摘要:

PURPOSE:This study was undertaken to assess results of surgery for fistula‐in‐ano and identify risk factors for fistula recurrence and impaired continence.METHODS:We reviewed the records of 624 patients who underwent surgery for fistula‐in‐ano between 1988 and 1992. Follow‐up was by mailed questionnaire, with 375 patients (60 percent) responding. Mean follow‐up was 29 months. Fistulas were intersphincteric in 180 patients, transsphincteric in 108, suprasphincteric in 6, extrasphincteric in 6, and unclassified in 75. Procedures included fistulotomy and marsupialization (n=300), seton placement (n=63), endorectal advancement flap (n=3), and other (n=9). Factors associated with recurrence and incontinence were analyzed by univariate and multivariate regression analysis.RESULTS:The fistula recurred in 31 patients (8 percent), and 45 percent complained of some degree of postoperative incontinence. Factors associated with recurrence included complex type of fistula, horseshoe extension, lack of identification or lateral location of the internal fistulous opening, previous fistula surgery, and the surgeon performing the procedure. Incontinence was associated with female sex, high anal fistula, type of surgery, and previous fistula surgery.CONCLUSIONS:Surgical treatment of fistula‐in‐ano is associated with a significant risk of recurrence and a high risk of impaired continence. Degree of risk varies with identifiable factors.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:Our aims were to determine the morbidity, survival and its influencing factors, and patterns of failure for patients who underwent further surgery with the hope of cure for locally recurrent rectal cancer.METHODS:Between January 1981 and December 1988, 224 patients with a preoperative diagnosis of recurrent rectal cancer underwent additional surgery at Mayo Medical Center in Rochester, Minnesota. Of these, 65 underwent further surgery with the hope of cure,i.e.,no gross/microscopic residual disease at tumor margins after reoperation. Factors assessed included type of original operation, time interval between operation for primary tumor and initial operation for recurrence, symptom status, degree of fixation, types of reoperations for recurrence, and adjuvant therapy.RESULTS:None of the patients died within 30 days of reoperation. Seventeen complications requiring hospitalization and/or surgical procedure were observed in 14 patients. Extended operations (involving partial or complete removal of surrounding organs/structures) required more time to perform, a greater number of transfusions, and a longer hospital stay than more limited operations. Three‐year, five‐year, and median survival were 57, 34, and 44.7 months, respectively. Survival was greater after curative than after palliative resection(P<0.001). Survival tended to be greater in females(P<0.075) and in patients without pain(P<0.065). Cumulative probability of local failure was 24, 41, and 47 percent at 1, 3, and 5 years, respectively. Cumulative risk of distant metastasis was 30, 51, and 62 percent at 1, 3, and 5 years, respectively.CONCLUSIONS:Our results indicate that complete excision of locally recurrent rectal cancer can provide a significant number of patients with long‐term survival and can be accomplished safely in select patients.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:The purpose of this study is to evaluate the effectiveness of colostomy performed as an adjunct measure in the attempt to heal pressure ulcers by flap closure.METHODS:Twenty‐seven consecutive patients who underwent colostomy for healing of pressure ulcers were studied by chart review and patient questionnaire. Fecal diversion was accomplished by colostomy in each case.RESULTS:There were four (15 percent) deaths. Twenty‐three patients subsequently underwent flap closure of their ulcer. Of 19 patients available for follow‐up, only 6 (32 percent) patients had completely healed, although most patients thought their quality of life improved because of the colostomy. None of the patients underwent colostomy closure.CONCLUSION:Our conclusions are that, although most patients will have an improved quality of life subsequent to diversion, the high mortality and low rate of pressure ulcer healing should temper enthusiasm for performing colostomy in this setting.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

&NA;Close relatives of patients with colorectal cancer are at an increased risk of developing a colorectal malignancy themselves.PURPOSE:A study was conducted to compare risks in relatives of patients diagnosed at different ages.METHODS:Family histories were taken from two cohorts of patients with colorectal cancer: Group A, a population group of 65 patients diagnosed at or under 45 (median, 42) years; Group B, 212 patients of all ages (median, 68 years) treated in a single surgeon's practice.RESULTS:Overall relative risk of colorectal cancer in first‐degree relatives was 5.2 in Group A and 2.3 in Group B. There was familial clustering of colorectal cancers suggestive of hereditary nonpolyposis colorectal cancer in 13 (20 percent) families to Group A but to only 3 (1.5 percent) families in the second group. Cumulative incidence of colorectal cancer for relatives of the young cohort rose steeply from 40 years, reaching 5 percent at age 50 years and 10 percent at age 70 years. This contrasts with risk for relatives of older patients, in whom the shape of the curve resembles that of the overall population risk, reaching 5 percent at age 70 years and 10 percent at age 80 years.CONCLUSIONS:There appears to be a quantitative and qualitative increase in risk to relatives of patients diagnosed at a young age compared with those diagnosed later to life, at least part of which is likely to be the result of a hereditary susceptibility. Close relatives of early onset cases warrant more intensive endoscopic screening and at an earlier age than relatives of patients diagnosed at older ages.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:This study was undertaken to assess subjective bowel function after anterior resection and to search for clinical characteristics that might affect the functional results.METHODS:A total of 70 patients answered a questionnaire concerning bowel function a median of 65 months after anterior resection, and 40 patients responded to the same questionnaire a median of 60 months after colonic resection.RESULTS:Median frequency of bowel movements per 24 hours was two (range, 0.2‐9) after rectal resection and one (range, 0.4‐6) after colonic resection(P<0.001). Incontinence for loose stools(P<0.01), need to wear a pad(P<0.05), and need to return to the toilet after defecation(P<0.05) was more common in the rectal resection group. In the latter group, advanced age, use of descending or transverse colon for anastomosis, and large amount of intraoperative bleeding was associated with fecal incontinence(P<0.05). Preoperative radiotherapy was correlated with a high bowel frequency(P=0.003).CONCLUSIONS:These data indicate that alterations of subjective bowel function frequently observed after colorectal anastomosis may be affected by both surgical technique and adjuvant radiotherapy.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:Technetium‐99m‐labeled red blood cell scans (Tc99m RBC scan) are recommended to confirm gastrointestinal (GI) bleeding. It is controversial whether these scans are sufficient to localize the site of bleeding. This study evaluated the efficacy of RBC scans in confirming and localizing GI bleeding. Our hypothesis was that these scans were effective in localizing GI bleeding if positive within the continuous phase of imaging.METHOD:Tc99m RBC scans were performed on a total of 80 patients over a four‐year period to localize GI bleeding (59 male, 21 female; age range 6‐88 (mean, 48) years). Films of 75 of the 80 patients were reread by a nuclear medicine physician who was blinded to the original reading and identity and history of the patient. Results of scans were compared with confirmatory studies.RESULTS:A total of 21 patients had positive scans (28 percent). Of these, the site of bleeding in 16 of 21 patients (76 percent) was confirmed by angiography (4/16), endoscopy (10/16), surgery (10/16), or a combination of these. In 14 of the 16 confirmed studies (88 percent), RBC scan correctly localized site of bleeding by our rigid definition. In six patients (4 not confirmed, 2 erroneously localized), scans were positive only at greater than 15 hours. Ten of the 14 correctly localized studies and none of the incorrectly localized studies were positive in the continuous phase of imaging.CONCLUSION:Tc99m RBC scan is effective in localizing GI bleeding when positive within the continuous phase of imaging. In this population supplemental angiography or endoscopy for the purpose of localization would seem unnecessary.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:The pathophysiology of sporadic proctalgia fugax remains unknown. This study investigates whether patients with this syndrome exhibit alterations in anal function and morphology.METHODS:Eighteen patients with sporadic proctalgia fugax and 18 sex‐matched and age‐matched healthy controls were studied. Manometric studies investigated anal resting and squeeze pressures, the rectoanal inhibitory reflex, rectal compliance, and smooth muscle response to edrophonium chloride administration. External and internal sphincter thickness was measured endosonographically.RESULTS:Patients had slightly higher(P=0.0291) anal resting pressures (65.5±11.4 mmHg) than controls (56±9.9 mmHg). However, anal squeeze pressure, sphincter relaxation during rectal distention, and rectal compliance were similar in both groups, and no alterations were detected in external and internal anal sphincter thickness. Edrophonium chloride administration was followed by sharp postrelaxation contractions in two patients, whereas anal function remained unaltered in controls. Acute episodes of proctalgia, which occurred in two patients while under study, were associated with a rise in anal resting tone and an increase in slow wave amplitude.CONCLUSIONS:In the resting state, patients with proctalgia fugax have normal anorectal function and morphology. However, they may exhibit a motor abnormality of the anal smooth muscle during an acute attack.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

BACKGROUND:The aberrant crypt focus (ACF) appears to be an important early step in colorectal carcinogenesis. Our objectives were to determine the natural history of ACF in a surgical model.METHODS:The natural history of ACF was followed by marking the lesionsin vivowith tattoos. Rats were given four weekly injections of azoxymethane (AOM; 20 mg/kg). One hundred days after the first injection of AOM, rats were anesthetized, and individual aberrant crypt focus was identified by staining with methylene blue. A 3× 3 mm area, identifying one large (4‐8 crypts) ACF was marked with a tattoo dye in each colon. Control animals received saline or AOM injections and were tattooed in areas without ACF. At 200 days, colons were examined for the presence of macroscopic lesions.RESULTS:A total of 54 tumors were found in the study group of 38 animals, and 21 of these were in the transverse and proximal descending colon. The marked areas (all in transverse and proximal descending colon) yielded 6 tumors and 2 ACF, but in 30 instances no abnormality was noted. Probability of observing a tumor in the 3×3 mm area of the colon that was identified as containing ACFs was 17 times greater than expected from the observed tumor rate in approximately the same zone (16vs.1.7 percent; 95 confidence interval, 10 to 22 and 0.5 to 1.3 percent). Twenty control animals receiving saline had no tumors of epithelial origin. Nine control animals that were carcinogen‐treated and tattooed in areas without ACF had no tumors in the marked areas.CONCLUSION:Results thus show regression of many ACF identified early in the carcinogenesis process. Results also support the hypothesis that some ACF are precursor lesions for adenomas and cancers.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:A study was undertaken to assess physiologic characteristics and clinical significance of anismus. Specifically, we sought to assess patterns of anismus and the relation of these findings to the success of therapy.METHODS:Sixty‐eight patients were found to have anismus based on history and diagnostic criteria including anismus by defecography and at least one of three additional tests: anorectal manometry, electromyography, or colonic transit time study. Interpretation of defecography was based on the consensus of at least three of four observers. Anal canal hypertonia (n=32) was defined when mean and maximum resting pressures were at least 1 standard deviation higher than those in 63 controls. There were two distinct defecographic patterns of anismus: Type A (n=26), a flattened anorectal angle without definitive puborectalis indentation but a closed anal canal; Type B (n=42), a clear puborectalis indentation, narrow anorectal angle, and closed anal canal. Outcomes of 57 patients who had electromyographybased biofeedback therapy were reported as either improved or unimproved at a mean follow‐up of 23.7 (range, 6‐62) months. These two types of anismus were compared with biofeedback outcome to assess clinical relevance.RESULTS:Patients with Type A anismus showed greater perineal descent at rest (mean, 5.1vs.3.5 cm;P <0.01), greater dynamic descent between rest and evacuation (mean, 2.7vs.1.4 cm;P<0.01), greater difference of anorectal angle between rest and evacuation (mean, 14.6vs.−3.1°;P<0.001), higher mean resting pressure (mean, 77.1vs.62.8 mmHg;P<0.05), lower mean squeeze pressure (58.8vs.80.7 mmHg;P<0.05), and a higher incidence of anal canal hypertonia (69.2vs.33.3 percent;P<0.01) than did patients with Type B anismus. Only 25 percent of patients who had Type A anismus with anal canal hypertonia were improved by biofeedback therapy. Conversely, 86 percent of patients with Type B anismus without anal canal hypertonia were successfully treated with biofeedback(P<0.001; Fisher's exact test).CONCLUSIONS:These two distinct physiologic patterns of anismus correlate with the success of biofeedback treatment. Therefore, knowledge of these patterns may help direct therapy.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:Surgery often fails to achieve local control in advanced rectal cancer. Additional measures are necessary to prevent local recurrence. The aim of this study was to evaluate intraoperative radiation therapy (IORT) (flab technique) combined with preoperative or postoperative radiochemotherapy.PATIENTS/METHODS:IORT is performed using a flexible flab containing hollow plastic tubes that are connected to a multichannel afterloading device with a 370 Gbq‐192‐Ir source. Patients receive an intraoperative dose of 15 Gy. Target volumes were measured in a cadaver experiment. From 1989 to 1993, 38 patients were included in this study. Nineteen patients were staged as T3 tumors by preoperative endosonography (Group I) and 19 as T4 tumors (Group II). Patients in Group I underwent resection (abdominoperineal resection (APR), 16; anterior resection, 3) and IORT, followed by postoperative radiochemotherapy (50 Gy/5‐fluorouracil), whereas patients in Group II received preoperative radiochemotherapy (40 Gy/5‐fluorouracil) followed by resection (APR, 18; anterior resection, 1) and IORT. Mean follow‐up was 25.5 months.RESULTS:Operative radicality in Group I was R0 (13), R1 (3), and R2 (3), and in Group II it was R0 (14), R1 (3), R2 (2). R2 resections were attributable to preoperative undetected distant metastases. Perioperative mortality was 0 percent in Group I and 10.5 percent (n=2) in Group II. Postoperative morbidity was 53 percent (n=10) in Group I and 84 percent (n=16) in Group II with delayed sacral wound healing being the predominant problem. Stenosis of the ureter occurred in two patients (Group II). Late or persistent therapy‐related complications were seen in two patients in Group I and in six patients in Group II. Local recurrence developed in three patients in Group I (15.8 percent) and in two patients in Group II (10.5 percent). Survival data do not reach statistical significance between the two groups because of small numbers but show a favorable trend for the preoperative radiochemotherapy group. When compared with a matched historical control group of patients receiving resection only, adjuvant/neoadjuvant radiotherapy with resection/IORT improves survival significantly.CONCLUSION:The flab method is a simple but especially practical technique for IORT in the pelvis. Adjuvant/neoadjuvant therapy combined with resection/IORT is associated with high morbidity but acceptable mortality. Preliminary survival data are encouraging and call for a controlled prospective randomized trial.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID