摘要:

PURPOSE:Virtually all untreated patients with familial adenomatous polyposis develop colorectal carcinoma. Thus, prophylactic colectomy is indicated. Detractors of ileal pouch‐anal anastomosis prefer ileorectal anastomosis for teenagers because of the potential negative impact of ileal pouch‐anal anastomosis on quality of life. The aim of this study was to assess the effects on quality of life of ileal pouch‐anal anastomosis in teenagers with familial adenomatous polyposis.METHODS:Between 1981 and 1998, 48 teenagers underwent ileal pouch‐anal anastomosis for familial adenomatous polyposis. One patient had proctectomy and ileal pouch‐anal anastomosis after previous ileorectal anastomosis. A temporary diverting loop ileostomy was established in 42 patients (87.5 percent). One patient had colonic carcinoma diagnosed preoperatively. Two other patients were found to have unsuspected rectal cancer at surgery. Mean follow‐up (± standard deviation) in 43 patients was 80.5±42 months.RESULTS:There was no immediate postoperative mortality. Postoperative complications included pelvic sepsis (3 patients; 1 requiring reoperation) and bleeding (1 patient; no surgery required). One patient died of metastatic colonic carcinoma. Ten patients required reoperation, seven had bowel obstruction, one had portal hypertension, and two required an ileostomy. The mean (± standard deviation) daytime and nighttime stool frequency was 4±1.5 and 1±1, respectively. One patient reported daytime and nighttime incontinence, and two patients reported nighttime incontinence only. No patient experienced impotence or retrograde ejaculation. Social, sexual, sport, housework, recreation, family, travel, and work activities were improved or unchanged in 82.5, 87, 80, 90, 80, 92.5, 77.5, and 89 percent of patients, respectively. Three male patients fathered children, and three female patients had a total of six children after normal pregnancies and deliveries.CONCLUSION:The impact of ileal pouch‐anal anastomosis on quality of life was favorable in the majority of teenagers. The risk of rectal cancer should be the major consideration before proposing an operation to teenagers with familial adenomatous polyposis.

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

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:It is now agreed that it is of vital importance to maintain the fascia propria as an intact envelope around the mesorectum to prevent tumor spillage while performing rectal excision for cancer. There are several surgical techniques described to achieve an intact fascial envelope, each arising from differing descriptions of the fascia propria of the rectum. The aim of this study was to describe the detailed surgical anatomy of the fascia propria.METHODS:Thirteen rectal specimens surgically removed by the technique of extrafascial excision were subjected to gross inspection, dissection, and histologic and electron microscopic examination. The attachments, thickness, and composition of the fascia propria were determined.RESULTS:The fascia propria is a continuous fascial sleeve surrounding the rectum and mesorectum that can be dissected as a complete “sock” off a fresh extrafascial specimen. It is 154 (±1 standard deviation = 61‐391) &mgr;m thick, is thinner anteriorly than posteriorly (P<0.05), and is composed predominantly of collagen. It can be identified surgically at the pelvic brim as a shiny membrane and lies inside the hypogastric nerves and the pelvic plexuses.CONCLUSION:The fascia propria forms a sleeve around the mesorectum, offering a surface against which to dissect, enabling safe removal of the rectum with its intact mesorectum while preserving the autonomic nerves of the pelvis. The term “extrafascial excision” highlights the importance of the fascia propria in this operation.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:The objective of this study was to analyze patient outcome after strictureplasty for management of intestinal stricture caused by Crohn's disease based on differences in surgical procedures.METHODS:A MEDLINE search was performed using a medical subject heading analysis for strictureplasty in Crohn's disease. Meta‐analysis of multiple variables for outcome was performed using random‐effects models.RESULTS:Five hundred six patients underwent 1,825 strictureplasties for Crohn's disease with minimal morbidity and zero mortality. Ninety percent of strictures were less than 10 cm in length. Approximately 85 percent of these procedures used the Heineke‐Mikulicz technique and 13 percent used Finney strictureplasty. Forty‐four percent of procedures included concurrent bowel resection. Recurrence rate of Crohn's disease after strictureplasty was increased in patients with longer study duration after surgery (P=0.04), who showed symptoms of active disease (P=0.02), who experienced preoperative weight loss (P=0.02), or who received the Heineke‐Mikulicz procedure (P=0.008). The proportion of patients requiring additional surgery was increased with longer study duration (P=0.006), with properative weight loss (P=0.001), or with the Heineke‐Mikulicz procedure (P=0.005). The proportion of patients requiring additional surgery was decreased when a Finney strictureplasty was used (P=0.008) as compared with those treated by the Heineke‐Mikulicz procedure.CONCLUSION:Although the Heineke‐Mikulicz technique is most often used for Crohn's strictureplasty, outcome analysis revealed the Finney strictureplasty may reduce the reoperation rate.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:The objective of this study was to review early and late results of our personal experience with strictureplasty for patients affected by Crohn's disease.METHOD:During a 16‐year period, 44 of 383 patients underwent strictureplasty. Of the 269 strictures present at surgery, 174 were treated by performing strictureplasties (156 were closed transversely according to the Heineke‐Mikulicz technique, 16 were done side‐to‐side in the Finney manner, and 2 were done according to Jaboulay technique), and 88 were treated with a synchronous resection. An individualized technique was used for seven other strictures, with side‐to‐side ileocolic (5 strictures in 3 patients) or ileoileal anastomosis (2 strictures in one patient).RESULTS:No operative mortality was recorded, nor were septic complications caused by anastomotic leakage observed. The mean follow‐up period was 47.8±42.4 (range, 3‐132) months. After a median follow‐up period of 50 (range, 18‐89) months, a second operation for symptomatic recurrence was performed on ten patients, and two of them developed new symptomatic strictures after 3 and 36 months, requiring a third operation. Symptomatic restrictures of previous strictureplasty sites requiring surgery occurred in 8.8 percent of cases. Furthermore, no statistically significant difference (Kaplan‐Meier) was observed in the reoperation rate among the patients with skip lesions or closed strictures or among patients treated by strictureplasty alone or with associated resection.CONCLUSION:We conclude that strictureplasty is a valuable adjunct or alternative to resection in the treatment of Crohn's strictures.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Bowel dysfunction is common in patients with spinal cord lesions. This study aims to determine whether there are any discriminatory findings at anorectal physiologic testing in patients with spinal cord lesions.METHODS:Twelve consecutive patients (6 females) with significant spinal cord lesions who had mixed symptoms of constipation, fecal impaction, and fecal incontinence were evaluated by perfusion manometry and pudendal nerve terminal motor latency. None of the patients had a sphincter defect as evaluated by endoanal ultrasonography.RESULTS:The median age was 54 (range, 40‐87) years. Eight (67 percent) of them had had traumatic spinal cord injuries. Other spinal cord lesions included spina bifida, syringomyelia, arachnoid cyst, and spinal cord ischemia after abdominal aortic aneurysm repair. In patients with spinal cord lesions, the mean (range) resting anal canal pressure and maximum squeeze anal canal pressure were 46 (10‐100) mmHg and 76 (30‐120) mmHg respectively compared with 62 (50‐70) mmHg, and 138 (100‐180) mmHg, respectively, in healthy controls. Eleven (92 percent) patients had prolonged pudendal nerve terminal motor latency (9 bilateral and 2 unilateral) whereas rectoanal inhibitory reflex was abolished in all 9 patients tested.CONCLUSIONS:Spinal patients with severe bowel symptoms tended to have lower anal canal pressures than healthy controls. Pudendal neuropathy and impaired rectoanal inhibitory reflex are common and may be important in the pathogenesis of bowel dysfunction in patients with spinal cord lesions.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Colonic motility is crucial for the resolution of postoperative ileus. However, few data are available on postoperative colonic motility and no data on postoperative colonic tone. We aimed to characterize postoperative colonic tone and motility in patients.METHODS:Nineteen patients were investigated with combined barostat and manometry recordings after left colonic surgery. During surgery a combined recording catheter was placed in the colon with two barostat bags and four manometry channels cephalad to the anastomosis. Recordings were performed twice daily from Day 1 to Day 3 after surgery.RESULTS:Manometry showed an increasing colonic motility index, which was a mean (± standard error of the mean) of 37±5 mmHg/minute on Day 1, 87±19 mmHg/minute on Day 2, and 102±13 mmHg/minute on Day 3 (P<0.05 for Day 1vs.Day 2 and Day 2vs.Day 3). Low barostat bag volumes indicating a high colonic tone were observed on Day 1 after surgery and increased subsequently (barostat bag I was 19±4, 32±6, and 32±6 ml; barostat bag II was 13±1, 19±3, and 22±5 ml on Days 1, 2, and 3, respectively; for both barostat bagsP<0.05 for Day 1vs.Day 2 but not Day 2vs.Day 3).CONCLUSIONS:Colonic motility increased during the postoperative course. The low barostat bag volumes indicated a high colonic tone postoperatively which would correspond to a contracted rather than to a distended colon. High colonic tone postoperatively may be relevant for pharmacologic treatment of postoperative ileus.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Constipation is a common complaint among geriatric patients and may result in significant morbidity, especially among nursing home residents. The prevalence of constipation increases with advancing age and may be a result of the aging process, but the exact cause is unknown. The aim of this study was to describe the prevalence of constipation and to determine risk factors for the development of constipation in a large population of nursing home residents.METHODS:The Minimum Data Set is an assessment instrument used in nearly all Medicare‐certified and Medicaid‐certified nursing facilities. Nursing home residents who were at least 65 years of age and who had assessments at baseline and at three months were included in the study (N = 21,012). Baseline risk factors were included in a multivariate logistic regression to determine their association with the development of constipation. To allow causal implications, nursing home residents with constipation at baseline were excluded. The variables examined included medications, mobility, comorbid illness, and nutrition.RESULTS:The mean age (± standard deviation) of nursing home residents was 83±8 years, and the population was 70 percent female and 83 percent white. At baseline, the prevalence of constipation was 12.5 percent (N=2,627). By the three‐month assessment, 7 percent (N=1,291) of nursing home residents had developed constipation. The factors associated independently with the development of constipation were, in order of magnitude, race, decreased fluid intake, pneumonia, Parkinson's disease, and the presence of allergies. Congestive heart failure and the use of a feeding tube were two factors identified as having a protective effect.CONCLUSION:The variables associated with the development of constipation may be used to identify geriatric nursing home residents at risk and to prevent constipation and its potential complications. Further study is needed to demonstrate a causal relationship between the risk factors and the development of constipation.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Fibrin adhesive has been successfully used to treat fistulas‐in‐ano, but long‐term data have been lacking. We report the results of our 18‐month study examining the repair of fistulas‐in‐ano using autologous and commercial fibrin adhesive.METHODS:A 79‐patient, prospective, nonrandomized clinical trial was performed in which fibrin adhesive was used to repair fistulas‐in‐ano. Twenty‐six patients were treated with autologous fibrin tissue adhesive made from their own blood, and 53 patients were treated with commercial fibrin sealant. In the operating room the patient underwent an examination under anesthesia, with an attempt to identify the primary and secondary fistula tract openings. The fistula tract was then curetted. Fibrin adhesive was injected into the secondary fistula tract opening until adhesive was seen coming from the primary opening. A petroleum jelly gauze was then applied over both the primary and secondary openings, and the patient was sent home. Follow‐up visits occurred one week, one month, three months, and one year later.RESULTS:Fourteen of 26 (54 percent) patients treated with autologous fibrin tissue adhesive made from their own blood had complete closure of their fistulas after a one‐year follow‐up, whereas 34 of 53 (64 percent) patients treated with commercial fibrin sealant had closure of their fistulas. Most treatment failures occurred within the first 3 months, but late failures were seen as far as 11 months postoperative.CONCLUSIONS:Fibrin tissue adhesive offers a unique mode of managing fistulas‐in‐ano, which is surgically less invasive, but recurrences up to one year later are being seen. Longer follow‐up and further research is recommended for improvement.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID