摘要:

PURPOSE:Traditional therapy for patients with terminal ileitis found at laparotomy for appendicitis has been to perform appendectomy when the cecum is normal and to leave the diseased ileum in place.METHODS:To determine the role of ileocolic resection in the setting of acute ileitis, records of 1,421 patients with Crohn's disease seen from 1986 to 1994 were retrospectively reviewed.RESULTS:Crohn's disease was found at laparotomy for presumed appendicitis in 36 patients (2.5 percent). Ten patients underwent ileocolic resection, 23 had appendectomy, and 3 had exploratory laparotomy alone. One patient whose appendix was removed also had ileocecal bypass. Of the 36 patients, 20 were women and 16 were men. Mean age at operation was 24 (range, 11‐61) years, and mean follow‐up time was 14 (range, 0.1‐49) years. After initial ileocolic resection, five patients (50 percent) required no further resection, with a mean follow‐up time of 12.4 (range, 4‐19) years. None required more than three ileocolic resections, with a mean follow‐up time of 18.1 (range, 4‐49) years. Of 26 patients treated traditionally, 24 (92 percent) required ileocolic resection for intractability or complications of Crohn's disease. Thirty‐eight percent required resection within one year and 65 percent within three years (intractability, 8; obstruction, 3; fistula, 4; and perforation, 2). Of 24 patients who subsequently underwent resection, only 6 (25 percent) required further small‐bowel resection for Crohn's disease, with a mean follow‐up time of 13 (range, 0.1‐34) years.CONCLUSION:The majority of patients found to have Crohn's disease at laparotomy for appendicitis required early ileocolic resection. Therefore, the traditional dictum of nonoperative therapy for these patients may not be in their best long‐term interest and merits re‐evaluation.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:This study was designed to evaluate the prognostic significance of various prognostic factors affecting recurrence after resection of colorectal hepatic metastases.PATIENTS AND METHODS:Records of 54 patients who had hepatic resection between 1986 and 1993 for metastatic liver tumor from colorectal cancer were reviewed. Factors analyzed were those reported to be of prognostic significance in other studies, including gender, primary tumor site, Dukes stage, diagnostic interval, grade, preoperative carcinoembryonic antigen (CEA) level, number of metastases, size of metastases, distribution of metastases, type of resection, resection margin, and estimated blood loss.RESULTS:Average follow‐up of surviving patients was 28 (range, 12‐89) months. Average survival time from date of hepatic resection was 26 months, with an estimated actuarial survival rate of 25.5 percent at five years. Using the multivariate analysis of factors, gender and preoperative CEA level were shown to be significantly related to overall survival(P=0.0455 and 0.054, respectively). Cancer of the right side colon had significant correlation with hepatic “recurrence”(P=0.0071).CONCLUSIONS:Female patients and those with preoperative CEA values higher than 20 ng/ml have a better chance of survival following hepatic resection. Cancer of the right colon has a greater tendency for hepatic recurrence than that of the left colon.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:This study was undertaken to determine the long‐term effects of vaginal deliveries on anorectal function in healthy perimenopausal women.METHODS:An observational study of 144 perimenopausal women living in the county of Aarhus, Denmark, aged 45 to 57 (mean, 50) years were randomly selected from the National Register. All women had delivered 0 to 6 (mean, 2) times 10 to 34 years before the investigation. Examinations describing pelvic floor function were measurements of perineal position at rest and descent during straining, anal mucosa electrosensitivity, maximum resting pressure and maximum squeeze pressure of the anal sphincters, and pudendal nerve terminal motor latency. All tests were performed by one of the authors (AMR) and without knowledge of parity. Data were analyzed using the multiple regression technique, and all associations between anorectal function and parity were corrected for age and hysterectomy status.RESULTS:Increasing parity correlated with a lowered perineal position at rest (correlation coefficient(r)=0.26;P=0.003), an increased descent during straining(r=0.24;P=0.006), an increased threshold of anal mucosa electrosensitivity(r=0.22,P=0.008), and an increased pudendal nerve terminal motor latency on both sides(r=0.27;P=0.002). No effect of parity on the maximum resting pressure(r=0.06;P=0.70) and maximum squeeze pressure(r=0.06;P=0.36) was found. The number of vaginal deliveries account for only a minor fraction of the total variability seen in the tests of pelvic floor function (between 1.6 and 5.7 percent).CONCLUSION:Repeated vaginal deliveries have a long‐term adverse effect on anorectal physiology in a population of randomly selected healthy perimenopausal women.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:This study was undertaken to audit the results of endoanal ultrasound in patients with fecal incontinence.METHODS:Endoanal ultrasound was used to investigate 53 patients with fecal incontinence. Data for endoanal ultrasound were collected prospectively. Results were compared with clinical and obstetric history, obtained retrospectively from case notes, and were compared with manometric and operative findings.RESULTS:Sphincter abnormalities were identified in 42 of 53 patients. A total of 28 anterior defects were thought to be obstetric in origin. Fourteen other defects were secondary to anal pathology or surgery. Patients with anterior external sphincter defects either had complete defects (4 patients; mean age, 31 years) or proximal defects (24 patients; mean age, 55 years). For patients with a proximal defect, 38 percent gave a history of obstetric tear, episiotomy, or forceps delivery, and the rest declared having had an apparently normal delivery. Only 50 percent had a sphincter weakness that was evident on clinical examination. Of those studied with manometry, only 21 percent had low squeeze pressures consistent with an external sphincter defect.CONCLUSIONS:Sphincter defects seen on ultrasound may not have a history of obstetric trauma or abnormal clinical and manometric findings. Endoanal ultrasound is recommended in all patients with fecal incontinence to detect occult sphincter defects.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:Few quantitative experiments evaluating colonic absorption of water and electrolytes have been performed using an awake, conscious animal model. The purpose of these experiments was to develop this type of model and evaluate both basal and meal‐stimulated colonic absorption of water and electrolytes.METHODS:Canine Thiry‐Vella fistulas were created using a 20 cm segment of distal colon under general anesthesia. Colonic absorption studies were performed using infusion of the Thiry‐Vella fistulas with a buffer solution containing[14C]polyethylene glycol. Electrolyte analysis and concentration of radioactivity in the effluent were obtained and used to calculate the net flux of water, sodium, and chloride. Each study consisted of an one‐hour basal period and a three‐hour experimental period divided into two groups. Group 1 received no meal. Group 2 orally ingested a mixed meal at the completion of the basal hour.RESULTS:In the basal state, water and electrolytes are absorbed from the distal colon at a steady and constant rate. An orally ingested meal produces a statistically significant increase in the rate of absorption, independent of direct colonic luminal contact with the nutrients of the meal given.CONCLUSIONS:These studies demonstrate anin vivoquantitative and qualitative measure of mammalian colonic water and electrolyte absorption. An increase in absorption rate occurs in response to a meal that is probably the result of an unidentified neural or humoral signal.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:A prospective trial was conducted to evaluate use of certain preoperative criteria in the choice of operative technique for ileal pouch‐anal anastomosis (IPAA). Handsewnvs.stapled anastomotic techniques were compared as was preservationvs.excision of the anal transition zone (ATZ).METHODS:Over an 18‐month period, 40 consecutive patients underwent restorative proctocolectomy with IPAA for ulcerative colitis (31 cases) or familial adenomatous polyposis (9 cases). In 28 patients, ATZ was completely excised, by either a transanal mucosectomy with handsewn anastomosis (Group I, 13 cases) or by double‐stapled technique (Group II, 15 cases). The ATZ was preserved and the anastomosis was double‐stapled in colitis patients with suboptimum sphincter function and/or greater than 50 years of age in the absence of dysplasia or severe distal proctitis (Group III, 12 cases).RESULTS:Groups I and II patients were homogeneous in their preoperative variables and had equivalent functional outcome. Group III patients were older (P=0.0001), with weaker preoperative anal sphincter resting tone (P=0.024). Compared with Groups I and II, patients in Group III had significantly greater 24‐hour stool frequency (P=0.0056), daytime stool frequency (P=0.0125), and incidence of daytime fecal seepage (P=0.007). There was no significant difference in other outcome variables in Group III patients. There was no difference in morbidity in the three groups.CONCLUSIONS:Transanal mucosectomy with handsewn anastomosis provided early functional results equivalent to low anal transection with double‐stapled IPAA in younger patients with excellent preoperative sphincter function. A double‐stapled technique with preservation of the ATZ may be reserved for older patients, with poorer anal sphincter function, at minimum dysplasia/cancer risk, to optimize continence figures.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:This study investigated the effect of anal sphincter repair on fecal continence in relation to anal endosonography and anal manometry.METHODS:Eighteen patients (7 male, 11 female) with anal sphincter defects and complaints of fecal incontinence (5), soiling (= liquid discharge; 3), or both (10) were studied before and after sphincter repair with endosonography and anal manometry. Complaints were the result of obstetric trauma (7), surgical trauma (7), both (3), and other trauma (1). Five patients had previous surgery. Preoperative endosonography showed a defect of both sphincters in nine patients, a defect of the external anal sphincter in five patients, and a defect of the internal anal sphincter in four patients. An overlapping sphincter repair was performed.RESULTS:Postoperatively and subjectively (S; patient's view), 13 (72 percent) patients became continent or improved; in 5 (28 percent) patients the complaints were unaltered. Objectively (O) (incontinence or soiling frequency), these figures were 12 (67 percent) and 6 (33 percent). Postoperative endosonographic images improved in 14 (78 percent) patients; defects of the sphincters (almost) disappeared (4) or were smaller (10). In the other four patients, images were unchanged. In two patients, overlapping of the muscle was clearly visible with anal endosonography. Clinical result (subjective (S) and objective (O)) of sphincter repair correlated with changes in anal endosonography (S,r=0.64,P<0.004; O,r=0.51,P=0.03) and anal manometry (S,r=0.54,P=0.038; O,r=0.44,P=0.09 (not significant)) and not with pudendal nerve latency.CONCLUSION:In 78 percent of our patients, endosonographic sphincter defect had diminished or disappeared after sphincter repair. There was a good correlation between clinical effect of sphincter repair and changes with anal endosonography and anal manometry. Postoperative persistent incontinence is attributable to remaining sphincter defects. Anal endosonography should be performed as a routine procedure in patients with fecal incontinence or soiling, also after failed surgery.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:The aim of the study is to outline the rising importance of local treatment of rectal tumors and a changing strategy in therapy of early rectal cancer.METHODS:As the surgical procedure, transanal endoscopic microsurgery was used. Indications for the local procedure were pT1 low‐risk tumors and tumors of higher stages in patients with severe risk factors and of those who refused the operation according to oncologic guidelines.RESULTS:A total of 236 rectal adenomas and 98 carcinomas were locally excised using the transanal endoscopic microsurgery technique. Mortality rate was 0.3 percent, and rate of complications requiring surgical reintervention was 5.5 percent in adenomas and 8 percent in carcinomas. Final histology of removed carcinomas revealed 56 pT1, 27 pT2, and 15 pT3 stages. After an average follow‐up time of 24 months, two recurrences were observed in the group of patients with pT1 low‐risk carcinomas who only underwent local therapy. In both cases, a second intervention for cure was undertaken but for tumors in a late stage.CONCLUSIONS:In selected cases, local therapy of rectal carcinoma avoids high morbidity and mortality of the classical operation. Quality of life will be improved, especially if an artificial anus can be avoided. In case of recurrence, the chance of a secondary procedure for cure is not to be underestimated.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:Ileal pouch‐anal anastomosis (IPAA) is the surgical treatment of choice for most patients with chronic ulcerative colitis. Crohn's disease is, however, a contraindication. Because distinction between UC and Crohn's disease can be difficult, some patients with Crohn's disease inadvertently undergo IPAA. The aim of this study was to determine the long‐term outcome of patients with Crohn's disease who have undergone IPAA.METHODS:A total of 37 patients (20 men) were studied. Each had undergone mucosectomy with handsewn IPAA (J‐pouch, n=35; S‐pouch, n=1; W‐pouch, n=1). Histologic examination of the resected specimen at time of IPAA showed features of ulcerative colitis (n=22), indeterminate colitis (n=9), or Crohn's disease (n=6). The stoma was closed in all patients.RESULTS:A total of 11 of 37 patients developed complex fistulas (pouch‐cutaneous (n=6), pouch‐vaginal (n=4), or pouch‐vesical (n=1). Crohn's disease has recurred in the pouch (n=20), anal canal (n=4), pouch and anal canal (n=10), and elsewhere (n=3). After ten years (range, 3‐14), the pouch remainsin situin 20 patients in whom frequency of bowel movement is seven times (3‐10)/24 hours,in situbut defunctioned in seven patients, and excised in ten patients (failure rate, 45 percent).CONCLUSIONS:Inadvertent IPAA for Crohn's disease is associated with a high rate of failure (45 percent) but an acceptable long‐term functional result if the pouch can be keptin situ.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:Radiographic imaging of dynamic changes within the pelvic cavity and rectum during evacuation has been recognized as a valuable method of assessment. This study was designed to assess the incidence and clinical significance of defecographic findings in patients with possible evacuation disorders.MATERIALS ANDMETHODS:All defecographic studies were reviewed by a single colorectal surgeon familiar with patients' histories and physical findings.RESULTS:Between July 1988 and July 1995, 744 patients (566 females and 178 males) with a mean age of 63.5 (range, 12‐95) years had defecographic and proctographic examination. Four hundred forty‐six (60 percent) patients were diagnosed who complained of constipation, 123 (16.5 percent) of fecal incontinence, 42 (5.6 percent) of rectal prolapse, 82 (11 percent) of rectal pain, and 51 (6.9 percent) had a combination of more than one of these diagnoses. Although 93 (12.5 percent) of these evaluations were considered normal, 61 (8 percent) revealed rectal prolapse, 191 (25.7 percent) rectocele, 82 (11 percent) sigmoidocele, and 94 (12.6 percent) intussusception; in 223 (30 percent) patients, a combination of these findings was noted. Patients with paradoxical puborectalis contraction had an extremely high frequency of constipation compared with other symptoms (P<0.0001).CONCLUSION:Defecography can reveal abnormalities in the majority of patients with evacuatory disorders. There was a high incidence of rectocele, sigmoidocele, and intussusception. Care must be taken not to treat patients strictly based on radiographic findings.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID