摘要:

PURPOSE:The advent of laparoscopic surgery has altered the manner by which surgical specialties address pathologies of the abdominal cavity. This advance in technology has also changed colorectal surgery. One of the more common procedures of colorectal surgery is segmental resection for polyps that are large, broad based, or inaccessible for colonoscopic removal. We present a technique combining colonoscopy and laparoscopy to remove troublesome polyps without the need for segmental resections.METHODS:From May 1990 to September 1999 laparoscopicmonitored colonic polypectomies were performed in 47 patients, with a total of 60 polyps being removed. After laparoscopic mobilization of the involved segment of the colon, the proximal bowel is cross‐clamped and the colonoscope passed to the involved portion of the colon. The polyp is then presented to the colonoscopist by the laparoscopist facilitating removal. The serosal surface is monitored for any indications of transluminal injury, and the area is repaired if needed. All polyps undergo immediate frozen section analysis. If the pathologic evaluation indicates malignancy then a segmental resection may be performed, otherwise the patients are decompressed and fed within a short time before discharge.RESULTS:The polyps were located most commonly in the ascending colon (18 polyps), transverse colon (12 polyps), and cecum (12 polyps). The most common histopathologic diagnosis was tubulovillous adenoma in 28 polyps followed by villous adenoma in 11 polyps. In three cases histopathologic diagnosis revealed malignancy necessitating segmental resection (1 low anterior resection and 2 right hemicolectomies), which were performed laparoscopically. Patients received a liquid diet within 6 hours, were discharged in an average of 21 hours, and returned to full activity, usually within days. The only complication presented in this group of patients was an umbilical port seroma. Virtually all patients (97 percent) behaved as if only a colonoscopy had been performed. Pain at the trocar sites was managed with acetaminophen 600 mg by mouth as needed.CONCLUSION:Laparoscopic‐monitored colonoscopic polypectomy allows patients to undergo removal of colonic polyps without a segmental resection. This less invasive procedure yields recovery times similar to that of colonoscopy alone, and the potential complications of a segmental resection are avoided. All polyps are examined by frozen section, and if a malignancy is encountered, a laparoscopic resection can be performed.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Recent advances have made possible the treatment of small invasive colorectal cancer by means of polypectomy or endoscopic mucosal resection. CD44 expression in cancer cells was identified as an indicator of lymph‐node metastasis, which could be evaluated in specimens removed by colonoscopy.METHODS:The correlation between lymph‐node metastasis and the expression of standard‐type CD44 in cancer cells was examined immunohistologically using the invaded cancer cells of 61 tissue samples of superficially invasive colorectal cancer. We defined the above as invasive cancer restricted within the colorectal wall. Of the 61 samples, 31 had submucosal invasion and 30 had muscular invasion.RESULTS:Standard‐type CD44 expression in the area of invasion in cases with lymph‐node metastasis was remarkably down‐regulated. In 43 cases with no lymph‐node metastasis, 36 (83.7 percent) of patients had CD44 expression in invaded cells, whereas only two of 18 cases (11.1 percent) with lymph‐node metastasis had expression of standard‐type CD44 in the same area (P<0.0001). A total of 69.6 percent (16/23) of patients with loss of standard‐type CD44 expression in invaded sites were found to have positive metastasis in the lymph nodes. These results suggest that standard‐type CD44 in invasive colon cancer cells could suppress metastasis to the regional lymph nodes.CONCLUSION:In cases of invasive colorectal cancer, the loss of standard‐type CD44 expression in the invaded area is a sensitive marker for metastasis to the lymph nodes. Further investigation with larger patient groups is required to clarify the reliability of loss of standard‐type CD44 expression as an indicator for additional surgery after endoscopic resection of submucosal invasive colorectal carcinoma.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Several methods of neurophysiologic assessment exist in the investigation of patients with fecal incontinence. However, the clinical significance of the information gained is uncertain. The aim of this prospective study was to evaluate the results of pudendal nerve terminal motor latency and fiber density in relation to clinical variables and manometric measurements.METHODS:Seventy‐two patients with fecal incontinence (63 women; mean age, 62; range, 24‐81 years) responded to a bowel questionnaire and underwent anorectal manovolumetry, anal ultrasonography, defecography, and electromyography, including pudendal nerve terminal motor latency and fiber density.RESULTS:Pudendal neuropathy (pudendal nerve terminal motor latency >2.5 ms) was found in 46 percent and increased fiber density (>1.7) in 82 percent. Pudendal neuropathy and increased fiber density were most common in patients with rectal prolapse or intra‐anal intussusception. No difference was seen concerning anal resting and incremental pressures, rectal compliance, rectal sensibility or severity of incontinence in patients with unilateral, bilateral, or marked (>4 ms) pudendal neuropathyvs.patients with normal pudendal nerve terminal motor latency. In contrast, patients with increased fiber density had lower incremental pressures (P<0.05) and stated decreased rectal sensibility (P<0.05) compared with those with normal fiber density. These differences were most pronounced in patients with neurogenic or idiopathic incontinence.CONCLUSIONS:Pudendal neuropathy and increased fiber density are common in patients with fecal incontinence. Fiber density but not pudendal nerve terminal motor latency was correlated with clinical and manometric variables. The severity of nerve injury correlated with anal motor and sensory function in patients with neurogenic or idiopathic incontinence. The routine use of pudendal nerve terminal motor latency in the assessment of patients with fecal incontinence can be questioned.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:The aim of this study was to examine the long‐term results of electromyographic biofeedback training in fecal incontinence.METHODS:Thirty‐seven patients (1 male) received a customised program of 2 to 11 (median, 3) biofeedback training sessions with an anal plug electromyometer. Nine patients had persistent incontinence after anal sphincter repair, a further 8 patients had postsurgical or partial obstetric damage of the sphincter but no sphincter repair, 9 patients had neurogenic sphincter damage, and 11 patients were classified as having idiopathic fecal incontinence. Duration of voluntary sphincter contraction was measured by anal electromyography (endurance score) before and after treatment. A postal questionnaire was used to investigate the following variables: 1) subjective rating on a four‐grade Likert‐scale of the overall result of the biofeedback training; 2) incontinence score (maximum score is 18, and 0 indicates no incontinence); and 3) rating of bowel dissatisfaction using a visual analog scale (0 to 10).RESULTS:Twenty‐two patients (60 percent) rated the result as very good (n=8) or good (n=14) immediately after the treatment period. Median endurance score improved from 1 to 2 minutes (P<0.0001). Median incontinence score improved from 11 to 7, and bowel dissatisfaction rating improved from 5 to 2.8 (bothP<0.0001). After a median follow‐up of 44 (range, 12‐59) months, 15 patients (41 percent) still rated the overall result as very good (n=3) or good (n=12). The incontinence score did not change during follow‐up. Median bowel dissatisfaction rating deteriorated from 2.8 to 4.2 but remained better than before treatment. Poor early subjective rating and the need for more than three biofeedback sessions were predictive of worsening during follow‐up.CONCLUSION:We think it is encouraging that in this study biofeedback treatment for fecal incontinence with an intra‐anal plug electrode resulted in a long‐term success rate in nearly one‐half of the patients.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Large rectoceles have been associated with symptoms of impaired rectal evacuation, often leading to rectocele repair. However, these symptoms, or the anatomic abnormality, may be caused, at least in part, by a primary disturbance of rectoanal coordination. This study aimed to determine the efficacy of biofeedback therapy in such patients.METHODS:Thirty‐two female patients (median age, 52 years) complaining of impaired rectal evacuation and with a rectocele greater than 2 cm at proctography were evaluated by structured questionnaire before, immediately after treatment, and at follow‐up. Physiologic and proctographic findings were related to outcome.RESULTS:Immediate results were available in 32 patients and medium‐term follow‐up (median, 10; range, 2‐30 months) in 25 patients. At follow‐up 14 (56 percent) patients felt a little and 4 (16 percent) patients felt major improvement in symptoms, including 3 (12 percent) with complete symptom relief. Immediately after biofeedback there was a modest reduction in need to strain (from 72 to 50 percent), feeling of incomplete evacuation (from 78 to 59 percent), need to assist defecation digitally (from 84 to 63 percent), and need to use an evacuant (from 47 to 28 percent), and this was maintained at follow‐up. Bowel frequency was significantly normalized at follow‐up (P=0.02). Pretreatment presence of symptoms of digitally assisting defecation, pelvic floor incoordination, and proctographic rectocele size and contrast trapping, did not predict outcome.CONCLUSIONS:Behavioral therapy, including biofeedback, leads to major symptom relief in a minority, and partial symptom relief in a majority, of patients with a feeling of impaired defecation and the presence of a large rectocele. Residual symptoms are common. Biofeedback may be a reasonable first‐line treatment for such patients.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:The aim of this study was to assess the clinical and functional outcome of surgery for recurrent rectal prolapse and compare it with the outcome of patients who underwent primary operation for rectal prolapse.METHODS:All patients who underwent surgery for rectal prolapse were evaluated for age, gender, procedure, anorectal manometry and electromyography findings, and morbidity. The results for patients who underwent surgery for recurrent rectal prolapse were compared with a group of patients matched for age, gender, surgeon, and procedure who underwent primary operations for rectal prolapse.RESULTS:A total of 115 patients underwent surgery for rectal prolapse. Twenty‐seven patients, 10 initially operated on at this institution and 17 operated on elsewhere, underwent surgery for recurrent rectal prolapse. These 27 patients were compared with 27 patients with primary rectal prolapse operated on in our department. In the recurrent rectal prolapse group, prior surgery included rectopexy in 7 patients, Delorme's procedure in 7 patients, perineal rectosigmoidectomy in 7 patients, anal encirclement procedure in 4 patients, and resection rectopexy in 2 patients. Operations performed for recurrence were perineal rectosigmoidectomy in 14 patients, resection rectopexy in 8 patients, rectopexy in 2 patients, pelvic floor repair in 2 patients, and Delorme's procedure in 1 patient. There were no statistically significant differences between the groups in preoperative incontinence score (recurrent rectal prolapse, 13.6±7.8vs.rectal prolapse, 12.7±7.2; range, 0‐20) or manometric or electromyography findings, and there were no significant differences in mortality (0vs.3.7 percent), mean hospital stay (5.4±2.5vs.6.9±2.8 days), anastomotic complications (anastomotic stricture (0vs.7.4 percent), anastomotic leak (3.7vs.3.7 percent) and wound infection (3.7vs.0 percent)), postoperative incontinence score (2.8±4.8vs.1.5±2.7), or recurrence rate (14.8vs.11.1 percent) between the two groups at a mean follow‐up of 23.9 (range, 6‐68) and 22 (range, 5‐55) months, respectively. The overall success rate for recurrent rectal prolapse was 85.2 percent.CONCLUSION:The outcome of surgery for rectal prolapse is similar in cases of primary or recurrent prolapse. The same surgical options are valid in both scenarios.

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 review the clinical presentation and characteristics of primary colorectal lymphoma, analyze the prognostic factors, and assess the results of treatment with adjuvant chemotherapy.METHODS:We identified 37 cases at our institution between 1980 and 1996. They comprised 0.48 percent of all cases of colon malignancies (37/7,658) during this period. The following clinical information was obtained: age, gender, signs and symptoms, tumor site, tumor size, histology grade, pathology, and adjuvant chemotherapy.RESULTS:The most common presenting signs and symptoms were abdominal pain (62 percent), abdominal mass (54 percent), and weight loss (43 percent). The most frequent site of involvement was the cecum (45 percent). Histologically, 29 (78 percent) were classified as high‐grade, and 8 (22 percent) as intermediate‐grade‐to‐low‐grade lymphoma. Nine (24.3 percent) of the cases were Stage EI, 23 (62.2 percent) were Stage EII, and 5 (13.5 percent) were Stage EIV. Twenty‐one (57 percent) cases received adjuvant chemotherapy. The five‐year survival rate was 33 percent for all patients and 39 percent for patients treated with combination chemotherapy. Overall median survival time was 24 months and 36 months for those with adjuvant chemotherapy. Only histology grade, among the factors examined, was a significant prognostic factor for survival. The mean survival time of the patients with Stage II disease who received chemotherapy was 117.4 months, and it was 47.9 months for the patients with Stage II disease who did not received chemotherapy. Conclusions: In our retrospective study high‐grade lymphoma was the only significant adverse prognostic factor for survival. Receiving adjuvant chemotherapy significantly improved survival in patients with Stage II disease. Patients with diffuse large‐cell type had better survival than patients with small noncleaved‐cell type in Stage II high‐grade lymphoma.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Colonic and anorectal function are altered after posterior rectopexy. The aim of this randomized, prospective study was to evaluate the effects of rectal mobilization and division of the lateral ligaments on colonic and anorectal function.METHODS:Posterior rectopexy was performed in 18 patients with complete rectal prolapse. Anal manometry and measurement of rectal compliance, total and segmental colonic transit time, constipation score, and defecation frequency were performed preoperatively and three months postoperatively. Ligaments were divided in ten patients.RESULTS:Mean preoperative total transit time was similar between the two patient groups and doubled postoperatively (P=0.03). Mean postoperative segmental transit time increased by a factor of 1.7 in segments I (ascending colon) and II (descending colon) and by a factor of 2.3 in segment III (rectosigmoid). The same pattern was found in both groups. Mean resting pressure decreased after division of the lateral ligaments and increased after preservation. Mean rectal compliance decreased after division of the ligaments and increased when they were preserved. Mean postoperative constipation score differed little from the preoperative score. Mean defecation frequency was decreased in the group with the ligaments preserved and increased in the group with the ligaments divided. None of the effects of rectal mobilization or division of the lateral ligaments on anorectal function reached statistical significance.CONCLUSION:Rectal mobilization had a statistically significant effect on colonic function. Total and segmental colonic transit times doubled. The effects on anorectal function were not significant. Division of the lateral ligaments did not significantly influence postoperative functional outcome.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Several treatments are used for the treatment of levator syndrome, such as rectal massage, biofeedback, and galvanic stimulation. But their effects are inconsistent, and multiple treatment sessions are usually required. Triamcinolone acetonide and lidocaine mixture was injected locally into the tenderest point in levator syndrome under the hypothesis that levator syndrome is caused by tendinitis of pelvic floor musculature.METHODS:A mixture of 40 mg of triamcinolone acetonide and 1 ml of 2 percent lidocaine was injected into the tenderest point transanally in 104 patients (33 males; mean age, 51 years) with levator syndrome from December 1996 to May 1998 at Daehang Clinic. Additional injections were repeated at two‐week intervals to a maximum of three injections in cases of poor response. Follow‐up was performed prospectively concerning patient's perception of pain level using a visual analog scale. Depending on the response, the patients were classified into four groups: pain‐free, good, fair, and no response. More than 50 percent pain reduction was classified as “good,” and less than 49 percent reduction as “fair.”RESULTS:The injection regions, where the tenderest points were identified on digital rectal compression, were left anterior anal canal in 71.2 percent of patients, right anterior in 3.8 percent of patients, and posterior in 25 percent of patients. The results of treatment were as follows: at three months after injection, response was classified as pain‐free in 36.8 percent of patients, good in 35 percent of patients, fair in 19.5 percent of patients, and no response in 8.7 percent of patients; at six months the response was pain‐free in 30.1 percent of patients, good in 46.5 percent of patients, fair in 18.2 percent of patients, and no response in 5.2 percent of patients. Most patients, except 8.7 percent at three months and 5.2 percent at six months, experienced treatment benefits. There were no complications during the follow‐up periods.CONCLUSION:Transanal injection of triamcinolone acetonide and lidocaine mixture into the tenderest point is such a simple, safe, and very effective modality that it can be recommended as a primary therapy for levator syndrome.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID