摘要:

PURPOSE:The incidence of colorectal anastomotic strictures varies from 3 to 30 percent. Most of these anastomotic strictures are simple narrowings shorter than 1 cm that can be successfully treated by dilation or endoscopic alternatives. However, up to 28 percent of patients will require surgical correction. This can be technically difficult, with the possibility of a permanent colostomy. This study reports the outcomes after operative treatment of severe strictures of colorectal anastomoses.METHODS:From August 1992 to October 1996, 27 patients were referred for surgical treatment of severe rectal anastomotic strictures. The reasons for the initial surgery were as follows: rectal cancer (13), diverticular disease (7), Hirschsprung's disease (2), rectal endometriosis (2), uterine carcinoma with rectal invasion (1), ruptured abdominal aortic aneurysm with rectosigmoid necrosis (1), and rectovaginal fistula (1). There were 15 (56 percent) stapled anastomoses, and 21 (78 percent) patients had developed a postoperative leak.RESULTS:The median time between initial surgery and diagnosis of the stenosis was 7.2 (range, 1‐24) months and between the last operation and referral was 15.1 (range, 1‐44) months. Stenosis was located at a mean distance of 9.5 (range, 4‐15) cm from the anal verge. Eleven patients (41 percent) had been unsuccessfully dilated before referral. Surgical correction of the stenosis required 7 colorectal anastomoses for upper rectal anastomotic strictures and 20 coloanal anastomoses for middle and lower rectal strictures (19 Soave's procedures and 1 colon J‐pouch‐anal anastomosis). Intestinal continuity was restored in all cases. After a mean follow‐up of 28.7±14 months, no recurrences were detected and functional results were satisfactory.CONCLUSIONS:Resection of the stenosis and construction of a new colorectal anastomosis can be performed successfully for upper rectal anastomotic stricture. For a stenosis located in the middle and lower rectum, Soave's procedure offers a good alternative, with satisfactory long‐term functional results. Whichever technique is used, a permanent colostomy should rarely be required.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:The aim of this study was to analyze failures in the operative management of perirectal abscesses resulting in early reoperation.METHODS:This was a retrospective case study of 500 consecutive patients who underwent 627 drainage procedures for a perirectal abscess.RESULTS:Forty‐eight patients (7.6 percent of all drainage procedures) required reoperation within ten days of the original procedure. The main factors leading to reoperation were incomplete drainage (23 patients), missed loculations within a drained abscess (15 patients), missed abscesses (4 patients), and postoperative bleeding (3 patients). Incomplete drainage was more common with simple perirectal abscesses, whereas most overlooked collections were located posteriorly. Horseshoe abscesses were associated with a particularly high rate (50 percent) of operative failures. Neither preexisting perianal pathology nor systemic immunosuppressive disease contributed to early failures.CONCLUSION:Surgical errors are the leading cause of early failures in the surgical treatment of perianal abscesses. These errors occur in a limited number of typical patterns and can therefore be identified and taught with an aim to decrease their occurrence.

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 purpose of this study was to evaluate the healing rate of transsphincteric perianal fistulas after anocutaneous advancement flap repair and to examine the impact of this procedure on fecal continence.METHODS:Between January 1997 and June 1999, 26 consecutive patients with a transsphincteric perianal fistual passing through the middle or upper third of the external anal sphincter underwent anocutaneous advancement flap repair. There were six female patients, and the median age was 39 (range, 27‐54) years. Twenty patients (77 percent) had previously undergone one or more prior attempts at repair. With the patient in the prone‐jackknife position, the internal opening of the fistual was exposed using a Lone Star Retractor System, and the crypt‐bearing tissue around the internal opening as well as the overlying anoderm was excised. An (inverted) U‐shaped flap, including perianal skin and fat, was created. The base of the flap was approximately twice the width of its apex. The flap was advanced and sutured to the mucosa and underlying internal anal sphincter proximal to the closed internal opening. The median follow‐up time was 25 months. Fecal continence was evaluated in 23 patients by means of a questionnaire.RESULTS:Anocutaneous advancement flap repair was successful in 12 patients (46 percent). Success was inversely correlated with the number of prior attempts. In patients who had undergone no or only one previous attempt at repair (n=9), the healing rate was 78 percent. In patients with two or more previous repairs (n=17) the healing rate was only 29 percent. In seven patients (30 percent) continence deteriorated after anocutaneous advancement flap repair. Eleven patients (48 percent) had a completely normal continence preoperatively. Two of these patients (18 percent) encountered soiling and incontinence for gas after the procedure, whereas two subjects (18 percent) complained of accidental bowel movements. Twelve patients (52 percent) presented with continence disturbances at the time of admission to our hospital. In this group, deterioration was observed in two patients (17 percent).CONCLUSION:The results of anocutaneous advancement flap repair in patients with no or only one previous attempt at repair are moderate. In patients who have undergone two or more previous attempts at repair the outcome is poor. Based on the relatively low healing rate and deterioration of continence, this procedure seems less suitable for high transsphincteric fistulas than transanal mucosal advancement flap repair.

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:Intraoperative radiation therapy is reportedly effective for local control and pain relief in colorectal cancer. However, this treatment requires a large number of medical personnel, which hinders expanded use of this method. A mobile electron linear accelerator for intraoperative radiation therapy has been developed and is now commercially available. This report analyzes the applicability of this accelerator to colorectal cancer. The applicability of the mobile accelerator is analyzed based on its specifications by simulating the intraoperative radiation therapy delivered to these patients with a conventional intraoperative radiation therapy unit.METHODS:From 1987 to 1999, 49 colorectal cancer patients underwent 54 surgical resections and received intraoperative radiation therapy to 75 sites.RESULTS:The mean intraoperative radiation therapy dose for colorectal cancer with the conventional unit was 22 (range, 10‐30) Gy. The mean electron energy level was 10 (range, 3‐30) MEV. Applicator size ranged from 4 to 10 cm in diameter. The mobile accelerator can achieve a dose rate of 10 Gy/min and an applicator unit size range of 3 to 10 cm in diameter, facilitating intraoperative radiation therapy for colorectal cancer. The electron energy limitation (12 MEV at maximum) suggests that the indications for this machine are limited. In our experience, 30 percent of patients received intraoperative radiation therapy with electron energy levels exceeding 12 MEV. Of these cases, 81 percent had macroscopic residual tumor and 69 percent had pain.CONCLUSION:An intraoperative radiation therapy mobile accelerator can cover 72 percent of the irradiation sites covered using our conventional unit. This accelerator is useful for intraoperative radiation therapy with curative intent for patients with no or slight residual tumor. Patients with gross residual tumor and pain may not be suitable.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:A randomized, double‐blind, controlled study was conducted to investigate the efficacy of oral calcium dobesilate therapy in treating acute attacks of internal hemorrhoids.METHODS:Twenty‐nine well‐documented adult patients with first‐ or second‐degree internal hemorrhoids were treated with calcium dobesilate for two weeks, while 16 patients received only a high‐fiber diet to serve as control. Both symptoms and anoscopic inflammation were scored on a scale from 0 to 2 before (T0) and two weeks after treatment (T2).RESULTS:A success rate of 86.21 percent with cessation of bleeding plus lack of severe anitis anoscopically at two weeks were achieved with calcium dobesilate. The pretreatment symptom score of 2 fell significantly to 0.45±0.13, and the pretreatment anitis score of 1.69±0.09 fell to 0.55±0.12 at T2(P=0.0001 for both comparisons). The symptom and anoscopic inflammation scores obtained with calcium dobesilate treatment were also significantly better than those with diet only (P=0.0017 andP=0.0013, respectively).CONCLUSION:Together with recommendations about diet and bowel discipline, oral calcium dobesilate treatment provides an efficient, fast, and safe symptomatic relief from acute symptoms of hemorrhoidal disease. This symptomatic healing is associated with a significant improvement in the anoscopically observed inflammation.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:Anal carcinoma is being found in HIV‐positive patients with increasing frequency. Most patients are treated with combined chemotherapy and radiation. It was our impression that HIV‐positive patients do not fare as well as HIV‐negative patients in terms of both response to and tolerance of therapy.METHODS:To test this hypothesis, we reviewed our experience with anal carcinoma and compared HIV‐positive to HIV‐negative patients by age, gender, sexual orientation, stage at diagnosis, treatment rendered, response to treatment, tolerance, and survival. From 1985 to 1998, 98 patients with anal neoplasms were treated. Seventy‐three patients had invasive squamous‐cell carcinoma (including cloacogenic carcinoma), and this cohort was analyzed. Thirteen patients were HIV positive and 60 were HIV negative.RESULTS:The HIV‐positive and HIV‐negative groups differed significantly by age (42vs.62 years,P<0.001), male gender (92vs.42 percent,P<0.001), and homosexuality (46vs.15 percent,P<0.05). There were no differences by stage at diagnosis or radiation dose received. Acute treatment major toxicity differed significantly (HIV positive 80 percentvs.HIV negative 30 percent;P<0.005). Only 62 percent of HIV‐positive patients were rendered disease free after initial therapyvs.85 percent of HIV‐negative patients (P=0.11). Median time to cancer‐related death was 1.4vs.5.3 years (P<0.05). A survival model did not show age, gender, stage, or treatment to be independent predictors.CONCLUSION:We found that HIV‐positive patients with anal carcinoma seem to be a different population from HIV‐negative patients by age, gender, and sexual orientation. They have a poorer tolerance for combined therapy and a shorter time to cancer‐related death. A strong trend to poorer initial response rate was also seen. These results suggest that the treatment of HIV‐positive patients with anal carcinoma needs to be reassessed.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:This study was designed to determine whether loss of heterozygosity and/or microsatellite instability correlate with HIV infection and tumor recurrence after chemoradiation therapy in patients with squamous‐cell carcinoma of the anus.BACKGROUND:The molecular mechanisms leading to the progression of HIV‐related squamous‐cell carcinoma of the anus are poorly understood. In particular, genetic alterations responsible for resistance to chemoradiation have important clinical and functional implications.METHODS:In a case‐control study, we analyzed normal and tumor DNA samples of four patients with squamous‐cell carcinoma of the anus who were successfully treated with chemoradiotherapy and four patients with radio‐resistant squamous‐cell carcinoma of the anus who required abdominoperineal resection for local recurrence. To determine the presence of microsatellite instability, we used the reference panel of five pairs of microsatellite primers recommended for colorectal cancer specimens. These include the microsatellite markers BAT25, BAT26, D5S346 (APC), D2S123 (hMSH2), and D17S250 (P53). In addition, we used microsatellite markers for loss of heterozygosity analyses that were tightly linked to tumor suppressor genes. These included D3S1611 (hMLH1), D17S513 (P53), D18S46 and 18qTA (DCC/SMAD4), D5S107 (APC), and CA5 (hMSH2).RESULTS:There were two HIV‐positive and two HIV‐negative patients in each group. Three HIV‐positive patients (one in the chemoradiotherapy group and two in the nonchemoradiotherapy group) demonstrated loss of heterozygosity. In the chemoradiotherapy group, one HIV‐positive patient demonstrated loss of heterozygosity at the hMLH1 locus. In the nonchemoradiotherapy group, two HIV‐positive patients exhibited a total of four instances of loss of heterozygosity. One tumor had loss of heterozygosity at hMSH2 and DCC/SMAD4; another tumor demonstrated loss of heterozygosity at hMSH2 and APC. Microsatellite instability‐low was found in two HIV‐positive patients. No instances of loss of heterozygosity and microsatellite instability were detected in HIV‐negative patients.CONCLUSION:Loss of heterozygosity and microsatellite instability, which reflect inactivation of tumor‐suppressor genes and genomic instability, occur with increased frequency in HIV‐associated squamous‐cell carcinoma. These data demonstrate for the first time evidence of loss of heterozygosity at the APC and DCC/SMAD4 gene loci in anal carcinoma. Although the findings presented here need to be expanded in a larger study, the recurrent loss of heterozygosity at D2S123, which was demonstrated in HIV‐positive patients with radio‐resistant squamous‐cell carcinoma of the anus, is notable.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:It has been documented that Crohn's disease affects anorectal function when anorectal manifestations of the disease are present. The aim of this study was to investigate whether the presence of histologic lesions in rectal biopsy affected anorectal motility in patients with Crohn's disease but no evidence of macroscopic anorectal involvement.METHODS:Forty‐one patients with documented Crohn's disease were included in the study. Twenty‐one of them had no endoscopic or histologic lesions in the rectum, and 20 patients had a positive histology for Crohn's disease on rectal biopsy, with or without macroscopic or endoscopic involvement of the anorectum. All patients underwent a standard anorectal manometry, with an eight‐channel, water‐perfused catheter.RESULTS:Patients with positive rectal biopsy but no evidence of endoscopic rectal involvement had lower anal resting and squeeze pressures (76±16 standard deviationvs.86±19 standard deviationP=0.002; 152±56 standard deviationvs.192±52 standard deviationP<0.001, respectively), and a lower sphincter and high‐pressure zone length (2.8±0.8 standard deviationvs.3.2±0.8 standard deviationP=0.006; 1.7±0.6 standard deviationvs.2±0.6 standard deviationP=0.005, respectively) compared with patients with negative rectal histology. Also, slow and ultra slow wave amplitude and ultra slow wave frequency were significantly lower (10±6 standard deviationvs.13±7 standard deviationP=0.04; 17±16 standard deviationvs.34±24 SDP=0.004; 0.9±0.8 standard deviationvs.1.3±0.6 standard deviationP=0.05, respectively), rectal sensation more affected, and rectal compliance significantly reduced (7.4±1 standard deviationvs.11.1±2.2 standard deviationP<0.001) in the former group of patients. Simultaneous presence of endoscopic and histologic lesions in the rectum was associated with further impairment of the anorectal function.CONCLUSION:Microscopic presence alone of Crohn's disease in the rectum appears to induce anorectal motility disorders. The synchronous presence of endoscopic rectal and macroscopic anal involvement is associated with further deterioration of anorectal function.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID