摘要:

OBJECTIVE:The purpose of this study was to compare long‐term functional results of two methods of reconstruction after anterior rectal resection for cancer: low colorectal anastomosis and colonic J‐pouch‐anal anastomosis.SUMMARY BACKGROUND DATA:After anterior resection for mid or low rectal cancer, the decision to perform low colorectal or coloanal anastomosis is made intraoperatively, depending on the distance of the tumor from the anal verge. Functional results of these operations are considered to be similar one to two years after surgery. No study to date has compared long‐term functional results after rectal excision followed by either low colorectal anastomosis or colonic J‐pouch‐anal anastomosis.METHODS:From 1987 to 1992, 173 patients underwent anterior resection for cancer located between 2 to 12 cm from the anal verge. All patients alive without recurrence were contacted by telephone interview for assessment of functional results. There were 47 patients with colonic J‐pouch‐anal anastomosis and 34 patients with low colorectal anastomosis. Minimum follow‐up was three years for all patients (mean, 5 years).RESULTS:The two groups were well matched for gender, age, histologic stage, and use of adjuvant therapies. Patients with colonic J‐pouch‐anal anastomosis displayed significantly better function in terms of frequency of defecation (1.57±1vs.2.79±1;P=0.001) and presence of irregular transit or stool “clustering” (30vs.71 percent;P=0.003). Patients who underwent colonic J‐pouch‐anal anastomosis were significantly less likely to require constipating agents (4vs.21 percent;P=0.03) or need to follow a estricted diet (14vs.41 percent;P=0.01). Results concerning the need to defecate again within one hour and disruption of social or professional life as a consequence of surgery showed a tendency in favor of colonic J‐pouch‐anal anastomosis.CONCLUSION:Colonic J‐pouch‐anal anastomosis offers superior long‐term function compared with low colorectal anastomosis after radical treatment of rectal cancer. Preservation of a short rectal segment followed by a straight colorectal anastomosis does not offer any clinical advantage over colonic J‐pouch‐anal anastomosis.

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:The cause of abdominal wall tumor recurrences after laparoscopic surgery for cancer remains unknown. A recent study from our laboratory using a murine splenic tumor model suggests that poor surgical technique (i.e., crushing of the tumor) and not the CO2pneumoperitoneum is responsible for port wound tumors. However, in that experiment no actual laparoscopic procedure or manipulation was performed. The purpose of the current study was to determine the rate of abdominal wound tumors after laparoscopic‐assisted splenectomy performedviaa CO2pneumoperitoneumvs.open splenectomy using the mouse splenic tumor model.METHODS:To establish splenic tumors, female BALB/c mice (N=72) were given subcapsular splenic injections of a 0.1‐ml suspension containing 105C‐26 colon adenocarcinoma cellsviaa left flank incision at the initial procedure. Eight days later, animals were randomized into one of two groups: 1) laparoscopic‐assisted splenectomy, or 2) open splenectomy. Laparoscopic‐assisted splenectomy animals had three laparoscopic ports placed and then underwent laparoscopic mobilization of the spleen under a CO2pneumoperitoneum followed by extracorporeal splenectomyviaa subcostal incision. Group 2 animals underwent open splenectomyviaa subcostal incision after three port incisions were made in the same locations as for laparoscopic‐assisted splenectomy mice. The incision was closed after 20 minutes in both groups. Ten days later, the mice were killed and inspected for abdominal wall tumor implants. The experiment was performedviatwo separate trials.RESULTS:When results of the two trials were combined, there was no significant difference in the incidence of animals in each group with at least 1 port tumor (open, 21 percent; laparoscopic‐assisted splenectomy, 33 percent;P=0.14). However, the overall incidence of port site tumors (number of ports with tumors/total number of ports for each group) was significantly higher in the laparoscopic‐assisted splenectomy group than in the open group (20vs.7 percent;P=0.01). The subcostal incisional tumor recurrence rate was also higher in the laparoscopic‐assisted splenectomy group (50vs.21 percent;P=0.02). as was the perioperative mortality rate (21vs.7 percent;P=0.08). Results of the two individual trials were also considered separately. The incidence of port wound tumors decreased significantly from the first to the second laparoscopic‐assisted splenectomy trial (36vs.9 percent;P=0.003), although the incidence of tumors at the subcostal incision and the mortality rate for the two laparoscopic‐assisted splenectomy group trials were not significantly different. The open group tumor incidences did not change from trial to trial.CONCLUSIONS:Overall, significantly more port and incisional tumors were noted in the laparoscopic‐assisted group. Although not statistically significant, mortality rate of the laparoscopic‐assisted group was higher than the open group. The reasons for these findings are unclear. Laparoscopic mobilization was quite difficult and required excessive splenic manipulation, which may have liberated tumor cells from the primary tumor and facilitated port tumor formation. With increased experience, less manipulation was required to complete mobilization. Of note, the incidence of port tumors in the laparoscopic‐assisted splenectomy group decreased significantly from the first to the second trials; therefore, it is possible that surgical technique is a factor in port tumor formation. However, the persistently high tumor incidence at the subcostal incision site argues against the hypothesis that the second trial's laparoscopic mobilizations were less traumatic. The CO2pneumoperitoneum may also be a factor. Further studies are warranted to clarify these issues.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:We compared laparoscopic with open colectomy for treatment of colorectal cancer.METHODS:We performed a retrospective review of patients undergoing colectomy for colorectal cancer between January 1991 and March 1996 at a large private metropolitan teaching hospital. Operative techniques included open (n=90) and laparoscopic (n=80) colectomy. Laparoscopic colectomy was further subdivided into the following groups: facilitated (n=62), with extracorporeal anastomosis; near‐complete (n=9), with small incision for specimen delivery only; complete (n=3), with specimen removal through the rectum; and converted to an open procedure (n=6). Main outcome measures included operative time, blood loss, time to oral intake, length of postoperative hospitalization, morbidity, lymph node yield, recurrence, survival, and costs.RESULTS:Operative time was equivalent in the laparoscopic and open groups (laparoscopic, 161 minutes; open, 163 minutes;P=0.94). Blood loss was less for the laparoscopic group (laparoscopic, 104 ml; open, 184 ml;P=0.001), and resumption of oral intake was earlier (laparoscopic, 3.9 days; open, 4.9 days;P=0.001), but length of hospitalization was similar. Mean lymph node yield in the laparoscopic group was 12 compared with 16 in the open group (P=0.16). Rates of morbidity, recurrence, and survival were similar in both groups. No port‐site recurrences occurred.CONCLUSIONS:Laparoscopic and open colectomy were therapeutically similar for treatment of colorectal cancer in terms of operative time, length of hospitalization, recurrence, and survival rates. The laparoscopic approach was superior in blood loss and resumption of oral intake.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:The aim of this study was to determine whether the number of involved or uninvolved lymph nodes in resected specimens can be used to predict the effectiveness of surgical resection for rectal cancer.METHODS:Local recurrence and survival rates for 118 patients undergoing curative resection for rectal carcinoma, without adjuvant therapy, were retrospectively studied.RESULTS:Mean follow‐up was 62±37 months. Mean number of involved or uninvolved lymph nodes per resected specimen was 12±7. Overall local recurrence rate was 15.2 percent. In patients without involved lymph nodes (N0 patients) and with T1 or T2 tumors, the local recurrence rate ranged from 0 to 8 percent (not significant), depending on the number of lymph nodes on the specimen. In patients without involved lymph nodes and those with T3 tumors, the actuarial survival rate at ten years was significantly lower (P<0.05), and the local recurrence rate was higher (P<0.02) in patients with fewer than ten lymph nodes than in those with more than ten nodes. In patients with involved lymph nodes, the mean number of nodes on the resected specimen correlated closely with the mean number involved by the tumor.CONCLUSION:The assessment of the effectiveness of rectal excision for cancer is in part helped by the number of involved or uninvolved lymph nodes found on the resected specimen. This is of particular interest in patients without involved lymph nodes and those having infiltrating T3 tumors, for whom the long‐term survival and local recurrence rates were significantly better when more than ten lymph nodes were present. On the other hand, when fewer than ten nodes were found, whatever the cause, adjuvant radiotherapy had to be considered, because of the high risk of local failure rate.

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 was undertaken to investigate the morphologic and functional changes with time in the mucosa of the ileoanal pouch.METHODS:A morphologic study by histopathologic analysis, mucosal morphometry, and mucin histochemistry and a functional study by analysis of transmucosal potential difference were performed in 27 patients with an ileoanal J‐pouch after restorative proctocolectomy for ulcerative colitis. In 19 patients with a normal ileoanal pouch, two prospective follow‐up analyses were performed after median functional pouch times of 14 and 39 months. We also evaluated eight patients with the diagnosis of pouchitis (median follow‐up, 52.5 months).RESULTS:In the normal ileoanal pouch group, some degree of chronic and acute inflammatory infiltration was identified in 100 percent and 63.2 percent of cases, respectively, with no significant differences being observed between the two follow‐up analyses. The mean villous atrophy index at the first and second follow‐up was 0.54 and 0.52, respectively, significantly lower (P<0.001; an indication of a greater degree of villous atrophy) than the value obtained from the control group with a healthy terminal ileum (0.77). The group of patients with pouchitis exhibited statistically significant differences in the degree of acute and chronic inflammatory infiltration, the extent of ulceration, the crypt depth, and the villous atrophy index, compared with patients without pouchitis. In the normal ileoanal pouch group, the median percentage of sulfomucin with each degree of atrophy (1=mild; 2=moderate; and 3=severe) was 2.6, 4.5, and 20.9 percent, respectively. In patients with pouchitis, the median percentage of sulfomucin was 5.9 percent. The mean transmucosal potential difference at the first follow‐up (−25.3 mV) was significantly lower (P=0.001) than at the second (−30.4 mV). Significant differences were apparent with respect to both the normal ileum (−8.9 mV) and the normal rectum (−40.2 mV).CONCLUSION:These results suggest that the ileal pouch behaves as a neorectum, with different degrees of colonic metaplasia from a morphologic and a functional perspective.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BACKGROUND:Following proctocolectomy and ileal pouch‐anal anastomosis, a small percentage of patients will have poor functional results attributable to pouchitis or anastomotic or septic complications. Additionally, functional failures can occur secondary to limited pouch capacity and compliance. We present five such patients managed with operative conversion to W‐ileal pouch‐anal anastomosis and examined physiologic parameters important for improving functional results.METHODS:Five female patients (mean age, 30 (range, 24‐39) years) with poorly functioning J‐ileal pouch‐anal anastomoses were referred for evaluation with symptoms of high stool frequency and incontinence problems. Three had severe nocturnal incontinence, and the remaining two patients experienced minor nocturnal incontinence. Preoperative and postoperative evaluation included barium pouch studies, flexible sigmoidoscopy, anal manometry, evacuation volume, and pouch compliance. Pouch‐to‐anal pressure gradients were calculated. To improve reservoir capacity and compliance, all five patients underwent conversion to W‐ileal pouch‐anal anastomoses.RESULTS:Twenty‐four hour and nocturnal stool frequencies decreased from 13.8±1.7 and 3±1.3 to 5.8±0.3 and 0.3±0.2 postconversion (P<0.05). Mean pouch evacuation volume increased from 83±27 to 290±29 ml postoperatively (P<0.05). Pouch compliance increased from 2.7±0.5 mmHg/ml to 7.7±0.6 mmHg/ml postconversion (P<0.05). Improvement in postconversion stool frequency correlated with an increase in pouch evacuation volume (r=−0.87). All patients reported improved day and nocturnal continence, despite no significant change between preoperative and postoperative anal manometric pressures. Improved continence correlated with a significant widening of the pouch‐to‐anal pressure gradients, which increased from 5 to 25 mmHg at 150 ml following pouch conversion.CONCLUSIONS:Poorly functioning ileal reservoirs secondary to limited capacity and compliance can be successfully managed with conversion to W‐ileal pouch‐anal anastomosis. The increased pouch capacity is associated with improvement in compliance and widening of the pouch‐to‐anal pressure gradients, providing excellent functional results.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:Lengthening of the mesentery is the technical key point of the ileoanal pouch procedure. Division of the superior mesenteric pedicle high in the mesentery is an original artifice that regularly provides sufficient descent of the pouch to reach the dentate line without any tension. A retrospective study compares two groups of patients with ulcerative colitis.METHODS:Group 1 consisted of 21 patients with superior mesenteric pedicle division (mean lengthening, 6.1 cm), and Group 2 consisted of 44 patients without superior mesenteric pedicle division. Mortality and postoperative and late morbidity were studied along with functional outcome.RESULTS:One patient died in Group 2 (postoperative pelvic sepsis); one patient died in Group 1 at six months from late liver transplant complications. Postoperative morbidity was insignificantly less important in Group 1 (P=0.02). Five patients in Group 2 had the pouch removed; none in Group 1 did. Pouchitis episodes developed in both groups, with no significant difference (P=0.5). Three patients in Group 1 developed anastomotic stenosisvs.8 in Group 2 (P=0.5). Functional results at one‐month, one‐year, and two‐year follow‐ups are not significantly different, except that nighttime stool frequency increased in Group 2.CONCLUSIONS:On the whole, morbidity and functional outcome appear similar. This suggests that high superior mesenteric pedicle division has no adverse effect and can be proposed routinely as an effective lengthening technique.

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