摘要:

INTRODUCTION:Although transanal ultrasound has rapidly become the test of choice for the diagnosis of anal sphincter injury, the accuracy and reliability of this technique are unknown. This study evaluates the accuracy and reliability of transanal ultrasound for anterior (obstetric‐related) anal sphincter injury.METHODS:Sixty‐two women underwent transanal ultrasound with hard‐copy images obtained at 0.5‐cm intervals from the anal verge to 2.5 cm into the anal canal. All transanal ultrasound procedures were also recorded on videotape. Two experienced ultrasonographers blinded as to the patients' clinical history and examination independently reviewed the images and videotape recordings for the presence or absence of anal sphincter injury.RESULTS:The accuracy of transanal ultrasound in 22 incontinent women with known anal sphincter injury was 100 percent. The accuracy of transanal ultrasound in 20 nulliparous women with intact anal sphincters was only 35 percent but improved to 50 percent after the “real time” videotape was reviewed (P=0.16) and further improved to 85 percent when interpretation was limited to the distal 1.5 cm of the anal canal (P=0.004). In these nulliparous women, intact internal sphincters were more accurately predicted than intact external sphincters (95vs.85 percent;P=0.24). Measurement agreement between the two ultrasonographers was 68 percent (fair; kappa, 0.26) but significantly improved to 78 percent (moderate; kappa, 0.48;P=0.0001) when interpretation was limited to the distal 1.5 cm of the anal canal. Overall clinical agreement (final scan interpretation) was good (81 percent agreement; kappa, 0.61). Agreement was better for the internal sphincter (74 percent; fair; kappa, 0.36) than the external sphincter (61 percent; poor; kappa, 0.17;P=0.0002).CONCLUSIONS:Although transanal ultrasound can accurately identify anterior anal sphincter injury when present, transanal ultrasound falsely identifies sphincter injury in at least 5 to 25 percent of normal anal sphincters. Only fair agreement in the interpretation of transanal ultrasound exists between experienced ultrasonographers. Both the accuracy and reliability of transanal ultrasound are significantly improved by limiting transanal ultrasound to the distal 1.5 cm of the anal canal.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:Electrophysiologic evaluation has been suggested as a means of identifying prognostic factors for patients with fecal incontinence who undergo anal sphincter repair. The purpose of this study was to evaluate the results of anal sphincter repair in patients with documented pudendal neuropathy and to determine the usefulness of electrophysiologic studies for prognostication of sphincteroplasty.METHODS:A retrospective review of a series of patients undergoing electrophysiologic studies and anterior anal sphincteroplasty was performed. Data collected included age, standardized incontinence scores (preoperative, immediately postoperative, and current follow‐up), and results of pudendal nerve terminal motor latency and monopolar electromyography. Outcomes of sphincteroplasty were designated as excellent, good, fair, or poor based on incontinence scores. Prolonged pudendal nerve terminal motor latency was defined as longer than 2.2 ms and evaluated as unilateral or bilateral.RESULTS:During the time period of the study (1991‐1996), 15 patients had electrophysiologic studies and underwent sphincteroplasty. Twelve patients (80 percent) were available for follow‐up and form the basis for this study. All patients were women, with a mean age of 45±18.6 (27‐75) years and a mean follow‐up of 49.7±18.6 (20.4‐72.6) months. Mean duration of incontinence preoperatively was 13±16.1 (range, 1‐58) years. The incontinence score was 15.8±3.5 preoperatively, 5.4±4.5 postoperatively, and 5±5.1 currently for all 12 patients. There was one patient with normal pudendal nerve terminal motor latency. In the four patients with bilateral prolonged pudendal nerve terminal motor latency, the incontinence scores were 15±4.2 preoperatively, 8.5±5.3 postoperatively, and 6±6.1 (statistically significant compared with preoperation) currently. Seven patients were found to have unilateral prolonged pudendal nerve terminal motor latency with incontinence scores of 16.3±3.5 preoperatively, 4.4±3.2 (statistically significant compared with preoperation) postoperatively, and 5.1±4.9 (statistically significant compared with preoperation) currently. Based on incontinence scores, results of the sphincteroplasty at the most current follow‐up were as follows: no neuropathy, excellent in one patient; unilateral neuropathy, five with good/excellent results, two with fair/poor results; bilateral neuropathy, two with good/excellent results, two with fair/poor results (P>0.05 bilateralvs.unilateral). By monopolar electromyographic examination, external anal sphincter denervation was noted in 11 patients; their incontinence scores were 15.5±3.5 preoperatively, 5.9±4.3 (statistically significant compared with preoperation) postoperatively, and 5.5±5.0 (statistically significant compared with preoperation) currently. Monopolar electromyographic results in the puborectalis included four normal examinations and six that were unobtainable. In the two patients with puborectalis denervation, the incontinence scores were 19.5±0.7 preoperatively, 8.5±4.9 postoperatively, and 2.5±3.5 (statistically significant compared with preoperation) currently.CONCLUSIONS:Anterior anal sphincteroplasty in patients with unilateral or bilateral prolonged pudendal nerve terminal motor latency can provide significant improvement in continence with minimum morbidity. Therefore, correction of the anatomic sphincter defect should still be considered, even in patients with documented pudendal neuropathy.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:The aims of the study contained herein were to analyze the efficacy and safety of a chronically electrostimulated double‐wrap graciloplasty for restoration of continence after a curative abdominoperineal resection for rectal carcinoma and to evaluate late results of a stimulation protocol that was begun early.METHODS:During the last six years, 31 consecutive patients underwent this procedure: in 24 patients, electrostimulated double‐wrap graciloplasty was performed simultaneously with abdominoperineal resection for lower rectal cancer; 7 strictly selected patients underwent conversion to an abdominal stoma following previous abdominoperineal resection (mean length of time from stoma creation, 71.4 months). Anorectal reconstruction was performed following a surgical scheme already standardized since 1985 in 102 patients: after abdominoperineal resection, the distal colon was pulled through to the perineum and surrounded by both gracilis muscles following an “alfa and new‐sling” configuration; using platinumiridium electrodes, both muscles were then connected to a pulse generator, which was implanted subcutaneously in the abdomen. All surgical steps were performed during the same surgical session to allow early postoperative stimulation of the transposed muscles. A contemporary covering stoma was abandoned as a standard procedure; the distal colon was left closed for a few postoperative days, then it was resected and sutured to the perineum under local anesthesia. Eighteen patients underwent preoperative or postoperative radiotherapy or both, without any significant adverse outcome. To increase gracilis resistance to prolonged “tonic” contraction, patients underwent a chronic, low‐frequency stimulation protocol. In the last 11 patients, a new “over‐the‐nerveandintramuscular” implant was adopted to optimize fiber recruitment and to reduce electrostimulation thresholds. At regular intervals, all patients were evaluated using continence scores and questionnaires, electromanometry, endoluminal ultrasound study, and defecography.RESULTS:Twenty‐six of 31 patients were evaluable for continence, with a mean length of follow‐up of 37.8 (range, 4‐68) months; 3 patients died because of cancer recurrence, 1 underwent conversion to an abdominal stoma, and 1 is waiting for stoma closure. Continence to liquid and solid stools was achieved in 22 patients (85 percent), and electromanometry findings confirmed a good muscular contraction postoperatively and during follow‐up intervals. No postoperative mortality (40 days) was observed; the postoperative complication rate was high (22 percent), but early treatment (drainage and temporary diversion in 7 patients) led to favorable outcomes (4 resolutions, 3 partial muscular impairments). Four stimulators had to be temporarily explanted because of late complications, and two stimulators had to be replaced because of battery exhaustion after three years of use with high stimulation parameters. A significant difference was observed comparing full‐contracting threshold after intramuscular (14 patients) and the new over‐the‐nerve and intramuscular implant technique.CONCLUSIONS:The study contained herein confirms the efficacy of the surgical scheme we have adopted since 1985 to reconstruct sphincteric apparatus after abdominoperineal resection of the rectum. The “one‐step” timing of surgical and electrostimulation‐related procedures and the early start of stimulation did not show a significant increase in the complication rate and did not produce noticeable muscular or nerve damage. Adoption of chronic electrostimulation protocols using implantable devices increased the rate of fully continent patients; nevertheless, the overall cost for devices and medical staff duties was high, and a small increase of late morbidity was observed. Finally, the preliminary experience with our new technique of electrode implants encourages further application.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:Paradoxical sphincter reaction is frequently found in constipated patients but sometimes also in incontinent patients and in asymptomatic subjects. Its significance in defecation disorders has, therefore, been debated. The aim of the present study was to investigate whether paradoxical sphincter reaction is influenced by rectal filling volume.PATIENTS AND METHODS:Eighteen patients with defecation disorders and paradoxical sphincter reaction shown by electromyography were reinvestigated with an extended electromyographic investigation while in the lying position and while in the sitting position, with 50‐ml, 100‐ml, and 150‐ml water‐filled rectal balloons.RESULTS:All 18 patients showing paradoxical sphincter reaction in the first investigation also showed the reaction at the second investigation in the lying position with a 0‐ml volume of rectal contents. In the sitting position, with a volume of 150 ml of rectal contents, the increase in electromyographic activity disappeared in seven patients (39 percent) and no longer showed paradoxical sphincter reaction. Electromyography showed decreased activity in one patient and unchanged activity in six patients during straining. A closing reflex was seen after completed straining in all of these seven patients.CONCLUSIONS:The present study demonstrates that paradoxical sphincter reaction diagnosed by electromyography is influenced by the rectal filling volume and might diminish when the rectum is filled with contents. The conventional electrophysiologic technique in the diagnosis of paradoxical sphincter reaction might, therefore, overdiagnose this condition.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:The purpose of this study was to evaluate the use and timing of computed tomography in the treatment of patients with acute left‐sided diverticulitis.METHODS:We reviewed our four‐year experience of 47 patients with the diagnosis of acute diverticulitis. We have evaluated the benefits of admissionvs.delayed computed tomography in patients with this diagnosis.RESULTS:Of the 47 patients, 17 were diagnosed on clinical grounds alone, treated, and released. Thirty patients had their clinical diagnoses of diverticulitis evaluated with either computed tomographic scan (26) or laparotomy (4). Eleven of those 30 (36 percent) patients were found to have normal computed tomographic scans, indicating inaccurate clinical diagnosis, and all patients who underwent laparotomy had the pathologic diagnosis of diverticulitis. Six of the 47 patients had abscesses, but only 2 were identified at the time of admission. The remaining four abscesses were identified on delayed computed tomographic scans after failure of medical therapy. Thirty‐seven hospital days were used by patients with inaccurate diagnoses before their computed tomographic scans. Analysis of cost revealed that a computed tomographic scan for all 47 patients would have cost less than the expense of admission for just the 11 patients who had normal computed tomographic scans.CONCLUSION:Routine admission computed tomographic scan for patients with acute diverticulitis leads to more accurate diagnosis, earlier identification of complications, and possible decreased hospital costs.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:There is increasing evidence that screening for colorectal cancer may save lives, and consequently, both professional and public interest in screening for colorectal cancer is increasing. As yet, however, there is no perfect screening test. Insidious blood loss is a common feature of colorectal cancer and may lead to a fall in serum ferritin before the patient becomes anemic. Measurement of serum ferritin, which is widely available and easily and inexpensively performed, has, therefore, been postulated as a potential screening test for colorectal cancer.METHOD:This study used samples of serum collected from 148 patients recruited to a screening study for colorectal cancer. All patients were thoroughly investigated by double‐contrast barium enema and/or colonoscopy. Patients were selected randomly from each of three clinical diagnostic groups: 50 patients with proven colorectal cancer, 49 patients without colon disease, and patients with adenomas of the colon. Serum ferritin was assayed by immunoradiometry. The expected adult reference range is 25 to 350 &mgr;g/l, and results were reported without patient identification.RESULTS:There were no significant differences in serum ferritin levels among any of the three groups.CONCLUSION:Serum ferritin is unlikely to be of value as a screening test for colorectal cancer.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:Identification of prognostic factors is a primary basis for planning the treatment and predicting the outcome of patients with colorectal cancer. Reviewing studies from the literature performed using univariate and multivariate analyses and their own study, the authors critically discuss the prognostic value of the clinicopathologic parameters of the tumor.METHODS:Among 853 patients with colorectal tumors seen at the Department of Clinical Surgery of the Catholic University of Rome, Italy, 690 cases that were curatively resected entered the study. Overall survival rate, related to the clinicopathologic variables, was calculated, and univariate and multivariate analyses were performed.RESULTS:Five‐year and ten‐year overall survival rates were 70 and 55 percent, respectively. Univariate and multivariate analyses showed that node involvement, distant metastases, bowel obstruction, and patient gender are factors independently related to outcome.CONCLUSIONS:Data from the literature and the present study suggest that only a few clinical parameters, particularly bowel obstruction, and some pathologic factors (tumor stage, vessels invasion, and tumor ploidy) are related to patient survival rate and are the most reliable prognostic criteria. In prospective clinical studies, any other new pathologic or molecular factors should be matched with these parameters to confirm their value in outcome prediction.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

&NA;A method for bowel irrigation through an appendicostomy (antegrade colonic enema) for patients with a left colostomy is described. The appendicostomy is easily constructed without morbidity. Irrigation through the appendicostomy is performed with minimum equipment, uses a small volume of irrigation water, and takes a relatively short time. This may improve colonic evacuation in patients with left colostomy.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID