摘要:

PURPOSE:We studied patients with Crohn's disease affecting the colon to characterize disease behavior and to determine whether such patients might be candidates for sphincter‐sparing surgery.METHODS:Ninety‐two consecutive patients with Crohn's colitis were studied prospectively. Mean follow‐up after diagnosis was 82 (range, 6‐291) months. Parameters that were evaluated included previous surgery for Crohn's disease, granulomatousvs.nongranulomatous disease, extent of colonic involvement, and presence or absence of extracolonic disease. The clinical course of the disease and postoperative outcome were evaluated. The outcome of Crohn's colitis patients who underwent ileal pouch‐anal anastomosis for presumed ulcerative colitis was also evaluated.RESULTS:There were 39 patients with granulomatous colitis and 53 patients without granulomas. There was no statistical difference in the age of diagnosis or presence of small‐bowel (23vs.27 percent), ileocolic (34vs.30 percent), or perineal (36vs.22 percent) disease in these patients. At initial presentation, 88 percent of patients with pancolitis had colitis alone without other sites of intestinal disease compared with only 37 percent of patients with segmental colitis (P< 0.001). Kaplan‐Meier analysis showed that patients with granulomas and patients with segmental colitis at presentation have a significantly higher recurrence when compared with patients without granulomas and patients with pancolitis (P< 0.03). Thirteen patients without granulomatous disease and eight with granuloma underwent ileal pouch‐anal anastomosis. Seven patients (3 with granuloma, 4 without granuloma) had a recurrence of Crohn's disease in the ileal pouch; 2 required pouch removal and permanent diversion for fistulizing disease in the ileal pouch and 5 were successfully treated conservatively without surgery.CONCLUSION:The presence of granulomas and segmental involvement of the colon in patients with Crohn's colitis may reflect a more virulent clinical course. Ileal pouch‐anal anastomosis may be considered as an option in select patients with Crohn's colitis without small‐bowel or perianal disease. Based on our data, patients with nongranulomatous pancolitis may be better candidates for sphincter‐sparing surgery.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:The purpose of this study was to determine the cumulative success rate of Kock continent ileostomy and the reasons leading to excision and to compare the results with pelvic pouch and ileal pouch‐anal anastomosis.METHODS:The data were collected from the histories of 96 patients, who underwent a Kock continent ileostomy operation from 1972 to 2000 at Helsinki University Central Hospital. The failure rate was calculated by the Kaplan‐Meier method.RESULTS:Overall, the continent ileostomy was converted to conventional stoma in 21 patients (24 percent). The cumulative success rate was 96 percent at 1 year, 86 percent at 10 years, 77 percent at 15 years, and 71 percent at 29 years. The most common reason for pouch excision was partial or total nipple‐valve sliding. Eighty‐five re‐reconstructions were performed among 57 patients (59 percent), the most common indication being nipple‐valve dysfunction. Of these patients, 14 later ended up with pouch excision. The success rate of continent ileostomy was significantly lower than that of ileoanal anastomosis (P< 0.01).CONCLUSION:The durability of continent ileostomy is mainly related to the mechanism of the nipple valve and not to ileitis or other systemic effects of the basic disease. Kock continent ileostomy can offer satisfactory long‐term function in more than two‐thirds of patients up to 30 years.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

INTRODUCTION:Rectal administration of corticosteroids is advocated in patients with proctosigmoiditis who have failed therapy with mesalamine enema. Foam offers patients better tolerability than an enema. In this study the efficacy and adverse effects of a new budesonide foam are compared with the presently available hydrocortisone foam.METHODS:Two hundred fifty‐one patients with proctosigmoiditis were randomly assigned to receive either budesonide foam or hydrocortisone foam for eight weeks.RESULTS:Remission rates were comparable in the budesonide and hydrocortisone groups, 53 and 52 percent, respectively. The mean disease activity index for the two groups decreased to a similar extent, from 7.2 ± 1.9 and 7 ± 2 to 3.6 ± 3.1 and 3.9 ± 3.4 in the budesonide and hydrocortisone groups, respectively. In a subgroup of patients who had not responded to rectal administration of mesalamine, 23 of 44 (52 percent) patients who received budesonide responded favorably to the foam, as compared with 14 of 38 (37 percent) patients who received hydrocortisone (P= not significant). Low plasma cortisol occurred in 3 percent of the budesonide group and in none of the hydrocortisone patients.CONCLUSIONS:This trial demonstrates a similar efficacy and safety of the two foams in patients with proctosigmoiditis.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:The aim of this study was to compare the results of two surgical techniques (direct end‐to‐endvs.overlapping) of delayed repair of a localized anterior defect of external anal sphincter after an obstetric trauma.METHODS:During a five‐year period, 23 patients were randomly assigned to direct end‐to‐end repair (n = 12) or overlapping sphincter repair (n = 11), using 2‐0 PDS™ sutures. Two patients from each group had an internal anal sphincter defect that also was repaired. All patients had a normal pudendal nerve terminal motor latency preoperatively. Evaluations included endoanal ultrasound, anorectal manometry, and neurophysiologic evaluation. Continence was assessed by the Cleveland Clinic Continence Score (0‐20; 0, perfect continence; 20, complete incontinence).RESULTS:The two groups were comparable with regard to age (median, 45 years), past history of sphincter repair (n = 2), and posterior vaginal repair. There was no major morbidity. The wound‐healing rate was identical between the two groups. However, of the patients undergoing overlapping repair, two had fecal impaction, and one had a urinary retention. Median preoperative continence score was 17 in both the direct‐repair group (score, 8‐20) and the overlap group (score, 7‐20). At a median follow‐up of 18 months, the improvement in continence was similar between the two surgical groups, with a median continence score of 3, respectively. In both surgical groups there was a significant and similar improvement in maximum squeeze pressure and in the functional anal canal length postoperatively (P< 0.05), but the mean resting pressure was relatively unchanged. In the overlap group, one patient developed a unilaterally prolonged pudendal nerve terminal motor latency that was persistent 22 months after surgery, and two patients had impaired fecal evacuation postoperatively.CONCLUSIONS:This randomized, controlled study suggests that the outcome is similar whether direct end‐to‐end or overlapping repair of a sphincter defect is performed. Overlapping repair might be associated with more difficulties with fecal evacuation and a prolonged pudendal nerve terminal motor latency postoperatively.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:Hidradenitis suppurativa is a chronic inflammatory disease of the skin and subcutaneous tissue. Extensive gluteal and perianal disease represents a challenge presentation. The aim of this study was to present results of management of extensive hidradenitis suppurativa in gluteal, perineal, and inguinal areas.METHODS:From January 1980 to May 2000, 56 patients underwent treatment of hidradenitis suppurativa in gluteal, perineal, and inguinal areas through wide excision; 52 (93 percent) were male and 36 (64 percent) were white. Mean age was 40 years. We evaluated distribution of disease, associated conditions, use of diverting colostomy, management of operative wounds, time to complete healing, complications, and recurrence.RESULTS:Twenty‐one (37.6 percent) and 17 (30.6 percent) patients had gluteal and perineal disease, respectively. Squamous‐cell carcinoma and Crohn's disease were observed in one patient each. Wide surgical excision was performed in all. Healing by second intention was the choice in 32 (57.1 percent) patients, and 24 (42.9 percent) patients underwent delayed skin‐grafting. Diverting colostomy was used in 23 (41 percent) patients. Mean time for complete healing in the nongrafted group was 10 (range, 7‐17) weeks and in the skin graft group was 6 (range, 3‐9) weeks. New resection was performed in five (8.9 percent) patients. Partial graft loss rate was 37.5 percent and recurrence was observed in only one (1.8 percent) patient.CONCLUSION:Significant morbidity derives from extensive gluteal and perineal hidradenitis suppurativa caused by the disease extension and large wounds that result from surgical treatment. Wide surgical excision is the treatment of choice and leads to cure. Skin‐grafting and healing by second intention lead to effective wound healing.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:Glyceryl trinitrate ointment acts as a dilator of the internal anal sphincter. It has been used as a treatment modality that replaces the lateral sphincterotomy in chronic anal fissures. When glyceryl trinitrate ointment is applied to the wound from a hemorrhoidectomy, it is thought that it will shorten the healing time and decrease postoperative pain. Our study focused on the efficacy of using 0.2 percent glyceryl trinitrate ointment to shorten the healing time after a hemorrhoidectomy.METHODS:A randomized, prospective, double‐blind, and placebo‐controlled study was designed. The power test indicated that 55 patients should be in each group to give a 90 percent chance of finding a 30 percent difference in healing time. The selection criteria for inclusion in this study were patients with third‐degree or fourth‐degree hemorrhoids and patients undergoing hemorrhoidectomies for three or more piles. From November 2000 to July 2001, the first 110 patients to meet our criteria were selected, 55 in the nitroglycerin group and 55 in the placebo group. The same physician performed all of the hemorrhoidectomies, and intravenous patient‐controlled analgesia was not used. Cases involving other procedures for fissures or fistulas were excluded. The patients randomly received glyceryl trinitrate and placebo ointments from the pharmacologist. The pain score was checked using a visual analog scale (minimum = 0, maximum = 10) during the hospital stay, and complete wound healing was checked at three weeks after the operation. Demands for analgesics and the frequency of postoperative complications were recorded.RESULTS:When the trial was completed, 49 patients remained in the nitroglycerin group and 53 patients in the placebo group. No significant differences in the gender and the age distributions, the number of excised piles, the time for the procedures, the length of hospital stay, and the consumed amounts of analgesics existed between the two groups. The pain score in the nitroglycerin group showed a significant difference with the repeated measures analysis (P< 0.001). The wound healing rates at three weeks postoperative were 74.5 percent in the nitroglycerin group and 42 percent in the placebo group (P= 0.002). There was no significant increase in complications in the nitroglycerin group.CONCLUSION:More rapid healing of hemorrhoidectomy wounds without any specific complications was effected by 0.2 percent glyceryl trinitrate ointment.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:The purpose of the study was to determine the variables associated with postoperative pain and the clinical response of patients with uncomplicated hemorrhoidal disease treated with stapled rectal mucosectomy in the medium term.METHODS:Patients with Grade II to IV, uncomplicated hemorrhoidal disease who underwent stapled rectal mucosectomy were prospectively included. The basal characteristics of the population were evaluated and level of stapling and placement of hemostatic suture determined. Histologically, the type of resected epithelium and presence of muscle fibers was evaluated. Postoperative pain was evaluated by means of a visual analog scale. Complications and clinical response were evaluated.RESULTS:One hundred patients with a mean age of 43.9 years were included. Only columnar epithelium was resected in 48, transitional epithelium in 47, and squamous epithelium in 5 patients. Smooth muscle fragments were found in 55 patients, and, in 12 of these, fibers from the external muscular layer of rectum were also seen. Follow‐up was 12.6 ± 3.4 (range, 7‐24) months. A total of 79 patients were completely asymptomatic at the end of follow‐up. Resected squamous epithelium was associated with a higher postoperative pain level in the multivariate analysis (coefficient beta = 1.16 (95 percent confidence interval, 0.08‐2.24);P= 0.035).CONCLUSIONS:Rectal mucosectomy with stapler is an effective method for the treatment of uncomplicated prolapsing hemorrhoidal disease. Intensity of postoperative pain was associated with the type of resected epithelium. This suggests that low transection of hemorrhoids must be avoided.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:In vitrodata suggest that nitric oxide is an important inhibitory neurotransmitter in the internal anal sphincter, and morphologic evidence implies that it mediates the rectoanal inhibitory reflex. This study examined the anatomy, physiology, and pharmacology of the internal sphincter in control and neuronal nitric oxide synthase knockout mice.METHODS:Neuronal nitric oxide synthase, nicotinamide adenosine triphosphate dinucleotide phosphate diaphorase histochemistry, and PGP 9.5 immunohistochemistry were compared between knockout and sibling control mice. Anorectal manometry was performed with a balloon‐tipped water‐perfused catheter.In vitrostudies were performed on both whole internal anal sphincter rings and strips.RESULTS:Staining of the myenteric plexus and nerves traversing the internal anal sphincter in sibling control mice demonstrated the presence of neuronal nitric oxide synthase and nicotinamide adenine dinucleotide phosphate diaphorase at these sites. These markers were absent in knockout mice. Maximum anal resting pressure was similar in control and knockout mice (15.6 ± 2.6 cm H2O (n = 4)vs.14.0 ± 2.3 cm H2O (n = 7)). The rectoanal inhibitory reflex was present in all control mice (n = 4) but in only four of seven knockout mice. Field stimulation with parameters designed to activate inhibitory nerves produced relaxation of internal sphincter tissue from both control and knockout mice, which was partially attenuated in control mice only by pretreatment with the nitric oxide synthase inhibitorN&ohgr;‐nitro‐L‐arginine. Further inhibition of nerve‐induced relaxation in control mice was achieved with antagonists of vasoactive intestinal peptide, adenosine triphosphate, and heme oxygenase.CONCLUSIONS:Although in the normal mouse, nitric oxide is an inhibitory neurotransmitter in the internal sphincter, other transmitters may play a role in the rectoanal inhibitory reflex. These other inhibitory neurotransmitters can apparently compensate for the absence of nitric oxide synthase in knockout mice to maintain approximately normal function.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

&NA;A 16‐year‐old male riding as a passenger on a personal watercraft fell behind the jet nozzle while jumping waves. An unusual rectal injury caused by the accident and resulting in the death of the patient is presented. The surgical management and postoperative course is discussed. Attention is drawn to the need for adequate protective clothes for all passengers of personal watercraft and to the necessity of a complete examination for correct diagnosis and treatment.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:Currarino triad, which comprises >anorectal stenosis, anterior sacral defect, and a presacral mass, is an uncommon cause of constipation in children and adults. The presacral mass in this triad is most often caused by an anterior sacral meningocele, a teratoma, or an enterogenous cyst, but rarely may be caused by dual pathology. A neonate with Currarino triad and dual pathology in the presacral mass is described in this report.METHOD:A male Chinese neonate, who presented with abdominal distention and constipation on the second day of life, was found to have features of Currarino triad. Colostomy was done in the neonatal period, and the presacral mass was excised by posterior sagittal perineal approach at the age of six months.RESULTS:The excised presacral mass consisted of an anterior meningocele and a teratoma. The patient continued to have constipation during follow‐up and required anorectoplasty to correct residual anorectal stenosis. At the time of this report the patient was three years old and growing normally with normal anorectal function.DISCUSSION:Of a total of about 200 cases of complete Currarino triad found in the literature, in only 22 patients did the presacral mass contain both meningocele and teratoma. The features of these 22 patients and the current views on the surgical management of Currarino triad are discussed.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID