ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Preservation of the anal transitional zone during ileal pouch‐anal anastomosis is still controversial because of the risk of dysplasia and the theoretical risk of associated cancer. Without long‐term follow‐up data, the natural history and optimal treatment of anal transitional zone dysplasia are unknown. The aim of this study was to determine the long‐term risk of dysplasia in the anal transitional zone and to evaluate the outcome of a conservative management policy for anal transitional zone dysplasia.METHODS:Two hundred ten patients undergoing anal transitional zone‐sparing ileal pouch‐anal anastomosis for ulcerative or indeterminate colitis between 1987 and 1992 and who were studied with serial anal transitional zone biopsies for at least five years postoperatively were included. Median follow up was 77 (range, 60‐124) months.RESULTS:Anal transitional zone dysplasia developed in seven patients 4 to 51 (median, 11) months postoperatively. There was no association with gender, age, preoperative disease duration or extent of colitis, but the risk of anal transitional zone dysplasia was significantly increased in patients with prior cancer or dysplasia in the colon or rectum. Dysplasia was high grade in one and low grade in six. Two patients each with low‐grade dysplasia detected on three separate occasions underwent mucosectomy 29 and 38 months after detection of low‐grade dysplasia, but no cancer was found. The five other patients with dysplasia on one or two occasions were treated expectantly and were apparently dysplasia‐free for a median of 72 (range, 48‐100) months.CONCLUSIONS:Anal transitional zone dysplasia after ileal pouch‐anal anastomosis is infrequent, is most common in the first two to three years postoperatively and may apparently disappear on repeated biopsy. Anal transitional zone preservation did not lead to the development of cancer in the anal transitional zone after five to ten years of follow‐up. Long‐term surveillance is recommended to monitor dysplasia. If repeat biopsy confirms persistent dysplasia, anal transitional zone excision with neoileal pouch‐anal anastomosis is recommended.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Stapled hemorrhoidectomy is performed without leaving painful perianal wounds. The aim of this study was to assess any benefits, compared with a conventional open diathermy technique.METHODS:A total of 119 consecutive patients with prolapsed irreducible hemorrhoids were randomly assigned (conventional open diathermy technique=62; stapled hemorrhoidectomy=57). Preoperative fecal incontinence scoring, anorectal manometry, and endoanal ultrasound were performed. Postoperatively, these were repeated at up to three months with pain scores, analgesic requirements, quality of life assessment, and total related medical costs.RESULTS:Conventional open diathermy technique was quicker to perform (mean, 11.4 (standard error of the mean, 0.9)vs.17.6 (3.1) minutes). Hospitalization was similar, but conventional open diathermy technique patients felt more pain during defecation (5.1 (0.4)vs.2.6 (0.4);P<0.005) at two weeks, and analgesic requirements were more for up to six weeks (P<0.05). Up to the latter, 85.5 percent conventional open diathermy technique wounds remained unhealed, with more bleeding (33 (53.2 percent)vs.19 (33.3 percent);P<0.05) and pruritus (27 (43.5 percent)vs.9 (15.8 percent);P<0.05). Total complication rates were similar (conventional open diathermy technique 16 (25.8 percent)vs.stapled hemorrhoidectomy 10 (17.5 percent)), including mild strictures and bleeding in both groups. Minor incontinence occurred postoperatively in two conventional open diathermy technique and two stapled hemorrhoidectomy patients at six weeks. Endoanal ultrasound internal anal sphincter defects were found in the incontinent conventional open diathermy technique patients, but were asymptomatic in another one conventional open diathermy technique and one stapled hemorrhoidectomy. Only one patient (conventional open diathermy technique with internal sphincter defect) remained incontinent at three months. Changes between preoperative and postoperative anorectal manometry were similar in the two groups. Patients' satisfaction scores and quality of life assessments were also similar. Conventional open diathermy technique patients resumed work later (mean 22.9 (1.8)vs.17.1 (1.9) days;P<0.05), but the total costs incurred were less ($921.17 (16.85)vs.$1,283.09 (31.59);P<0.005).CONCLUSIONS:Stapled hemorrhoidectomy is a safe and effective option in treating irreducible prolapsed piles. It is more expensive but less painful, with less time needed off work. Nonetheless, long‐term results are still awaited.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

INTRODUCTION:Amitriptyline, a tricyclic antidepressant agent with anticholinergic and serotoninergic properties, has been used empirically in the treatment of idiopathic fecal incontinence with good results.METHODS:An open study was conducted to test the response to amitriptyline 20 mg daily for four weeks by 18 patients (2 males) of median age 66 years with idiopathic fecal incontinence. Incontinence scores, number of bowel movements, computerized ambulatory anorectal pressures, and pudendal nerve terminal motor latencies were evaluated before and after four weeks of therapy. Twenty‐four control subjects (10 males) of median age 61 years were also assessed.RESULTS:Amitriptyline improved incontinence scores (median pretreatment score=16vs.median posttreatment score=3;P<0.001) and reduced the number of bowel movements per day (P<0.001). Amitriptyline also decreased the frequency (median pretreatment frequency=4.5 per hourvs.median immediate posttreatment frequency=1.2 per hour (P<0.05); control median frequency=0.3 per hour) and the amplitude of rectal motor complexes (median pretreatment rectal pressure=94 cm H2Ovs.median immediate posttreatment rectal pressure=58 cm H2O (P<0.05); control median rectal pressure=36 cm H2O) and improved anal pressures during these events (P<0.001).CONCLUSIONS:Amitriptyline improved symptoms in 89 percent of patients with fecal incontinence. The data support that the major change with amitriptyline is a decrease in the amplitude and frequency of rectal motor complexes. The second conclusion is that drug increases colonic transit time and leads to the formation of a firmer stool that is passed less frequently. These in combination may be the source of the improvement in continence.

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:Enteroceles are herniations of the lining of the peritoneum and intestinal loops into the pouch of Douglas. They may accompany other pelvic and anorectal disorders or cause outlet obstruction. So far they are only diagnosed by defecography. We investigated the use of dynamic anorectal endosonography to detect this disorder.METHODS:Seventeen female patients with a defecation disorder were investigated by proctoscopy and endoluminal ultrasonography. In 14 patients defecography followed. Endosonography was performed using the curved array 7.5 MHz scanner directed to the ventral rectal wall. Dynamic studies were undertaken during rest and during maximal straining. The minimal distance between the inner verge of the anal canal and the peritoneal cavity was determined.RESULTS:Dynamic endosonography detected enteroceles in six patients in which the pouch of Douglas opened during straining and intestinal loops moved toward the anus. The diagnosis of enteroceles was confirmed in all patients by defecography giving a specificity of 100 percent. No enterocele was detected in the remaining eight patients with defecography, leading to a 100 percent sensitivity for endosonography. Comparing the 6 patients with enteroceles with the 11 patients without enterocele, the peritoneal‐anal distances were at rest 3.9±0.5 and 3.3±0.5 cm (P<0.05) and during straining 3.6±0.5 and 1.3±0.2 cm (P<0.001), respectively. The change in peritoneal‐anal distance was 2±0.5 cm in the enterocele group and 0.3±0.4 cm in the control group (P<0.001). Two patients with enteroceles had complete rectal prolapse. Four patients with enteroceles underwent surgery. Postsurgical endoluminal endosonography showed closure of the pouch of Douglas.CONCLUSIONS:Enteroceles may be diagnosed by dynamic anorectal endosonography. Compared with defecography dynamic anorectal endosonography is easier to perform, less cumbersome for the patient, and bears no radiation exposure. Therefore, this new diagnostic means may be useful in first‐line search for enteroceles, but further studies are needed to prove its sensitivity for screening of this disorder.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:The aim of this study was to test the hypothesis that a delay in pudendal nerve conduction as measured by pudendal nerve terminal motor latency should be associated with atrophy of the external anal sphincter as measured using endoanal ultrasound.METHODS:Sixty‐two adult females (median age, 58.9 (range, 22‐88) years) presenting for evaluation of fecal incontinence with no evidence of an external anal sphincter tear on ultrasound were recruited. Ultrasound was performed with a 7.5‐MHz radial rotating axial endoprobe in the left lateral position. Four measurements were made in the transverse plane—the external anal sphincter thickness in the midanal canal at the 6 o'clock and 9 o'clock positions, the internal sphincter at the 9 o'clock position, and the external anal sphincter in the low canal at the 9 o'clock position. Pudendal nerve terminal motor latency was measured using a transrectal nerve stimulation technique with measurement of the evoked muscle response.RESULTS:Although there was a trend toward thinner external sphincter muscles in those with bilateral prolonged pudendal nerve terminal motor latency, independent sample t‐tests and Pearson correlation coefficients showed no statistically significant relationship (right pudendal nerve terminal motor latency:P=0.083, 0.184, 0.128, 0.910;r=0.228, 0.175, −0.201, −0.015; left pudendal nerve terminal motor latency:P=0.946, 0.276, 0.510, 0.123;r=−0.009, −0.143, −0.087, −0.201).CONCLUSIONS:No statistically significant relationship between ultrasound‐measured anal sphincter muscle thickness and pudendal nerve terminal motor latency was identified. Although a trend was suggested that could be further evaluated by a study with a larger sample size and a control group with asymptomatic patients, the small differences in muscle thickness involved and the difficulties in measurement suggest that the establishment of clinically useful ultrasound criteria for the detection of the neuropathic anal sphincter complex is unlikely.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:This study was performed to determine the quality of life and cost‐effectiveness of therapeutic options for patients with locally recurrent rectal carcinoma, determined from the perspectives of patients and health care providers.METHODS:We reviewed the records of patients (N=68) with locally recurrent rectal carcinoma evaluated from 1992 through 1995. We constructed a decision‐analytic model incorporating outcomes, survival, and costs. Utilities were elicited from convenience samples of health care providers and patients using the standard gamble technique.RESULTS:The median survival for patients undergoing surgical resection (n=40) was 42 months, compared with 16.8 months for patients undergoing diagnostic or palliative surgery (n=16) and 18.3 months for patients treated nonoperatively (n=12;P<0.005). The mean cost of treatment per patient was $19,283 for the nonoperative group, $45,647 for the diagnostic or palliative surgery group, and $70,878 for the surgical resection group. The diagnostic or palliative surgical strategy was dominated by the nonoperative strategy because the former had greater costs with fewer health benefits. The incremental cost‐utility ratio of surgical resection compared with nonoperative management using health care provider utilities was $109,777 per quality‐adjusted life year gained; it was reduced to $56,698 using per quality‐adjusted life year using mean patient utilities.CONCLUSIONS:Patients with recurrent rectal carcinoma view surgery and morbidity to be less severe than health care providers. Diagnostic or palliative surgery is expensive and affects quality‐adjusted survival adversely compared with nonoperative therapy. Surgical resection may be a cost‐effective use of resources, particularly when cost‐effectiveness is calculated using patient preferences.

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:Because the elderly population in Western countries is rapidly increasing, as is their life expectancy, studies aimed at determining the impact of major surgery for primary rectal cancer in this group are warranted. The purpose of this study was to compare perioperative morbidity and mortality and long‐term disease‐specific and overall survival in primary rectal cancer patients, older and younger than 75 years of age, subject to major pelvic surgery.METHODS:From September 1986 to December 1996, the Prospective Colorectal Service Database identified 1,120 consecutive patients who underwent major pelvic surgery for primary rectal cancer. Of these, 157 (15 percent) were 75 years of age or older and comprise the elderly group. From the remaining 963 patients younger than 75 years of age, a representative random sample of 174 was selected and constitutes the younger group. Data were obtained from computerized databases and confirmed via chart review and telephone interviews.RESULTS:Perioperative complications were observed in 53 (34 percent) elderly and 63 (36 percent;P=not significant) younger patients. Perioperative deaths occurred in two (1.3 percent) elderly and one (0.6 percent;P=not significant) younger patient. The median follow‐up time was 48 months. Although the overall survival was lower in the elderly group (P=0.02; the 5‐year overall survival rates were 51 and 66 percent), the disease‐specific survival rate was similar in the two groups (P=0.75; the 5‐year disease‐specific survival rates were 69 and 71 percent).CONCLUSION:In select individuals 75 years of age or older, major pelvic surgery for primary rectal cancer can be done with perioperative morbidity and mortality rates comparable to those obtained in younger individuals, while achieving excellent disease‐specific and overall long‐term survival.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID