摘要:

PURPOSE:It is possible that implantation of viable malignant cells is one of the mechanisms of anastomotic recurrence in rectosigmoid cancer. The viability of shed intraluminal cells was previously established and malignant cells were retrieved on circular staplers in unwashed rectal stumps. The aim of this study is to evaluate the effectiveness of a defined and uniform washout protocol in eradication of intraluminal malignant cells during anterior resection.METHODS:In 14 consecutive patients the closed rectal stump was washed before insertion of the circular stapler. The washout was performed uniformly by instillation of ten increments of 50 ml of saline through a rectal tube. Samples from the first, fifth, and tenth washings were collected for cytologic examination. The presence or absence of malignant cells was then correlated with rectal stump length, length of the tumor‐free distal margin, and differentiation and Dukes staging of the tumor.RESULTS:In 11 patients the first washing was positive for free malignant cells, and the fifth washing was still positive in 7 patients; however, the last (tenth) samples were clear in 10 patients, and malignant cells were recovered in only 4 patients. The rectal stump and the tumor‐free distal margin were shorter in patients who still had positive cytology for free intraluminal malignant cells after stump irrigation with 500 ml of saline. No correlation was found with tumor differentiation or staging.CONCLUSIONS:Free malignant cells are shed into the rectal stump during anterior resection. Mechanical lavage with saline effectively eradicates these cells; however, the completeness of cleansing is volume related. Incomplete cleansing with 500 ml of saline correlates with lower tumors. Technically more difficult surgery involves traumatic handling of the tumor and possibly induces shedding of more malignant cells. We suggest that rectal stump washout during anterior resection for carcinoma should be routine, and the volume of the lavage fluid should be larger than 500 ml.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Exfoliated or soiled free malignant cells have serious consequences in patients undergoing gastrointestinal cancer surgery. The present study evaluates the toxicity and efficacy of cytotoxic agents in the prevention of cell seeding and tumor growth in the peritoneal cavity in an experimental model.METHODS:Mtln3 adenocarcinoma cell viability was testedin vitrousing the trypan blue exclusion test after incubation with povidone‐iodine or chlorhexidine.In vivo, Fischer rats were inoculated with 105or 106cells followed by peritoneal lavage with physiological saline, chlorhexidine 0.02 percent, providone‐iodine low molecular weight 1 percent or povidone‐iodine high molecular weight 1 and 2 percent in different quantities and incubation times.RESULTS:Chlorhexidine 0.02 percent and povidone‐iodine low molecular weight 1 percent or high molecular weight 2 percent, killed over 98 percent of 105or 106tumor cellsin vitro. Povidone‐iodine low molecular weight 1 percent and high molecular weight 2 percent were toxic and lethal when 5 ml were applied in the peritoneal cavity three times for five minutes. Chlorhexidine 0.02 percent applied after inoculation of 105or 106cells, reduced the tumor development only to 70 and 80 percent. Application of 5 ml povidone‐iodine 1 percent low molecular weightorhigh molecular weight, three times for one and five minutes, after inoculation of 106cells did not change the tumor take. However, inhibition of Mtln3 cells to form metastases was observed. When povidone‐iodine low molecular weight 1 percent was used three times for one minute after 105tumor cells were “soiled”, no toxicity was observed and the tumor take was reduced to 30 percent (P<0.05).CONCLUSIONS:Povidone‐iodine toxicity proved to be a major issuein vivo. However, povidone‐iodine low molecular weight 1 percent was safe when used for short periods and very effective when a limited number of tumor cells was inoculated. The use of cytotoxic agents to prevent recurrent disease caused by tumor cell seeding in patients seems to make sense only when the “inoculum size” of exfoliated or soiled cancer cells is limited.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:The aims of the study were to investigate the effects of ileorectal anastomosis and the follow‐up program on rectal cancer morbidity and mortality and to identify risk factors that predict the fate of the rectal stump.METHODS:One hundred ninety‐five patients with familial adenomatous polyposis on whom an ileorectal anastomosis was performed between 1957 and the end of 1995 were included. Median follow‐up time was 14 (range, 1‐39) years. The cumulative risks of rectal cancer and rectal excision were estimated using survival analysis.RESULTS:Eighteen patients (9.2 percent) developed cancer, 17 in the retained colorectal segment and one on the ileal side of the anastomosis, and nine died of their cancer during the study period. The cumulative rectal cancer morbidity and mortality 20 years after ileorectal anastomosis was 12.1 percent (95 percent confidence interval=5.7‐18.5) and 7 percent (95 percent confidence interval=2‐12), respectively. The cumulative age‐dependent risk of rectal cancer was 22.9 percent (95 percent confidence interval=11.4‐34.5) and 25.7 percent (95 percent confidence interval=13.2‐38.2) at the ages of 60 and 70 years, respectively. The corresponding cumulative mortality was 11.1 percent (95 percent confidence interval=2.9‐19.3) at the age of 70 years. Patients with dense polyposis at colectomy had an increased risk for cancer in the retained colorectal segment compared with patients with intermediate or sparse polyposis (P=0.04). Sixty‐six patients (34 percent) had their rectum removed, and the cumulative rectal excision rate 35 years after ileorectal anastomosis was 65.5 percent (95 percent confidence interval=53‐78).CONCLUSION:Patients on whom ileorectal anastomosis was performed had, despite the high rectal excision rate, a substantial risk of developing cancer in the retained colorectal segment, with an ensuing high mortality. Our results indicate that patients with dense polyposis should undergo restorative proctocolectomy as primary operation for familial adenomatous polyposis. In younger patients with intermediate or sparse polyposis and good expected follow‐up compliance, ileorectal anastomosis still is an alternative.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:The purpose of this study was to evaluate the safety and efficacy of laparoscopic‐assisted sigmoid colectomy for the treatment of diverticulitis.METHODS:The Norfolk Surgical Group Laparoscopic Surgery Registry identified all patients undergoing laparoscopic colon and rectal surgery. Retrospective chart review was performed for all patients undergoing elective sigmoid resection for a final diagnosis of diverticulitis and minimum follow‐up of 12 months. Demographic data, indications for surgery, operative data, conversion rate, reason for conversion, complications, postoperative course (days to flatus and regular diet), and length of stay were identified. A telephone survey determined the incidence of recurrent diverticulitis. Statistical analysis was performed to evaluate the frequency of conversion over time, to determine risk factors for conversion, and to compare the laparoscopic‐assisted and conversion groups with regard to postoperative days to flatus, regular diet, and discharge.RESULTS:From June 1992 to September 1997, elective laparoscopic‐assisted sigmoid colectomy was attempted in 69 patients. Uncomplicated recurrent diverticulitis was the most common indication for surgery, occurring in 51 of 69 patients (75 percent). No deaths occurred. Complications were identified in seven patients (10.1 percent) including one wound infection and one incarcerated port‐site hernia with small bowel obstruction. There were no anastomotic leaks or major septic complications. Conversion to laparotomy occurred in 18 of 69 patients (26 percent). Uncomplicated, recurrent diverticulitis was associated with conversion in 7 of 51 patients (14 percent), whereas complicated diverticulitis required conversion in 11 of 18 patients (61 percent). Logistic regression identified fistula and abscess as predictors of conversion (P=0.0009). Comparison of the laparoscopic‐assisted sigmoid colectomy group with the conversion group revealed that postoperative days to regular diet were 3.5 and 5.2 (P=0.0004), respectively, and lengths of stay were 4.2 and 6.4 days (P<0.0001), respectively. No difference was noted with regard to operative time or postoperative complications. Median follow‐up was 48 (range, 13‐76) months, and a single recurrence of diverticulitis has been identified.CONCLUSIONS:Laparoscopic‐assisted sigmoid colectomy for diverticulitis can be safely performed. Conversion appears to be associated with complicated diverticulitis (fistula or abscess), which may be better approached by laparotomy. Short‐term follow‐up indicates that recurrence is rare and suggests that laparoscopic‐assisted sigmoid colectomy achieves adequate resection. Laparoscopic‐assisted sigmoid colectomy offers benefits of decreased ileus and length of stay and may represent the procedure of choice for elective resection for uncomplicated sigmoid diverticulitis.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:The clinical impact of rectal compliance and sensitivity measurement is not clear. The aim of this study was to measure the rectal compliance in different patient groups compared with controls and to establish the clinical effect of rectal compliance.METHODS:Anorectal function tests were performed in 974 consecutive patients (284 men). Normal values were obtained from 24 controls. Rectal compliance measurement was performed by filling a latex rectal balloon with water at a rate of 60 ml per minute. Volume and intraballoon pressure were measured. Volume and pressure at three sensitivity thresholds were recorded for analysis: first sensation, urge, and maximal toleration. At maximal toleration, the rectal compliance (volume/pressure) was calculated. Proctoscopy, anal manometry, anal mucosal sensitivity, and anal endosonography were also performed as part of our anorectal function tests.RESULTS:No effect of age or gender was observed in either controls or patients. Patients with fecal incontinence had a higher volume at first sensation and a higher pressure at maximal toleration (P=0.03), the presence of a sphincter defect or low or normal anal pressures made no difference. Patients with constipation had a larger volume at first sensation and urge (P<0.0001 andP<0.01). Patients with a rectocele had a larger volume at first sensation (P=0.004). Patients with rectal prolapse did not differ from controls; after rectopexy, rectal compliance decreased (P<0.0003). Patients with inflammatory bowel disease had a lower rectal compliance, most pronounced in active proctitis (P=0.003). Patients with ileoanal pouches also had a lower compliance (P<0.0001). In the 17 patients where a maximal toleration volume<60 ml was found, 11 had complaints of fecal incontinence, and 6 had a stoma. In 31 patients a maximal toleration volume between 60 and 100 ml was found; 12 patients had complaints of fecal incontinence, and 6 had a stoma. Proctitis or pouchitis was the main cause for a small compliance. All 29 patients who had a maximal toleration volume>500 ml had complaints of constipation. No correlation between rectal and anal mucosal sensitivity was found.CONCLUSION:Rectal compliance measurement with a latex balloon is easily feasible. In this series of 974 patients, some patient groups showed an abnormal rectal visceral sensitivity and compliance, but there was an overlap with controls. Rectal compliance measurement gave a good clinical impression about the contribution of the rectum to the anorectal problem. Patients with proctitis and pouchitis had the smallest rectal compliance. A maximal toleration volume<60 ml always led to fecal incontinence, and stomas should be considered for such patients. A maximal toleration volume>500 ml was only seen in constipated patients, and therapy should be given to prevent further damage to the pelvic floor. Values close to or within the normal range rule out the rectum as an important factor in the anorectal problem of the patient.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Although its defining feature is the development of multiple large‐bowel polyps, familial adenomatous polyposis is a generalized disorder of tissue growth regulation, with a range of manifestations. An association between adrenal neoplasms and familial adenomatous polyposis has been suggested, but not prospectively documented. Patients with familial adenomatous polyposis were therefore screened to determine the frequency of adrenal masses.METHODS:Patients with familial adenomatous polyposis underwent spiral abdominal CT scan reported by two radiologists specialized in cross‐sectional imaging.RESULTS:One hundred seven individuals were examined (median age, 36 (interquartile range, 30‐48) years; 57 male). Fourteen (13 percent) had an adrenal mass of 1 cm or greater (bilateral in one case); none had clinical evidence of endocrine disturbance or hypertension. Two lesions were histologically confirmed adrenocortical adenomas and one a phaeochromocytoma; the remaining 12 had CT appearances of nonhyperfunctioning adrenocortical adenoma.CONCLUSIONS:The prevalence of unsuspected adrenal masses in the general population is approximately three percent. This prospective study found a significantly higher frequency of 13 percent in patients with familial adenomatous polyposis (chi‐squared=6.973; df=1;P=0.008). There is no evidence that the histologic nature of these differs from that in the general population.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Inflammation and dysplasia may affect the ileal pouch after restorative proctocolectomy and ileal pouchanal anastomosis. The aim of this prospective study was to evaluate the morphologic changes and the risk of dysplasia within the pouch after ileal pouch‐anal anastomosis.METHODS:Thirty‐seven patients with ileal pouch‐anal anastomosis underwent endoscopies and biopsies of the pouch: 21 patients were affected by ulcerative colitis and 16 by Crohn's colitis. The mucosal biopsy specimens were studied to investigate the degree of acute and chronic inflammation and the occurrence of dysplasia. A score system was calculated for each patient and correlated with the histologic diagnosis of ulcerative colitis or Crohn's colitis.RESULTS:After a median follow‐up of 85 (range, 7‐198) months, the inflammation histologic score evaluated was 3.8 (95 percent confidence interval, 2.4‐5.1) and 3.5 (95 percent confidence interval, 2.6‐4.3), respectively, in patients with Crohn's colitis and ulcerative colitis (mean and 95 percent confidence interval;P=0.74, not significant), and no patient developed mucosal dysplasia. Fifteen patients (40.5 percent) developed clinical pouchitis that occurred in Crohn's colitis (9/16 patients or 56 percent) and in ulcerative colitis (6/21 patients or 28 percent;Pnot significant). The score was 4.1 (95 percent confidence interval, 3.2‐5) in patients with pouchitis and 3.2 (95 percent confidence interval, 2.1‐4.3) in patients without clinical pouchitis (P=0.012) and was 4.1 (95 percent confidence interval, 2.6‐5.5) and 4 (95 percent confidence interval, 2.9‐5.3), respectively, in pouchitis patients with Crohn's colitis and ulcerative colitis.CONCLUSION:No difference in the inflammation histologic score was observed in ileal pouches after restorative proctocolectomy for ulcerative and Crohn's colitis. In our series, which includes those patients with longer follow‐up (>5 years) or with chronic unremitting pouchitis, no case of dysplasia was found. The occurrence of pouchitis was higher in the case of ileal pouch‐anal anastomosis for Crohn's disease than for ulcerative colitis, but no difference in the severity of the histologic score was noted.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:The purpose of this study was to document prospectively the time required to gain access to the abdomen to perform a planned procedure in patients with and without previous surgery.METHODS:Patients were obtained from the consecutive cases of 11 surgeons at three colorectal surgery centers. Opening time (skin incision to retractor placement) was measured and recorded in the operating room by the circulating nurse or by an independent researcher. Demographic data including the number and type of previous operations and the presence and severity of adhesions were recorded by the staff surgeon. A comparison of opening times between patients with and without previous abdominal operations was conducted.RESULTS:One hundred ninety‐eight patients had abdominal operations. Fifty‐five percent had previous abdominal procedures. Patients with prior surgery required a mean of 21 minutes to open their abdomens, whereas patients without prior surgery required a mean of 6 minutes (P<0.01). The median times were 17 and 6 minutes, respectively. Eighty‐three percent of patients with prior surgery had adhesions, whereas only 7 percent of patients had adhesions on their initial operation. Patients with prior surgery also had higher grade adhesions (P<0.001). Irrespective of previous surgery, comparing patients with adhesions with those without, patients with adhesions required a mean of 22 minutes to open, whereas the lack of adhesions resulted in a mean opening time of 6 minutes.CONCLUSIONS:Previous surgery and the presence of adhesions add significant time to opening the abdomen.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Colorectal cancer is one of the major causes of cancer death in the world, including in the United States and Japan. We recently identified the tumor‐rejection antigen gene SART1, which encodes both the SART1259antigen expressed in the cytosol of epithelial cancers and the SART1800antigen expressed in the nucleus of the majority of proliferating cells. This study investigated the expression of these tumor antigens to explore a potential molecule for specific immunotherapy of colorectal cancer patients.METHODS:SART1 antigens were investigated by Western blotting in six colorectal cancer cell lines and in 33 colorectal cancer tissues. The cancer cell lines were tested for their ability to stimulate interferon‐&ggr; production by the human‐leukocyte‐antigen‐A24‐restricted and SART1‐specific cytotoxic T lymphocytes and were also tested for their susceptibility to the lysis by the cytotoxic T lymphocytes.RESULTS:The SART1259antigen was detected in the cytosol of four of six cancer cell lines, 13 of 33 (39 percent) cancer tissues, and 0 of 20 nontumorous colorectal tissues. The SART1800antigen was expressed in the nucleus of all the colorectal cancer cell lines, 18 of 33 (55 percent) cancer tissues, and 0 of 20 nontumorous tissues. The human‐lymphocyte‐antigen‐A24‐restricted and SART1‐specific cytotoxic T lymphocytes killed the human‐lymphocyte‐antigen‐A24+SART1259+cancer cells.CONCLUSIONS:The SART1259antigen could be an appropriate target molecule for specific immunotherapy of approximately 40 percent of the human‐lymphocyte‐antigen‐A24+patients with colorectal cancer.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Desmoids are rare, locally aggressive but nonmetastasizing fibrous masses that occur sporadically and in association with familial adenomatous polyposis. Therapeutic options are limited, and there is reluctance to operate on mesenteric desmoids because of the risk of complications or recurrence. Consequently, there is an increasing reliance on alternative therapeutic modalities. Nonsurgical options are of variable efficacy, however, and surgery is still required for the complications of desmoids. Each of the last four patients with desmoids presenting to this unit has required life‐saving surgery as a result of failure of nonsurgical treatments or the development of complications.METHODS:We present case reports of four consecutive patients with large mesenteric desmoid tumors requiring surgical management.RESULTS:All four patients had massive mesenteric desmoids. Three cases associated with familial adenomatous polyposis had developed their desmoids after colectomy while the sporadic desmoid had continued to grow rapidly after diagnosis at laparotomy. Sulindac and toremifene were unsuccessful in all cases and one patient with familial adenomatous polyposis suffered dramatic erosion of her desmoid through the abdominal wall during antisarcoma chemotherapy. Two others required emergency laparotomy for complications, and the sporadic case underwent elective resection for symptomatic relief. Three had complete excision of their desmoid, and all remained well with no recurrence at a median follow‐up of 12 (range, 7‐14) months.CONCLUSION:Despite the risks, there remains a role for surgery in the management of large mesenteric desmoids.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID