摘要:

PURPOSE:The aim of this study was to assess the long‐term clinical and quality of life outcomes for patients after referral to a four‐month treatment program for fecal incontinence based on pelvic floor exercises and biofeedback. Secondary objectives were to document patients' subsequent treatment activities and their perception of the biofeedback training; to establish the long‐term outcomes and initial predictors for the subset of patients who did not complete the treatment, or who failed to improve during the program; and to correlate changes in clinical outcome measures and quality of life over time.METHODS:Patients were contacted by telephone to determine their perception of progress subsequent to the treatment program, any subsequent treatment or activities relating to their fecal incontinence, and which aspect of the treatment program they believed was most helpful. St. Mark's and Pescatori fecal incontinence scores were also recorded, along with patients' self‐assessments of their incontinence severity and quality of life.RESULTS:Eighty‐three (69 percent) patients were contacted for interviews at a median of 42 (range, 26‐56) months after program completion. At the time of follow‐up, patients who completed the program continued to enjoy strongly significant improvements in all outcome measures, with 75 percent perceiving a symptomatic improvement and 83 percent reporting improved quality of life. For many patients, improvement continued subsequent to program completion. Patients whose incontinence scores became worse during treatment still reported improvement in their quality of life and perceived incontinence severity during the same time period; many experienced some degree of “catch‐up” in their continence scores during the follow‐up period. Fourteen patients (17 percent) went on to have surgery for fecal incontinence; of these, 6 (7 percent) had a stoma. Twenty (24 percent) regularly took antidiarrheal medication. Thirty program completers (41 percent) were continuing pelvic floor exercises.CONCLUSIONS:This study confirms the long‐term improvement in fecal incontinence achieved through treatment with biofeedback and pelvic floor exercises. In this study, patients also continued to improve after treatment completion, possibly because of the strong emphasis placed on patients during treatment to continue the pelvic floor exercises on their own. The poor correlation between quality of life and quantitative scores of fecal incontinence suggests that there are important aspects of continence that are not being appropriately recognized.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PURPOSE:This study was designed to assess the relationship of anal endosonography and manometry to anorectal complaints in the evaluation of females a long time after vaginal delivery complicated by anal sphincter damage.METHODS:Thirty‐four patients with anal sphincter damage after delivery, 22 with and 12 without anorectal complaints, and 12 controls without anorectal complaints underwent anal endosonography, manometry, and rectal sensitivity testing. Complaints were assessed by questionnaire, with a median follow‐up of 19 years.RESULTS:Median maximum anal resting pressures were significantly lower in patients with anal sphincter damage with complaints (31 mmHg) than in controls (52 mmHg;P< 0.001). Median maximum anal squeeze pressures were significantly lower in patients with (55 mmHg) and without (69 mmHg) complaints than in controls (112 mmHg;P< 0.001 for both). Maximum anal resting pressures were significantly lower in patients with anorectal complaints after anal sphincter damage than in patients without complaints (P= 0.02). Results of anal manometry showed a large overlap between all groups. Rectal sensitivity showed no significant differences between the three groups. Persisting sphincter defects, shown by anal endosonography, were significantly more present in patients with anal sphincter damage after delivery with (86 percent) and without (67 percent) complaints than in controls (8 percent;P< 0.001 andP< 0.01, respectively). No differences in the number of echocardiographically proven sphincter defects were found between patients with or without anorectal complaints after anal sphincter damageCONCLUSIONS:Echographically proven sphincter defects are strongly associated with a history of anal sphincter damage during delivery. Sphincter defects are present in the majority of patients with anorectal complaints. Anal manometry provides little additional therapeutic information when performed after anal endosonography in patients with anorectal complaints after anal sphincter damage during delivery.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PURPOSE:This study was designed to evaluate long‐term results and quality‐of‐life outcomes after the muscle‐filling procedure for posterior transsphincteric fistulas.METHODS:A questionnaire was mailed to 207 patients who had been treated by the muscle‐filling procedure for posterior transsphincteric fistulas with cryptoglandular origin at the Social Health Insurance Hospital during a ten‐year period. One hundred fifty‐one patients who returned their questionnaires were included in this retrospective study. Information regarding fistula recurrence, time required for wound healing, postoperative incontinence, overall satisfaction with the procedure, and quality‐of‐life data were surveyed from the returned questionnaires.RESULTS:One hundred fifty‐one patients (140 males) with a mean age of 48 (range, 17‐75) years were analyzed. The mean follow‐up was 70 (range, 12‐131) months. Fistulas recurred in seven patients (4.6 percent). Fifty‐eight patients (38 percent) healed within 3 months, and 52 (34 percent) healed within 6 months. Eighty‐four patients (56 percent) reported some reduction in their sense of sphincter‐tightening ability after surgery. Seventy‐eight patients (52 percent) reported some degree of incontinence. One hundred thirty‐three patients (88 percent) were satisfied or very satisfied with their outcomes. Of the 18 patients (12 percent) who reported unsatisfactory or very unsatisfactory results, 7 experienced recurrence. Thirty‐seven patients (25 percent) indicated one or more lifestyle alterations, including social activities (11 percent), travel (12 percent), sports (5 percent), diet (4 percent), housework (1 percent), or sexual activities (1 percent), because of incontinence after surgery. Eighteen patients (12 percent) had more than one restriction in their quality‐of‐life parameters.CONCLUSION:The muscle‐filling procedure is a viable option in the treatment of transsphincteric fistulas, with a favorable recurrence rate and an overall patient satisfaction rate above 88 percent.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PURPOSE:Sensation is an essential aspect of fecal continence. We aimed to correlate manovolumetric and radiologic changes at successive levels of rectal filling sensation.METHODS:Combined anorectal manometry and proctography were performed in nine volunteers. Images, volumes, and pressures were analyzed at the start of the test, at 20 seconds before first sensation, and at first, constant, urge, and maximum tolerable sensation.RESULTS:Consecutive levels of rectal filling sensation were associated with progressive opening and dilation of the upper anal canal (up to 44 mm) and sliding down of the rectal contents (14 mm), which had already started before the first sensation. This coincided initially with a pressure decrease in the proximal anal canal (from 94 to 42 mmHg). With constant sensation and particularly with urge sensation, rectal pressure increase appeared to be responsible for further proximal anal dilation. This was accompanied by a significant increase of proximal anal pressure (up to 133 mmHg) and sharpening of the angle between the anal axis and the horizontal reference line.CONCLUSION:The proximal anal canal or its surrounding structures play an important role in the desire‐to‐defecate sensation. They can be activated by a progressive buildup of rectal reservoir pressure in the presence of a competent distal anal sphincter barrier.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

INTRODUCTION:Oral inoculation with a nontoxic, attenuated strain ofSalmonella typhimuriumreduces tumor burden and improves survival in a mouse model of metastatic colon cancer. These effects are likely mediated byS. typhimurium‐induced increases in hepatic natural killer leukocytes. Cyclooxygenase‐2 inhibitors may mediate antitumor effects through antiangiogenic, immune, or proapoptotic pathways. We hypothesized that cyclooxygenase‐2 inhibitors would act synergistically withS. typhimurium, resulting in additional antitumor effects.METHODS:Four groups of mice were studied: control,S. typhimuriumalone, cyclooxygenase‐2 inhibitor alone, andS. typhimuriumplus cyclooxygenase‐2 inhibitor. Mice were given normal drinking water (control,S. typhimuriumalone) or water with 1,600 parts per million cyclooxygenase‐2 inhibitor (cyclooxygenase‐2 inhibitor alone, andS. typhimuriumplus cyclooxygenase‐2 inhibitor) and orally inoculated with saline (control, cyclooxygenase‐2 inhibitor alone) or 109S. typhimurium(S. typhimuriumalone,S. typhimuriumplus cyclooxygenase‐2 inhibitor). Twenty‐four hours later, all mice underwent laparotomy, and 5 × 104 MCA38 murine adenocarcinoma cells were injected into the spleen. On Day 14, hepatic tumor number and tumor volume was quantitated and hepatic leukocytes were analyzed by flow cytometry.RESULTS:Compared with control mice orally inoculated with saline,S. typhimurium‐treated mice had fewer and smaller tumors; mice treated with cyclooxygenase‐2 inhibitor alone had tumor burden similar to control mice, and mice treated withS. typhimuriumplus cyclooxygenase‐2 inhibitor had fewer and smaller tumors compared with all other groups. Increased liver natural killer cells and decreased CD4+ and CD8+ T cells were observed in bothS. typhimurium‐treated groups. No alterations in hepatic leukocyte phenotype were observed in mice receiving cyclooxygenase‐2 inhibitor alone.CONCLUSION:Oral cyclooxygenase‐2 inhibitor appeared to act synergistically withS. typhimuriumto reduce tumor burden. This combination therapy may have clinical application in the treatment or prevention of hepatic metastases associated with colorectal cancer.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PURPOSE:The aim of this retrospective study was to determine which aspects of tumor morphology and histology influenced the incidence of local recurrence after curative resection of colonic adenocarcinoma.METHODS:Patients who had a curative resection for a primary colonic adenocarcinoma between 1980 and 1993 (inclusive) were identified from the colorectal cancer database in the Department of Colorectal Surgery. The charts of patients diagnosed with a local recurrence were then reviewed and their findings at operation and histologic assessment analyzed. Patients were followed up for at least five years or until death.RESULTS:Over the period of study, 1,031 patients had a curative resection for colonic adenocarcinoma. Local recurrences were detected in 32 patients (3.1 percent). The gender distribution of patients with local recurrence was 18 males (56.3 percent) and 14 females (43.7 percent) with a mean age of 63.4 years. The median time to local recurrence was 13 (range, 2‐71) months. The distribution of primary tumors that recurred locally favored the cecum (n = 9; 28.1 percent) and sigmoid colon (n = 14; 43.7 percent) over other locations; these were, however, the most common sites of primary lesions. Less common sites included the ascending colon (n = 0; 0 percent), hepatic flexure (n = 2; 6.3 percent), transverse colon (n = 1; 3.1 percent), splenic flexure (n = 3; 9.4 percent), and descending colon (n = 3; 9.4 percent). Of the total number of tumors, 101 were found to be adherent to at least 1 other intra‐abdominal viscus, and 12 (11.9 percent) recurred locally. Other factors associated with local recurrence were tumor perforation and fistulation. Overall, 30 tumors (2.9 percent) were perforated, and 6 (20 percent) recurred locally. Four tumors (0.4 percent) were fistulating; of these, 2 (50 percent) recurred locally. Advanced tumor stage was also associated with an increased rate of local recurrence (Stage I, 0 percent; Stage II, 2.05 percent; Stage III, 7.0 percent; and Stage IV, 6.1 percent). Similarly, tumor differentiation was related to local recurrence, with no instances in well‐differentiated tumors, 2.8 percent in moderately differentiated tumors, and 6.8 percent in poorly differentiated tumors.CONCLUSIONS:The location of the primary tumor is not a factor in producing local recurrence. Fixity to another viscus, perforation or fistulation, advanced stage of disease, and differentiation of tumor appear to increase the chances of recurrence of curatively resected colonic carcinoma. Although the recurrence rate is higher in these groups than for tumors overall, definitive oncologic surgery prevents recurrence in the majority of cases. No colonic tumor that was T1 or T2 (N0, N1, or N2) or that was well differentiated recurred locally.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PURPOSE:Previous analyses of the time trends of colorectal cancer have suggested a shift from left‐sided toward right‐sided cancer sites. The aim of this study was to determine whether such trends in the subsite distribution of colorectal cancer could be confirmed in hospitalization statistics similarly as in the incidence data.METHODS:The inpatient files of the Department of Veterans Affairs and the Surveillance, Epidemiology, and End Result database of the National Cancer Institute were used to study the time trends of colorectal cancer in the United States during the past three decades. Any cancer location in the rectum, sigmoid, or descending colon was defined as left‐sided colorectum.RESULTS:For the period between 1970 and 2000, the data from the Department of Veterans Affairs revealed a statistically significant 16 percent increase in the proportion of proximal lesions among white males and females, as well as a 22 percent increase in black males. For the period between 1973 and 1997, the data from the Surveillance, Epidemiology, and End Result revealed a 6 percent increase in the proportion of proximal colon cancers among whites and blacks of both genders.CONCLUSIONS:The epidemiologic data confirm a rightward shift in the colonic distribution of cancer.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PURPOSE:The aim of this study was to assess the effects of smoking on the risk of colorectal cancer according to anatomic subsite.METHODSBetween 1979 and 1985 a population‐based case‐control study of cancer at multiple sites was performed in Montréal, which accrued over 4,000 males in total, including cases of colorectal cancer, other cancers, and population controls. The present analysis was restricted to the 585 cases with histologically proven adenocarcinoma of the large bowel, aged 35 to 70 years, who underwent face‐to‐face interviews and provided adequate smoking histories. Of these, 176 had cancer in the proximal colon, 179 had cancer in the distal colon, and 230 had rectal cancer. Our control group consisted of 405 cancer controls, whose tumor types were considered unrelated to smoking, and 500 population controls.RESULTS:We observed a positive association between cigar smoking and cancer of the rectum. We also found some suggestion of a weak positive association between cigarette smoking and cancer of the proximal colon, an inverse association with cancer of the distal colon, although neither was statistically significant, and no association with rectal cancer.CONCLUSIONS:Cigar smoking seems to be associated with the development of rectal cancer. If the positive association between cigarette smoking and cancer of the proximal colon is real, it might partially explain the proximal shift in the anatomic distribution of colorectal cancer that has been observed, because of the increasing prevalence of cigarette smoking during the middle of the 20th century.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PURPOSE:Long‐course preoperative radiotherapy has been recommended for rectal carcinoma when there is concern about the ability to perform a curative resection, for example, in larger tethered tumors or those sited anteriorly or near the anal sphincter. “Downstaging” of the tumor may occur, and this is of importance when estimating the prognosis and selecting postoperative therapy for patients. We studied the effects of preoperative chemoradiotherapy on the pathology of rectal cancer, and we propose a simplified measurement of tumor regression, the Rectal Cancer Regression Grade.METHODS:We have reviewed those patients who received preoperative chemoradiotherapy followed by surgical resection for carcinomas of the mid or distal third of the rectum found to be Stage T3/4 on transrectal ultrasound or CT between January 1995 and December 1998. Patients received 45 to 50 Gy irradiation and an infusion of 5‐fluorouracil. The surgical specimens were examined by one pathologist, and the Rectal Cancer Regression Grade was quantified.RESULTS:Forty‐two patients, mean age 60 (range, 42‐86) years, underwent chemoradiotherapy before surgery for rectal carcinoma. There were 28 anterior resections (67 percent; 9 with a colonic pouch), 12 abdominoperineal resections (27 percent), and 2 Hartmann's procedures (5 percent). Comparison of preoperative and pathologic staging revealed that the depth of invasion was downstaged in 17 patients (38 percent), and the status of involved lymph nodes was downstaged in 13 (50 percent) of 26 patients. Tumor regression was more than 50 percent (Rectal Cancer Regression Grades 1 and 2) in 36 patients (86 percent), with 7 patients (17 percent) having complete regression with absence of residual cancer cells.CONCLUSION:Significant tumor regression was seen in 86 percent of cases after chemoradiotherapy, with 19 patients showing a “good” responsiveness. We propose a modified pathologic staging system for irradiated rectal cancer, the Rectal Cancer Regression Grade, which includes a measurement of tumor regression. The utility of the proposed Rectal Cancer Regression Grade must be tested against long‐term outcomes before its value in predicting prognosis and survival can be determined.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PURPOSE:The role of laparoscopic surgery in patients with Crohn's disease remains to be defined, although increasingly difficult cases are being treated using minimally invasive techniques. We examined technical feasibility in 20 patients with Crohn's disease associated with fistulas.METHODS:Laparoscopic surgery was attempted in 37 patients with stricturing ileal disease or ileocolonic Crohn's disease from 1994 to 2000 after failure of strict nutritional therapy. Twenty of these patients with a total of 31 intestinal fistulas (14 ileoileal, 6 ileocolonic, 5 ileorectal, 2 ileovesical, 2 ileocutaneous, 1 gastrocolic, and 1 ileoduodenal) underwent 25 operations. Fistulas were divided intracorporeally, except for ileoileal fistulas. Fifteen patients underwent ileocecal resection; six underwent strictureplasty; six underwent partial resection of the small intestine; three underwent segmental colonic resection; and one underwent resection of anastomotic recurrence. Median follow‐up was 48 (range, 5‐77) months.RESULTS:Oral intake was started a median of 1 (range, 1‐9) day after operation, and patients were discharged a median of 8 (range, 6‐21) days after surgery. Four complications were observed in 25 operations (16 percent), including 1 intestinal obstruction/ileus, 2 wound infections, and 1 intra‐abdominal abscess. There were no intraoperative or postoperative deaths. Four of the 5 operations were converted to open surgery (16 percent). Three of the 5 patients (60 percent) who required reoperation for anastomotic recurrence underwent repeated laparoscopic surgery using the same small incision.CONCLUSION:Laparoscopic treatment for Crohn's disease complicated by fistulas is feasible without high complication or conversion rates. Recurrent disease requiring reoperation can also be successfully treated using laparoscopic methods.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID