ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:Numerous investigators have shown increased bowel permeability in patients with Crohn's disease. It is unclear whether this is a precondition affecting the entire intestine or a consequence of the inflammation and, therefore, only affecting the diseased bowel. The present study tested the hypothesis that resection of diseased bowel in patients with ileocolonic Crohn's disease would correct abnormalities in bowel permeability.METHODS:Ten patients (5 females; mean age, 33±2 years) with ileocolonic Crohn's disease who underwent elective ileocolic resections had bowel permeability measured preoperatively and postoperatively by the relative urinary clearance of orally consumed lactulose and rhamnose.RESULTS:Mean preoperative bowel permeability in patients with Crohn's disease was significantly elevated relative to healthy volunteers (0.172±0.04vs.0.046±0.01;P<0.05, unpairedt‐test). After ileocolectomy, bowel permeability decreased in patients with Crohn's disease and reached a normal range by postoperative day 30.CONCLUSIONS:Bowel permeability is increased in patients with ileocolic Crohn's disease because of the presence of diseased bowel and decreases to a normal range in these patients after resection of gross intestinal disease. This suggests that bowel permeability may be a quantitative and clinically effective method with which to assess the presence and severity of diseased bowel in patients with Crohn's disease.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:This study investigated the functional significance of perineal complications after ileal pouch‐anal anastomosis.METHODS:Review of a prospective registry of 628 patients was undertaken. Bowel function was assessed by detailed functional questionnaire. Statistical analyses were performed using chi‐squared and Fisher's exact probability tests.RESULTS:Of 628 patients, 153 (24.4 percent) had 171 perineal complications. The 277 control patients had no complications. Complications included 66 (10.5 percent) anastomotic strictures, 28 (4.5 percent) anastomotic separations, 36 (5.7 percent) pouch fistulas, 41 (6.5 percent) episodes of pelvic sepsis, and 18 (2.9 percent) patients with multiple complications. After these complications were addressed, the pouch failure rate was low (10 percent); in 90 percent of patients, the pouch could be salvaged. Most pouch failures were the result of pouch fistulas, and most occurred in patients ultimately diagnosed with Crohn's disease. Functional results after cure of these perineal complications revealed no significant functional differences between control patients and those cured of anastomotic separations, anastomotic strictures, and pouch fistulas. Only a few minor differences were demonstrated in function after an episode of pelvic sepsis. The major deterioration in function occurred after treatment for multiple perineal complications.CONCLUSIONS:An appreciable number of perineal complications occur after ileal pouch‐anal anastomosis. Pouch‐perineal fistulas are associated with the highest pouch failure rate. The majority of these fistulas occur in patients ultimately diagnosed with Crohn's disease or indeterminate colitis. Although there is no substitute for good technique and sound clinical judgment in the success of ileal pouch‐anal anastomosis, if perineal complications are successfully treated, functional outcome is equivalent to that in patients without perineal complications.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:This study was undertaken to determine the incidence and risk factors for urinary retention after operations for benign anorectal diseases.METHODS:We reviewed 1,026 consecutive operations for benign anorectal diseases from 1989 to 1994. Risk factor analysis was done for patients undergoing hemorrhoidectomy (Group I) and other procedures (Group II) using logistic regression analysis.RESULTS:The number of procedures and urinary retention rate was as follows: 344 (34 percent) hemorrhoidectomies, 159 (2 percent) fistulotomies, 95 (5 percent) incision/drainage, 247 (4 percent) lateral internal sphincterotomy, 181 (17 percent) combinations of the above four procedures, and overall 1,026 (16 percent). In Group I, four‐quadrant excision (odds ratio, 3.3;P=0.0004), three quadrant excision (odds ratio, 2.4;P=0.003), morphine equivalents >33 (odds ratio, 1.8;P=0.01), and male gender (odds ratio, 1.7;P=0.02) were independent risk factors. In Group II, more than one operation (odds ratio, 3.0;P=0.004), older age (odds ratio, 3.1;P=0.005), intraoperative fluids (odds ratio, 2.6;P=0.03), and postoperative fluids (odds ratio, 2.7;P=0.02) were independent risk factors. Urinary obstructive symptoms for both groups and perioperative fluids for Group I were NOT independent risk factors. Hospital stay was prolonged significantly in patients with urinary retention (P=0.0001).CONCLUSIONS:Urinary retention is a common postoperative complication that increases hospital stay. It is most common after hemorrhoidectomy. Disease severity (quadrants excised and analgesia requirement for Group I and number of operations for Group II) is an important risk factor for both groups studied. Older age in Group I and perioperative fluid in Group II may be important risk factors.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

&NA;Endoanal ultrasonography has become an important tool in the evaluation of patients with anal incontinence. However, the extent of anterior defects is sometimes difficult to quantitate during endoanal ultrasonography.PURPOSE:This study was designed to evaluate perineal body measurement during endoanal ultrasonography in assessing patients with obstetric anal sphincter injuries.METHODS:Forty‐two patients with anal incontinence because of obstetric sphincter injuries and 13 asymptomatic subjects were investigated with endoanal ultrasonography. Sphincter muscle thickness, sphincter defects, and perineal body were measured. Perineal body measurement was performed by inserting a finger, held gently against the posterior vaginal wall, into the vagina and measuring the distance between the inner surface of the internal sphincter and the ultrasonographic reflection of the finger.RESULTS:All patients had anterior sphincter lesions of varying extent. Mean size of internal sphincter lesions was 146°, and mean size of external sphincter lesions was 107° (P<0.001). Perineal body measurement was performed without difficulty in all patients and subjects. Perineal body measurement (mean ± standard deviation) was 6±2 mm in patients and 12±3 mm in asymptomatic subjects (P<0.001). Ninety‐three percent of patients had perineal body measurement <‐10 mm, and 70 percent of asymptomatic subjects had perineal body measurement >10 mm. Digital delineation of the perineal body during endoanal ultrasonography improved the visualization of sphincter lesions in 74 percent of patients.CONCLUSIONS:Digital delineation of the perineal body during endoanal ultrasonography improved the visualization of sphincter lesions in the majority of patients. Perineal body measurement is performed without difficulty and is a good predictor of anterior sphincter lesions. Use of this technique improves visualization of sphincter lesions.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:Early detection of recurrence after curative resection for primary colorectal cancer should improve patients' prognosis. However, the usefulness of postoperative surveillance programs has not been clarified yet. The present cohort study was aimed at assessing the effectiveness of systematic follow‐up in patients with colorectal cancer who were operated on for cure, regarding both rate of tumor recurrence amenable to curative‐intent surgery and rate of survival.METHODS:One hundred ninety‐nine colorectal cancer patients who underwent radical primary surgery were followed according a well‐defined postoperative surveillance program, which consisted of laboratory studies (including serum carcinoembryonic antigen assay) every three months, physical examination and abdominal ultrasound or computed tomography every six months, and chest radiograph and total colonoscopy once per year. Cohorts were defined according to patients' compliance with the proposed follow‐up program. A multivariate regression model was constructed to predict survival.RESULTS:One hundred forty patients were considered to be compliant with the surveillance program, whereas the remaining 59 patients occasionally attended follow‐up investigations or did not comply at all. Although there were no differences in the overall recurrence rate (38vs.41 percent;P=0.52), curative‐intent reoperation was possible in 18 patients (34 percent) of those with tumor recurrence in the compliant cohort but in only 3 patients (12 percent) in the noncompliant cohort (P=0.05). Similarly, the probability of survival was higher in the compliant cohort, both regarding overall (63vs.37 percent at 5 years;P<0.001) and cancer‐related (69vs.49 percent at 5 years;P<0.02) rates. Cox regression analysis disclosed that only a more advanced TNM stage (odds ratio, 8.17; 95 percent confidence interval, 1.13‐59.29) and noncompliance with the postoperative surveillance program (odds ratio, 2.32; 95 percent confidence interval, 1.50‐3.60) had an independent negative impact on survival.CONCLUSION:Systematic postoperative surveillance in patients with colorectal cancer who were operated on for cure increases both the rate of tumor recurrence amenable to curative‐intent surgery and rate of survival.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:This study evaluates the cost‐effectiveness of dynamic graciloplasty for intractable fecal incontinence.PATIENTS AND METHODS:The costs and effects of dynamic graciloplasty were measured in a prospective, longitudinal study and in a clinical trial. Forty‐three patients with intractable fecal incontinence were evaluated before and after dynamic graciloplasty. Costs were obtained from the hospital information system and from patient‐oriented questionnaires. We compared the costs of a dynamic graciloplasty with the costs of a colostomy. Colostomy costs were evaluated using a group of seven patients who had a stoma in place for incontinence for several years. Sensitivity analyses were included.RESULTS:Total direct costs of lifelong dynamic graciloplasty were $31,733 (United States dollars), costs of lifelong conventional treatment were $12,180 (United States), and costs of colostomy, including lifelong stoma care, were $71,576 (United States). The clinical success rate of dynamic graciloplasty was 74 percent. Quality of life after successful dynamic graciloplasty was better than with conventional treatment.CONCLUSION:We found that dynamic graciloplasty was more expensive than conventional treatment but resulted in a significantly higher quality of life. Stoma treatment was the least attractive alternative regarding both costs and effects. The Dutch Health Insurance Executive Board recommended reimbursement for the dynamic graciloplasty procedure.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:Physiologic tests such as manometry, colonic transit times, balloon compliance, defecography, pudendal nerve latency, and electromyography are used to evaluate patients with severe constipation. Patients referred because of severe constipation between 1991 and 1996 were studied to examine the role that physiologic testing played in making a diagnosis and directing treatment.METHODS:Of 139 patients referred for severe idiopathic constipation, physiologic testing was recommended in 127, and 104 patients underwent the studies. The pretesting impression was noted, and test results were evaluated to determine diagnostic accuracy. If a specific initial impression was documented, tests were classified as refuting it, confirming it or confirming and adding significant information. If there was no clear pretest impression, tests were evaluated for their ability to indicate a diagnosis. The patient's history also was evaluated to determine what information was most useful in making a diagnosis. Historical features including duration of constipation, symptoms consistent with outlet obstruction or dysmotility, age, associated urinary incontinence, and prior hysterectomy were analyzed. Data were collected prospectively, then reviewed by an independent observer.RESULTS:Ninety‐eight study patients remained after 29 were excluded who did not undergo the recommended studies (19) or because no initial impression was documented (10). In 43 patients (44 percent), testing did not provide additional useful information. In 8 patients, testing confirmed the initial impression and added information impacting the treatment plan. Test results clearly refuted the initial impression in only one patient. In 46 (47 percent) patients the initial impression was uncertain, and in 43 (94 percent) of these, testing aided in making the diagnosis. In three cases, the diagnosis remained uncertain after testing. Prior hysterectomy (P=0.003), urinary incontinence (P<0.001), and symptoms of pelvic outlet obstruction (P=0.03) were associated with a high incidence of rectocele. Defecography and transit times were the most useful tests. Surprisingly, symptoms of outlet obstruction or dysmotility did not show an overall correlation with transit times.CONCLUSIONS:In one‐half of these patients with severe constipation, physiologic testing added significant information, leading to a specific diagnosis. Pretesting history and symptoms did not predict which patients were most likely to benefit from these studies.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID