摘要:

PURPOSE:Improved functional results can be obtained by construction of a colonic J‐pouch after coloanal anastomosis. Variability in pouch size following coloanal anastomosis is prevalent in current literature. In this study, the authors compare clinical bowel function after complete rectal excision with coloanal anastomosis for patients with rectal carcinoma using either a small 6‐cm or a large 10‐cm colonic J‐pouch anastomosis. The clinical outcome is assessed both at short‐term and long‐term follow‐up.METHODS:Fifty‐nine consecutive patients with rectal cancers 4 to 8 cm from the anal verge were recruited into the study. Patients were randomized intraoperatively to either a 6‐cm J‐pouch group or a 10‐cm J‐pouch group. Clinical assessments were performed prospectively at 3, 6, 12, and 24 months postoperatively, following colostomy closure. Clinical parameters such as frequency, urgency, continence, and laxative and enema use were assessed and compared between the two groups.RESULTS:There was no statistical differences in the mean defecation frequency, urgency, and fecal continence between the two groups at 3, 6, 12, and 24 months. In the first year, laxative and enema use between the two groups was negligible; however at two years, 30 percent of patients with a large reservoir compared with 10 percent of patients in the small‐pouch group required laxative and/or enema for constipation and evacuation of bowels.CONCLUSION:Similar clinical results can be expected from patients with either small or large reservoirs at one year. However, with long‐term follow‐up, patients with a large reservoir are more likely to require medication for constipation and evacuation. To avoid these inconveniences a small reservoir is advocated for patients undergoing coloanal anastomosis.

ISSN:0012-3706    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

PURPOSE:Preoperative radiation with combined chemotherapy is effective in shrinking advanced rectal cancer locally and facilitating subsequent surgery. Suppository delivery of 5‐fluorouracil is associated with less toxicity and higher rectal tissue concentrations than intravenous administration. This prompted us to evaluate suppository and intravenous administration of 5‐fluorouracil and mitomycin C with concomitant radiation to determine associated toxicity.METHODS:Rectal, liver, lymph node, and lung tissue and systemic and portal blood were collected serially from male Sprague Dawley rats to determine drug concentrations following suppository or intravenous delivery of 5‐fluorouracil or mitomycin C. Thirty‐six animals were randomly assigned to treatment groups and received 5‐fluorouracil suppositories, mitomycin C suppositories, or an equivalent intravenous dose of 5‐fluorouracil or mitomycin C 30 minutes before radiation therapy. Before and 3, 6, 10, and 15 days following this treatment, blood was collected, colonoscopy was performed, and rectal tissue was harvested for histologic examination.RESULTS:Mitomycin C suppository was significantly less toxic compared with intravenous delivery, and higher rectal tissue concentrations were observed from 10 to 30 minutes (P< 0.05). Compared with intravenous 5‐fluorouracil administration and radiation, 5‐fluorouracil suppository and radiation resulted in additive myelosuppression at day 6 (P<0.05) with rapid recovery.CONCLUSIONS:5‐Fluorouracil and mitomycin C suppository delivery combined with radiation causes less systemic toxicity and is more effective than intravenous administration.

ISSN:0012-3706    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

PURPOSE:This study was performed to analyze the outcomes of patients with local (pelvic) recurrence (following radical surgery for rectal cancer) who subsequently underwent a new operation.METHODS:Forty‐five patients (19 percent of 213 local recurrences) were explored surgically because the disease was deemed to be confined to the pelvis with a limited extension and, therefore, amenable to surgical cure.RESULTS:Only 21 of the 45 patients who underwent surgical exploration had an oncologically radical operation (RO). In the remaining 24 patients, either a simple exploration or palliation or a nonradical procedure (R1‐R2) was performed. In the RO group, there was a 19 percent five‐year survival ratevs.a 0 percent rate in the R1‐R2 group (median survival, 4 months). Site of recurrence (anastomosisvs.other sites) was statistically associated with a higher chance of long‐term survival for those who underwent an RO operation.CONCLUSIONS:The prognosis of locally recurrent rectal cancer is dismal; less than 10 percent of all patients who underwent surgical treatment benefit from reoperation with an overall survival for five years. On the basis of these results, we no longer consider the surgical approach as the primary option for treating locally recurrent rectal cancer.

ISSN:0012-3706    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

PURPOSE:It frequently is observed that widely varying prognoses are given for patients with the same extent of liver metastases from colorectal cancer, even though the same treatment is performed on these patients. One of the reasons for this variance is that prognostic factors for these patients have not been defined. This study was designed to elucidate which clinicopathologic factors were the most important in the prognosis of 73 patients with unresectable synchronous liver metastasis from colorectal cancer.METHODS:Univariate and multivariate analysis of 11 clinicopathologic factors were performed using the Cox proportional hazard model. Survival curves were generated using the Kaplan‐Meier method.RESULTS:Extent of liver metastases was the most significant variable in this survival analysis, although the extent of lymph node metastases of the primary lesion also was significant. However, the method of treatment was not a significant determinant in the survival for patients with unresectable liver metastases. Median survival of patients with H1, H2, and H3was 13, 12, and 6 months, respectively, and there was a significant difference between survival curves for patients with H1and patients with H3. Median survival of patients with n0, n1and n2was 13, 7, and 7 months respectively, and there was a significant difference between survival curves for patients with n0and patients with n2. Median survival of 6 patients with H1and n0and of 17 patients with H3and n2was 28 and 4 months, respectively. There was a significant difference in survival curves between these two groups.CONCLUSION:Longevity of patients with unresectable synchronous liver metastases from colorectal cancer is affected adversely by the presence of nodal metastases and extent of liver metastases. This should be considered in the planning treatment.

ISSN:0012-3706    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

PURPOSE:This study was undertaken to evaluate how well anorectal manometry and transanal ultrasonography diagnose anal sphincter injury.METHODS:Anorectal manometry and transanal ultrasonography were performed in 20 asymptomatic nulliparous women and 20 asymptomatic parous women, and the results were compared with those obtained in 31 incontinent women who subsequently underwent sphincteroplasty and, thus, had operatively verified anal sphincter injury. By using computerized manometry analysis, mean maximum resting and squeeze pressures, sphincter length, and vector symmetry were determined in all women. All transanal ultrasounds were interpreted blinded as to the patient's history, physical examination, and manometry results.RESULTS:Manometric resting and squeeze pressures were significantly higher in the asymptomatic nulliparous women than in the asymptomatic parous women, and both groups had significantly higher pressures than the incontinent women (P<0.001). Anal sphincter length and vector symmetry index were significantly decreased in incontinent women compared with asymptomatic women (P<0.01). Decreased resting and squeeze pressures suggestive of possible sphincter injury were found in 90 percent of incontinent women with known anal sphincter injury. Decreased anal sphincter length and vector symmetry were found in only 42 percent of women with known anal sphincter injury. Transanal ultrasound was able to identify 100 percent of the known sphincter injuries but also falsely diagnosed injury in 10 percent of the asymptomatic nulliparous women with intact anal sphincters. False identification of sphincter injury increased when transanal ultrasound scanning was performed proximal to the distal 1.5 cm of the anal canal.CONCLUSION:Although nonspecific, decreased resting and squeeze pressures were found in 90 percent of patients with anal sphincter injury. Decreased anal sphincter length or vector symmetry index were present in only 42 percent of patients with known sphincter injury. When limited to the distal 1.5 cm of the anal canal, transanal ultrasound identified all known sphincter injuries but falsely identified injury in 10 percent of women with intact anal sphincters. Transanal ultrasound in combination with decreased anal pressures correctly identified all intact sphincters and 90 percent of known anal sphincter injuries.

ISSN:0012-3706    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

PURPOSE:Primary fistulotomy may be advantageous for perianal abscesses because unlike ischiorectal abscesses, fistulas are more commonly found and can be laid open with full preservation of the external anal sphincters. Therefore, a randomized, controlled trial was conducted to compare primary fistulotomy with incision and drainage alone, specifically for perianal abscesses.METHODS:Fifty‐two consecutive patients (43 males; mean age, 40 (standard error of mean, 2) years) with perianal abscesses were randomized to treatment by either incision and drainage (controls; N=28) or fistulotomy (N=24). Patients were followed up clinically for a mean of 15.5 (standard error of the mean, 0.7) months. Anorectal manometry was also performed before, six weeks, and three months after surgery.RESULTS:Persistent fistulas developing after surgery were significantly more common after incision and drainage (N=7; 25 percent) than after fistulotomy (N=0;P=0.009). One patient in each group was also found to have a residual abscess, which required repeat drainage. All patients remained fully continent. The anal pressures after incision and drainage and fistulotomy were not significantly different. Operative time, hospital stay, and time for the wound to heal completely were the same in both groups.CONCLUSIONS:Primary fistulotomy at the time of drainage for perianal abscesses results in fewer persistent fistulas and no added risk of fecal incontinence.

ISSN:0012-3706    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

PURPOSE:Most surgical texts describe the length of division of the internal sphincter during closed lateral sphincterotomy as “to just above the dentate line,” resulting in significant rates of incontinence. This study reviews our experience using a “tailored” lateral sphincterotomy by selecting the height of sphincter to be divided with the aim of preserving more sphincter.METHODS:From 1976 to March 1996, the files of 440 patients who had sphincterotomies were reviewed by an independent research assistant. After exclusions, a residual group of 352 patients had undergone tailored left lateral sphincterotomy for chronic anal fissure that had failed conservative treatment or for acute anal fissure requiring surgical intervention.RESULTS:A total of 287 patients from the group who had tailored left lateral sphincterotomy returned for review (81.5 percent). Of these, four complained of imperfect control of flatus (1.4 percent), one of minor staining (0.35 percent), and two of urgency (0.7 percent). None had incontinence of feces or leakage of stool. Five patients had repeat sphincterotomies, four for recurrence and one for a persistent fissure.CONCLUSION:The technique of tailored lateral sphincterotomy is safe, effective, and preserves more anal sphincter. It might be argued that a controlled trial comparing tailored sphincterotomy with the standard height of incision (with preprocedure and postprocedure manometry) should be performed, but the clinically significant reduction in incontinence rates using the tailored approach would seem to support its use.

ISSN:0012-3706    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

PURPOSE:Long‐term results of cutting seton in the treatment of anal fistulas were studied.METHODS:Of the 44 patients with anal fistulas, mainly of the high variety, managed with this method, 35 (25 men) attended a clinical and manometric follow‐up examination on average 70 (range, 28‐184) months after operation. Fistula distribution was high transsphincteric (25), low transsphincteric (5), extrasphincteric (3), and suprasphincteric (2). The seton was tightened at one‐week to two‐week intervals to achieve gradual sphincter division.RESULTS:Time required to achieve complete fistula healing ranged from 37 to 557 (mean, 151) days. Two (6 percent) of the 35 patients reexamined had recurrence of fistula and 22 (63 percent) reported symptoms of minor impairment in anal control, which in four patients had existed already before operation. Anal resting pressures were similar for defective and normal control, but other manometric variables were inferior in incontinence, although total squeeze pressure only showed statistically significant difference from normal continence (P=0.0345). Incontinence was likely associated with hard and gutter‐shaped operation scars in the anal canal, but the difference from normal continence was not statistically significant.CONCLUSION:Cutting seton yields fairly good results in regard to cure of fistula, but the risk of anal incontinence, despite its minor degree, seems to be too high to recommend its routine use for all high fistulas. The suprasphincteric fistulas and some extrasphincteric fistulas are difficult to treat otherwise, but especially for high transsphincteric fistulas, other methods of treatment (preferably those in which sphincter division can be avoided and the risk of anal canal deformity and incontinence are minimized) are advocated.

ISSN:0012-3706    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

PURPOSE:In this study, we sought to determine the outcome of patients with ischemic colitis, comparing patients with segmental disease with those with total colonic ischemia.METHODS:Patients with the diagnosis of ischemic colitis over the past six years were selected and reviewed for demographics, presenting symptoms, diagnosis, and treatment.RESULTS:Forty‐three consecutive patients with ischemic colitis were identified and were grouped into those with segmentai ischemic colitis and total colonic ischemia. Mean age was 68.8 years; 28 of 43 patients (65 percent) were males. Diagnosis was established by colonoscopy in 31 of 43 patients (72 percent), whereas in the remainder, diagnosis was made in the operating room. Ischemic colitis developed in the hospital in 17 of 43 patients (40 percent) during admission for an unrelated illness. In 6 of 43 (14 percent) of these patients, ischemic colitis developed following surgery. Thirty‐one of 43 patients (72 percent) were found to have segmental colitis; 11 of 31 patients (35 percent) were successfully managed nonoperatively. Segmental colitis was present in 31 of 43 patients (72 percent), and 12 of 31 (35 percent) of these patients were successfully managed nonoperatively. In the patients with segmental colitis who required surgery, the 30‐day mortality rate was 22 percent. Among 12 of 17 patients (71 percent) with segmental ischemia treated by resection and stoma, 9 of 12 (75 percent) underwent eventual stoma closure. All 12 patients with total colonic ischemia required surgery, and 9 of 12 patients (75 percent) died.CONCLUSION:Ischemic colitis occurs commonly during an unrelated hospital admission and following previous surgery. Most patients treated by resection and stoma undergo stoma closure. Total colonic ischemia carries a worse prognosis than segmental colonic ischemia.

ISSN:0012-3706    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

PURPOSE:This retrospective study assesses the results of total colectomy and ileorectostomy for inflammatory bowel disease.METHODS:Between January 1974 and December 1990, 90 patients underwent total colectomy and ileorectal anastomosis for chronic ulcerative colitis (n=48) or Crohn's colitis (n=42) at the Mayo Clinic. Patients' records were reviewed retrospectively. Long‐term results were assessed by chart reviews and postal questionnaires. Conversion to a permanent ileostomy, with or without proctectomy, was considered a failure of the procedure. The Kaplan‐Meier method was used to estimate survivorship free of failure. The log‐rank test was used to compare survivorship curves. Ninety‐five percent confidence intervals were calculated at selected time points.Pvalues<0.05 were considered to be statistically significant.RESULTS:The main indication for surgery was refractory chronic disease. There were no immediate postoperative deaths. The anastomotic leakage rate was 4.4 percent, and small‐bowel obstruction occurred in 15.6 percent. At the time of follow‐up (mean, 6.5±4.8 years), 46 patients (58.9 percent) had recurrence or exacerbation of the disease. This was the most common indication for subsequent proctectomy/permanent ileostomy in the follow‐up period. There were 8 failures in 48 patients with ulcerative colitis (16.7 percent) and 11 failures in 42 patients with Crohn's disease (26.2 percent), although this difference was not statistically significant. Cumulative probability of having a functioning ileorectal anastomosis at five years was 84.2 percent (95 percent confidence interval, 71‐95.9 percent) for ulcerative colitis and 73.8 percent (95 percent confidence interval, 58.6‐88.6 percent) for Crohn's disease. In the latter group, females showed a significantly lower cumulative probability of having a functioning ileorectal anastomosis (females, 634 percent; males, 92.3 percent;P=0.04). Crohn's patients 36 years of age or younger also showed a lower probability of success (patients ≤36 years, 57 percent; patients >36 years, 93.8 percent;P=0.03). In the group with chronic ulcerative colitis, younger patients also seemed to require additional surgery more frequently; however, this difference was not statistically significant. Previous duration of symptoms, with mild or moderate disease in a distensible rectum, had no effect on results in either disease group. Functional results were acceptable in 63.6 and 87.5 percent of patients with Crohn's and ulcerative colitis, respectively. Eighty‐four percent of ulcerative colitis patients and 91 percent of Crohn's disease patients reported an improvement in their quality of life, and overall, more than 90 percent considered their health status to be better than before surgery. One patient with ulcerative colitis developed carcinoma of the rectal stump 11.5 years after the colectomy and ileorectal anastomosis (cumulative probability of remaining free of cancer, 85.7 percent at 12 years; 95 percent confidence interval, 57.7‐100 percent).CONCLUSIONS:These results demonstrate that, in selected patients with a relatively spared rectum and without severe perineal disease, total colectomy and ileorectal anastomosis still remains a viable option to total proctocolectomy with extensive Crohn's colitis. In addition, ileorectal anastomosis, as a sphincter‐saving procedure, continues to have a place in the surgical treatment of chronic ulcerative colitis for high‐risk or older patients who are not good candidates for ileal pouch‐anal anastomosis, when the latter procedure cannot be done because of technical reasons and in the presence of advanced carcinoma concomitant with colitis, when life expectancy is limited.

ISSN:0012-3706    

出版商:OVID    

年代:1997

数据来源: OVID