摘要:

PURPOSE:The aim of this study was to understand better the cause and predictability of pouch failure requiring rediversion after ileal pouch‐anal anastomosis and to assess the ultimate outcome of patients in a large ileal pouch series who required rediversion.METHODS:Data from 460 patients completing ileal pouch‐anal anastomosis at one institution were recorded from both a prospectively accumulated ileal pouch registry and patient medical records.RESULTS:Of 460 patients, 21 (4.6 percent) who underwent ileal pouch‐anal anastomosis required rediversion. Five of these patients subsequently had successful restoration of pouch continuity, leaving a permanent failure rate of 16 of 460 patients (3.5 percent). The most common reasons for rediversion were pouch fistula formation (12) and poor functional results (5). Preoperative factors, including age, previous colectomy, and indication for colectomy, did not predict eventual need for rediversion. Patients requiring rediversion had significantly higher rates of postoperative complications (95vs.43 percent;P<0.001). Specifically, this group had a higher rate of postoperative pouch fistula (57vs.3.4 percent;P<0.001). Additionally, a final diagnosis of Crohn's disease significantly predicted the need for rediversion. Permanent pouch failure occurred in 36.8 percent of patients with a final diagnosis of Crohn's disease compared with 1.4 percent of patients with a final diagnosis of ulcerative colitis (P<0.001). All five salvaged patients had fistula formation in the absence of Crohn's disease.CONCLUSIONS:The overall rate of permanent pouch failure is low. The majority of failures were related to fistula formation associated with Crohn's disease or poor functional results. Pouches complicated by fistulas not associated with Crohn's disease can be salvaged with temporary rediversion.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:This study was designed to analyze factors of importance for local recurrence after radical surgery for rectal cancer and to analyze course and outcome of treatment of pelvic recurrence.METHODS:One hundred seventy‐five patients treated for rectal cancer with low anterior resection (LAR) or abdominoperineal resection (APR) were studied, retrospectively. Seventy‐four patients had LAR and 101 had APR.RESULTS:The two groups were comparable with respect to Dukes classification, histologic differentiation, and male to female ratio. The rate of pelvic recurrence was 18 percent for LAR and 24 percent for APR (not significant). Recurrence rates were 27 percent after stapled anastomoses and 10 percent after handsewn anastomoses respectively(P=0.09). Twenty five had pelvic recurrence diagnosed without signs of distant metastatic disease. They were treated with radiotherapy, palliative operations, or analgesics. The group receiving radiotherapy had a significantly longer survival (15.9 months) compared with other groups (2.4 months;P<0.001).CONCLUSIONS:There is no difference in local recurrence rate after LAR and APR. Radiotherapy seems to increase survival in patients with an unresectable recurrence and should be offered irrespective of pain.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

&NA;One technique used during restorative proctocolectomy to prevent loss of continence involves preservation of the anal canal. This technique retains a small amount of colonic mucosa and transitional mucosa that may become inflamed or develop dysplastic or neoplastic changes.PURPOSE:This study was designed to determine the presence and severity of anal canal inflammation and the need for treatment.METHOD:Records of 217 patients with mucosal ulcerative colitis who underwent restorative proctocolectomy with a stapled ileal pouch‐anal anastomosis without anal mucosectomy from 1987 through 1990 were retrospectively reviewed.RESULTS:Anal canal inflammation was evident on both endoscopy and biopsy in 48 patients (22.11 percent); 18 patients (8.29 percent) had a normal ileal pouch (9 had symptoms; 5 required topical treatment), and 30 patients (13.82 percent) had associated ileal pouch inflammation (23 with symptoms requiring systemic treatment because of pouchitis; 10 patients had concomitant topical treatment).CONCLUSION:Symptomatic inflammation of the retained mucosa occurred in 32 (14.7 percent) patients. Nine (4.1 percent) patients had inflammation of the anal canal alone, and 23 (10.6 percent) had pouchitis in addition. The need for treatment occurred in 28 (12.9 percent) of the total ((2.3 percent) patients with anal canal inflammation and 23 (10.6 percent) with anal canal inflammation plus pouchitis).

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:This study was designed to determine functional outcomes and rates of survival and recurrence of coloanal anastomosis in rectal cancer patients.METHODS:Between 1981 and 1991, 117 patients underwent coloanal anastomosis. Fifteen percent of the patients had a J‐pouch; the rest had a straight coloanal anastomosis. Thirty‐eight percent had no diverting stoma. Median distance of the tumor from the anal verge was 6.7 cm.RESULTS:Local recurrence rate was 7 percent. Five‐year survival was fully 69 percent. Satisfactory fecal continence was achieved by 78 percent of patients; no J‐pouch patient had frequent incontinence. Sixty‐two percent of the patients had major (anastomotic leak = 18 percent) or minor complications; complications were not mitigated by a diverting stoma or worsened by adjuvant therapy.CONCLUSION:Although coloanal anastomosis is associated with a high chance of complications, the long‐term outcome, in terms of disease‐free survival and satisfactory function, is excellent.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:This nonrandomized, controlled Phase II pilot study aims at the lowest effective dose of rectally applied sulindac to achieve and maintain adenoma reversion in colectomized patients with familial adenomatous polyposis (FAP).METHODS:The study group (n = 15) underwent proctoscopic and laboratory follow‐up for polyp reversion every 6 to 12 weeks. Polyp reversion was followed by dose reduction in predefined steps. Proliferating cell nuclear antigen/cyclin (PCNA) and KI‐67 proliferation indices (PI) were performed by point counting. Prostaglandin (PG)E2and PGF2&agr;were quantified by time‐resolved competitive fluorescence immunoassay.RESULTS:All patients responded to therapy within 6 to 24 weeks. Sixty and 87 percent of patients achieved complete adenoma reversion after 48 weeks at 53 and 67 mg of sulindac per day per patient on average, respectively. Reversion was evident compared with the control group. Dose reduction by one‐sixth to one‐eighth of the usual oral dose was significant (Mann's trend test,P< 0.05). PCNA and KI‐67 Pls of adenomatous and flat mucosa were significantly reduced (Wilcoxon's test,P<0.05). Correlation of PCNA and KI‐67 Pls indicate similar reaction of different tissue structures (Spearman's rank correlation test,P<0.01). Nonsteroidal anti‐inflammatory drug‐induced redifferentiation from high‐grade to low‐grade dysplasia occurred in all but two patients. Tissue‐PGE2 levels were greatly reduced. Unwanted, curable side effects were rare (gastritis,n=2), and laboratory controls are within detection limits.CONCLUSIONS:Low‐dose rectal sulindac maintenance therapy is highly effective in achieving complete adenoma reversion without relapse in 87 percent of patients after 33 months. Rectal FAP phenotype should be crucial for the surgical decision. Colectomy with ileorectal anastomosis and regular chemoprevention might proceed to be a promising alternative to pouch procedures. Chemoprevention with lower incidence of FAP‐related tumorsviadysplasia reversion may be possible in the future.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:Controversy exists as to whether pouchitis represents a reactivation of the immunologic mechanisms that lead to ulcerative colitis (UC). The aims of this study were to determine local levels of the cytokines: interleukin‐1&bgr;(IL‐1&bgr;), interleukin‐6 (IL‐6), interleukin‐8 (IL‐8), and tumor necrosis factor alpha (TNF&agr;) in the mucosa of patients with “asymptomatic” ileoanal pouch (n=25), pouchitis (n=9), active UC (n=20), normal ileum (n=15), proctitis (n=10), and normal colon (n=15).METHODS:Lamina propria mononuclear cells were isolated from mucosal biopsies by enzymatic dispersion and cultured for 48 hours. Proinflammatory cytokine levels were measured in the supernatants by enzyme‐linked immunosorbent assay.RESULTS:IL‐1&bgr;,IL‐6, IL‐8, and TNF&agr;secretions were significantly greater in pouchitis and active UC than in the noninflamed ileoanal pouch and normal controls (P<0.001). There was significant correlation (r=0.63,P< 0.05) between levels of cytokines expressed in pouchitis and active UC.CONCLUSIONS:Increased cytokine expression occurs in both active UC and pouchitis and to a lesser extent in the long‐standing ileoanal pouch.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:Treatment of perianal condyloma acuminata is frustrating because most treatment options are fraught with high recurrence rates and patient discomfort. We propose that surgical excision followed by vaccination with an autogenous condyloma acuminata vaccine is the most effective therapy available in primary and recurrent perianal condyloma acuminata.METHODS:Eighty‐three patients with perianal condyloma acuminata were treated from 1985 to 1992. Treatment was divided for patients as follows: surgical excision, 20; bichloroacetic acid, 10; podophyllin and interferon A, 5; excision followed by autogenous condyloma acuminata vaccination twice weekly using 0.1 ml subcutaneously for three weeks increasing to 1.0 ml subcutaneously for seven weeks, 43. Syphilis was diagnosed in seven patients; two were human immunovirus‐positive. All but three patients were male. Of those patients treated with the vaccination protocol, 25 had primary and 18 had recurrent disease.RESULTS:Recurrence rates were: excision alone and bichloroacetic acid, 50 percent; podophyllin and interferon A, 85 percent; whereas only 4.6 percent recurred when treated with excision and vaccination. Mean follow‐up was 13 (range, 6‐23) months. All patients treated with the vaccination protocol tolerated the full course of therapy.CONCLUSION:We believe that excision of perianal condyloma acuminata followed by autogenous condyloma acuminata vaccination for approximately ten weeks is the most effective and definitive treatment option and, moreover, should be considered in all patients with perianal condyloma acuminata.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:Submucosa‐invasive colorectal carcinoma is a colorectal carcinoma extending only into the submucosal layer. To clarify the metastatic potential of submucosa‐invasive colorectal carcinoma, we studied the relationship between the immunohistochemical staining pattern of carcinoembryonic antigen (CEA) and that of lymphatic invasion/ lymph node metastasis.METHODS:We investigated 49 submucosa‐invasive colorectal carcinomas resected surgically or endoscopically. CEA distribution patterns of the neoplastic tissues were divided into three patterns: Pattern 1 = luminal type; Pattern 2 = apical cytoplasmic type; and Pattern 3 = diffuse cytoplasmic type. We also observed the submucosal stromal staining of CEA.RESULTS:Lymphatic invasion and lymph node metastasis were found in 48.8 percent (21/43) and 11.6 percent (5/43) of the Pattern 2/Pattern 3 cases, whereas these were seen in none (0/6) of Pattern 1 cases. Lymphatic invasion and lymph node metastasis were found in 63.3 percent (19/30) (chi‐squared =21.94;P<0.001) and 16.7 percent (5/30) of the positive stromal CEA cases, whereas these were seen in 10.5 percent (2/19) and none (0/14) of the negative stromal CEA cases, respectively.CONCLUSION:Pattern 2/Pattern 3 and stromal CEA can be predictors of the lymph node metastasis with 11.6 percent and 16.7 percent risks.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:Adenocarcinoma of the appendix is a rare neoplasm, and controversies persist regarding management. The purpose of this study was to identify prognostic factors and define management strategies for patients with adenocarcinoma of the appendix.METHODS:A retrospective case series was conducted at three medical school teaching hospitals over a 20‐year period from 1972 to 1992. Overall survival was determined by the actuarial life table method. Comparisons of prognostic factors were made using exact nonparametric log‐rank tests.RESULTS:Thirteen patients were diagnosed during the study period. Median age was 62 years. There were five males and eight females. The disease swas not suspected in any patient preoperatively. Seventyseven percent of patients had metastatic disease at presentation. Second primary malignancies were found in 15 percent of patients. Thirty‐eight percent of female patients had synchronous ovarian lesions. Median survival was 22 months, with an estimated five‐year survival of 43 percent (95 percent confidence interval, 22‐84 percent). Patients with colonic histology had significantly worse survival than patients with mucinous histology (tP=0.0093). Patients with carcinomatosis had a significantly worse survival than noncarcinomatosis patients (tP=0.0078). Patients who underwent right hemicolectomy had a better prognosis for survival than appendectomy patients, but the difference was not statistically significant.CONCLUSIONS:Carcinoma of the appendix is very difficult to diagnose preoperatively, and most patients are not identified until disease is advanced. Good prognostic factors include mucinous histology and the absence of carcinomatosis. Right hemicolectomy appears to be a reasonable option, although its superiority to appendectomy alone has not been definitively proven. High frequency of ovarian metastases in women suggests a role for bilateral oophorectomy. In addition, a complete work‐up of the patient for a synchronous malignancy, especially in the gastrointestinal tract, should be considered.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID