摘要:

PURPOSE:Many patients with fecal incontinence demonstrate a functional deficit of the internal anal sphincter or the external sphincter muscles without any apparent structural defects. Few patients are amenable to repair or substitution of the sphincter. However, sacral nerve stimulation appears to offer a valid treatment option for fecal incontinence. The objectives of this study were: to evaluate the efficacy of temporary stimulation of the sacral nerve roots (percutaneous nerve evaluation) in patients with functional fecal incontinence; to determine the mechanisms of possible improvement; and to evaluate if temporary stimulation could be reproduced and maintained by implanting a permanent neurostimulation system.METHODS:Twenty‐three patients with fecal incontinence, 18 females and 5 males, median age of 54.9 years (range 28‐71), underwent a percutaneous nerve evaluation test. Eleven patients (47.8 percent) also had urinary disorders: urge incontinence (4), stress incontinence (3), and retention (4). Associated disorders included perineal and rectal pain (1), spastic paraparesis (1), and syringomyelia (1). All patients underwent a preliminary evaluation using stationary anal manovolumetry, pudendal nerve terminal motor latency measurements, and anal ultrasound. A percutaneous electrode for the stimulation of the sacral nerve roots was positioned at the level of the third sacral foramen (S3) in 20 patients and S2 in 2 patients (1 patient missing). Stimulation parameters used were: pulse width 210&mgr;sec, frequency 25 Hz, and average amplitude of 2.8 V (range 1‐6). The electrode was left in place for a minimum of 7 days. Five patients were successively implanted with a permanent sacral electrode with a stimulation frequency of 16 to 18 Hz and amplitude of 1.1‐4.9 V.RESULTS:Seventeen of the 19 patients (89.4 percent) who completed the minimum percutaneous nerve evaluation period of 7 days (median 10.7 (range 7‐30)), had a reduction of liquid or solid stool incontinence by more than 50 percent, and fourteen (73.6 percent) were completely continent for stool. The most important changes revealed by manovolumetry were an increase in resting pressure (P<0.001) and voluntary contraction (P=0.041), reduction of initial pressure for first sensation (P=0.049) and urge to defecate (P=0.002), and a reduction of the rectal volume for urge sensation (P=0.006). The percutaneous nerve evaluation results were reproduced at a median follow‐up of 19.2 months (range 5 to 37) in the 5 patients who received a permanent implant.CONCLUSIONS:Temporary stimulation of the sacral roots (percutaneous nerve evaluation) can be of help in those patients with fecal incontinence, and the results are reproduced with permanent implantation. The positive effect on continence seems to be derived from not only the direct efferent stimulation on the pelvic floor and the striated sphincter muscle, but also from modulating afferent stimulation of the autonomous neural system, inhibition of the rectal detrusor, activation of the internal anal sphincter, and modulation of sacral reflexes that regulate rectal sensitivity and motility.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:The purpose of this study was to develop a surgical training program and to test the accuracy of laparoscopic ultrasound in detecting injected lesions in pig livers.METHODS:Pig livers were divided into eight segments and injected with Surgilube® “malignant” and silicone “benign” lesions. All were examined by laparoscopic ultrasound followed by liver explantation to confirm results. First, a pilot study was conducted on six swine by injecting Surgilube® lesions and performing laparoscopic ultrasound through 3 different ports (left upper quadrant (I), umbilicus (II), and right lower quadrant (III)) to determine per‐segment accuracy and to optimize port placement. Second, blinded injection of Surgilube® and silicone implants was done on 18 pigs with laparoscopic ultrasound conducted through the two most accurate ports from the pilot study. This model was then tested during a resident training workshop.RESULTS:In the pilot study, per‐lesion and per‐segment sensitivity was 96 percent, with no difference among the three ports used. Ports I and II were chosen for the blinded study for their convenience in performing laparoscopic colectomy. In the blinded study, per‐segment sensitivity, specificity, and accuracy were 97 percent, 94 percent, and 96 percent and 99 percent, 94 percent, and 97 percent for ports I and II, respectively. At the conclusion of a pilot workshop, trainee per‐segment sensitivity, specificity, and accuracy were 60 percent, 80 percent, and 70 percent, respectively. The major difficulty was differentiating benign from malignant lesions.CONCLUSIONS:A useful liver laparoscopic ultrasound training model for surgeons was developed with good preliminary results. It is anticipated that further training will enhance laparoscopic ultrasound accuracy rates before application of this modality in humans.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:All types of trauma to the organism produce a systemic response that is proportional to the severity of the lesion caused. The more rapid clinical recovery during the postoperative period of patients undergoing laparoscopic‐assisted colectomyvs.patients receiving conventional surgery suggests that laparoscopic surgery produces less surgical trauma. The aim of this randomized, prospective study was to compare acute phase postoperative response in patients diagnosed with colon neoplasm undergoing open segmentary colectomyvs.laparoscopic‐assisted colectomy.METHODS:From June 1994 to July 1997 the results of 97 patients (58 submitted to open colectomy and 39 undergoing laparoscopic‐assisted colectomy) were analyzed. Blood determinations of cortisol, prolactin, C‐reactive protein and interleukin‐6 were performed before surgery and at 4, 12, 24, and 72 hours after surgery.RESULTS:The plasma levels of cortisol and prolactin were higher in the postoperative period with both surgical techniques with no significant differences being observed. The levels of interleukin‐6 achieved a maximum peak at 4 hours after surgery, later showing a decrease and practically achieving basal levels at 72 hours in both groups. The levels of interleukin‐6 were higher with significant differences at 4, 12, and 24 hours in the patients undergoing open colectomy. The plasma levels of C‐reactive protein were significantly lower at 72 hours in patients receiving laparoscopic‐assisted colectomy.CONCLUSIONS:The results obtained in this randomized, prospective study suggest that acute phase systemic response is attenuated in patients undergoing laparoscopic‐assisted colectomy in comparison with patients receiving open colectomy.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:Previous studies on recurrence and reoperation after colectomy in Crohn's colitis have been based on heterogeneous groups of patients, and divergent findings may be explained by referral biases and small numbers of patients. The aim of this study was to account for recurrence rates, present risk factors for recurrence after primary colectomy, and account for the ultimate risk of having a stoma after colectomy with ileorectal anastomosis in patients with Crohn's colitis.METHODS:Data on the primary resection, postoperative recurrence, influence of concomitant risk factors, frequency of stoma operations and proctectomy were evaluated retrospectively using multivariate analysis in a population‐based cohort of 833 patients with Crohn's colitis.RESULTS:The cumulative 10‐year risk of a symptomatic recurrence was 58 percent (95 percent confidence interval, 53‐63 percent) and 47 percent (95 percent confidence interval, 42‐52 percent), respectively, after colectomy with ileorectal anastomosis and segmental colonic resection. In colectomy with ileostomy, lower rates were found with respectively 24 percent (95 percent confidence interval, 18‐30 percent) and 37 percent (95 percent confidence interval, 32‐43 percent) after subtotal colectomy and proctocolectomy with ileostomy. The multivariate analysis showed that perianal disease, ileorectal anastomosis, and segmental resection were independent risk factors for postoperative recurrence. In 76 percent of patients with ileorectal anastomosis, a stoma‐free function could be retained during a median follow‐up of 12.5 years.CONCLUSION:Colectomy with ileorectal anastomosis or segmental resection is a feasible option in the surgical treatment of Crohn's colitis, although anastomoses, in addition to perianal disease, carry an increased risk of recurrent disease.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:This study was designed to evaluate the effectiveness of overlapping anal sphincter reconstruction and to determine the manometric parameters that correlate with a successful functional outcome.METHODS:A retrospective review of patients who had undergone overlapping sphincter reconstruction for anal incontinence from 1988 to 1999 was undertaken. Only patients with preoperative and six‐months‐postoperative anal manometry were included in this study. Standard statistical tests were used to compare pre‐ and postoperative findings.RESULTS:A total of 52 overlapping sphincter reconstructions were performed on 49 patients (46 females). The mean age was 44 (± standard error, 15.8; range, 20‐81) years, with follow‐up at six months. Forty‐two patients had a history of complicated vaginal delivery (episiotomies, tears, forceps delivery); 36 patients had a history of anal or perineal surgery; and two patients had perianal Crohn's disease. Nine patients (17 percent) had undergone prior sphincter repair. Incontinence grade improved in 37 patients (71 percent), and complete continence returned in 21 patients (40 percent). The presence of a rectovaginal fistula, postoperative complications, previous sphincter repair, and increase in pudendal nerve terminal motor latency did not affect functional outcome (P= not significant). Patients older than 50 years had a better functional outcome than their younger counterparts after sphincter repair (P=0.02). Although mean maximal squeeze pressure and mean anal sphincter length increased significantly after sphincter reconstruction (P=0.0006 and 0.004, respectively), only squeeze pressure difference correlated with functional outcome (r=0.37;P=0.007).CONCLUSIONS:Overlapping sphincter reconstruction improved anal function in the majority of patients. The most important factor in the return to normal sphincter function is an increase in squeeze pressure.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:This study was undertaken to analyze whether intra‐anal ultrasound examination, anorectal physiologic evaluation, and histopathologic examination in patients with chronic idiopathic anal pain presented any common features and whether the results of different treatment modalities correlated with these findings.METHODS:Eighteen patients who met the criteria for chronic idiopathic anal pain were studied. All had an intra‐anal ultrasound examination and a complete anorectal physiologic evaluation. In a selected group of patients, ultrasound‐guided biopsy samples were taken from pathological areas in the internal and external sphincter. Treatment consisted of analgesics only in four patients, 0.2 percent nitroglycerin ointment in four, and ultrasound injection of botulin (botulinum toxin, Botox®) into the intersphincteric space in nine. Two patients, including one who was previously treated with botulin, ultimately had a colostomy.RESULTS:Four patients were managed satisfactorily on analgesic treatment under the guidance of the hospital's pain clinic. Nitroglycerin ointment resulted in temporary pain relief in one of four patients. Injection of botulin resulted in a permanent improvement in four patients, a temporary improvement in one patient, and no effect in four patients. Two patients had a colostomy, resulting in complete pain relief. The effect or lack of effect of nitroglycerin ointment and botulin was not related to changes in anal pressure.CONCLUSION:Chronic idiopathic anal pain is a condition of unknown origin for which no proven therapy exists. As in other syndromes based on muscular dystonia, some patients may benefit from injection of botulin.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:With the advent of transanal ultrasonography it has been possible to identify those incontinent patients without sphincter defects. The majority of these patients are now thought to have neurogenic fecal incontinence secondary to pudendal neuropathy. They have been found to have reduced anal sphincter pressures and increased pudendal nerve terminal motor latencies. The aim of this study was to determine whether in those incontinent patients who do not have a sphincter defect, prolonged pudendal nerve terminal motor latency correlates with anal manometry, in particular maximum squeeze pressure.METHODS:Sixty‐six incontinent patients were studied with transanal ultrasonography, anorectal manometry, and pudendal nerve terminal motor latency. Twenty‐seven continent controls had anorectal manometry and pudendal nerve terminal motor latency measured.RESULTS:Maximum resting pressure and maximum squeeze pressure were significantly lower in the group of incontinent patients with bilateral prolonged pudendal nerve terminal motor latency (median maximum resting pressure = 26.5 mmHg; median maximum squeeze pressure = 60 mmHg) when compared with incontinent patients with normal bilateral pudendal nerve terminal motor latencies (median maximum resting pressure = 46 mmHg; median maximum squeeze pressure = 79 mmHg; maximum resting pressureP=0.004; and maximum squeeze pressureP=0.04). In incontinent patients with no sphincter defects no correlation between pudendal nerve terminal motor latency and maximum squeeze pressure was found (r=−0.109,P=0.48) and maximum squeeze pressure did not correlate with bilateral or unilateral prolonged pudendal nerve terminal motor latency (r=−0.148,P=0.56 andr=0.355,P=0.19 respectively).CONCLUSIONS:In patients with idiopathic fecal incontinence damage to the pelvic floor is more complex than damage to the pudendal nerve alone. Although increased pudendal nerve terminal motor latency may indicate that neuropathy is present, in patients with neuropathic fecal incontinence, pudendal nerve terminal motor latency does not correlate with maximum squeeze pressure. Normal pudendal nerve terminal motor latency does not exclude weakness of the pelvic floor.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:Intermittent distention of the rectum induces internal anal sphincter relaxation, but whether continuous rectal distention might affect the resting pressure of the anal canal and the frequency of internal anal sphincter relaxations has not yet been investigated. The aim of this study was to record anal pressure under resting conditions and at two levels of continuous rectal distention.METHODS:Anal pressure was recorded by means of water‐perfused catheters under resting conditions and at two levels of rectal distention controlled by an electronic barostat in eight healthy subjects.RESULTS:Continuous rectal distention did not significantly change mean anal resting pressure, but it did significantly decrease the amplitude of ultraslow waves (from 29±9 mmHg under resting conditions to 23±6 and 21±3 mmHg during lesser and greater rectal distention;P=0.017 andP=0.012, respectively) and increase the frequency of internal anal sphincter relaxations (from 1.3±1.3/hour under resting conditions to 8.8±4.3/hour and 11.0±4.8/hour during lesser and greater distention;P=0.012 in both comparisons).CONCLUSIONS:The resting pressure of the anal canal is maintained during continuous rectal distention. The decreased amplitude of ultraslow waves and increased frequency of the internal anal sphincter relaxations induced by rectal distention reveal a complex functional relationship between the rectum and the anal canal.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID