摘要:

&NA;Between 1978 and 1990, 23 patients underwent 35 thoracotomies for metastatic colorectal cancer. The pulmonary disease was diagnosed within an interval of 0 to 105 (average, 33.4) months after colon resection. Fifteen patients underwent a single thoracotomy; 12 patients had solitary lesions, and three patients had multiple nodules. Eight patients underwent multiple thoracotomies. The median survival following thoracotomy was 28 months; three‐year survival was 45 percent, and five‐year survival was 16 percent. Factors that had no significant bearing on survival included origin and stage of the primary tumor and patient age and sex. An interval before thoracotomy of three years had an impact on survival approaching statistical significance(P=0.17). Patients who underwent multiple thoracotomies had a significantly prolonged survival(P=0.04). Patients who underwent a single thoracotomy for a solitary lesion had a significantly prolonged survival compared with patients who had a single thoracotomy for multiple metastases. After thoracotomy, 14 patients eventually developed recurrent disease, which was confined to the lung in only four patients. Of these 14 patients, 11 subsequently died of cancer. We conclude that thoracotomy for metastatic disease should be considered when the primary tumor is controlled, the lungs are the only site of metastatic disease, and there is adequate lung reserve to withstand surgery. Survival following thoracotomy may be influenced by the interval before diagnosis, the number of pulmonary nodules, and the number of thoracotomies performed.

ISSN:0012-3706    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

&NA;We prospectively evaluated 50 patients (38 females and 12 males; mean age, 44.7±15 years) who complained of defecatory difficulties to determine the accuracy of the clinical examination in diagnosing and quantifying pelvirectal abnormalities. Each parameter was then compared with the features of anorectal manometry and evacuation proctography performed by two independent observers. Global agreement between clinical diagnosis and the reference method (radiology for rectoceles, rectal intussusceptions, and abnormal perineal descent; manometry for anismus) was observed in 80 percent of cases. In rectoceles, anismus, and rectal intussusceptions especially, excellent negative predictive values were obtained (96, 96, and 80 percent, respectively). Clinical examination always diagnosed high‐grade intussusceptions. Nevertheless, abnormal perineal descent was poorly evaluated in 20 patients. When compared with anal manometry, digital assessment was able to quantify resting and squeeze pressures and length of the anal canal with excellent correlation and good global agreement as well as predicting a short or hypotonic anal canal. Clinical assessment is usually sufficient and accurate in most pelvirectal disorders encountered in patients complaining of defecatory difficulties. Both anorectal manometry and evacuation proctography retain a definite but limited place in investigating pelvirectal disorders.

ISSN:0012-3706    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

PURPOSE:Many anorectal procedures are currently being performed on an outpatient basis, hemorrhoidectomy being the exception because of the need for parenteral narcotics postoperatively. We investigated the effectiveness of a subcutaneous morphine pump (SQMP) for outpatient posthemorrhoidectomy pain control.METHODS:In Phase 1 of our study, 22 patients undergoing radical hemorrhoidectomy were started on an SQMP protocol postoperatively. Twenty‐nine patients received conventional postoperative narcotic dosing. In Phase 2, 19 patients enrolled in an SQMP protocol underwent hemorrhoidectomy in an ambulatory setting. Length of hospitalization, catheterization rate, and pain control were evaluated.RESULTS:In Phase 1, zero patients in the study group and two in the control group required additional hospitalization beyond 23 hours for pain control. The rates of catheterization were similar between the two groups. Pain control was considered satisfactory in 21 of 22 study patients. There was no correlation between pain level and morphine dose. Eighteen of 22 patients experienced minor side effects, necessitating pump removal in two patients. In Phase 2, 18 of 19 patients on the SQMP were discharged from the recovery room. Cost analysis shows the combination of outpatient hemorrhoidectomy and the SQMP to be cost‐effective in comparison with an inpatient stay.CONCLUSIONS:The SQMP enables hemorrhoidectomy to be done on an outpatient basis. It provides effective pain control, enjoys high patient acceptance, and is cost‐effective.

ISSN:0012-3706    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

&NA;This nonrandomized series reports the use of autologous fibrin glue to treat complex rectovaginal and anorectal fistulas. The use of an autologous source to prepare fibrin glue eliminates the risk of disease transmission. Ten patients, six women and four men, with complex fistulas were treated with autologous fibrin glue application. Five patients had rectovaginal fistulas; one of them had Crohn's disease. Five patients had complex anal fistulas; two of them had Crohn's disease, and one had a large postanal ulcer associated with HIV disease. All patients had outpatient preoperative mechanical bowel preparation and prophylactic parenteral antibiotics. Six of the ten patients (60 percent) reported complete healing of the fistulas. Follow‐up ranged from three months to one year. Four of five rectovaginal fistulas healed. The two patients with Crohn's disease and complex anal fistulas and the patient with HIV disease did not heal, but all three reported significantly less drainage. Autologous fibrin glue is a viable alternative for the treatment of recurrent rectovaginal and complex abscess/fistulas.

ISSN:0012-3706    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

&NA;Thirteen nuclear and cellular morphometric variables were measured in 312 cases of colorectal adenocarcinoma. All variables, except nuclear shape factors, differed significantly(P<0.001) between normal colorectal and tumor tissue. In adenocarcinomas, epithelial nuclei in well‐differentiated mucosa tended to be elliptic, while those in poorly differentiated mucosa were more spheric. Increasing values of maximum nuclear and elliptic diameter were associated with progression from none to simple tubule configuration(P<0.001), none to easily discerned nuclear polarity(P<0.001), and expanding growth pattern(P<0.001). Univariate survival analysis revealed that none of the morphometric variables was significantly related to patient survival. Multivariate regression analysis showed that no morphometric variable could add significantly to a model containing the variables of patient age, Dukes stage, and tumor differentiation. Morphometry may be useful in distinguishing malignant from normal tissue and degrees of differentiation, but it is of little prognostic value in colorectal adenocarcinoma.

ISSN:0012-3706    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

&NA;Oxygen radicals play a key role in inflammation and inflammatory tissue damage. Quantitative determination of pentane, a hydrocarbon generated by membrane lipid peroxidation initiated by oxygen radicals, in expired air has been used as a noninvasive determinant or index of inflammation in various conditions. Herein we report the first examination of the relationship between exhaled pentane and colonic inflammation in a rodent model of colitis. Colitis was induced in rats (n=33) using the trinitrobenzene‐sulfonic acid (TNB) model of colitis. Exhaled air was collected in a closed chamber on randomly selected animals on days 1, 2, 4, 7, 11, 13, 15, 20, and 25 post‐TNB treatment, and pentane was assayed by means of gas chromatography. Gross and microscopic evidence of inflammation was compared with exhaled pentane levels. Pentane levels varied from 0.0 to 14.6 nmol/l of air and were significantly increased in TNB‐treated rats compared with control rats only on days 7 to 15 after treatment(P<0.05). Gross inspection showed severe colonie inflammation through the first week (mean score =4.7 out of a possible 5), persistent inflammation on days 7 to 15 (3.2), and healing and fibrosis from the end of week two until day 25 (1.9 to 0). Histologic evaluation confirmed a progression of inflammation from acute ulceration to chronic inflammation to fibrosis and scarring. We have demonstrated that pentane exhalation is increased after the induction of colonie inflammation, with a seven‐day lag time, and returns rapidly to normal as acute inflammation resolves. This suggests that pentane exhalation can be used as a noninvasive measure of colonic inflammation in rodent models of colitis and perhaps clinically in humans.

ISSN:0012-3706    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

&NA;As experience with laparoscopy increases, new applications in general surgery are being identified. Treatment of acute appendicitis through the laparoscope has been proposed. We present our initial experience with this new technique. Over a 12‐month period, laparoscopic appendectomy was attempted in 29 patients. There were no intraoperative complications. Two cases required conversion to the open technique owing to gangrene at the appendiceal base. The average operating time was 64 minutes. Two of nine patients with perforated appendicitis developed a pelvic abscess, and one patient developed wound cellulitis. Pain medication requirements were minimal, bowel function returned rapidly, and half of the patients were discharged on postoperative day one or two and returned to normal activity within one week. Based on our initial experience, it appears that laparoscopic appendectomy is a safe and effective technique for managing acute appendicitis and offers advantages in terms of decreased pain, decreased hospital stay, and a rapid return to normal activities

ISSN:0012-3706    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

&NA;Elevated cellular proliferation in the vicinity of an anastomosis may explain the enhanced susceptibility to carcinogens. The aim of this study was to determine whether anastomotic cellular proliferation was altered by different suture materials and whether a rise in cell turnover also occurred after a “sutureless” closure. A transverse descending colon enterotomy was repaired with interrupted sutures of 5/0 silk (n=20), stainless steel (n=20), or Vicryl®(Ethicon, Inc., Somerville, NJ) (n=20) or by a sutureless technique (n=20). Using a stathmokinetic technique, crypt cell production rates (CCPR) were calculated at the anastomosis and in the adjacent colon at varying intervals between one week and six months after treatment. Overall colonic cellular proliferation appeared to be elevated at a sutured colotomy for at least three months(P<0.05). In contrast, no significant elevation in cellular proliferation was observed at sutureless anastomoses. The duration of elevated proliferative response varied among the sutures.

ISSN:0012-3706    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

&NA;A prospective study was undertaken to assess the potential correlation between increased perineal descent (IPD) and pudendal neuropathy (PN) in 213 consecutive patients. These 165 females and 48 males of a mean age of 62 (range, 18‐87) years had constipation (n=115), idiopathic fecal incontinence (n=58), or chronic intractable rectal pain (n=40). All 213 patients underwent cinedefecography (CD) and bilateral pudendal nerve terminal motor latency (PNTML) assessment. Perineal descent (PD) of more than the upper limit of normal of 3.0 cm during evacuation was considered increased. Pudendal neuropathy was diagnosed when PNTML exceeded the upper limit of normal of 2.2 milliseconds. Although 65 patients (31 percent) had PD, only 16 (25 percent) of these 65 patients had neuropathy. Moreover, PN was also found in 42 (28 percent) of 148 patients without IPD. Conversely, only 16 (28 percent) of the 58 patients who had PN also had IPD, and IPD was present in 49 (32 percent) of 155 patients without PN. The frequency of PN according to the degree of IPD was: 30 to 4.0 cm, 6 of 27 patients (22 percent); 4.1 to 5.0 cm, 4 of 15 (27 percent); 5.1 to 6.0 cm, 4 of 12 (25 percent); 6.1 to 7.0 cm, 2 of 8 (25 percent); and >7.0 cm, 0 of 3 (0 percent). Linear regression analysis was undertaken to compare the relationships between measurements of PD at rest (R), push (P), and change (C=P−R) and values of PNTML. These values for all 213 patients were: R,r=0.048; P,r=0.031; and C,r=−0.050. The correlation coefficients were equally poor for all the individual subgroups analyzed, including the patient's sex or diagnosis. In summary, no correlation was found between PD and PNTML. The lack of a relationship was seen for the entire group as well as for those patients with either neuropathy or increased perineal descent. Therefore, the often espoused relationship between increased PD and PN was not supported by this prospective evaluation. Although increased PD and prolonged PNTML are frequently observed in patients with disordered defecation, they may represent independent findings.

ISSN:0012-3706    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

&NA;Anorectal function and colonic transit was assessed in 17 severely constipated patients and 15 age‐matched controls. The constipated patients were divided into those who had “immobile perineum” (perineal descent ≤1.0 cm during attempted defecation) and those who had a normal descent (>1.0 cm) of the perineum. When constipation was accompanied by an immobile perineum, patients had impaired balloon expulsion, impaired and delayed artificial stool expulsion, decreased straightening of the anorectal angle, decreased descent of the pelvic floor with defecation, and prolonged rectosigmoid colon transit compared with the patients with constipation who had a mobile perineum and with normal controls. The mobile‐perineum group differed from controls only in colon transit times, having prolonged total colon transit. Anal sphincter resting pressures, immediate artificial stool expulsion, resting anorectal angles, and electromyography of the external anal sphincter and puborectalis did not differentiate the constipated patients from the controls. We concluded that descent of the perineum of <1 cm was associated with impaired expulsion, an adynamic anorectal angle, and slowed distal colon transit. This simple sign of pelvic floor function distinguished constipated patients with disordered expulsion from constipated patients with normal pelvic floor function. These patients may respond poorly to surgery and conventional management and would therefore be candidates instead for pelvic floor retraining. Accurate characterization and appreciation of pelvic floor dysfunction in patients with severe chronic constipation may improve the selection for and results of surgical and nonsurgical intervention.

ISSN:0012-3706    

出版商:OVID    

年代:1993

数据来源: OVID