摘要:

PURPOSE:Colonic pouches have gained increasing popularity in reconstruction after low anterior resection. In this prospective, randomized trial colonic pouch reconstruction is compared with side‐to‐end anastomosis for functional outcome.METHODS:From October 1995 to October 1996, 29 patients had colonic pouch and 30 patients had side‐to‐end anastomosis reconstruction after low anterior resection. Patients were matched for age, gender, and tumor stage and localization. All patients underwent functional evaluation preoperatively and at three and six months post‐operatively.RESULTS:There was no difference in preoperative anorectal function. The operating time was higher in the colonic pouch group (167vs.149 minutes). Twenty‐three patients (79.3 percent) with colonic pouch had a protective stoma compared with 21 patients (70 percent) with side‐to‐end anastomosis. Postoperative complications were 10.3 and 13.3 percent, respectively. There was no difference in manometric pressure of the anus, in anorectal angle, and in continence status after three and six months. Stool frequency was higher in the side‐to‐end anastomosis group, with 2.2vs.5.4 per day at three months and 2.3vs.3.1 per day at six months. Constipation was noted in two patients with colonic pouch (7 percent) and none in the side‐to‐end anastomosis group at three months and twovs.none at six months. Maximum tolerated volume and threshold volume was higher in the colonic pouch group at three and at six months.CONCLUSION:Both forms of reconstruction have similar satisfactory long‐term functional results. The major advantage of colonic pouch was seen in the immediate postoperative phase.

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

PURPOSE:The aim of this study was to review the functional outcome in 20 patients with familial adenomatous polyposis and ulcerative colitis who were converted from ileorectal anastomosis to ileal pouch‐anal anastomosis.METHODS:From 1985 to 1997, 12 patients with familial adenomatous polyposis (5 males; mean age, 39.1 years) and 8 patients with ulcerative colitis (5 males; mean age, 36.7 years) underwent conversion from ileorectal anastomosis to ileal pouch‐anal anastomosis. Clinical and operative data were analyzed retrospectively. Functional results were obtained by telephone interview in 16 patients (94 percent) after pouch construction. Four patients were not interviewed (2 were deceased, 1 was lost to follow‐up, and 1 was not reachable).RESULTS:Indications for conversion were uncontrollable rectal polyps (10 patients) and colonic cancer found in the pathology specimen after ileorectal anastomosis in patients with familial adenomatous polyposis (2 patients), intractable proctitis (5 patients), colonic cancer found in the pathology specimen of patients with ulcerative colitis after ileorectal anastomosis (2 patients), and rectal dysplasia (1 patients). Mean follow‐up time was 5 (range, 1‐11) years. Ileal pouch‐anal anastomosis was handsewn in 14 patients, and the remaining cases were double‐stapled in 4 patients with ulcerative colitis. No intraoperative difficulties were reported in 13 cases; technical problems were related to adhesions (3 cases), difficult rectal dissection (2 cases), and stapler‐related difficulties (2 cases). Postoperative complications after ileal pouch‐anal anastomosis included small‐bowel obstruction (4 patients) and ileal pouch‐anal anastomosis leak (1 patient). Patients with ileorectal anastomosisvs.those with ileal pouch‐anal anastomosis had a better functional outcome with regard to nighttime continence (14 (88 percent)vs.6 (38 percent) patients) and average bowel movements (<6/day; 12 (75 percent)vs.4 (25 percent) patients). Complete daytime continence, 15 (94 percent)vs.10 (62 percent) patients, was similar in the two groups. Physical and emotional well‐being were similarly rated as very good to excellent.CONCLUSIONS:In patients with familial adenomatous polyposis and ulcerative colitis with ileorectal anastomosis, conversion to ileal pouch‐anal anastomosis may be required. In view of the risk of rectal cancer or intractable proctitis, patients seem to accept the conversion in spite of poorer bowel function.

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

PURPOSE:Three‐column excision has traditionally been the preferred treatment for symptomatic hemorrhoidal disease in patients failing nonoperative treatments. There are few data evaluating focused surgical management of only the symptomatic hemorrhoidal complexes by limited hemorrhoidectomy. The purpose of this study was to evaluate patient outcome after one‐quadrant or two‐quadrant hemorrhoidectomy for symptomatic hemorrhoids.METHODS:We retrospectively studied patients undergoing a one‐quadrant or two‐quadrant hemorrhoidectomy as initial surgical treatment of symptomatic columns from April 1987 to July 1993. Patients undergoing a traditional three‐quadrant hemorrhoidectomy during the same time period were used as controls. Statistical analysis was used to determine significance.RESULTS:There were 115 evaluable patients who had undergone a one‐quadrant or two‐quadrant hemorrhoidectomy. One hundred thirty‐three three‐quadrant patients were studied as the control group. The mean follow‐up was 8.1 years and 7.2 years for the limited and three‐quadrant hemorrhoidectomy group, respectively. The majority of patients (96 percent limited and 98 percent three‐quadrant) experienced initial relief of symptoms after surgery. There was no significant difference between the two groups in the development of recurrent anorectal symptoms (34 percent limited and 29 percent three‐quadrant), in the need for additional medical therapy (11.3 percent limited and 15.8 percent three‐quadrant), or in the need for additional interventional therapy (2.9 percent limited and 0.8 percent three‐quadrant). No patients in either group required additional surgical hemorrhoidectomy.CONCLUSIONS:The majority of patients with hemorrhoidal disease requiring excision can be managed effectively by focused treatment of the problematic columns. With this approach fewer than 2 percent of patients will require further procedural intervention of their hemorrhoidal disease.

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

PURPOSE:Lower limb compartment syndrome has been reported to occur after colorectal, urological, and gynecological procedures during which the patient's lower limbs are elevated for prolonged periods of time.METHOD:We investigated lower limb perfusion in a group of patients undergoing prolonged pelvic surgery both during and immediately after surgery, using intra‐arterial blood pressure monitoring, laser doppler flowmetry, and pulse oximetry.RESULTS:Use of the modified lithotomy position was not associated with any demonstrable decrease in lower limb perfusion. The addition of 15° head‐down tilt, however, during pelvic dissection, led to an immediate and significant drop in lower limb perfusion (P<0.05; Mann‐WhitneyUtest). The subgroup of patients analyzed postoperatively showed a ten‐fold increase (P<0.01) in perfusion that was confined to the muscle compartment with no demonstrable increase in skin perfusion or intra‐arterial pedal blood pressure.CONCLUSION:The use of the modified lithotomy position during pelvic surgery is not associated with lower limb ischemia. Addition of Trendelenburg position, however, causes profound ischemia of the lower limbs, and this is followed during the recovery period by hyperperfusion that is confined to the muscle compartments, which may put patients at risk of developing lower limb compartment syndrome.

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

&NA;The contribution of carcinoembryonic antigen carcinoembryionic antigen for the effective management of colorectal cancer patients remains a controversial issue. The aim of this study is to attempt to get some valid answers to its function in the diagnosis, prognosis, and overall management of colorectal cancer patients.METHODS:A retrospective review of colorectal cancer patientsmanaged and prospectively registered by the authorsbetween 1985 and 1998 was performed. Serum carcinoembryionic antigen levels were determined preoperatively in 209 patients with primary colorectal cancer and postoperatively in 196 patients who had undergone curative resection of their tumors, according to a fixed schedule. A maximum value of 5 ng/ml was accepted as being normal. With the exception of endoscopy, all other diagnostic techniques were only used after an abnormal carcinoembryionic antigen result (a raised value found twice consecutively).RESULTS:carcinoembryionic antigen preoperative values were raised only in 40 percent of patients and were related to disease stage, with the highest values found in patients with Stage IV disease. However, an elevated preoperative carcinoembryionic antigen value had a very marked prognostic importance, with a statistically significant difference in survival curves (Kaplan‐Meier); the same was valid for curatively resected patients (Stages I, II, and III) and for Stages II and III patients considered separately. Multivariate analysis using the Cox proportional hazards technique confirmed these results, showing preoperative carcinoembryionic antigen to have an independent prognostic value, with a relative risk of recurrence of 3.74 for patients with raised preoperative carcinoembryonic antigen levels. In postoperative follow‐up, carcinoembryionic antigen elevation was found to be a very accurate marker of recurrence (sensitivity, 77 percent; specificity, 98 percent), mainly in liver metastasis (sensitivity, 100 percent), and the best marker of asymptomatic recurrence (63 percent of cases). However, carcinoembryionic antigen's impact on overall survival was negligible because of the poor results of surgical treatment of recurrences.CONCLUSIONS:Preoperative carcinoembryionic antigen is a very important prognostic indicator and should be considered in future trials. Postoperative carcinoembryionic antigen elevation is a very sensitive marker of recurrence and even of asymptomatic recurrence, but its impact on overall survival does not seem to be relevant. Nevertheless, carcinoembryionic antigen should continue to be used in colorectal cancer patients until better methods of diagnosis and treatment of recurrence are developed.

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

PURPOSE:The aim of this study was to compare the safety and efficacy of laparoscopic abdominoperineal resection and open abdominoperineal resection for cancer.METHODS:Records of 194 patients who underwent laparoscopic abdominoperineal resection (42 patients) or open abdominoperineal resection (152 patients) at three institutions between 1991 and 1997 were reviewed. Follow‐up was through office charts, American College of Surgeons cancer registry, or telephone contact. Tumors included (laparoscopic abdominoperineal resection and open abdominoperineal resection, respectively) adenocarcinoma (86 and 92 percent), squamous (12 and 7 percent), and gastrointestinal stromal (2 and 1.4 percent) types; Stages I (17 and 26 percent), II (24 and 33 percent), III (43 and 32 percent), and IV (14 and 9 percent); and those with invasion of pelvic structures (14 and 16 percent).RESULTS:Laparoscopic abdominoperineal resection was converted to open abdominoperineal resection in 21 percent because of vessel injury (33 percent), poor exposure (22 percent), adhesions (22 percent), inguinal hernia (11 percent), or radiation fibrosis (11 percent). Perineal infections occurred more often in the laparoscopic abdominoperineal resection group (24vs.8 percent;P=0.02). Late stoma complications were similar. Mean hospital stay was shorter after laparoscopic abdominoperineal resection (7vs.12 days). Radial margins were positive in 12 percent of laparoscopic abdominoperineal resection and 12.5 percent of open abdominoperineal resection specimens. Tumor recurrence was similar for both local (19 and 14 percent) and distant (38 and 26 percent) recurrence. Survival rates were similar by Kaplan‐Meier curves, with median follow‐up of 19 and 24 months, respectively (P=0.22; log rank).CONCLUSION:Laparoscopic abdominoperineal resection can be performed safely and results in a shorter hospital stay. A randomized, prospective trial is needed to determine the long‐term outcome of cancer treatment.

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

PURPOSE:Enterocele is defined as a herniation of the peritoneal sac between the vagina and the rectum. This hernial sac contains either sigmoid colon or small bowel. It is well known that enteroceles are associated with symptoms of pelvic discomfort. It is unclear whether enteroceles contribute to evacuation difficulties. Controversies also exist regarding their treatment of choice. The aim of the present prospective study was to evaluate the impact of obliteration of the pelvic inlet on evacuation difficulties and on symptoms of pelvic discomfort.METHODS:From October 1994 to August 1996 20 females (median age, 53; range, 41‐73 years) with symptomatic enterocele diagnosed on evacuation proctography underwent obliteration of the pelvic inlet with a nonabsorbable Mersilene® mesh. All patients presented with pelvic discomfort, characterized by feelings of prolapse (n=20), pelvic pressure (n=16), lower abdominal pain (n=13), and false urge to defecate (n=15). Symptoms of obstructed defecation were noted in 15 patients. Six months after repair, evacuation proctography with opacification of the small bowel and the vagina was repeated.RESULTS:The median duration of follow‐up was 25 (range, 10‐34) months. A persistent or recurrent enterocele was observed in none of the patients. All symptoms of pelvic discomfort disappeared except feelings of a false urge to defectate, which persisted in 27 percent of cases. Symptoms of obstructed defecation persisted in all patients with evacuation difficulties.CONCLUSIONS:In patients with pelvic discomfort enterocele should be considered as a possible causative factor. It is unlikely that this abnormality contributes to the problem of obstructed defecation. In patients with a symptomatic enterocele, obliteration of the pelvic inlet with a Mersilene® mesh is an adequate treatment.

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

PURPOSE:The aim of this study was to review the literature with regard to perianal Bowen's disease and anal intraepithelial neoplasia.METHODS:A literature review was conducted from 1960 to 1999 using MEDLINE.RESULTS:Perianal Bowen's disease and anal intraepithelial neoplasia are precursors to squamous carcinoma of the anus. They are analogous to and are associated with cervical and vulvar intraepithelial neoplasia, and have human papillomavirus as a common cause. Biopsy and histopathologic examination is required for diagnosis and to distinguish other perianal dermatoses. Treatment options range from aggressive wide local excision of all disease with negative margins to observation alone for microscopic lesions not visible to the naked eye. The disease has a proclivity for recurrence and recalcitrance.CONCLUSIONS:Most surgeons caring for patients with perianal Bowen's disease and high‐grade anal epithelial neoplasia use wide local excision, with an effort to obtain disease‐free margins. Some authors have reported the advantages of ablative procedures such as laser ablation and cryotherapy. Microscopic disease found serendipitously in hemorrhoidectomy specimens can probably be treated conservatively with serial examinations alone. There is a lack of controlled data supporting an optimal treatment strategy. A multicenter controlled study comparing wide local excision with ablative procedures may be warranted.

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID