摘要:

Purpose:The current trend in health delivery is managed care, in which the primary care provider (PCP) manages patient care and triages specialty referrals. It has not been established, however, that PCPs can accurately diagnose, treat, or triage anorectal disorders.MATERIALS ANDMETHODS:A retrospective study was undertaken at a health maintenance organization that hired a colon and rectal surgeon. Charts of the first 100 consecutive consultations for anorectal complaints were analyzed for accuracy of diagnosis and appropriateness of care.RESULTS:Correct diagnoses were made by 45 of 85 (53 percent) PCP physicians, 6 of 15 (40 percent) PCP physician assistants, and 8 of 15 (53 percent) general surgeons. A delay to diagnosis or appropriate treatment occurred in 25 patients (25 percent), resulting in an adverse outcome in 15 people. Of these, five complications were caused by delayed diagnosis, and ten patients had symptoms that persisted from 5 months to 14 years (mean, 4.5 years). Seven unnecessary referrals to a gastroenterologist resulted in three unnecessary colonoscopies. Of 19 patients evaluated by a general surgeon, 4 had inadequate/inappropriate operations, 5 were untreated because of misdiagnosis, 3 correctly diagnosed were untreated, 3 had inappropriate follow‐up, 1 was referred to a gastroenterologist, and 2 were advised to have appropriate treatment.SUMMARY:The PCP correctly diagnosed anorectal disorders in 51 percent of cases and referred patients promptly 75 percent of the time. Of the 25 percent with delay, 60 percent experienced a complication or persistent symptoms. Fifteen of 19 (79 percent) patients seen by a general surgeon were inappropriately managed.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Background:In Crohn's disease, ten‐year reoperative recurrence rates after resection range from 30 to 53 percent. To determine the effect of strictureplasty on reoperative “recurrence” rates, experience at a single tertiary care institution was reviewed.PATIENTS AND MATERIALS:Records of all patients who underwent strictureplasty for Crohn's disease from June 1984 to July 1994 at a tertiary care institution were reviewed. Data collected included duration of disease, medical and surgical history related to Crohn's disease, indications for strictureplasty, and longterm outcome.RESULTS:One hundred sixty‐two patients (87 male) underwent 191 operations for a total of 698 strictureplasties (Heineke‐Mikulicz, 617; Finney's, 81). Mean number of strictureplasties was three, and mean patient age was 36 years. No mortality occurred. Cumulative five‐year incidence of reoperative recurrence was 28 percent (95 percent confidence interval, 18.8‐37.2 percent), with a median follow‐up of 42 (range, 1‐120) months. Obstructive symptoms were relieved in 98 percent of patients. To determine whether any difference in reoperative rates exists between patients who have strictureplasty alone and those who have strictureplasty with bowel resection, we divided patients in two groups, those receiving strictureplasty alone and those undergoing strictureplasty plus resection. For patients treated by strictureplasty alone (Group A, n=52; 32 percent), cumulative reoperative rate at five years was 31±9.6 (±standard error) and for patients with concomitant bowel resection (Group B, n=110; 68 percent), it was 27.2±5.4 (±standard error). No statistical difference was present between these two groups. Of patients undergoing strictureplasty alone (Group A), operative recurrence was managed by new strictureplasty in seven, by restrictureplasty in two, and by bowel resection in one. Among patients in Group B (strictureplasty and concomitant bowel resection), new strictureplasty was performed in 11, restrictureplasty in 6, and bowel resection in 9.CONCLUSION:Strictureplasty is a safe and effective procedure for Crohn's disease in selected patients. Reoperative rates are comparable with resective surgery, and most recurrences occur at new sites.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Purpose:This study was undertaken to elucidate characteristic findings of tuberculous (TB) colitis at double‐contrast barium enema examination (DCBE).MATERIALS ANDMETHODS:Twenty‐five patients with TB colitis diagnosed by biopsy (n=13) or therapeutic trial (n=12) were included. DCBE findings were retrospectively analyzed, with special emphasis on distribution of lesions and mucosal changes.RESULTS:Involvement was asymmetric in 12. The lesion was noted more commonly in the ascending colon (n=23), cecum (n=21), and terminal ileum (n=19) compared with the transverse colon (n=15) and descending and sigmoid colon (n=9). Skipped lesions were seen in 13 patients. Sixteen patients had multiple ulcers that were mostly transverse or circumferential in alignment (n=11). Depth of ulcers was superficial (<2 mm) in 9 patients and deep in 13. Two patients had fistulas. Twelve patients had inflammatory polyposis. Three patients presented with mass, and misdiagnosis of malignant tumor was made in two. Thickening, deformity, and incompetence of the ileocecal valve were frequently noted (5, 6, and 8, respectively).CONCLUSION:DCBE revealed detailed mucosal changes of TB colitis. Ulcers aligned in transverse or circumferential pattern, involvement of the right side colon, and deformity of the ileocecal valve suggest diagnosis of TB colitis.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Purpose:Usefulness of transrectal ultrasonography (TRUS) for detecting distal intramural spread of rectal carcinoma was investigated.METHODS:Thirty‐seven patients with advanced rectal carcinoma, who had not received preoperative adjuvant therapy, underwent TRUS before surgery. Distal intramural spread was evaluated by TRUS and by pathologic examination of resected specimens.RESULTS:Distal intramural spread was found in 7 of 37 patients (19 percent) by pathologic examination. Presence or absence of distal intramural spread was correctly diagnosed by TRUS in 86 percent of the 37 patients. Misdiagnosis by TRUS mainly occurred when distal intramural spread was 5 mm. Tumor penetration of muscularis propria, lymph node involvement, and a higher histologic grade of malignancy showed a significant relationship with the presence of distal intramural spread.CONCLUSION:TRUS was useful for detecting distal intramural spread >5 mm in patients with lower rectal carcinoma and may be helpful for selecting appropriate surgery.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Purpose:This study was undertaken to document the effect of pudendal nerve function on anal incontinence after repair of rectal prolapse.METHODS:Patients with full rectal prolapse (n=24) were prospectively evaluated by anal manometry and pudendal nerve terminal motor latency (PNTML) before and after surgical correction of rectal prolapse (low anterior resection (LAR; n=13) and retrorectal sacral fixation (RSF; n=11)).RESULTS:Prolapse was corrected in all patients; there were no recurrences during a mean 25‐month follow‐up. Postoperative PNTML was prolonged bilaterally (>2.2 ms) in six patients (3 LAR; 3 RSF); five patients were incontinent (83 percent). PNTML was prolonged unilaterally in eight patients (4 LAR; 4 RSF); three patients were incontinent (38 percent). PNTML was normal in five patients (3 LAR; 2 RSF); one was incontinent (20 percent). Postoperative squeeze pressures were significantly higher for patients with normal PNTML than for those with bilateral abnormal PNTML (145vs.66.5 mmHg;P=0.0151). Patients with unilateral abnormal PNTML had higher postoperative squeeze pressures than those with bilateral abnormal PNTML, but the difference was not significant (94.8vs.66.5 mmHg; P=0.3182). The surgical procedure did not affect postoperative sphincter function or PNTML.CONCLUSION:Injury to the pudendal nerve contributes to postoperative incontinence after repair of rectal prolapse. Status of anal continence after surgical correction of rectal prolapse can be predicted by postoperative measurement of PNTML.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

&NA;Introduction: Sigmoid volvulus is a disease of the elderly who often have severe comorbid conditions that increase their operative risk and limit treatment options. Conservative treatment with decompressionviasigmoidoscopy with rectal tube placement has high success and recurrence rates. Surgical resection with primary anastomosis is the treatment of choice when decompression fails or if the volvulus recurs. Unfortunately, perioperative complications are frequent. Moreover, many patients with sigmoid volvulus are bedridden or incontinent of stool and do not benefit from extensive resection and maintenance of bowel continuity.METHODS:Twelve debilitated patients with sigmoid volvulus determined preoperatively to be poor candidates for laparotomy and reanastomosis were treated with a trephine stoma. Initially, each patient had decompressionviarigid sigmoidoscopy and rectal tube placement. Surgical intervention consisted of formation of a small hole (trephine) in the left lower quadrant. Through this hole, a sigmoid resection and end colostomy were performed. No midline laparotomy was required.RESULTS:Operative times and analgesia requirements were significantly decreased(P=0.05) compared with patients who underwent formal laparotomy. Length of hospital stay, complication rates, and length of bowel resected were similar using either surgical technique.CONCLUSIONS:The trephine stoma procedure offers significantly shorter operative times, with decreased perioperative morbidity. For high operative risk or debilitated patients with sigmoid volvulus, resection with end colostomy using the trephine stoma technique is the procedure of choice.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Purpose:The trend toward avoidance of a colostomy at both elective and emergency large‐bowel surgery is partly driven by the perceived morbidity and low closure rates of temporary stomas. The aim of this study was to examine whether significant colostomy‐related morbidity remains persistently high.METHODS:To examine this, we reviewed 120 patients with a potentially reversible colostomy performed during either elective or emergency large‐bowel surgery during a seven‐year period. RESULTS Forty‐seven patients underwent elective and 73 patients underwent emergency colonic or colorectal resection. Fifty‐eight patients had colorectal carcinoma (48.3 percent), diverticular disease accounted for 39 patients (32.5 percent), and a miscellaneous group of 23 patients (19.2 percent) made‐up the remainder. Seven patients died, all in the emergency group (9.6 percent). Colostomy‐related morbidity, which included stenosis, retraction, prolapse, and hernia formation, occurred in 19.2 percent of patients, with no difference between the elective (14.9 percent) and emergency (21.9 percent) groups or underlying pathologic condition. Colostomy closure was performed initially in 71 patients (59.2 percent). Highest closure rates occurred in the diverticular group (84.6 percent), followed by the colorectal carcinoma group (48.3 percent), and then the miscellaneous group (43.5 percent). One patient died undergoing colostomy closure, and complications occurred in 25 patients (35.2 percent), requiring fashioning of a second colostomy in eight patients, two of whom were closed. Final colostomy closure rate was 54.2 percent.CONCLUSIONS:This study confirms the contention that both formation and closure of defunctioning colostomies are associated with significant complications; furthermore, approximately one‐half of patients will not have their colostomy closed.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Background:Many surgical techniques to keep the small intestine out of the pelvis after cancer surgery have been developed.METHODS:We used part of the ileum and its mesentery sutured around the linea terminalis in ten patients who underwent surgery for rectal or gynecologic carcinomas.RESULTS:All imaging studies of our patients on the tenth postoperative day confirmed the position of the bowel above the pelvis. Four of ten patients had radiation treatment postoperatively without any problems.CONCLUSION:Use of the ileum to reconstruct the pelvic floor seems to be a simple and efficacious technique to keep the pelvic area free. We believe this warrants further investigation in a larger number of patients.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Purpose:A subnormal status of vitamin C has been associated with an increased risk for several malignant diseases and may play a causative role in their development. The aim of the present study was to investigate whether this occurs also in neoplasms of the colon.METHODS:We have studied dietary intake and status of vitamin C in a consecutive group of patients with adenomatous colonic polyps (n=31) and compared it with that of patients with no such history and a normal colonic mucosa, as confirmed by colonoscopy (n=54).RESULTS:Dietary intake of this vitamin, as assessed by the dietary recall method, was similar in the two groups, as were the levels of vitamin C in plasma and leukocytes. There were no significant differences in intake of dietary fiber, fat, vitamin A, or calcium between the two groups. Lack of association between vitamin C intake or status and colonic polyps persisted after adjustment for potential confounders.CONCLUSION:We conclude that in this population, a deficient status of vitamin C is not an important factor in colonic neoplasia.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Purpose:Best chances of a cure from colorectal cancer are obtained before metastatic spread. Lack of specific tests allowing early diagnosis of the tumor accounts for investigation of gene alterations involved in carcinogenesis by a noninvasive method. In the present study, K‐rascodons 12 and 13 mutations were studied in neoplastic cells shed from the bowel into the stool and those contained in the tumor and normal mucosa. Moreover, healthy patients and a few others with precancerous conditions were examined.METHODS:Stool, tumor, and mucosa samples were taken from 25 patients with colorectal adenocarcinoma. Stool and mucosa samples were obtained from 11 healthy patients, and stool, pathologic bowel tissue, and normal mucosa samples were obtained from 3 patients with adenoma (1) or ulcerative colitis (2). Polymerase chain reaction amplification and restriction enzyme analysis were performed.RESULTS:K‐rascodon 12 mutations were detected in both tumor and stool samples of 10 cancer patients, and no gene alterations were observed in 14 patients. In one patient with a tumor, a mutation was shown in only the tumor tissue. The agreement rate in tumor and stool analysis was 96 percent. A normal pattern of K‐rascodons 12 and 13 was observed in the bowel mucosa. All stool and mucosa samples from healthy patients were not altered in K‐ras.Agreement was registered between samples taken from patients with preneoplastic lesions.CONCLUSIONS:These preliminary findings show a high rate of accuracy in the investigation of K‐rasalterations in the colorectal cells shed into the feces, suggesting that such an approach could be used to study other gene alterations and, prospectively, to identify early colorectal cancers.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID