摘要:

PURPOSE:The aim of this study was to compare diathermy and Harmonic Scalpel® hemorrhoidectomy.METHODS:Fifty consecutive patients were randomly assigned to 2 groups: Group 1 (diathermy) and Group 2 (Harmonic Scalpel®).RESULTS:The median duration of surgery was 10 minutes for both groups. The median number of pethidine injections used for both groups was zero. The median number of oral analgesic tablets taken was 13 by Group 1 and 14 by Group 2 patients. The median number of tubes of lidocaine jelly used was two by Group 1 and three by Group 2. There was no statistical difference between pain scores recorded by both groups. Five patients in Group 1 developed posthemorrhoidectomy bleedvs.one patient in Group 2 (P=NS).CONCLUSION:Hemorrhoidectomy by Harmonic Scalpel® is comparable to diathermy hemorrhoidectomy in terms of postoperative pain and complications.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:Anal sphincter spasm is believed to play an important role in pain after hemorrhoidectomy. We tested a different form of nitroglycerin: the Nitroderm TTS® band. We investigated its efficacy on posthemorrhoidectomy pain and the relation between pain and anal resting pressure measured preoperatively and postoperatively.METHODS:Thirty‐eight hemorrhoid patients were divided into two groups: those with high anal resting pressure were classified as group A (n=24) and those with low anal resting pressure were classified as group B (n=14). After hemorrhoidectomy, Nitroderm TTS® bands were placed into the anal canal in half of the patients in groups A and B (groups A‐1 and B‐1) and not in the remaining half (groups A‐2 and B‐2). Anal resting pressure measurement was repeated at the first day and third month postoperatively. Postoperative pain was assessed by linear analog scale, and analgesic consumption was recorded.RESULTS:Preoperative anal resting pressure was 112.0 (range, 95‐140) cm H2O in group A‐1 and 110.6 (range, 96‐138) cm H2O in group A‐2. The difference was insignificant. However, on the first postoperative day, anal resting pressures were 88.7 (range, 75‐115) and 110.9 (range, 92‐135) cm H2O (P=0.0001), and at the third month, they were 76.5 (range, 70‐100) and 78.0 (range, 70‐105) cm H2O, respectively (P=0.690). Postoperative pain scores were significantly lower in group A‐1 than group A‐2 (P=0.0001). In the low‐pressure groups (B‐1 and B‐2), anal resting pressures before surgery, on the first postoperative day, and at the third month postoperatively were 70.4 (range, 56‐76), 67.4 (range, 50‐75), and 67.2 (range, 55‐74) cm H2O in group B‐1 and 69.8 (range, 58‐76), 70.2 (range, 60‐76), and 68.4 (range, 60‐74) cm H2O in group B‐2. The differences were insignificant (P≥0.660). The differences between pain scores in these groups were also insignificant (P≥0.160).CONCLUSION:Nitroderm TTS® bands effectively reduced anal resting pressure and relieved pain in patients with high preoperative anal resting pressure.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:The WAND™ is a computer‐controlled local anesthetic delivery system. Its use has been proven to be more comfortable for dental patients. The purpose of this study is to explore its applicability to anal procedures. Our hypothesis is that the WAND™ will provide greater comfort during anesthesia delivery while achieving the same anesthetic effect as traditional syringe technique.METHODS:Twenty patients with painless anal pathology were randomized to receive anal anesthesia using either the WAND™ or traditional syringe technique to a randomly selected half of the anoderm (right or left). The opposite side was then anesthetized by the alternate method, allowing patients to act as their own control. Objective and subjective pain scores were obtained from the patient after each mode of delivery. An independent observer interpreted the patient's tolerance by giving a subjective pain score. The volume of anesthetic used was recorded. Adequacy of anesthesia was tested by a pinch test.RESULTS:Sixteen (80 percent) of the 20 patients preferred the use of the WAND™. Objective and subjective pain scores per the patients and subjective pain scores per the observer were significantly lower for the WAND™ than for traditional syringe technique (P<0.05). The mean volume of local anesthetic used with the WAND™ was 1.7 ml compared with 3.2 ml for traditional syringe technique (P<0.005). Anesthesia achieved with the WAND™ was as good as that achieved with traditional syringe technique when the pinch test was used.CONCLUSION:The WAND™ is as effective as the traditional syringe technique in the delivery of anal anesthesia while providing a more comfortable experience for the patient.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

INTRODUCTION:Anal high‐grade squamous intraepithelial lesions are probable invasive anal squamous‐cell cancer precursors, and although unproved, treatment of high‐grade squamous intraepithelial lesions may prevent progression to anal squamous‐cell cancer. Men who have sex with men are often treated for benign anorectal disorders without consideration given to the possibility of concurrent high‐grade squamous intraepithelial lesions or anal squamous‐cell cancer. We determined the prevalence of anal high‐grade squamous intraepithelial lesions and anal squamous‐cell cancer in an urban surgical practice of men who have sex with men referred for treatment of anal condyloma and other benign noncondylomatous anal disorders.METHODS:One hundred thirty‐one HIV‐positive and 69 HIV‐negative men who have sex with men referred for surgical treatment of presumed benign anorectal disease were evaluated by anal cytology, high‐resolution anoscopy, and biopsy. Anal cytology and histology were reported with a modified Bethesda classification.RESULTS:One hundred fifty‐seven patients (79 percent) were referred for condyloma, 4 (2 percent) for anal squamous intraepithelial lesions (anal high‐grade squamous intraepithelial lesions) diagnosed by primary care providers, and 39 (19 percent) for other benign anorectal disorders. One hundred forty‐three patients (93 percent) had abnormal anal cytology, with 107 (54 percent) having high‐grade squamous intraepithelial lesions on cytology. Biopsy results revealed 120 patients (60.0 percent) with high‐grade squamous intraepithelial lesions and 5 patients (3 percent) with invasive squamous‐cell carcinoma. Four of five men with anal squamous‐cell cancer were HIV positive. Fourteen men (36 percent) who have sex with men referred for noncondylomatous benign anal disorders had high‐grade squamous intraepithelial lesions, and three (8 percent) had anal squamous‐cell cancer. High‐grade squamous intraepithelial lesions and anal squamous‐cell cancer were seen most often at the squamocolumnar junction.CONCLUSIONS:Men who have sex with men referred for treatment of either condyloma or noncondylomatous benign anorectal disease had a high prevalence of anal high‐grade squamous intraepithelial lesions and anal squamous‐cell cancer. All men who have sex with men referred for treatment of benign anorectal disease should have high‐resolution anoscopy and aggressive biopsy of all abnormal areas. Treatment of external lesions alone could miss high‐grade squamous intraepithelial lesions or anal squamous‐cell cancer.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:Our hypothesis was that in patients with perforated sigmoid colon diverticulitis and peritonitis (Hinchey Stage III and IV) a one‐stage sigmoid colon resection is safe and cost effective when performed by an experienced colorectal surgeon. We evaluated outcome and cost of one‐stagevs.two‐stage sigmoid colon resection after diverticulitis perforation and peritonitis.METHODS:Patients undergoing emergency resection for perforated sigmoid colon diverticulitis and peritonitis (Hinchey Stage III and IV). Outcome, costs, and insurers reimbursement were compared between 13 patients undergoing sigmoid colon resection and primary anastomosis (Group A) and 42 patients undergoing sigmoid colon resection with Hartmann's procedure and secondary descendorectostomy (Group B).RESULTS:Group A patients were comparable to Group B patients in age, gender, preoperative risk and severity of peritonitis (Mannheim Peritonitis Index and C‐reactive protein). Operating room time for sigmoid colon resection with primary anastomosis (3.3±1.2 hours) was identical to the time for sigmoid colon resection with colostomy (3.3±1 hour), and morbidity and mortality, intensive care unit, and in‐hospital stay were not significantly different between the two groups. In Group B patients' intestinal continuity was restored 169±74 days after the primary resection in 32 of 42 patients only (78 percent). The second procedure took on average 1.4 hours longer than the first procedure. Patients in Group B received more antibiotics (2.2vs.2) albeit for a shorter period of time (4.5vs.5.7 days,P= not significant). Overall expenses for restoration of intestinal continuity were between 74 and 229 percent higher for Group B patients than for Group A patients. Reimbursement was 18,191±16,761 SFr (Group A) and 41,321±26,983 SFr (Group B) respectively.CONCLUSION:With meticulous surgical technique and extensive intraoperative lavage, perforated sigmoid colon diverticulitis with peritonitis can be treated by a one‐stage sigmoid colon resection and anastomosis with a low mortality and morbidity. A one‐stage procedure is considerably cheaper and patients are rehabilitated faster and to a higher percentage.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:The aim of the study was to assess the impact of sodium hyaluronate and carboxymethylcellulose membrane (Seprafilm®) on postoperative intestinal obstruction as judged by the rates of bowel obstruction and laparotomy for bowel obstruction. A secondary aim was to assess early postoperative morbidity.METHODS:All patients who had Seprafilm® placed during colorectal surgery between June 1993 and October 1998 were included in the study group and compared with a matched group of patients without Seprafilm®. All patients were assessed for intestinal obstruction and complications by telephone interview and chart review. Statistical tests for independence were used where appropriate; alpha was 0.05 for all tests, and the two groups were tested for case matching. Fisher's exact test was used to compare gender distribution, nature of diagnosis (inflammatoryvs.noninflammatory), and urgency of surgery (electivevs.emergency). The age distribution, number of prior abdominal surgeries, and operative time were compared by Student'st‐test. Approximation of Katz test was used for independent proportions to compare the two groups for early postoperative morbidity and overall incidence of intestinal obstruction and surgical enterolysis. The incidence of intestinal obstruction between the two groups was also compared with Kaplan‐Meier product limit method and log‐rank test.RESULTS:Two hundred fifty‐nine patients in whom Seprafilm® was placed were compared with a well‐matched control cohort of 179 patients. The two groups did not differ in gender or age. One‐half of each group had inflammatory conditions, and approximately 90 percent of each group underwent elective operations. The operative times were similar. Both groups had a similar number of abdominal operations before inclusion (mean = 1.2, both groups). Early morbidity rates were 17.8 percent for the Seprafilm® group and 15.6 percent for the controls, with mortality rates of 0.8 percent and 0.0 percent, respectively. There were 12 intestinal obstructions in 12 patients in the Seprafilm® group and 12 intestinal obstructions in 11 patients in the control group at a follow‐up period of 65 months in the Seprafilm® group and 81 months in the control group. Eight of the 12 intestinal obstructions in the Seprafilm® group resolved with conservative management while only 5 of 12 in the control group responded without surgery. Thus the enterolysis rate was 1.5 percent in the Seprafilm® group and 3.9 percent in the control group, demonstrating a trend in favor of Seprafilm®. There were no statistically significant differences in the incidence of either overall or abdominopelvic septic complications between the Seprafilm® (3.4 percent) and control (1.1 percent) groups.CONCLUSION:During short‐term follow‐up in this nonprospective, nonrandomized study, limited placement of Seprafilm® did not significantly reduce the need for surgical enterolysis for intestinal obstruction or significantly adversely affect the morbidity rate. However, a long‐term, prospective, randomized trial is underway to elucidate these issues.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:This study was designed to assess the medical and surgical treatment of colonoscopic perforations.METHODS:A retrospective review of colonoscopic perforations from 1970 to 1999 was performed.RESULTS:In 30 years, 34,620 colonoscopies resulted in 31 (0.09 percent) perforations. Eighteen (58 percent) resulted from therapeutic colonoscopies, whereas 13 (42 percent) occurred after diagnostic colonoscopies. Sixteen perforations (52 percent) were identified during the procedure, 13 (42 percent) within 24 hours, and two (6 percent) within 48 hours. Twenty patients (65 percent) underwent surgical therapy, and 11 (35 percent) were treated medically with intestinal rest and intravenous antibiotics. In the medically treated group, one patient required rehospitalization for percutaneous drainage of an intra‐abdominal abscess, and one patient died after requesting no further treatment because of an underlying terminal medical condition. Three patients failed medical treatment and required surgical intervention. One underwent repair with proximal diversion, whereas the remaining two received a colorrhaphy without resection or diversion. In the surgical treatment group, nine patients received colorrhaphy without diversion, seven underwent resection with primary anastomosis, and four had resection with diversion.CONCLUSION:Selected patients with colonoscopic perforation may be safely treated nonoperatively. Surgical treatment is reserved for patients with a large perforation or diffuse peritonitis.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:Surgical treatment of rectal cancer is followed by local recurrence in up to 30 percent of cases. Recently, preoperative low‐dose radiotherapy has been shown to improve both local recurrence rate and overall survival. Downstaging of locally advanced tumors, however, requires preoperative doses of at least 50 to 60 Gy. Most experimental studies investigating the effect of preoperative radiotherapy have made use of a single dose or a limited number of fractionated doses. Moreover, in most studies, both limbs of the anastomosis were irradiated, in contrast to clinical practice, in which one limb of the anastomosis consists of nonirradiated bowel. We studied the effect of a fractionated, clinically relevant scheme of high‐dose preoperative radiotherapy on colonic anastomotic healing in the rat.METHODS:Male Wistar rats randomly received 0, 40, 60, or 80 Gy of preoperative radiotherapy on one limb of the anastomosis only. Radiotherapy doses were validated with implanted dosimeters; before the start of radiotherapy, the cecum was fixed outside the radiation field. A clinically used fractionation scheme of 2 Gy per day, 5 days per week for 4 to 8 weeks was used. The day after radiotherapy completion, a side‐to‐side colorectal anastomosis was performed. Rats were killed 10 days after surgery. The following parameters were determined: presence of abscess or peritonitis, anastomotic complications (stenosis, leak, or dehiscence), intestinal obstruction, anastomotic bursting pressure, and anastomotic hydroxyproline content.RESULTS:No significant differences were found in peritonitis rate, anastomotic complications, anastomotic bursting pressure, or hydroxyproline content. Irradiated animals gained weight more slowly than the control group.CONCLUSION:In this rat model, preoperative high‐dose radiotherapy using a clinically relevant fractionation scheme does not affect outcome or anastomotic healing when only one limb of the anastomosis is irradiated.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:A 30‐percent gas incontinence rate has been reported after the use of the cutting seton in complex anal fistulas. This study was undertaken to determine the morbidity and efficacy of the cutting seton in the management of complex anal fistulas at the King Faisal Specialist Hospital.METHODS:All patients who had a cutting seton inserted in the colorectal unit at King Faisal Specialist Hospital between 1990 and 1998 were identified from a colorectal data base. The charts of these patients were examined and form the basis of this report. Setons were inserted and tied under general anesthesia after the fistula tract had been identified. All fistulas were transsphincteric, and if it seemed that more than 30 percent of the internal sphincter would need to be divided to “lay open” the tract, a seton was used. Fistulas were designated “high” if the internal opening was above the level of the anal crypts. Setons were tightened under general anesthesia at intervals of three to four weeks until cutting was complete. Patients were followed up until wounds had healed and fistula symptoms had resolved.RESULTS:Data from 47 patients were analyzed. The mean duration of disease before surgery was 39.1 months. Twenty‐five patients had had previous anorectal abscess drainage. The mean number of previous fistula operations was 2.2. Before seton insertion five patients were incontinent to gas, two to liquid stool, and none to solid stool. Continence status before seton surgery was unknown in 11 patients. There were 16 “high” fistulas. Methylene blue dye was used to identify the internal opening in 14 patients when simple probing failed. Setons were tightened on three or more occasions in 12 patients, twice in 19 patients, and once in 16 patients. Mean perineal wound healing time was six months. The mean length of follow‐up was 1.1 years, and during this time one fistula recurred. After treatment a total of 17 patients (36.2 percent) were incontinent to gas, 4 to liquid feces (8.5 percent), and 1 to solid feces (2.3 percent). Four patients complained of soiling. Of previously continent patients, 9.5 percent were significantly incontinent to gas, but in addition 21.4 percent were “occasionally” incontinent for gas.CONCLUSION:The use of the cutting seton resulted in a significant gas incontinence rate of 9.5 percent after a mean follow‐up of 1.1 years. Only 1 fistula recurred.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID