摘要:

INTRODUCTION:The aim of this study was to determine the effect of pneumoperitoneum on the rate of trocar‐site implantation with decreasing inoculum of cancer cells.METHODS:A total of 0.5 ml of GW‐39 human colon cancer cell suspensions at 1 percent (˜3.2×105cells) and at 0.5 percent (˜1.6×105cells; v/v) were injected into the abdomen of hamsters through a midline incision. Animals in each group were randomized to receive either pneumoperitoneum (1 percent=33; 0.5 percent=43) or not (1 percent=32; 0.5 percent=39). Gross and microscopic tumor implants were documented seven weeks later at four trocar sites.RESULTS:In the 1 percent group, pneumoperitoneum significantly increased trocar‐site tumor implants from 50 to 71 percent (P<0.001). Pneumoperitoneum also resulted in the following: 1) more frequent involvement of all four concurrent sites (38vs.10 percent;P<0.02); 2) more frequent palpable tumors (13vs.5 percent;P<0.01); 3) larger tumor mass (2.1±0.6 gvs.0.2±0.1 g;P<0.02). In the 0.5 percent group, pneumoperitoneum did not significantly increase trocar‐site tumor implants, and it did not result in a larger tumor mass. The percent increase in trocar‐site implants owing to pneumoperitoneum was influenced by the amount of tumor inoculum (21 percent in the 1 percent group; 10 percent in the 0.5 percent group). The mass of palpable tumor implants after pneumoperitoneum decreased with decreased inoculum: 1 percent =2.1±0.6 g; 0.5 percent=0.3±0.1 g (P<0.0001).CONCLUSIONS:Pneumoperitoneum significantly increased both tumor implantation rate and mass when ˜3.2×105colon cancer cells were injected into the peritoneal cavity. These effects of pneumoperitoneum diminished with one‐half as many tumor cells injected in the peritoneal cavity.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:Although rectal cancer is common in the United States, there is significant variation in management and outcome of this disease. The aim of this study is to measure the amount of variability that exists in the way colorectal surgeons investigate and manage patients with rectal cancer.METHODS:A detailed questionnaire covering preoperative assessment, operative technique, and follow‐up of primary rectal cancer was sent to all colorectal surgeons associated with colorectal residency programs throughout North America.RESULTS:One hundred ten responses were obtained (response rate, 71 percent). Surgeons were in broad agreement (>75 percent agree) on the routine preoperative use of endorectal ultrasound and carcinoembryonic antigen and the postoperative use of endorectal ultrasound. There was also broad agreement about the use of adjuvant therapy and radical resection for a poorly differentiated uT2,N0 cancer, the use of total mesorectal excision for a mid rectal cancer, and for the choice of loop ileostomy if diversion is necessary. Two‐thirds of the surgeons used adjuvant therapy and radical resection for a uT3,N0 cancer and preferred a follow‐up schedule of three monthly visits for two years with six monthly visits for the next three years. Opinion was divided (<63 percent agreement) on the use of a preoperative liver scan, the approach to a moderately differentiated uT2,N0 cancer, the use of rectal irrigation before resection, the timing of colonoscopy in a patient with stenosing rectal cancer, and the frequency of postoperative colonoscopies.CONCLUSIONS:There is considerable variation in the management of low rectal cancer advocated by colorectal surgeon educators. For each histologic and pathologic stage, opinion is divided about which operation is best. Careful outcomes analysis is required to clarify the situation.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

&NA;Instillation of 4 percent formalin effectively treats radiation hemorrhagic proctitis; however, little is known regarding its side effects.PURPOSE:The study contained herein was undertaken to determine rectal compliance and collagen content, mucosal and vascular histologic changes, and kinetics of formalin absorption following instillation.METHODS:Fifteen mongrel dogs (50‐60 pounds) were randomized into five experimental groups according to time elapsed from formalin treatment: control, acute, one week, two weeks, and four weeks. Formalin was instilled in 30‐ml aliquots to a total volume of 400 ml. Rectal compliance (closed manometry system) was assessed pre‐formalin and post‐formalin at the designated time interval. Serum formalin metabolites were determined at time 0, 0.5, 1, and 3 hours. A segment of rectal wall was analyzed for collagen content, mucosal injury, and blood vessel density.RESULTS:Serum formalin levels peaked within 30 minutes, returning to normal by 3 hours. With the exception of one dog, toxic levels were not reached at any time during the study. No dogs experienced sepsis, fever, or altered gastrointestinal function. Acute and one‐week dogs showed mild diffuse proctitis and mucosal slough, which healed within two weeks. Rectal compliance and collagen content were unchanged. Mucosal blood vessels decreased in number early (P=0.03).CONCLUSIONS:Instillation of 4 percent formalin in sequential aliquots of a small volume that is kept in contact for a short period of time is safe. Serum formalin levels generally do not reach toxic levels, and the slight elevation in formalin concentration that was seen returns to normal within three hours. Formalin‐induced proctitis heals within two weeks, and no long‐term changes in rectal compliance or collagen content were seen.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:The present prospective, randomized clinical trial compares the outcome of surgical hemorrhoidectomy according to Parks and Milligan‐Morgan in terms of hospital stay, duration of incapacity to work, symptom relief, length of morbidity, and patient convenience.METHODS:Thirty‐four consecutive patients with third or fourth degree internal hemorrhoids were randomly allocated to the two groups. Before surgery, all patients were interviewed using a standard questionnaire, followed by rectal examination. All patients underwent a follow‐up interview and examinations 1, 2, 4, 8, and 12 weeks after the operation.RESULTS:No serious postoperative complications were seen. Length of hospital stay (3.2 days for Parks hemorrhoidectomyvs.4.6 days for Milligan‐Morgan hemorrhoidectomy; 95 percent confidence interval, 0.2 and 2.6, respectively;P=0.02) and mean duration of incapacity to work (12.3 days for Parks hemorrhoidectomyvs.20.2 days for Milligan‐Morgan hemorrhoidectomy; 95 percent confidence interval, 5.7 and 10.2, respectively;P<0.001) differed significantly between the Milligan‐Morgan and Parks patients. Until two weeks after the operation, Milligan‐Morgan hemorrhoidectomy patients experienced significantly more pain.CONCLUSIONS:Our study confirms that both operations are safe, easy to perform, and lead to satisfactory results. However, the Parks procedure is the preferred option, because it minimizes patients' postoperative discomfort, is more economic, has a significantly reduced hospital stay, and has a shorter time for return to work.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:We examined the survival benefit of pelvic exenteration for locally advanced colorectal cancer with lymph node metastases, because this issue remains controversial.METHODS:Medical records of 50 patients who underwent curative pelvic exenteration for colorectal cancer were reviewed retrospectively. Nodal metastases were examined by the clearing method in 29 patients and by the conventional manual method in 21 patients.RESULTS:Invasion to contiguous pelvic organs was present in 40 patients (80 percent) and absent in 10 patients (20 percent). Node metastases were present in 33 patients (66 percent). Operative morbidity and mortality rates were 22 percent (11 patients) and 6 percent (3 patients), respectively. Respective five‐year survival rates were 60 and 80 percent in the groups with and without organ invasion (no significant difference). Five‐year survival rates in patients with nodal metastases was 54.6 percent but was significantly higher, 82.4 percent, in patients without nodal metastases. Five‐year survival in 28 patients with both organ invasion and nodal metastases was 53.6 percent.CONCLUSIONS:Long‐term survival was afforded by pelvic exenteration for locally advanced colorectal cancer with nodal metastases.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:Standard treatment of anal cancer is a protocol of combined chemotherapy and percutaneous radiotherapy. We developed a new endosonography‐based radiation target simulation method, because endoanal sonography gives the best opportunity to stage the tumor accurately. Based on this method, an afterloading needle application procedure could be performed to optimize the radiation target geometry and to control the application of afterloading needles. In a prospective study, this new method was evaluated, with special regard for complications and tumor recurrence.METHODS:Anal cancer was restaged endosonographically six weeks after external beam radiation with 45 Gy. A computer‐generated three‐dimensional reconstruction of the tumor and radiation target simulation was performed based on endoanal sonographic imaging. By using a new type of applicator, which is permeable to ultrasound waves, the transperineal implantation procedure of afterloading needles could be controlled. Application needles were inserted into the target area according to the endoanal sonography‐based dosimetry planing. The dose of the (high‐dose rate) brachytherapy boost was started with two 6‐Gy fractions, each within eight days. The fraction dose was reduced to 4 Gy to minimize side effects. Lymph node‐positive tumors got additional chemotherapy (5‐fluorouracil and mitomycin C).RESULTS:From January 1992 until August 1996, we performed 42 endosonography‐guided afterloading procedures in 18 patients. One patient underwent percutaneous radiation two years before and was treated only by afterloading radiation. In every patient, we found complete tumor remission at the end of radiotherapy. Three patients with a high‐dose rate of 2×6 Gy developed radiogenic proctitis, and two patients developed ulceration, which lead to reduction of the dose. After reduction to 4 Gy per fraction, no more side effects could be seen. In follow‐up (median, 24 (range, 1‐56) months), we detected two anal cancer recurrences (2/18 patients).CONCLUSION:The radiation target field can be optimized by individual endosonography‐based three‐dimensional tumor reconstruction and radiotherapy simulation. Endosonography‐guided transperineal implantation of afterloading needles can be performed according to the computer‐generated simulation by using a new type of applicator. We could achieve total primary tumor remission in every patient. After reduction of the afterloading dose to 2×4 Gy, no brachytherapy‐related side effects could be seen.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:The aim of this work was to compare wound‐healing after anal fistulotomy in human immunodeficiency virus (HIV)+ and HIV− patients and to recognize healing parameters in HIV+ patients.METHODS:Sixty patients were treated with fistulotomy for intersphincteric anal fistula. For each patient, we evaluated white blood cell count values, T CD4 counts, Centers for Disease Control and Prevention classification, and healing duration. There were 31 HIV+ patients (7 A2; 1 A3; 7 C1; 6 C2; 10 C3).RESULTS:Seven C3 patients had incomplete healing. Statistically, there was no difference in the healing duration in HIV+ A2, C1, C2, and HIV‐negative patients. C3 patients who did heal took longer than other HIV+ patients. T CD4 counts were similar to healed and not healed C3 patients, although healed C3 values of white blood cell counts were higher than not healed C3 values (4,450 and 2,380/mm3).CONCLUSION:After anal fistulotomy, HIV+ C3 patients either had retarded healing or no healing at all. Therefore, we feel that surgery should be done only in emergency cases of anorectal diseases or in patients with more than 3,000 white blood cells/mm3.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:Trials comparing handsewn with stapled anastomoses in colon and rectal surgery have not found statistical differences. Despite this, authors have differed in their conclusions as to which technique is superior. To help determine whether differences in patient outcomes are present, a meta‐analysis of all trials was performed.METHOD:A meta‐analysis of all randomized, controlled trials assessing handsewn and stapled colon and rectal anastomoses was done using a fixed‐effects model. Outcome variables were mortality, technical problems, leak rates, wound infections, strictures, and cancer recurrence. Outcomes were assessed for all anastomoses involving the colon and for the subset of colorectal anastomoses.RESULTS:Thirteen distinct trials met the inclusion criteria. Intraoperative technical problems were more likely to occur with stapled than with handsewn anastomoses for all anastomoses (P<0.0001) and for colorectal anastomoses (P<0.001). Strictures were also more common following stapled anastomoses (P=0.015 for all anastomoses;P=0.028 for colorectal anastomoses). All other outcome measures, including mortality, clinical and radiologic leak rates, and local cancer recurrence rates showed no difference between groups.CONCLUSION:Although intraoperative technical problems and postoperative strictures were more common with stapled anastomoses, other outcome measures showed no difference between groups. Thus, both techniques are effective, and the choice may be based on personal preference.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BACKGROUND:Creating a defunctioning stoma for anorectal disease in patients in whom no resection or anastomosis is required appears eminently suited for laparoscopic techniques, with the intended advantages of early recovery, reduced pain, and avoidance of a laparotomy.OBJECTIVES:The study contained herein was undertaken to determine the feasibility of laparoscopic defunctioning stoma formation using a three‐port technique (including one at the stoma site) and to compare initial results with a historical control group.METHODS:Duration of operation (anesthetic plus surgery), the time to tolerance of a liquid and then a solid diet, time to passage of flatus and feces, patient morphine requirements in the first 48 hours, and day of discharge were documented.RESULTS:Nineteen laparoscopic stomas were attempted (3 converted to open) and 23 open stomas were formed in the control group. The laparoscopic stoma group had lower morphine requirements (mean, 47.7vs.89.9 mg;P<0.01), an earlier tolerance of both liquid (mean, 2.1vs.3.7 days; P<0.01) and solid diets (mean, 3.6vs.5.5 days;P<0.001), and an earlier time to passage of both flatus (mean, 2.2vs.3.6 days;P<0.001) and feces (mean, 3.7vs.5.6 days;P<0.001). Operating time was longer for the laparoscopic group (mean, 176vs.104 minutes;P<0.001), whereas median time to discharge from hospital was shorter (median, 8vs.11 days;P=0.014). Postoperative 30‐day morbidity occurred in 1 of 19 laparoscopic group patients and 4 of 23 open group patients.CONCLUSIONS:In this select group of patients requiring defunctioning stoma only, laparoscopic surgery is feasible and safe and may have advantages over open procedures of less pain, earlier tolerance of diet, earlier return of bowel function, and a shorter median length of stay.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:Mycobacterium paratuberculosishas been proposed as a causative agent in patients with Crohn's disease. The purpose of this study was to determine whetherM. paratuberculosiswas present in tissue from patients with Crohn's disease in a defined geographic area.METHODS:We prospectively evaluated, using polymerase chain reaction and culture, whetherM. paratuberculosiswas present in 44 specimens (37 from intestinal mucosal biopsies and 7 from surgical resections) from patients with Crohn's disease, ulcerative colitis, or normal colonic mucosa.RESULTS:Of the 25 specimens tested from the 21 Crohn's patients, only 1 positive specimen was noted, whereas the 8 specimens from the 5 ulcerative colitis patients and the 11 specimens from the 11 control patients failed to demonstrate a positive result with polymerase chain reaction. Cultures of all specimens revealed no growth ofM. paratuberculosis.CONCLUSION:M. paratuberculosiswas only rarely detected in biopsy or surgical specimens from patients with Crohn's disease. These results do not support a common causative role ofM. paratuberculosisin Crohn's disease.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID