ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

INTRODUCTION:Seprafilm® adhesion barrier (Seprafilm®) has been proven to prevent adhesion formation after abdominal and pelvic surgery. This article reports safety results, including the postoperative incidence of abdominal and pelvic abscess and pulmonary embolism, from a large, multicenter trial designed to evaluate the safety and effectiveness of Seprafilm® for reduction of adhesion‐related postoperative bowel obstruction after abdominopelvic surgery.METHODS:A total of 1,791 patients participated in this prospective, randomized, multicenter, multinational, single‐blind, controlled study in patients undergoing abdominopelvic surgery, the majority of whom had inflammatory bowel disease. Just before closure of the abdomen, patients were randomized to a Seprafilm® or no‐treatment control group. Patients received an average of 4.4 and as many as 10 Seprafilm® adhesion barriers applied to organs and tissue surfaces that sustained direct surgical trauma and to suspected adhesiogenic surfaces. Complications that occurred within the first month after surgery were evaluated.RESULTS:During the safety evaluation period, the difference between the Seprafilm® and control groups for the incidence of abscess (4vs.3 percent, respectively) or pulmonary embolism (<1 percent in both groups) was not statistically significant (P> 0.05). Foreign body reaction was not reported in either group. Fistula (2vs.<1 percent) and peritonitis (2vs.<1 percent) occurred more frequently (P≤ 0.05) in the Seprafilm® group. In a subpopulation of patients in whom Seprafilm® was wrapped around a fresh bowel anastomosis, leak‐related events, which included anastomotic leak, fistula, peritonitis, abscess, and sepsis, occurred more frequently (P≤ 0.05). There were no other differences in the incidence, severity, or causative relationship of complications between study groups.CONCLUSIONS:This study confirmed the safety of Seprafilm® adhesion barrier with respect to abdominal abscess, pelvic abscess, and pulmonary embolism when administered to patients undergoing abdominopelvic surgery. Foreign body reaction was not reported for any patient. However, wrapping the suture or staple line of a fresh bowel anastomosis with Seprafilm® should be avoided, because the data suggest that this practice may increase the risk of sequelae associated with anastomotic leak.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:The purpose of this study was to determine the local control and survival of patients with adenocarcinoma of the anus who received combined modality therapy as a component of their treatment.METHODS:Thirteen patients with primary anal adenocarcinoma (T1: 1, T2: 4, T3: 3, T4: 5; and N0: 9, N1: 2, N2: 2) were treated between 1989 and 2001 in the Department of Radiation Oncology at Memorial Sloan Kettering Cancer Center. Three general treatment approaches were used that were based on physician and patient preference as well as tumor stage. These included preoperative combined modality therapy followed by abdominoperineal resection (n = 5), with four of the five receiving postoperative chemotherapy; local excision followed by postoperative radiation alone or combined modality therapy (n = 5); and abdominoperineal resection followed by postoperative combined modality therapy (n = 3). Two patients received brachytherapy.RESULTS:With a median follow‐up of 19 months, the median survival was 26 months, the local failure rate was 37 percent, and the two‐year actuarial survival was 62 percent. In the subset of eight patients treated with abdominoperineal resection and preoperative or postoperative radiation or combined modality therapy, local control was 63 percent, and three of eight are without evidence of disease. Of the five patients who underwent a local excision followed by postoperative radiation or combined modality therapy, the local control rate was 60 percent, with one of the local failures salvaged by abdominoperineal resection and one of five patients without evidence of disease.CONCLUSION:Although the experience is limited, our data suggest that the combination of abdominoperineal resection and combined modality therapy is a reasonable approach for this rare tumor.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:The purpose of this study is to discuss indications, technical approach, and morbidity of laparoscopic approaches to major bowel resection in the pediatric/adolescent population with inflammatory bowel disease and familial polyposis.METHODS:Retrospective review of laparoscopic‐assisted bowel procedures between May 1991 and January 2002 was performed. Laparoscopic‐assisted bowel resection is defined as complete intracorporeal mobilization and devascularization of a segment of colon or rectum. The indications for extracorporealvs.intracorporeal anastomosis will be discussed. Clinically unstable, septic, or massively bleeding patients were not candidates for this technique. The decision to attempt the laparoscopic approach was based on the experience of the consulting surgeon. There were 31 patients, including 14 females. Five patients had undergone prior surgery. Twenty‐nine patients had inflammatory bowel disease, one had familial polyposis, and one had a cavernous hemangioma. We included all pediatric/adolescent patients in our practice undergoing laparoscopic resection.RESULTS:Twenty‐nine patients had 33 laparoscopic operations, including proctocolectomy with ileal pouch‐anal anastomosis (n = 14), proctocolectomy with ileostomy (n = 3), ileocolectomy with ileocolic anastomosis (n = 13), and small‐bowel obstruction (n = 1). Average operating time was 158 (range, 30‐400) minutes, with average blood loss of 159 ml. Average wound length was 4.9 cm. The complication rate was 16 percent (n = 5), with one anastomotic leak. The rate of conversion to open operations was 5.8 percent. Liquid diet was begun on Day 3, and the average length of stay was 5.9 days.CONCLUSION:Major laparoscopic bowel surgery can be performed safely in the pediatric/adolescent population, with reasonable operative times, low conversion to open operations, and low morbidity.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

INTRODUCTION:Natural history of progression from anal intraepithelial neoplasia to invasive carcinoma remains unproven. The risk of progression may be linked to the severity of dysplasia. Important therapeutic decisions are thus based on the severity of anal intraepithelial neoplasia. Consistency and reliability in the interpretation of anal intraepithelial neoplasia are unproven.METHODS:One hundred ninety anal biopsy specimens were identified for review of dysplasia with a six‐point grade system from normal to invasive cancer, evidence of human papillomavirus infection, and quality of histology by three pathologists.RESULTS:Results revealed poor to moderate agreement on grading of quality of histology (weighted kappa score, 0.07‐0.22), human papillomavirus status (weighted kappa score, 0.24‐0.53), and dysplasia (weighted kappa score, 0.38‐0.7). Complete agreement between the original pathology and the three pathologists was observed in only 32 percent of cases. Analysis of 86 slides previously read by one of the pathologists revealed only moderate agreement, with a weighted kappa score of 0.64.CONCLUSION:Significant interobserver and intraobserver bias exists in the interpretation of anal intraepithelial neoplasia. These inconsistencies may explain the uncertainty about the natural progression of anal intraepithelial neoplasia and the varied results of surgery reported for anal intraepithelial neoplasia in the literature.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:Septic complications related to the ileal pouch‐anal anastomosis after restorative proctocolectomy have been reported in up to 16 percent of patients in major series. Management strategies are not well established. The aim of this study was to evaluate the results of salvage surgery and to assess the impact diversion had on the outcome.METHODS:Patients who developed ileal pouch‐anal anastomosis‐related septic complications after restorative proctocolectomy were identified from a prospectively maintained database. Surgical procedures and follow‐up data were obtained at the time of hospital and office visits. Successful salvage was defined as the absence of clinical evidence of fistula, sinus, or abscess at least three months after salvage surgery or closure of ileostomy.RESULTS:Fifty‐one patients with ileal pouch‐anal anastomosis‐related sepsis were identified. All patients had sinus or fistulous tracts from pouch‐anal anastomoses. Eighty‐nine salvage procedures were performed among these 51 patients (range, 1‐4 procedures per patient). Forty‐eight transanal anastomotic revisions were performed in nondiverted patients. Thirty‐seven transanal revisions and four abdominoperineal revisions were performed in diverted patients. At a median follow‐up of 65.2 (range, 3 to 166) months after salvage surgery or closure of the diverting stoma, 21 patients (41 percent) had complete resolution of their septic problems. Bowel frequency and continence for these patients were similar to patients who had not had ileal pouch‐anal anastomotic problems. Eleven (29.7 percent) of 37 transanal procedures with diversion succeeded, whereas 10 (20.8 percent) of 48 nondiverted procedures succeeded. This difference was not significant (11/37vs.10/48;P= 0.448). None of the four abdominoperineal revisions succeeded. Of 51 patients, 34 (66.7 percent) retained their pouches and 21 (41.2 percent) were successfully revised. Seventeen patients (33.3 percent) had pouch excision. Five (9.8 percent) had persistent fistulas and remained diverted, and 8 (15.7 percent) had persistent fistulas and were not diverted. Thus, pouch function was retained in 29 patients (56.9 percent).CONCLUSIONS:This study shows that anastomotic failure after restorative proctocolectomy is associated with a high rate of pouch failure. Ileal pouch‐anal anastomosis‐related fistula or sinus warrants an aggressive surgical approach in selected, highly motivated patients because acceptable functional results are possible. Multiple procedures may often be necessary to achieve complete healing. Successful repair can be achieved after one or more unsuccessful attempts. Repeat procedures can be performed safely without adversely affecting ultimate outcome.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:Transanal excision of rectal villous adenomas is a widely used surgical technique, because it is a one‐step procedure, requiring no sophisticated instrumentation, and allowing complete histologic analysis of the excised tumor. Therefore, it ranks alongside radical surgery and palliative destructive procedures, but its results are highly variable in the published series. This discrepancy may be explained by the variable completeness of tumor excision because of potential dissection difficulties. Because intraoperative exposure may be a major limiting factor, one of us (JF) has developed a tractable cutaneomucous flap procedure to lower the rectal tumor to the anal verge, where control of the dissection line is easier. This retrospective review of consecutive patients operated on during ten‐year period reports long‐term results after transanal excision for large rectal villous adenomas with the tractable flap technique.PATIENTS:From 1978 to 1988, 207 consecutive patients (100 males), mean age 68 (range, 24‐90) years, were operated on for an apparently benign villous rectal adenoma. Twenty‐one patients (10 percent) were referred after failure of previous treatments: 11 endoscopic, 8 surgical, 1 laser, 1 radiotherapy. Mean distance of lower tumor edge from anal margin was 5.6 (range, 0‐13) cm and was <10 cm in 82 percent.RESULTS:Three patients (1.5 percent), including one with a Tis carcinoma, underwent a secondary treatment for immediate gross failure of resection: one further local excision and two palliative laser destructions. Immediate postoperative course was uneventful for 96 percent; there was one death from perineal gangrenous infection, four cases of hemorrhage, and three urinary retentions. Subsequently one case of transient fecal incontinence and 11 medically managed stenoses were noted. Mean size of resected tumor was 5.4 (range, 1‐17) cm. Deep excision margins concerned the rectal muscular layers in 199 patients (96 percent) and perirectal fat in 8 (4 percent). Specimen margins were negative for cancer in 175 (85 percent) and positive or unknown in 32 cases. Histologic evaluation demonstratedin situcancer in 28 (14 percent) and invasive carcinoma in 9 (4 percent). In three patients (1 percent), two abdominoperineal resections were immediately performed (one T2 with a mucinous contingent, one T3) and one adjuvant radiotherapy (one undifferentiated T2). Four patients (2 percent) did not return for postoperative evaluation. For the remaining 198 patients, mean follow‐up was 74 ± 34 (median, 75; range, 1‐168) months. Forty‐four died from unrelated causes. Recurrence occurred in seven (3.6 percent) and was malignant in two, who subsequently died. Specific recurrence‐free probability was 99.5 percent at one year, 96 percent at five years, and 95 percent at ten years. A lesion size >6 cm (10vs.1 percent for smaller tumors) and the presence of an invasive carcinoma (20vs.3 percent without invasive carcinoma) were significantly associated with an increased probability of recurrence at five years.CONCLUSION:Providing that adequate intraoperative exposure is obtained and advanced malignant tumors receive immediate secondary treatment, transanal resection of clinically benign, large rectal villous adenomas is safe and effective. It is an alternative to rectal resection, which exposes the patient to potentially adverse effects, and also to destructive procedures, which preclude any histologic evaluation of the tumor.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:Clinicians often make decisions for their patients, despite evidence that suggests that correspondence between patient and clinician decision making is poor. The management of colorectal cancer presents difficult decisions because the impact of treatment on quality of life might overshadow its survival efficacy. This study investigated whether patients are able to trade survival for quality of life as a means to express their preference for treatment options and to compare their preferences with those expressed by clinicians.METHODS:Patients undergoing curative surgery for colorectal cancer were interviewed postoperatively to elicit their preferences in four hypothetical treatment scenarios. A questionnaire was mailed to all Australian colorectal surgeons and medical oncologists that asked them to respond as if they themselves were patients.RESULTS:One hundred patients (91 percent), 43 colorectal surgeons (77 percent), and 103 medical oncologists (50 percent) participated. In all four scenarios, patients were able to trade survival for quality of life. Patients' responses varied between scenarios, both in willingness to trade and the average amount traded. There were significant differences between patients and clinicians. Clinicians were more willing than patients to trade survival to avoid a permanent colostomy in favor of chemoradiotherapy. Patients' strongest preference was to avoid chemotherapy, more than to avoid a permanent colostomy.CONCLUSIONS:Patients are able to trade survival as a measure of preference for quality of life and can do so differentially between treatment scenarios. Patients' preferences do not always accord with those of clinicians. Unless patients' preferences are explicitly sought and incorporated into clinical decision making, patients may not receive the treatment that is best for them.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:The purpose of this study was to analyze the postoperative follow‐up of HIV‐positive patients with anal condylomata acuminata, associating recurrence to the AIDS status.METHODS:Ninety‐seven male, homosexual patients with anal condylomata were submitted to surgical treatment from August 1992 to December 1997. Specimens were obtained for histologic investigation of Ki‐67 cell proliferation marker and for polymerase chain reaction to define the human papillomavirus type. The patients were advised to return weekly during the first month, and monthly up to the sixth month, to evaluate recurrence. Patients with high‐grade anal intraepithelial neoplasia remain in follow‐up.RESULTS:Histology revealed low‐grade anal intraepithelial neoplasia in 81.44 percent of patients and high‐grade lesions in 18.56 percent. The results showed that high‐grade lesions were not more frequent in late‐stage AIDS patients. Ki‐67 expression, a cell proliferation marker, was greater in high‐grade than in low‐grade anal intraepithelial neoplasia, but had no association with AIDS status. Nononcogenic human papillomavirus 6 and 11 were the commonest types. Comparing papillomavirus types and anal intraepithelial grade, we noticed that both oncogenic and nononcogenic types were responsible for high‐grade lesions. All patients healed and 51 (52.6 percent) had recurrence up to the sixth month. AIDS status and papillomavirus type were not associated with recurrence. However, high‐grade anal intraepithelial neoplasia patients had more recurrence than those with low‐grade lesions. Topical treatment failed in 20 patients (41.6 percent), and these were submitted to new surgical treatment. All of them were in the late stage of AIDS. Three who had high‐grade lesions in the first operation had low‐grade lesions in specimens from the second surgery. The same histologic pattern was observed in 17 patients who had low‐grade lesions in warts removed in the first operation. Other patients with high‐grade lesions had no recurrence or evolution to invasive carcinoma from five to ten years of follow‐up.CONCLUSION:High‐grade anal intraepithelial neoplasia and late‐stage AIDS are risk factors for recurrence of anal condylomata.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:Digital pressure on the perineum was reported to result in an increase of the rectal tone. This effect has been related to a reflex action named perineorectal reflex but was not verified. The mechanism of action of perineal pressure on the rectal tone was studied.METHODS:Eighteen healthy volunteers (mean age ± standard deviation, 39.7 ± 11.8 years; 10 males) were studied. The barostat system used consisted of a polyethylene balloon connected to a strain gauge and a computer‐controlled, air‐injection system. The balloon was introduced into the rectum, and the rectal tone was assessed by recording the balloon volume variations in response to digital pressure on the perineum. The test was repeated after individual anesthetization of perineum and rectum. It was performed again using normal saline instead of Xylocaine®.RESULTS:During perineal pressure, all the volunteers exhibited rectal tone increase with a mean decrease in the balloon volume of 72.3 ± 14.7 percent. There was no significant difference (P> 0.05) in the rectal tone response between females and males nor between young and elderly patients. The mean latency was 17.3 ± 1.8 ms. Perineal pressure 20 minutes after individual anesthetization of perineum and rectum effected no significant rectal tone changes. The response returned after the anesthetic effect had waned. The rectal tone response after saline administration was similar to that before administration.CONCLUSION:The study has shown that rectal tone increase during digital perineal pressure represents most probably a reflex action. This was evidenced by absence of rectal tone response on individual anesthetization of the assumed two arms of the reflex arc: perineum and rectum. The perineorectal reflex may be of diagnostic significance in rectal motor disorders and has the potential to be used as an investigative tool, provided further studies are performed to prove these points.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID