摘要:

INTRODUCTION:In an era of dwindling hospital resources and increasing medical costs, safe reduction in postoperative stay has become a major focus to optimize utilization of healthcare resources. Although several protocols have been reported to reduce postoperative stay, no Level I evidence exists for their use in routine clinical practice.METHODS:Sixty‐four patients undergoing laparotomy and intestinal or rectal resection were randomly assigned to a pathway of controlled rehabilitation with early ambulation and diet or to traditional postoperative care. Time to discharge from hospital, complication and readmission rates, pain level, quality of life, and patient satisfaction scores were determined at the time of discharge and at 10 and 30 days after surgery. Subgroups were defined to evaluate those who derived the optimal benefit from the protocol.RESULTS:Pathway patients spent less total time in the hospital after surgery (5.4vs.7.1 days;P= 0.02) and less time in the hospital during the primary admission than traditional patients. Patients younger than 70 years old had greater benefits than the overall study group (5vs.7.1 days;P= 0.01). Patients treated by surgeons with the most experience with the pathway spent significantly less time in the hospital than did those whose surgeons were less experienced with the pathway (P= 0.01). There was no difference between pathway and traditional patients for readmission or complication rates, pain score, quality of life after surgery, or overall satisfaction with the hospital stay.CONCLUSIONS:Patients scheduled for a laparotomy and major intestinal or rectal resection are suitable for management by a pathway of controlled rehabilitation with early ambulation and diet. Pathway patients have a shorter hospital stay, with no adverse effect on patient satisfaction, pain scores, or complication rates. Patients younger than 70 years of age derive the optimal benefit, and increased surgeon experience improves outcome.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:This study was performed to determine whether the adoption of a standardized technique for resection of colon cancer, based on mobilization along anatomic planes, resulted in improved survival after adjustment for other known prognostic factors.METHODS:Patients undergoing a potentially curative, elective colonic resection at Concord Hospital from 1971 to 1995 were included. None received adjuvant therapy. Data were recorded prospectively. Overall survival and colon‐cancer‐specific survival were examined by the Kaplan‐Meier method and proportional‐hazards regression in relation to patient and tumor characteristics and the introduction of a standardized surgical technique in 1980.RESULTS:Overall five‐year survival rose from 48.1 percent before 1980 to 63.7 percent after 1980 (P< 0.0001); cancer‐specific survival rose from 66.4 percent to 76.6 percent (P= 0.002). Factors that did not change significantly before and after 1980 were patient age and gender, tumor site, stage, grade, serosal surface involvement, and apical node metastases. The proportion of tumors ≥5 cm in diameter decreased after 1980 (61.9 to 49.2 percent,P= 0.001) but survival was unrelated to size. Venous invasion rose after 1980 (9 to 15.8 percent,P= 0.014). Multiple regression with adjustment for age, stage, grade, venous invasion, serosal surface involvement, and apical node metastases showed significantly shorter overall survival before the introduction of the standardized technique (hazard ratio, 1.5; 95 percent confidence interval, 1.2‐1.8) and significantly shorter colon‐cancer‐specific survival (hazard ratio, 1.7; 95 percent confidence interval, 1.3‐2.2). The proportion of patients having a noncurative operation because of residual tumor in a line of resection (excluded from the survival analyses) fell from 10.6 percent (confidence interval, 7‐15.3 percent) before 1980 to 3.2 percent (confidence interval, 2‐4.9 percent) after 1980.CONCLUSION:As in rectal cancer surgery, mobilization of the colon along anatomic planes is an important principle that influences outcome and needs to be emphasized.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:The role of abdominoperineal resection for rectal cancer has changed because of advances in sphincter‐preserving surgery. Our aim was to evaluate the results of this operation in the five‐year period following introduction of the concept of total mesorectal excisionMETHODS:Data on all patients undergoing abdominoperineal resection for very low rectal cancer between 1992 and 1997 were collected prospectively. All patients had had total mesorectal excision. Curative resection was defined as absence of macroscopic disease after resection and local recurrence as any infiltration or tumor identified in the pelvis, alone or combined with distant disease. Survival and local recurrence rates were calculated using the Kaplan‐Meier method and log‐rank analysis.RESULTS:Of 165 abdominoperineal resections performed, 106 were for primary adenocarcinoma of the rectum. The male:female ratio was 50:56, with a median age of 65 (range, 33‐85) years. There was one postoperative death. Twenty‐seven patients received short‐course preoperative radiotherapy (25 Gy over 1 week), whereas 22 had a longer course, with concomitant chemotherapy in 2. Postoperative chemotherapy was administered in 29, postoperative radiotherapy in 4, and combined therapy in 8. After curative resection (n = 91), survival at five years was 76 percent and differed significantly by stage. Recurrence at any site was 7 percent (3/34) for Stage I, 27 percent (6/26) for Stage II, and 53 percent (16/31) for Stage III. Nine patients presented with local recurrence, with an overall rate at five years of 10 percent. Isolated locale recurrence was observed in only 5 percent of patientsCONCLUSIONS:After abdominoperineal resection and total mesorectal excision, good rates of local control may be achieved provided surgical technique is meticulous.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:Preoperative chemoradiotherapy for advanced rectal cancer has been an important therapeutic tool to improve the long‐term results of curative resection. It is not known whether preoperative chemoradiotherapy for advanced rectal cancer influences the perioperative course of immune parameters.METHODS:Thirty patients with rectal cancer underwent surgery with (study group, n = 15) or without (control group, n = 15) preoperative chemoradiotherapy (2 cycles of 5‐fluorouracil, 45 Gy). Blood samples were taken before neoadjuvant therapy, preoperatively, and on Days 1, 2, and 5 after surgery. Cell numbers of lymphocyte subpopulations, granulocytes, monocytes, and natural killer cells were determined by flow cytometry; tumor necrosis factor‐&agr; and interleukin‐6 serum levels were measured with enzyme‐linked immunosorbent assay.RESULTS:Significant differences between study and control patients (P< 0.05) were detected regarding circulating interleukin‐6 and tumor necrosis factor‐&agr; levels, with depression of the proinflammatory response to surgery in study patients. Similarly, granulocytosis and monocytosis after surgery were significantly lower in patients after neoadjuvant therapy. Furthermore, cell counts of total T lymphocytes, T helper cells, B lymphocytes, and natural killer cells were significantly reduced after preoperative chemoradiotherapy. This depression of cell‐mediated immunity in study patients was even more pronounced after surgery.CONCLUSIONS:Preoperative chemoradiotherapy for advanced rectal cancer results in a significant preoperative and postoperative immune dysfunction as indicated by depression of lymphocyte subpopulations, monocytes, granulocytes, and proinflammatory cytokine release. These findings are of importance because increased perioperative morbidity and mortality rates have been observed after preoperative chemoradiotherapy.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:Preoperative radiotherapy for rectal cancer avoids radiation to the reconstructed rectum and may circumvent the detrimental effects on bowel function associated with postoperative radiotherapy. We compared the long‐term functional results of patients who received preoperative radiotherapy, postoperative radiotherapy, or no radiotherapy in conjunction with low anterior resection and coloanal anastomosis to assess the impact of pelvic radiation on anorectal function.METHODS:One hundred nine patients treated by low anterior resection and straight coloanal anastomosis for rectal cancer between 1986 and 1997 were assessed with a standardized questionnaire at two to eight years after resection. All radiotherapy was given to a total dose of 4,500 to 5,400 cGy with conventional doses and techniques. Most patients received concurrent 5‐fluorouracil‐based chemotherapy.RESULTS:There were 39 patients in the preoperative radiotherapy group, 11 patients in the postoperative radiotherapy group, and 59 patients in the no radiotherapy group. The postoperative radiotherapy group reported a significantly greater number of bowel movements per 24‐hour period (P< 0.01) and significantly more episodes of clustered bowel movements (P< 0.02) than either the preoperative radiotherapy group or the no radiotherapy group. No significant difference in anal continence or satisfaction with bowel function was found among the three groups.CONCLUSION:In this study of straight (nonreservoir) coloanal anastomoses, postoperative pelvic radiotherapy had significant adverse effects on anorectal function, with higher rates of clustering and frequency of defecation than with preoperative radiotherapy. No differences in continence rates were demonstrated, perhaps because of the sample size of the compared groups. We attribute the adverse effects of postoperative radiotherapy to irradiation of the neorectum, which is spared when treatment is given preoperatively. The deleterious effects of adjuvant radiation on long‐term anorectal function can be reduced by preoperative treatment.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

INTRODUCTION:Locally recurrent rectal cancer is associated with poor quality of life and has justified aggressive surgical and adjuvant approaches to control the disease. This study was designed to evaluate the use of fractionated perioperative high‐dose‐rate brachytherapy in association with wide surgical excision (debulking). Our hypothesis is that this combined therapy can help control locally recurrent rectal cancer.METHODS:Patients with biopsy‐proven locally recurrent rectal cancer that could not be completely removed surgically were considered candidates for this procedure. All patients had abdominal exploration, aggressive tumor debulking, and placement of afterloading brachytherapy catheters. Patients underwent simulation on postoperative Day 3 and received 1,200 to 2,500 (mean, 1,888) cGy of fractionated high‐dose‐rate brachytherapy between postoperative Days 3 and 5. All patients had involvement of the lateral pelvic sidewall and/or the sacrum.RESULTS:Twenty‐seven patients (18 males) aged 32 to 79 years underwent therapy. Follow‐up ranged from 18 to 93 (mean, 50) months and was available in 27 patients. Ten patients (37 percent) were alive at the time of this report. Nine patients are without evidence of disease. Five patients (18 percent) died of non‐cancer‐related causes without evidence of recurrent disease. Five complications potentially related to treatment (3 abscesses, 2 fistulas) occurred in five patients.CONCLUSION:High‐dose radiation brachytherapy delivers high‐dose, highly controlled, focused radiation to specific sites of disease, thereby minimizing injury to normal tissues. The results in this series suggest increased local control, better palliation, and increased salvage of patients.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:The protective effect of 5‐aminosalicylic acid against colon carcinogenesis was investigated.METHODS:Eighty female F344 rats aged seven weeks received an intrarectal dose of 2 mgN‐methylnitrosourea dissolved in 0.5 ml of water three times weekly for five weeks to induce colon cancer. Beginning at 6 weeks after the last dose ofN‐methylnitrosourea, the rats were treated with an intrarectal dose of 1 mg 5‐aminosalicylic acid suspended in 0.5 ml of vehicle solution (0.3 percent water solution of methylcellulose) three times weekly for 15 weeks.RESULTS:Colon cancer incidence and mean number of tumors per rat at the end of the 15‐week treatment period were significantly lower and smaller in the 5‐aminosalicylic acid‐treated group (10 percent and 0.2) than in the vehicle‐treated (80 percent and 1.6) and untreated (68 percent and 1.1) control groups. However, the mean numbers of tumors per tumor‐bearing rat were comparable: 1.5, 2, and 1.6. No distinct differences among the groups were observed in the tumor pathology with respect to their location (within 0‐10 cm proximal to the anus), shape (plaque shaped or polypoid), size (<10 mm in diameter), invasion (restricted to the mucosa or submucosa), or histologic type (differentiated adenocarcinoma).CONCLUSION:Our results indicate that 5‐aminosalicylic acid administered directly into the colonic lumen strongly suppresses the promotion stage of colon carcinogenesis.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:Age is reported as a risk factor for carcinogenesis, even though age can affect cancer behavior both positively and negatively. Young patients with colorectal cancer reveal different tumor characteristics than average‐age and older‐age groups, although few studies report the influence of age among the entire range of patient ages. The influence of age on clinicopathologic characteristics of sporadic colorectal cancer was analyzed. Whether an age group with distinct tumor characteristics was present was determined.METHODS:A total of 5,436 patients who underwent colectomy in a single institute within a seven‐year period were studied. Data on clinical and histopathologic features of colorectal cancer were collected from the cancer registry and medical records. These characteristics were analyzed according to ten‐year age groups.RESULTS:Eighty‐three patients (1.6 percent) were 30 years of age or younger, whereas 285 (5.5 percent) were 31 to 40 years of age. Most patients (74.6 percent) were 51 to 80 years of age. The proportion of localized tumors (Dukes A and Dukes B) significantly increased as age increased, from 31.3 percent in the 30 years or younger age group to 49 percent in the 80 years or older group (P< 0.001). The proportion of poorly differentiated tumors tended to decreased as age increased (from 16.9 percent in the 30 years or younger group to 6.2 percent in the 80 years or older group;P= 0.009). A similar trend in the proportion of mucin‐producing tumors was also observed (36 percent in the younger groupvs.7.5 percent in the older group;P< 0.001). There was no significantly different distribution of tumor locations among the different age groups.CONCLUSIONS:Age appears to favorably influence the clinicopathological characteristics of sporadic colorectal cancer. As age increased, the characteristics of tumor stage at diagnosis, tumor differentiation, and mucin production improved.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:The purpose of the study was to evaluate the outcome of surgical management of pouch‐vaginal fistulas in females who had undergone restorative proctocolectomy.METHODS:This study was designed as a retrospective chart review of females treated for pouch‐vaginal fistulas from 1983 to 2000. All patients were followed up using our prospective pouch registry, with additional data collected by interview or mailed questionnaire.RESULTS:Sixty females were identified (mean age, 33.3 ± 1.3 years), of whom 33 had their initial restorative proctocolectomy done at our institution. Preoperative diagnosis was ulcerative colitis (88 percent), indeterminate colitis (10 percent), and familial adenomatous polyposis (2 percent). Average time to pouch‐vaginal fistula following restorative proctocolectomy was 21 months (range, 1‐132 months). Postoperative pelvic sepsis had occurred in 17 (28 percent) patients. Primary treatment modalities included the following: local repairs (n = 46, 77 percent), the majority of which were ileal advancement flaps; redo restorative proctocolectomy (n = 6, 10 percent); and pouch excision (n = 5, 8 percent). Initial healing was achieved in 20 patients. An additional 11 patients with recurrences healed after repeat procedures. The overall healing rate was 52 percent at 49.4 ± 3.8 months follow‐up. Pouch failure was the eventual outcome in 13 (22 percent) patients and 16 (27 percent) patients had persistent pouch‐vaginal fistula. A delayed diagnosis of Crohn's disease was made in 24 patients. Crohn's disease patients had lower success rates following ileal advancement flaps compared with the non‐Crohn's group (25vs.48 percent, respectively), much lower overall healing rates of their pouch‐vaginal fistulas (17vs.75 percent, respectively), and a higher incidence of pouch failure (33vs.14 percent, respectively).CONCLUSION:Pouch‐vaginal fistulas are a difficult problem in females following restorative proctocolectomy. However, local repair can be successful with good functional outcomes. Redo restorative proctocolectomy may also achieve healing if local repairs are not possible or have failed. A delayed diagnosis of Crohn's disease results in worse treatment outcome and higher pouch failure rates.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID