty-five percent (60 to 92) of fistulas were colovesical, 25 percent (23 of 92) colovaginal, 6.5 percent (6 of 92) coloenteric, and 3 percent (3 of 92) colouterine fistulas. There were 66 percent (35 of 53) males and 34 percent (18 of 53) females with colovesical fistulas only. Hysterectomies had been performed in 50 percent (12 of 24) and 83 percent (19 of 23) of females with colovesical and colovaginal fistulas, respectively. Operative management included: resection anastomosis, resection with anastomosis and diversion, Hartmann procedure, and three-stage procedure. In the latter half of the series there was a significant decrease in staging procedures with no significant statistical difference in complications. There were three deaths (3.5 percent) in the series. Other complications included: wound infection, 21 percent (18 of 84), enterocutaneous fistula, 1 percent (4 of 84), and anastomotic dehiscence, 5 percent (4 of 84). Primary anastomosis can be performed with acceptable morbidity and mortality and today is the procedure of choice, leaving staging procedures to selected patients.

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.

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%)

Our experience with closure of loop ileostomies between the years 1975-1986 was reviewed. Ninety-three percent of stoma closures were done by simple transverse suture. The overall complication rate was 17%. Of the early postoperative complications (13%), the major complication was small bowel obstruction especially in patients where the stoma was protecting a pelvic ileal reservoir. Abdominal septic complications (postclosure) were rare (1%). These were generally caused by unrecognized enteric tears during the mobilization of the stoma rather than anastomotic leakage. A careful operative technique is required. The wound infection rate after healing by both secondary intention and primary skin closure was low (3%) and mainly superficial. Only one incisional hernia was observed in the late postoperative period. In three patients a posterior rectus sheath defect at the stoma site was found incidentally at laparotomy, without clinical evidence of an incisional hernia. Closure of a loop ileostomy is a safe operation with a low morbidity. In patients with a previous total colectomy there was a significant risk of small bowel obstruction after ileostomy closure.

In a retrospective study, the records of 95 patients who underwent rectal resection for carcinoma were reviewed to assess the efficacy and complications of pelvic packing for hemorrhage. Heavier blood loss was noted with fixed tumors, where preoperative radiation had been given, or there had been previous pelvic surgery, compared with situations where these factors were absent. Three patients died from myocardial infarction, pulmonary embolus, and renal failure, respectively. No patients required further hemostatic measures after pack removal. Perineal wound infection or delayed perineal wound healing occurred in 22 percent and abdominal wound infection in 6 percent of the patients. There were no instances of anastomotic leak, abdominal abscess, or pelvic abscess requiring laparotomy for treatment in this series. Pelvic packing is a safe, simple, and effective procedure for patients with problematic pelvic bleeding after rectal resection.