摘要:

&NA;To determine objectively the causes of malpractice litigation involving colon and rectal disease, a retrospective review was undertaken of all cases tried in the U.S. federal and state civil court system over a 21‐year period from 1971 through 1991. Ninety‐eight malpractice cases were identified from a computerized legal data base, involving 103 allegations of negligence. Allegations fell into five major categories: 1) failure to timely diagnose disease, principally colorectal cancer and appendicitis (n=44/ 103; 43 percent); 2) iatrogenic colon injury (n=25/ 103; 24 percent); 3) iatrogenic medical complications during diagnosis or treatment (n=16/103; 15 percent); 4) sphincter injury with fecal incontinence, resulting from anorectal surgery or midline episiotomy (n=10/ 103; 10 percent); and 5) lack of informed consent, especially regarding extent of procedures or risk of endoscopy (n=8/103; 8 percent). These data may aid in design of risk prevention strategies related to the diagnosis and treatment of colorectal disease.

ISSN:0012-3706    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

&NA;The role of surgery in the management of intra‐abdominal recurrence of colon cancer has not been clearly determined. We reviewed the charts of 28 patients operated upon at our institution for nonhepatic intra‐abdominal recurrence of carcinoma of the colon and followed for a median of 10.5 months after reoperation. Total resection of gross disease was possible in 15 patients, who had a median overall actuarial survival of 25.5 months and a disease‐free survival of 13 months. Within this group, disease‐free survival was significantly prolonged when time to first recurrence was greater than 16 months and when patients had not had a prior operation for recurrent disease(P<0.05). Six patients having a partial resection and seven patients having only a bypass or ostomy had significantly shorter survivals than those in the totally resected group, with median survivals of 8 and 3.5 months, respectively(P<0.05). Operative management of recurrent colon cancer may prolong survival when disease can be eradicated, and palliative operations appear more successful when tumor is resected rather than bypassed.

ISSN:0012-3706    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

&NA;This study was undertaken to determine the outcome of surgery for symptomatic hemorrhoids and anal fissures in patients with known Crohn's disease. Seventeen patients underwent surgery for symptomatic hemorrhoids. Fifteen of these 17 patients' wounds healed without complication. Twenty‐five patients underwent 27 operations for anal fissures. Twenty‐two of these patients had uncomplicated wound healing by two months. Long‐term follow‐up, which was at a mean of 11.5 years in the hemorrhoid patients and 7.5 years in the fissure patients, revealed that only three patients required proctectomy, none as a direct result of surgery. Patients with severe symptoms secondary to anal fissures and hemorrhoids, who are known to have Crohn's disease and who cannot be controlled with conservative medical management, may undergo surgery on a highly selective basis when the disease is in the quiescent state. Proctectomy is not an inevitable outcome.

ISSN:0012-3706    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

&NA;Ninety‐nine colonoscopically removed flat elevations were examined. They were divided into two groups: Group 1—flat elevations 1 to 5 mm in diameter (55 cases)‐ and Group 2—flat elevations 6 to 10 mm in diameter (44 cases). Group 2 had a higher percentage of adenomas (86.4 percent) than Group 1 (67.3 percent). In adenoma cases (flat adenomas), Group 2 tended to show a higher degree of dysplasia. The rates of mild and moderate dysplasia were 83.8 percent and 16.2 percent in Group 1vs.1.70 percent and 13.2 percent in Group 2, respectively. Group 2 contained six cases (15.8 percent) of intramucosal carcinoma (severe dysplasia), while there were no cancer cases in Group 1. Both malignancy rate and degree of dysplasia were size dependent; the larger the lesion the more severe the dysplasia. Our study also revealed that small flat elevations tend to contain higher numbers of nonneoplastic lesions than do larger lesions. Increased detection of nonneoplastic lesions seems to have contributed to an overall decline in the malignancy rate of flat elevations in recent reports.

ISSN:0012-3706    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

&NA;Experience with intrarectal ultrasonography (IRUS) is limited for the evaluation of perianal sepsis. The purpose of this article is to report our experience with IRUS in evaluating 24 cases of suspected perianal abscess and fistula. IRUS was performed intraoperatively using a Brüel & Kjaer (Model #1846; Naerum, Denmark) endoanal ultrasound scanner with a 7‐MHz transducer. After completion of the IRUS, careful anorectal examination and appropriate surgical therapy were performed. At surgery, 19/24 patients were found to have perirectal abscesses, with all 19 cases correctly identified preoperatively by IRUS. In 12 cases (63 percent), IRUS correctly defined the relationship between the abscesses and sphincters by Parks' classification. At surgery, internal openings of fistulous tracts were found in 14/19 cases, but IRUS identified only 4/14 (28 percent). In 6/24 cases, IRUS and clinical evaluation did not demonstrate a perirectal abscess. The role of IRUS in the evaluation of perirectal abscess is evolving. Certainly, uncomplicated abscesses can be managed without ultrasonography. However, IRUS can be an adjunct to careful evaluation of complex perianal suppurative disease.

ISSN:0012-3706    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

&NA;Dynamic graciloplasty for fecal incontinence includes gracilis muscle transposition around the anal canal as a new sphincter and subsequent electrical stimulation. The aim of electrical stimulation is to transform the gracilis fast‐twitch, “fatigue‐prone” fibers into slow‐twitch, “fatigue‐resistant” fibers to achieve a sustained tonic contraction. The latter is considered essential for sphincter function. Therefore, the following features of transposed gracilis muscle morphology were studied in nine patients before and after electrical stimulation: 1) the percentage of Type I fibers, 2) the lesser diameter of these fibers, and 3) the positive collagen staining area. Furthermore, the external anal sphincter and gracilis muscle histology was investigated in six autopsy cases. The mean percentage of Type I, slow‐twitch, fatigue‐resistant fibers in transposed gracilis muscle increased from 46 percent before electrical stimulation to 64 percent(P<0.01, paired Student'st‐test) after electrical stimulation. The mean lesser diameter of these fibers did not change significantly (from 32 to 29 &mgr;m), and the mean percentage of collagen increased from 4 percent before electrical stimulation to 7 percent(P<0.01) afterward. The external sphincter in cadavers demonstrated a predominance of Type I fibers (80 percent) with a lesser diameter of 23&mgr;m and a high percentage (12 percent) of collagen. Gracilis muscle histology was uniform at six different sample sites in these cadaver dissections. We conclude that electrical stimulation induces histologic changes in transposed gracilis muscle, allowing this muscle to function as an external anal sphincter.

ISSN:0012-3706    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

&NA;From 1980 to 1985, 471 patients with resectable rectal and rectosigmoid cancer were randomly allocated to receive either preoperative short‐term high‐dose irradiation (25.5 Gy in one week) for all patients or prolonged postoperative radiotherapy (60 Gy in seven to eight weeks) only for patients with a Dukes B or C lesion. After a minimum follow‐up of five years, the local recurrence rate was statistically significantly lower after preoperative than after postoperative radiotherapy (13 percentvs.22 percent;P=0.02). No difference in overall survival was noted(P=0.5). To evaluate possible late side effects on the bowel, urinary bladder, or skin after surgery and additional preoperative or postoperative radiotherapy, all patients included in the randomized trial, together with 58 patients from a preceding pilot study with the same preoperative regimen, were studied in a prolonged follow‐up program. The hospital files of all patients were re‐examined. Of the patients who were carefully examined, 176 had a survival exceeding five years and 19 had a survival exceeding 10 years. Overall, 7 percent (33/ 464) either were operated upon or have had a radiologic diagnosis of small bowel obstruction: 14/255 (5 percent) after preoperative irradiation, 14/127 (11 percent) after postoperative irradiation, and 5/82 (6 percent) after surgery alone. The cumulative risk of developing a bowel obstruction was significantly increased after postoperative radiotherapy. Among the 98 patients alive after preoperative irradiation, significant morbidity from the bowel was noted in 11 patients, from the urinary bladder in two, and from the skin in six. In the postoperatively treated group of 34 patients, the bowel, urinary bladder, and skin morbidity were significant in five, two, and five patients, respectively. Corresponding morbidity in 44 nonirradiated patients was seen in five, one, and two patients, respectively. It is concluded that preoperative, short‐term, high‐dose radiotherapy decreases the local recurrence rate relative to postoperative radiotherapy, with no indications of increased late morbidity after a follow‐up of 5 to 10 years.

ISSN:0012-3706    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

PURPOSE:To identify the incidence of major fecal incontinence and recurrence after staged fistulotomy using a seton.METHODS:A five‐year retrospective chart review of 116 patients (70 males and 46 females) ranging in age from 18 to 81 years (mean, 42 years), in whom setons were placed as part of a surgical procedure for anorectal fistulas, was carried out. Follow‐up ranged from 2 to 61 months (mean, 23 months).RESULTS:Setons were employed to identify and promote fibrosis around a complex anorectal fistula as part of a staged fistulotomy in 65 patients (56 percent). Other indications for seton placement included 24 women with anteriorly situated high transsphincteric fistulas (21 percent) and three patients with massive anorectal sepsis (floating, freestanding anus) (2.5 percent). In addition, setons were used to preclude premature skin closure and promote controlled long‐term fistula drainage in 21 patients with severe anorectal Crohn's disease (18 percent) and in three patients with AIDS (2.5 percent). Major fecal incontinence (requiring the use of a perineal pad) occurred in five patients (5 percent), and recurrent fistulas were noted in three (3 percent).CONCLUSIONS:Staged fistulotomy using a seton is a safe and effective method of treating high or complicated anorectal fistulas.

ISSN:0012-3706    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

&NA;Twenty consecutive patients (12 male and 8 female) with second‐degree, third‐degree, or thrombosed hemorrhoids were randomly allocated to undergo either diathermy hemorrhoidectomy (n=10) or a scissor dissection Milligan‐Morgan hemorrhoidectomy (n=10). No significant difference was found in the postoperative pain score between the groups. On a scale of 0 to 10, the mean daily pain score in the diathermy group was 4.0, and it was 4.1 in the scissor dissection group. Nor was there any significant difference in the length of inpatient stay (diathermy group, 3.5 days; scissor dissection group, 4.0 days) or in the time between the operation and the first bowel action (diathermy group, 2.0 days; scissor dissection group, 30 days). Diathermy hemorrhoidectomy has no significant advantage over the scissor dissection classical Milligan‐Morgan hemorrhoidectomy.

ISSN:0012-3706    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

&NA;There remains some reluctance among physicians to refer patients for restorative proctocolectomy (RP). They argue that their patients would be worse off with a pouch because of the attendant problems of urgency and frequent bowel actions. The aim of this study was to compare quality of life in patients who had undergone RP with that of patients with ulcerative colitis on long‐term medical treatment. A detailed questionnaire and the Hospital Anxiety and Depression (HAD) test were completed by 103 patients who had undergone RP and by 95 patients with ulcerative colitis on medical treatment and in remission attending a gastroenterology clinic. Patients with a pouch had a greater frequency of bowel action [five times per 24 hours (range, 4‐7)vs.two times per 24 hours (range, 1‐3);P<0.001] but less urgency of defecation [12/103 (11.7 percent)vs.69/95 (72.6 percent);P<0.001] than patients with medically treated colitis. Efficiency of evacuation, discrimination between flatus and feces, use of perianal pads, and perianal soreness were similar. Use of antidiarrheal medication was more common in the pouch group [53 of 103 patients (51.5 percent)vs.3 of 95 patients (3.2 percent);P< 0.05], whereas use of topical steroids was more common in medically treated patients [40 of 95 patients (47.1 percent)vs.9 of 103 patients (8.7 percent);P<0.05]. Limitation of social activity and HAD scores were significantly higher in medically treated patients. Quality of life for patients with a pouch appears to be as good as that for patients with medically treated colitis.

ISSN:0012-3706    

出版商:OVID    

年代:1993

数据来源: OVID