The need for protective transverse colostomy in low anterior resection using the EEA stapler was tested in a randomized series of 50 patients, half of whom received peroperative protective colostomy. Gastrografin enema on the tenth postoperative day showed a leakage frequency of 30 per cent in both groups. Clinical leakage was noted in 4 per cent (one patient) in the colostomy group and 12 per cent (three patients) in the noncolostomy group. Protective colostomy was followed by stenosis in nine instances, compared with only two in the noncolostomy group (2 alpha = 0.05). Routine protective colostomy should not be used in low anterior resection when the EEA stapling instrument is used. The occasional clinical leakage, which may appear in the postoperative period, can be revealed by close observation and successfully treated by an emergency colostomy. The majority of patients with anterior resection of the rectum, therefore, can be spared the inconvenience and cost of temporary colostomy.

No abstract

The records of 80 consecutive patients with extrahepatic bile duct cancer, 45 women and 35 men, median age 70 years (33-89 years), were reviewed. The histologic diagnoses were adenocarcinoma in 45 patients, 34 cholangiocarcinoma and one squamous cell carcinoma. In 34 patients the tumor was located to the confluence, the right or left hepatic duct, in 16 to the middle and in four to the distal portion of the bile duct. In the remaining 26 patients the tumor comprised more than one of these locations (mixed location). Twenty-seven of the 80 patients (34%) were operated on with resection of the tumor. Among patients 70 years of age and younger the resectability rate was 57%. In nine patients the main surgical procedure was bile duct resection, in 15 patients bile duct resection and liver lobe resection, in 2 patients total pancreatectomy and in one local excision were performed. The resection of the tumor was regarded as radical in 12 patients and palliative in 15. The mortality rate was 11% after resection as compared to 30% in patients with nonresectable tumors. The most common postoperative complication was insufficiency of the anastomosis which occurred in seven patients. Three of these patients required reoperation. The median survival time in patients operated on with radical resection was 20 months, palliative resection 7(1/2) months and in patients with nonresectable tumors 2(1/2) months. The quality of life was estimated according to a special schedule and was found to be improved after resection as compared to nonresection. Patients operated with radical resection spent significantly less of their remaining life at hospital as compared to palliatively resected patients or patients with nonresectable tumors.

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Twenty consecutive patients with secondary liver tumors were treated with a new method of liver dearterialization, performed by transient occlusion of the hepatic artery with strangulating slings, and followed by regional intra-arterial infusion of 5-fluorouracil. Tumor regression was confirmed by angiography, laboratory tests and symptom relief in more than 50% of the patients. For patients with metastatic colorectal carcinoma the mean survival time after operation was 17 months and the median survival -time was 11 months. The most common complications were abscesses and aneurysms. The treatment is judged suitable for patients with a tumor of moderate severity involving both liver lobes and without extrahepatic tumor growth.S URVIVAL TIME FOR PATIENTS with untreated hepatic malignant neoplasms is depressingly short, and many patients with hepatic tumors have such disabling symptoms as fever, anorexia, fatigue, epigastric fullness and pain.7'15 The disease frequently involves both liver lobes, and only a few patients can be helped by liver resection. Interruption of the arterial blood supply to the liver5" 9'25 or regional infusion of cytotoxic agents4'29'33 as treatment for disseminated liver malignancies have been used during the last two decades, and more recently combinations of these palliative procedures have also been used. 2'13'22'24'28'34 The rationale for treatment with liver dearterialization and intra-arterial chemotherapy is based on the fact that the nutrition of liver tumors is almost exclusively arterial, while normal liver tissue derives its blood supply from the portal vein as well as the hepatic artery.1 9"14 Dearterialization as the sole procedure has been disappointing, with high intraoperative mortality and doubtful therapeutic results.3'23 Regional intra-arterial infusion may produce tumor regression,4'29'33 but prolonged survival has not been convincingly shown after this treatment. We have tried to combine the effects of temporary arterial occlusion producing central From the Departments of Surgery and Diagnostic Radiology, University of Lund, Lund, Sweden tumor necroses, with intra-arterial infusion of 5-fluorouracil, which may affect the rapidly proliferating cells in the periphery of the tumors." Our method has previously been briefly described,6'12 but we are now able to review our experiences of the first 20 consecutive cases treated with temporary hepatic dearterialization followed by regional oncolytic infusion. From August 1972 to March 1976 patients with liver tumors underwent operation for transient hepatic dearterialization. Two patients had thrombosis of the hepatic artery at or shortly after operation, prior to the planned temporary occlusion, and they are excluded from this series. The mean age of the remaining 20 patients (11 men and nine women) was 59 years. Their ages ranged from 41 to 73 years at the time of surgery. Eighteen patients had had their primary tumors removed at an earlier operation, and only in two cases with intestinal carcinoids did we treat the primary...