摘要:

INTRODUCTION:Rectal cancer surgery has been characterized by a high incidence of local recurrence, an occurrence which influences survival negatively. In Norway there was a growing recognition that local recurrence rates were related to surgeon performance and that surgeons applying a standardized surgical technique in the form of total mesorectal excision could achieve better results. This contrasts with the prevailing argument voiced by many opinion leaders that local recurrence rates and possibly survival rates can only be improved by adjuvant or neoadjuvant treatment strategies. The Norwegian Rectal Cancer Project—initiated in 1993—aimed at improving the outcome of patients with rectal cancer by implementing total mesorectal excision as the standard rectal resection technique.METHODS:This observational national cohort study covers all new patients (3,319) with rectal cancer from a population of 4.5 million treated between November 1993 and August 1997. The main outcome measures were local recurrence, survival, and postoperative mortality and morbidity rates. The technique of total mesorectal excision was compared with conventional surgery.RESULTS:The proportion of patients undergoing total mesorectal excision was 78 percent in 1994, increasing to 92 percent in 1997. The observed local recurrence rate for patients undergoing a curative resection was 6 percent in the group treated by total mesorectal excision and 12 percent in the conventional surgery group. Four‐year survival rate was 73 percent after total mesorectal excision and 60 percent after conventional surgery. Postoperative mortality rate was 3 percent and the anastomotic dehiscence rate was 10 percent. Radiotherapy was given to 5 percent and chemotherapy to 3 percent of the patients in the curative resection group.CONCLUSION:A refinement of the surgical resection technique for rectal cancer can be achieved on a national level, the technique of total mesorectal excision can be widely distributed, and surgery alone can give good results.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PURPOSE:Since 1991, a laparoscopic‐assisted resection has been used at the Royal Brisbane Hospital selectively for patients with colorectal cancer. This article audits the intermediate to long‐term postoperative complications and cancer follow‐up data.METHODS:All patients undergoing a laparoscopic resection for cancer were prospectively followed up with regard to long‐term outcomes.RESULTS:One hundred eighty‐one patients have been studied. One hundred fifty‐four patients had potentially curative procedures performed in the study period. Median follow up was 71 (range, 7‐108) months. The overall recurrence rate in this group was 6 percent (21 recurrences). There was one port site recurrence after a potentially curative procedure (0.6 percent) and one port site recurrence after a palliative resection. Perioperative mortality was 1 percent (2 patients). Only six patients suffered an adhesive small‐bowel obstruction postoperatively. There was one incisional hernia. Unadjusted five‐year median survival data for Australian Clinico‐pathological Staging A was 91 percent (3.5 percent recurrence); for Australian Clinico‐pathological Staging B, 83 percent (15 percent recurrence); and for Australian Clinico‐pathological Staging C, 74 percent (26 percent recurrence).CONCLUSION:In selected patients a laparoscopic resection for colorectal cancer produces acceptable intermediate to long‐term oncologic outcomes and a low long‐term complication rate.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

OBJECTIVES:Local recurrence after transanal excision of rectal cancer is often amenable to salvage radical proctectomy, but the long‐term results remain unknown. This study was designed to determine the outcome of salvage radical surgery after failed local excision in patients with early rectal cancer.METHODS:We retrospectively reviewed the charts of 29 patients who underwent salvage radical surgery for local recurrence after a full‐thickness transanal excision for Stage I rectal cancer. End points included local and distant recurrences and disease‐free survival after salvage radical surgery. Comparisons between groups were performed by chi‐squared test.RESULTS:Recurrence involved the rectal wall in 26 patients (90 percent) and was purely extrarectal in only 3 (10 percent). Mean time between local excision and radical operation was 26 months. The resection was considered curative in 23 patients (79 percent). The stage of the recurrent tumor was more advanced than the primary tumor in 27 patients (93 percent). At a mean follow‐up of 39 (range, 2‐147) months after radical surgery, 17 patients (59 percent) remained free of disease. The disease‐free survival rate was 68 percent for patients with tumors with favorable histologyvs.29 percent for patients with tumors with unfavorable histology.CONCLUSION:Salvage surgery for recurrence after local excision of rectal cancers may not provide results equivalent to those of initial radical treatment. In the present study the poor results of salvage surgery emphasize the importance of appropriate selection of the initial treatment of Stage I rectal cancer.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PURPOSE:Salvage procedures for failed ileal pouch‐anal anastomoses frequently require total reconstruction with a combined abdominal and perineal approach. The aim of this study was to determine the indications for surgery and the outcomes in this group of patients.METHODS:All patients who underwent combined abdominal and perineal ileal pouch‐anal anastomosis reconstruction at the Mount Sinai Hospital between 1982 and 2000 were reviewed. Data were collected prospectively in the inflammatory bowel disease database.RESULTS:Sixty‐three reconstructive procedures were performed in 57 patients, with a mean age of 33.9 (±10.4) years at the time of reconstruction. There were 14 males. The mean follow‐up was 69.1 months. The initial indication for ileal pouch‐anal anastomosis was ulcerative colitis in 98 percent. The primary indication for reconstruction was pouch‐vaginal fistula in 21 patients, long outlet in 14, pelvic sepsis in 14, ileoanal anastomotic stricture in 5, pouch‐perineal fistula in 2, and chronic pouchitis in 1. The mean operative time was four hours (±1.1), the average blood loss was 500 mL (±400), and the average length of stay was 10.3 days (±4.6). All patients had a diverting ileostomy. Forty‐two (73.6 percent) of the patients have a functioning pouch. Seven (12.3 percent) patients have had their pouch excised. The ileostomy has not yet been closed in 8 (14 percent) patients; 3 of these patients are awaiting closure, whereas the remaining 5 have a permanently defunctioning ileostomy. Eighty‐nine percent have ten or fewer bowel movements per day. No patients are incontinent of stool during the day, whereas two patients are incontinent at night. Seventeen percent complain of frequent urgency. Despite this, more than 80 percent rate their physical and psychological health as good to excellent.CONCLUSION:Reconstructive pouch surgery has a high success rate in experienced hands. The functional results in those whose pouch is in use are good.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PURPOSE:Familial adenomatous polyposis is a general growth disorder caused by highly penetrant germline mutations in the tumor suppressor geneAPC. The major manifestation of these mutations is colorectal adenomatous polyposis, which, if untreated, leads to early development of colorectal cancer. To prevent this from happening, endoscopic screening of at‐risk family members begins early in the second decade of life. Patients with adenomas are offered surgery sometime in that decade. There is a concern about the risk of cancer in teenagers if such surgery is deferred. We conducted this study to investigate that risk.METHODS:A brief survey was sent by facsimile or mail to all familial adenomatous polyposis registries affiliated with the Leeds Castle Polyposis Group. This questionnaire asked for the number of teenage or younger patients in the registry diagnosed with invasive colorectal carcinoma. Other questions addressed the stages and treatment of the tumors and the outcome of their treatment. Patients with carcinoma‐in‐situor intramucosal carcinoma were excluded.RESULTS:Replies were received from 26 of 52 registries, but not all questions were answered by all registries. There were 14 patients identified as having invasive colorectal cancer younger than 20 years, the youngest of whom was 9 and the oldest 19. Two patients had two cancers each. Three patients were diagnosed at surgery, and seven were diagnosed when they presented with symptoms. Of the 13 cancers that had staging information, 8 were T1N0M0; 1 was T2N0M0; 2 were TxN1M0; 1 was T3N0M0; and 1 was TxNxM1. Only one patient died of their colorectal cancer.CONCLUSION:Cancer occurs rarely in familial adenomatous polyposis patients younger than 20 years, and only 1 case was reported younger than 15 years. Surgery for colorectal polyposis usually can be deferred safely until at least the age of 15, unless suspicious lesions are found.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PURPOSE:Concerns about morbidity and functional outcome have lead some authors to suggest that ileal pouch‐anal anastomosis should not be performed in older patients. This article evaluates the outcome of selected septuagenarians undergoing ileal pouch‐anal anastomosis at this institution.METHODS:Seventeen of 1,911 patients undergoing ileal pouch‐anal anastomosis for ulcerative colitis were older than the age of 70 at the time of surgery. Functional outcome, quality of life, and manometric data were assessed prospectively, whereas complications were assessed by chart review.RESULTS:There was one mortality related to sepsis after small‐bowel obstruction and one reoperation at 18 months for pelvic abscess. Minor complications occurred in five patients. Median (interquartile range) quality of life and health and levels of energy and happiness (scored out of 10) were 9 (7‐10), 9 (7‐10), 8 (5‐10), and 9.5 (7‐10), respectively. Medical Outcomes Study Short Form 36 quality of life scores were not different from those for the healthy population older than 65 years. There was complete continence in 38 percent, rare incontinence in 12 percent, and some incontinence in 50 percent. Nobody was usually or always incontinent. Overall, 82 percent would undergo pouch surgery again, and 89 percent would recommend it to others.CONCLUSIONS:Ileal pouch‐anal anastomosis is an acceptable surgical option for selected healthy, motivated septuagenarians with ulcerative colitis who are eager to preserve fecal continence.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PURPOSE:Preoperative chemoradiation therapy is used widely in the treatment of rectal cancer. The predictive value of response to neoadjuvant remains uncertain. We retrospectively evaluated the impact of response to preoperative and, specifically, of T‐level downstaging, nodal downstaging, and complete pathologic response after chemoradiation therapy on oncologic outcome of patients with locally advanced rectal cancer.METHODS:There were 88 patients with ultrasound Stage T3/T4 midrectal (n = 37) and low rectal (n = 51) cancers (63 males; mean age 62.6 years). All patients were treated by preoperative 5‐fluorouracil‐based chemotherapy and pelvic radiation followed by surgical resection in six weeks or longer (56 sphincter‐preserving resections).RESULTS:T‐level downstaging after neoadjuvant treatment was demonstrated in 36 (41 percent) of 88 patients, and complete pathologic response was observed in 16 (18 percent) of the 88. Of the 42 patients with ultrasound‐positive nodes, 27 had no evidence of nodal involvement on pathologic evaluation (64 percent). The overall response rate (T‐level downstaging or nodal downstaging) was 51 percent. At a median follow‐up of 33 months, 86.4 percent of patients were alive. The overall recurrence rate was 10.2 percent (three patients had local and six had metastatic recurrences). Patients with T‐level downstaging and complete pathologic response were characterized by significantly better disease‐free survival (P= 0.03,P= 0.04) and better overall survival (P= 0.07,P= 0.08), according to Wilcoxon's test comparing Kaplan‐Meier survival curves. None of the patients with complete pathologic response developed recurrence or died during the follow‐up period.CONCLUSION:T‐level downstaging and complete pathologic response after preoperative chemoradiation therapy followed by definitive surgical resection for advanced rectal cancer resulted in decreased recurrence and improved disease‐free survival. Advanced rectal cancers that undergo T‐level downstaging and complete pathologic response after chemoradiation therapy may represent subgroups that are characterized by better biologic behavior.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PURPOSE:The aim of this study was to determine the effect of surgeon specialty on disease‐free survival and local control in patients with adenocarcinoma of the rectum. Patients underwent curative treatment with neoadjuvant external beam radiotherapy and proctectomy by colorectal surgeons and noncolorectal surgeons.METHODS:The records of 384 consecutive patients treated by colorectal surgeons (n = 251) and noncolorectal surgeons (n = 133) from 1977 to 1995 were reviewed independently by physicians in the Division of Radiation Oncology. Local recurrence was defined as pelvic recurrence occurring in the presence or absence of distant metastatic disease.RESULTS:The study population comprised 213 males, mean age 64 (range, 19‐97) years. Preoperative radiotherapy was delivered as 4,500 cGy in 25 fractions six to eight weeks before surgery (n = 293) or 2,000 cGy in 5 fractions immediately before surgery (n = 91). Concurrent preoperative chemotherapy was given to 14 patients, postoperative chemotherapy to 55. Overall actuarial disease‐free survival and local control rates were 74 and 90 percent, respectively, at five years. Actuarial disease‐free survival and local control rates at five years were 77 and 93 percent for colorectal surgeonsvs.68 and 84 percent for noncolorectal surgeons (P≤ 0.005 for both, Tarone‐Ware). Multivariate analysis revealed that pathologic stage and background of the surgeon were the only independent predictors of disease‐free survival (bothP≤ 0.006, Cox proportional hazards) and that pathologic stage, background of the surgeon, and proximal location of the tumor were independent predictors of local control (allP≤ 0.02, Cox proportional hazards). Radiation dose and use of chemotherapy were not significant factors. Sphincter preservation was more common by colorectal surgeons (131/251, 52 percent) than noncolorectal surgeons (40/133, 30 percent;P= 0.00004, Fisher's exact test, two‐tailed).CONCLUSION:Good outcome for patients with adenocarcinoma of the rectum who undergo neoadjuvant external beam radiotherapy and proctectomy is associated with subspecialty training in colon and rectal surgery.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PURPOSE:In this prospective study we investigated the feasibility, safety, and efficacy of radio‐frequency energy delivery deep to the mucosa of the anal canal for the treatment of fecal incontinence.METHODS:We studied ten patients with fecal incontinence of varying causes. All patients underwent anoscopy, anorectal manometry, endorectal ultrasound, and pudendal nerve terminal motor latency testing at baseline and six months. The Cleveland Clinic Florida scale for fecal incontinence (Wexner, 0‐20), fecal incontinence‐related quality of life score, and Short Form 36 were administered at baseline, 1, 2, 3, 6, and 12 months. Using conscious sedation and local anesthesia, we delivered temperature‐controlled radio‐frequency energyviaan anoscopic device with multiple needle electrodes to create thermal lesions deep to the mucosa of the anal canal.RESULTS:Ten females (age, 55.9 ± 9.2 years; range, 44‐74) were enrolled and treated. Median discomfort by visual analog scale (0‐10) was 3.8 during and 0.9 two hours after the procedure. Bleeding occurred in four patients (14‐21 days after procedure), spontaneous resolution (n = 3) and anoscopic suture ligation (n = 1). At 12 months, the median Wexner score improved from 13.5 to 5 (P< 0.001), with 80 percent of patients considered responders. All parameters in the fecal incontinence‐related quality of life were improved (lifestyle (from 2.3 to 3.4), coping (from 1.4 to 2.7), depression (from 2.2 to 3.5), and embarrassment (from 1.3 to 2.8);P< 0.05 for all parameters). Protective pad use was eliminated in five of the seven baseline users. At six months, there was a significant reduction in both initial and maximum tolerable rectal distention volumes. Anoscopy was normal at six months.CONCLUSION:Radio‐frequency energy delivery to the anal canal for treatment of fecal incontinence is a new modality that, in this study group, safely improved Wexner and fecal incontinence‐related quality of life scores, eliminated protective pad use in most patients, and improved patient quality of life.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PURPOSE:Pudendal nerve complete motor latency, or the sum of the conduction time from the root of the sacral nerve to the end of the pudendal nerve and the synaptic delay, varied in length (from shortest to longest) in the puborectalis, the deep external anal sphincter, and the superficial/subcutaneous external anal sphincter, in that order, for middle‐aged people. The aim of this study was to elucidate whether such a phenomenon was physiologic or pathologic.METHODS:In 20 young adults (21.9 ± 1.37 years old, 10 females), pudendal nerve complete motor latencies were measured after magnetic stimulation to the sacral region. Electromyographic recordings were taken at depths of 5, 3.8, 2.6, and 1.5 cm from the perineal skin using a needle electrode and at 3 cm from the anal verge using surface electrodes within the anal canal. The data were compared with the data of the middle‐aged cohort (65.4 ± 7.70 years old) in our previous study.RESULTS:The pudendal nerve complete motor latencies were 3.85 ± 1.24 ms at 5 cm, 3.97 ± 1.25 ms at 3.8 cm, 5.41 ± 2.42 ms at 2.6 cm, 9.98 ± 4.01 ms at 1.5 cm, and 3.45 ± 0.52 ms while using surface electrodes. The pudendal nerve complete motor latencies at 5, 3.8, and 2.6 cm were significantly shorter in the young adults than in the middle‐aged subjects. The pudendal nerve complete motor latency using surface electrodes was significantly shorter than the pudendal nerve complete motor latency at 2.6 and 1.5 cm (mean ± standard deviation).CONCLUSIONS:Because pudendal nerve complete motor latency was progressively longer at 5, 3.8, 2.6, and 1.5 cm, in that order, in young adults as well as in middle‐aged people, this phenomenon was considered to be physiologic and may be mechanically reasonable and safe in shutting the anal canal and might be useful for milking the residual mucus out of the anal canal to prevent soiling. Aging disturbed the innervation of the upper three levels of the anal sphincter system. Pudendal nerve complete motor latency using intra‐anal surface electrodes approximated that at the highest of the anal sphincters.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID