摘要:

PURPOSE:Anal sphincter replacement offers a new treatment option for patients with severe refractory fecal incontinence or for those who require abdominoperineal resection for localized malignancy. The purpose of this study was to review the current status of anal sphincter replacement, formulate a consensus statement regarding its current use, and outline suggestions for future development.METHODS:Four areas of interests were selected: indications for sphincter replacement, continence scoring and quality of life, choice of therapy, and dissemination of new technology. A questionnaire regarding these issues was developed and circulated to working party members; its results served as the basis for this consensus document.RESULTS:Both electrically stimulated skeletal muscle neosphincter and artificial anal sphincter are options for patients with end‐stage fecal incontinence. Electrically stimulated skeletal muscle neosphincter is also appropriate for reconstruction after surgical excision of the anorectum in selected cases. Avoidance of complications requires strict attention to sterile technique, prophylactic antibiotics, and deep venous thrombus prophylaxis. A standardized scoring system is proposed that evaluates both continence and evacuation. Quality of life is a critical endpoint for assessing sphincter replacement, and use of The American Society of Colon and Rectal Surgeons incontinence‐specific quality‐of‐life instrument is recommended. As the efficacy of sphincter replacement becomes proven, dissemination of the technique should occur in a controlled manner to ensure adequate surgeon training, minimization of complications, and optimization of results.CONCLUSIONS:Sphincter replacement by electrically stimulated skeletal muscle neosphincter and artificial anal sphincter provide a continent option for patients with end‐stage fecal incontinence and those requiring abdominoperineal resection. The guidelines offered in this document are intended to facilitate the controlled and safe development and acceptance of these new techniques.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Hemorrhoidectomy can be associated with severe pain in the immediate postoperative period. The aim of this study was to assess the efficacy of a preemptive local anesthetic, ischiorectal fossa block, in the reduction of pain and analgesic requirements after hemorrhoidectomy.METHODS:All patients were suitable for an established day surgery hemorrhoidectomy protocol. Immediately before surgery patients were randomly assigned either to receive (Group 1) or not receive (Group 2) the local anesthetic block. All other aspects of surgery and anesthesia were standardized. Nursing staff assessed pain at 30 minutes and 2, 4, and 24 hours postoperatively using a visual analog scale (1‐10, where 1 represented no pain and 10 represented the worst pain imaginable). Analgesic requirements also were recorded at these times. Both the patients and the nursing staff were blinded to which local anesthetic protocol had been used.RESULTS:Twenty patients were enrolled in the trial. Ten patients were randomly assigned to Group 1 and ten to Group 2. Mean pain scores for Group 1 (anal block) at 0.5, 2, 4, and 24 hours were 1.5, 1.8, 2.1, and 2.5, respectively, compared with Group 2, with mean pain scores of 3.4, 3.4, 3.9, and 5.1. These differences were statistically significant. Patients in Group 1 used less analgesia in the first 24 hours postoperatively than those in Group 2.CONCLUSION:The use of a preemptive local anesthetic, ischiorectal fossa block, is associated with a significant decrease in pain and analgesia requirements after hemorrhoidectomy.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Although fecal incontinence is a topic of considerable importance, there are no validated self‐report measures of fecal incontinence available. The aim of this study was to develop a questionnaire to measure fecal incontinence and its risk factors in the community.METHOD:The reliability and concurrent validity of the fecal incontinence questionnaire were measured by test‐retest procedures in a population of clinic patients. The questionnaire was created for a sixth‐grade reading level, with large print. Ninety‐four adult patients were surveyed. Thirty‐four patients repeated the questionnaire through the mail. Forty‐one patients were independently retested over the telephone by a physician to assess concurrent validity. Nine patients refused retest, and ten patients did not respond to a second contact.RESULTS:The fecal incontinence questionnaire was well understood and well accepted. Reliability (overall median kappa, 0.68; interquartile range, 0.03‐1) and validity (overall median kappa, 0.59; interquartile range, 0.27‐1) were acceptable for the mailed retest and the telephone retest, respectively. The presence of fecal incontinence as measured by questionnaire was greatly increased when compared with physician history in clinical records; only 3 percent of patients reported no fecal incontinence on the questionnaire when the clinic chart had documented this problem.CONCLUSION:Our initial results indicated that this new self‐report questionnaire is a useful tool for assessing the presence of fecal incontinence in the population and has greater sensitivity compared with a standard physician interview. Specific attention should be given to identifying fecal incontinence and associated symptoms during history taking.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

&NA;PURPOSE. Multiple attempts have been made to improve the clinical/pathologic staging system of Dukes to focus adjuvant therapy decisions. The purpose of this study was to determine whetherK‐rasmutational status of regional nodes in patients with Dukes B2colorectal cancer could be used to stage their disease more accurately.METHODS:Using formalin‐fixed, paraffin‐embedded archival material, tumor samples were screened forK‐rasmutations using a mutation‐specific polymerase chain reaction method, followed by gel electrophoresis in a 96‐well array. Patients with Dukes B2tumors that have mutations in codon 12 or 13 of theK‐rasgene were identified.RESULTS:Mutational analysis of the lymph nodes from these patients revealed an 80 percent (16/20) incidence of the same mutations in regional lymph nodes. None of the four patients with mutation‐free nodes developed recurrence compared with 37.5 percent (6/16) withK‐raspositive lymph nodes.CONCLUSIONS:The data suggest that patients with Dukes B2colorectal cancers that have mutations in codon 12 or 13 of theK‐rasgene are at high risk for the development of nodal metastases. Mutational analysis of the lymph nodes identifies high‐risk patients who should be considered for adjuvant chemotherapy. Therefore,K‐rasmutational analysis should be considered for molecular staging of colorectal cancer.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Return of bowel function remains the rate‐limiting factor in shortening postoperative hospitalization of patients with colectomies. Narcotics are most commonly used in the management of postoperative pain, even though they are known to affect gut motility. Narcotic use has been felt to be proportional to the length of the abdominal incision. The aim of this study was to determine whether return of bowel function after colectomy is directly related to narcotic use and to evaluate the effect of incision length on postoperative ileus.METHODS:A prospective evaluation of 40 patients who underwent uncomplicated, predominantly left colon and rectal resections was performed. Morphine administered by patient controlled analgesia was the sole postoperative analgesic. The amount of morphine used before the first audible bowel sounds, first passage of flatus and bowel movement, and incision length were recorded. Spearman correlation coefficients were calculated between all variables.RESULTS:The strongest correlation was between time to return of bowel sounds and amount of morphine administered (r=0.74;P=0.001). There were also significant correlations between morphine use and time to report of first flatus (r=0.47;P=0.003) and time to bowel movement (r=0.48;P=0.002). There was no relationship between incision length and morphine use or incision length and return of bowel function in the total group.CONCLUSIONS:Return of bowel sounds, reflecting small‐intestine motility after colectomy, correlated strongly with the amount of morphine used. Similarly, total morphine use adversely affects colonic motility. Because no relationship with incision length was found, efforts to optimize the care of patients with colectomies should be directed less toward minimizing abdominal incisions and more toward diminishing use of postoperative narcotics.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Injury sustained from the transanally introduced stapling technique was assessed by comparison with biofragmentable anastomotic ring anastomosis, which excluded anal manipulation.METHODS:A randomized, controlled trial was conducted on consecutive patients undergoing sigmoid colectomy (where pelvic nerve injury was avoided). A bowel function questionnaire was administered six months after surgery. Anorectal manometry and endoanal ultrasonography were performed preoperatively and at six months postoperatively. The observers were blinded to the randomization.RESULTS:There were 18 patients in the transanally introduced stapling technique group and 17 patients in the biofragmentable anastomotic ring group, with no differences in age, gender, Dukes staging, and follow‐up. Three of the transanally introduced stapling technique patients had occasional liquid soiling, which was absent in biofragmentable anastomotic ring patients. Mean change in resting anal pressures was also significantly impaired when compared with patients with biofragmentable anastomotic ring (P=0.007). Endosonographic internal sphincter fragmentation was found in five transanally introduced stapling technique patients but none after biofragmentable anastomotic ring anastomosis (P=0.046). Internal sphincter fragmentation was associated with the impaired resting pressures (P=0.007). External sphincter deficiencies were found after transanally introduced stapling technique in two patients (biofragmentable anastomotic ring = 0), and these were associated with the soiling (P=0.005).CONCLUSIONS:The transanally introduced stapling technique may result in anal sphincter defects and impaired anal pressures when assessed at six months of follow‐up.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Internal anal sphincterotomy for treating chronic anal fissure can irreversibly damage anal continence. Reversible chemical sphincterotomy may be achieved by anal application of glyceryl trinitrate ointment (nitric oxide donor), which has been reported to heal the majority of patients with anal fissure by inducing sphincter relaxation and improving anodermal blood flow. This trial aimed to further clarify the role of glyceryl trinitrate in the treatment of chronic anal fissure.METHODS:A total of 132 consecutive patients from nine centers were randomly assigned to receive 0.2 percent glyceryl trinitrate ointment or placebo twice daily for at least four weeks. The severity of pain and maximum anal resting pressure were measured before and after one week of treatment. Anodermal blood flow was measured before and after application of glyceryl trinitrate or placebo in ten patients.RESULTS:The study was completed by 119 patients (59 glyceryl trinitrate and 60 placebo), matched for gender, age, duration of symptoms, duration of treatment, site of fissure, previous attempts to treat, pain score, and maximum anal resting pressure. Twenty‐nine patients (49.2 percent) healed after glyceryl trinitrate and 31 patients (51.7 percent) healed after placebo (P= not significant). Pain score fell significantly in both groups, in addition to maximum anal resting pressure. Anodermal blood flow improved significantly in seven patients receiving glyceryl trinitrate, but not in the three receiving placebo. Twenty‐three patients (33.8 percent) experienced headache and 4 (5.9 percent), orthostatic hypotension after glyceryl trinitrate.CONCLUSION:This trial fails to demonstrate any superiority of topical 0.2 percent glyceryl trinitrate treatmentvs.a placebo, although the effects of glyceryl trinitrate on anodermal blood flow and sphincter pressure are confirmed. This finding, together with the high incidence of side‐effects, should discourage the use of this treatment as a substitute for surgery in chronic anal fissure.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID