摘要:

PURPOSE:This study was undertaken to identify clinical characteristics, natural history, and results of medical and surgical treatment of anal fissures in Crohn's disease.METHODS:This is a retrospective review of patients with Crohn's disease and anal fissure.RESULTS:Of the 56 study patients, 49 (84 percent) had symptomatic fissures. Fissures were most commonly (66 percent) located in the posterior midline, and 18 patients (32 percent) had multiple fissures. Fissures healed in one‐half of patients treated medically. Factors predictive of successful medical treatment included male gender, painless fissure, and acute fissure. Of 15 patients, 10 (67 percent) treated surgically healed. Fissures in seven of eight patients (88 percent) who underwent anorectal procedures healed compared with fissures in only three of seven patients (43 percent) who underwent proximal intestinal resection. In the group of 50 patients with complete follow‐up studies, an anal abscess or fistula from the base of an unhealed fissure developed in 13 patients (26 percent). More fissures healed after anorectal surgery (88 percent) than after medical treatment alone (49 percent;P=0.05) or after abdominal surgery (29 percent;P=0.03).CONCLUSION:This series documents that unhealed fissures frequently progress to more ominous anal pathologic disease. Judicious use of internal sphincterotomy appears to be safe for fissures unresponsive to medical treatment.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

&NA;Normal defecation is associated with relaxation of sphincters during the evacuation process. However, obstructive defecation is sometimes seen clinically manifested by abnormal contraction of the puborectalis during defecation rather than relaxing. This condition has not previously been described after pelvic pouch construction.PURPOSE:This study was done to evaluate patients for defecation difficulties caused by paradoxical puborectalis contraction after pelvic pouch procedures.METHODS:Prospectively, patients with defecation difficulties were questioned. They then underwent electromyography if they met particular criteria. Biofeedback was offered to all patients demonstrating paradox on electromyography. Follow‐up was by clinic visits and interviews.RESULTS:After pelvic pouch construction, 13 patients were found to have paradoxical puborectalis contraction. Twelve of 13 patients elected to have biofeedback therapy. Eleven of these 12 were available for follow‐up an average of eight (1‐15) months after biofeedback. Nine improved, and two had no change in their defecation difficulty. Of the initial 13, 10 had an event, either pouchitis or abdominal trauma, directly before their defecation problems.CONCLUSION:Paradoxical puborectalis contraction can occur in patients after pelvic pouch surgery. It should be suspected in patients with defecation difficulties in the absence of an anatomic abnormality. Biofeedback is effective treatment.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

&NA;Health‐related quality of life (HRQOL) is a quantitative measurement of subjective perception of health state, including emotional and social aspects. It can be reliably measured with several valid instruments. Previous reviews of the literature suggested inadequate attention to HRQOL in studies of interventions in inflammatory bowel disease.PURPOSE:This study was undertaken to assess the current status of the quality of measurement of HRQOL in studies of inflammatory bowel disease and to review the clinical conclusions warranted by the literature.METHOD:Medline was searched for articles relating to ulcerative colitis, Crohn's disease, or inflammatory bowel disease and quality of life since 1981. The articles found were reviewed for citations of further articles. The adequacy of HRQOL measure was assessed and graded, and the study design was categorized to assess the strength of the literature on the whole.RESULTS:A trend was found toward higher quality of HRQOL measurement in the period 1988 to 1994 compared with 1981 to 1987. Most of the improvement was because of increased use of standardized and multidomain but unvalidated and unpublished questionnaires for measurement.CONCLUSIONS:Confidence in the following clinical conclusions in studies of surgical interventions in inflammatory bowel disease is limited by study design: that pelvic pouch is not inferior to ileostomy, that specific domains of HRQOL are differentially affected by different surgical procedures, and (with less confidence) that surgery is helpful in Crohn's disease. Medical studies have demonstrated that high quality HRQOL measures can be integrated into randomized, prospective trials. Clinically equivalent treatments have shown differential effects onHRQOL:9 mg daily of budesonide is superior to 15 mg, and hydrocortisone foam enemas are superior to prednisolone. Home parenteral nutrition has received modest support, limited again by study design. It is recommended that standard tests of HRQOL be used to increase comparability of studies and to increase the quality of this literature in general. In particular the Inflammatory Bowel Disease Questionnaire, Rating Form of Inflammatory Bowel Disease Concerns, and Direct Questioning of Objectives are recommended.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:Since the early 1980s to relieve functional disturbances after rectal excision, we have been performing nerve‐sparing surgery for rectal cancer. The aim of this study was to analyze patterns of recurrences, especially concerning causes of local ones. Furthermore, we would like to address the criteria we used in patient selection to effect successful nerve‐sparing surgery.METHODS:From 1982 to 1991, 306 patients underwent nerve‐sparing operations, which may be categorized into three types: 1) total autonomic nerve preservation (125 cases), 2) complete pelvic nerve preservation (105 cases), and 3) partial pelvic nerve preservation with removal of parasympathetic nerve (79 cases). Single and multivariant regression analyses were conducted to investigate patterns of recurrence, especially causes of local ones.RESULTS:Sixty‐five patients (21 percent) developed recurrent tumors, 19 of which (6.2 percent) were local. Using Dukes terms, there were five patients with Dukes A, 13 with Dukes B, and 47 (35 percent) with Dukes C stages. Rate of local recurrences was 13 percent in patients with Dukes C tumor. According to single‐variant analysis of Dukes C patients, the following factors are thought to influence local recurrences: number of lymph nodes metastases, level of primary growth, and direction of lymphatic spread. Multivariate regression analysis suggested that lymph node metastasis was the most important and influencing factor on local regrowth(P< 0.002).CONCLUSIONS:Compared with local recurrences in so‐called extended surgery, the rate of local recurrences in nerve‐sparing surgery appeared to be lower. Our current policy is aggressive application of nerve‐sparing surgery, even to patients with node‐positive rectal cancer, taking into consideration the exact extent of cancer spread. From the viewpoint of neuroanatomy related to mesorectum, we discussed patient determination for our nerve‐sparing surgery.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:Anorectal disease is commonly found in human immunodeficiency virus (HIV)‐infected patients. The aim of this study was to determine the spectrum of anorectal disease, its surgical treatment, clinical outcome, and its relation to immune status.METHODS:Medical records of all HIV‐infected patients with anorectal pathology that required surgical treatment from January 1984 to January 1994 were retrospectively reviewed. Patients were divided into five different groups: common anorectal pathology (hemorrhoids, polyps, Group A); condylomata acuminata (Group B); perianal sepsis (abscesses, fistulas, Group C); anorectal ulcers (Group D); malignancies (Group E).RESULTS:Eighty‐three patients needed 204 surgical consultations (13 percent conservative, 87 percent operative) for 170 anorectal diseases. Fifty‐one patients had multiple anorectal pathology. Operative intervention resulted in adequate wound healing and symptom relief in 59 percent of patients, adequate wound healing without relief of symptoms in 24 percent of patients, and disturbed wound healing in 17 percent of patients. Disturbed wound healing was related to type of anorectal disease(P<0.001) and to preoperative CD4+‐lymphocyte counts(P<0.01). Disturbed wound healing and most insufficient immune status were encountered in Groups C, D, and E. Within these groups low CD4+‐lymphocyte counts were a risk factor for disturbed wound healing(P=0.004). Median postoperative survival was highest (4.7 years) in Group A, lowest (0.6 years) in Groups D and E, and related to type of anorectal disease(P=0.0001).CONCLUSIONS:The spectrum of anorectal disease is complex. Type of anorectal disease is strongly related to immune status, wound healing, and postoperative survival.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:This study was designed to determine if p53 nuclear overexpression, as detected by immunohistochemistry, is a marker of prognostic significance in early (Stage I) colorectal cancer (CRC).METHODS:Tissue sections obtained from archival blocks of 66 patients with surgically treated Stage 1 CRC were stained immunohistochemically for p53 using a monoclonal antibody (PAB 1801‐Ab2). Differences in survival between p53 positive (p53+) and p53 negative (p53−) groups were compared using Kaplan‐Meier survival curves and the log‐rank test.RESULTS:Thirtyfour patients (51.5 percent) were p53+ and 32 (48.5 percent) were p53−. There were significantly more p53+ tumors in females (23 of 34) compared with males (11 of 34)(P=0.01). Follow‐up ranged from 1 to 128.5 (mean, 44.7; median, 38.2) months. Thirteen patients (197 percent) developed recurrence, of whom five died of disease. Univariate analysis of clinical and pathologic variables did not reveal any statistically significant differences between p53+ and p53− tumors. Mean actuarial survival was longer (48.2 months) in the p53− group compared with the p53+ group (41.5 months). However, comparison of survival curves using the log‐rank test did not show a statistically significant difference in survival (log‐rank chi‐squared=0.2;P=0.6).CONCLUSION:p53 nuclear overexpression does not appear to be an independent marker of prognostic significance in surgically treated early CRC. Females were more likely to have p53+ tumors. The biologic significance of this finding is unknown.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

BACKGROUND:Numerous anecdotal reports have documented the spread of colon cancer to trocar sites after laparoscopic‐assisted colectomy. We hypothesized that the pneumoperitoneum of laparoscopy potentiated tumor adherence to trocar sites.PURPOSE:This study was designed to determine the affect of CO2pneumoperitoneum on the rate of tumor implantation at trocar sites.METHODS:Viable GW‐39 human colon cancer cells were injected into the abdominal cavity of hamsters (2 × 106cells/hamster). A midline laparotomy, insertion of four 5‐mm trocars, injection of viable cells into the mesentery of the cecum, and free peritoneal cavity was performed in two groups: one control group (41) who did not receive a pneumoperitoneum and a comparison group (50) who underwent pneumoperitoneum for ten minutes at an insufflation pressure of 10 mmHg. Animals were killed at six weeks, and hematoxylin and eosin‐stained sections of trocar wounds, midline wound, small intestine, cecum, liver, and lung were examined by a veterinary pathologist, who was blinded to operation.RESULTS:Pneumoperitoneum increased tumor implantation in the cecal mesentery and the midline incision (P<0.05) but did not effect recurrence in the liver, lung, or jejunum. Trocar site implantation tripled with the addition of pneumoperitoneum (26vs.75 percent) (P<0.0001).CONCLUSION:Pneumoperitoneum increased implantation of free intra‐abdominal cancer cells at wound sites on the abdominal wall or within the abdominal cavity in this animal model. The use of pneumoperitoneum during laparoscopy in patients with colon cancer should only be performed in a protocol setting to evaluate the effect of pneumoperitoneum on the treatment of cancer.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:Colorectal signet‐ring cell carcinoma (SRCC) is uncommon; discordant data have been previously reported about clinicopathologic features. Thirty‐four cases of primary colorectal SRCC were retrospectively reviewed to clarify controversies.METHODS:Primary colorectal SRCC was diagnosed when the following criteria were satisfied: 1) the tumor was primary; 2) histologic material was adequate; 3) signet‐ring cell represented more than 50 percent of the cancer.RESULTS:We identified 34 cases (1.1 percent) of 2,995 consecutive large bowel cancers collected at the Institute of Anatomic Pathology of Florence between 1985 and 1993. Patients ranged in age from 31 to 89 (mean, 63.5; median, 65) years; 19 were male, and 15 were female (male:female=1.3:1). Fifteen tumors were located in the proximal colon, 11 in the rectum, and 8 in the distal colon. The gross shape was infiltrative in 24 cases and exophytic in 10; only 6 cases (17.6 percent) showed features of linitis plastica. Most cancers (61.8 percent) were Stage C, 29.4 percent were Stage B, and distant metastases were present in only three cases (8.8 percent). No Stage A case was found. Prognosis was extremely poor, and overall five‐year survival rate was 9.1 percent. Survival was influenced significantly by tumor stage(P<0.01).CONCLUSIONS:Comparison of our data with the literature showed many differences that could be related to different applied diagnostic criteria. We underlined the importance of histology as reproducible criterion for diagnosis of primary colorectal SRCC.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:Little is known regarding the long‐term outcome of patients with rectal cancer treated by local excision and radiation therapy. We updated our institutional experience with this approach.METHODS:From January 1986 to December 1991, 23 patients (median age, 64 (range, 30‐80) years) with mobile, moderately differentiated adenocarcinoma of the rectum were offered transanal excision. Two patients with large T3 tumors, who were judged intraoperatively to be unsuited for a local procedure, received radical resection and were excluded from analysis. Twenty‐one patients underwent transanal excisionen bloc(14) or piecemeal (7) through a resectoscope. Seventeen patients (74 percent) had either extensive medical problems or refused a colostomy. Patients received a median of 5,040 cGy postoperatively, and 15 also received 500 cGy preoperatively on protocol. Two patients received concomitant chemotherapy. Median follow‐up is 56 months for all patients and 67 months for survivors (range, 27‐92 months).RESULTS:There were 2 T1, 15 T2, and 4 T3 tumors. The distance from the anal verge was a median of 4 (range, 1‐7) cm. The median tumor size was 3 (range, 2‐7) cm. Sixteen patients had more than one‐third of the wall involved. Four patients (19 percent) developed a local recurrence at 26, 30, 33, and 48 (median, 31.5) months. Three were salvaged (abdominoperineal resection = 2; low anterior resection = 1) and remain disease‐free 18, 36, and 37 months postoperatively. Four patients (19 percent) developed metastases (lung = 3; liver = 1) at 3, 22, 25, and 44 months after initial treatment (median, 23.5 months). The actuarial five‐year overall, disease‐free and recurrence‐free survival are 77, 75, and 58 percent, respectively. Twelve patients (57 percent) have no evidence of disease while retaining their rectum. There was one postoperative death.CONCLUSIONS:Long‐term follow‐up confirms that local excision and radiation therapy is of value in patients with mobile tumors of the rectum. It suggests that this treatment can be offered to those patients who refuse a colostomy or are medically compromised and may be an acceptable option for selected patients with T2 or T3, mobile adenocarcinomas of the rectum.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:This experimental study was designed to investigate the collagen fibrils of colonic anastomoses in rats and to compare normal healing with rats treated with biosynthetic growth hormone (bGH).METHODS:The healing zone of left colonic anastomoses was studied at days 2, 4, and 6 after surgery by means of scanning electron microscopy.RESULTS:After four days of healing a normal anastomosis was filled with loosely packed and unorganized collagen fibrils, which were organized into collagen fibers after six days. Compared with normal anastomoses, rats treated with bGH showed a more organized healing, characterized by a dense structure of a new‐formed collagen framework of fibrils and immature collagen fibers after four days and with bundles of new collagen fibers after six days.CONCLUSIONS:Healing colonic anastomoses are characterized by new‐formed collagen fibrils at postoperative day 4, and bGH seems to stimulate structural organization of the anastomotic collagen fibrils into fibers.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID