ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:We sought to evaluate a new diagnostic technique for the identification of rectal and pelvic floor pathology in patients with obstructed defecation, pelvic fullness/ prolapse, and/or chronic intermittent pelvic floor pain.METHODS:Thirteen symptomatic women with either a nondiagnostic physical examination or nondiagnostic dynamic proctography (DPG) were studied. After placement of intraperitoneal and intrarectal contrast material, resting and straining pelvic x‐rays were obtained in all patients, and defecation was videotaped using fluoroscopy.RESULTS:Simultaneous DPG and peritoneography identified clinically suspected and unsuspected enteroceles in 10 of the 13 patients studied. An enterocele or other pelvic floor hernia was ruled out by the technique in three of the women studied. Rectoceles and rectal prolapse that were identified during physical examination were confirmed by DPG with peritoneography. Simultaneous DPG and peritoneography also gave a qualitative assessment of the severity and clinical significance of the identified pelvic floor disorders. Results of simultaneous DPG and peritoneography affected operative treatment planning in 85 percent of patients studied.CONCLUSION:Simultaneous DPG and peritoneography identifies both rectal and pelvic floor pathology and provides a qualitative assessment of pelvic floor pathology severity, which allows for better treatment planning in selected patients with obstructed defecation and pelvic prolapse.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:Denervation of the extrinsic anal sphincter and pudendal neuropathy are confirmed by electrophysiologic or electromyographic testing, techniques that may not be available universally and require special equipment and training. A simple manometric test that is easy to perform and complements existing studies was performed to confirm pudendal neuropathy.METHODS:Fourteen patients with excessive defecatory straining and 30 patients with idiopathic fecal incontinence were studied by electrophysiology and balloon reflex manometry. Pudendal nerve terminal motor latency (PNTML) and rectoanal excitatory reflex were evaluated for abnormalities. Results were compared with 20 controls who had no anorectal complaints and who had similar testing performed.RESULTS:In controls, PNTML was normal in all but one person. Rectoanal excitatory reflex could be elicited in all controls with either 20 or 40 ml of air. Four different types of balloon reflex responses were observed in patient groups: diminutive excitation, delayed excitation, excitation at high volume of distention only, and absent excitation. Ten patients with fecal incontinence had normal PNTML but abnormal distal excitatory reflex, 5 patients had abnormal PNTML but normal distal excitatory reflex, and 15 patients had both PNTML and excitatory reflex that were abnormal. In patients with excessive defecatory straining, results of both tests were abnormal in six patients, and eight patients had abnormal excitatory reflex but normal PNTML.CONCLUSION:Pudendal neuropathy may result in abnormalities of excitatory reflex morphology or other characteristics. Abnormal distal excitatory reflex may complement electrophysiologic findings or may serve as a suitable alternative to confirm pudendal neuropathy in centers where facilities for formal testing are not available.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:The purpose of this study was to assess results of treatment of rectovaginal fistulas (excluding pouch vaginal fistulas) that have failed previous attempts at repair.METHOD:A retrospective chart review of all patients presenting with nonhealing rectovaginal fistula was performed.RESULTS:Twenty eight patients with persistent fistulas were identified. In 18 patients the fistula was classified as simple, and in 10 the fistula was complex. Fourteen fistulas were secondary to obstetric injury, five were caused by Crohn's disease, and nine patients had miscellaneous etiologies for their fistulas. Of patients with persistent simple fistulas, 13 (72 percent) of the fistulas healed, 5 after advancement flaps, 5 following sphincteroplasty, and 3 after coloanal anastomoses. Of persistent complex fistulas, only four of ten (40 percent) healed, one following sphincteroplasty, one with coloanal anastomosis, and two after gracilis transposition. A total of 23 advancement flaps were done in 17 patients with five fistulas healing (29 percent). Sphincteroplasty and fistulectomy was successful in six of seven patients (86 percent). Coloanal anastomosis resulted in healing of four of six patients (67 percent) in whom it was attempted. Gracilis muscle transfer was successful in two of two patients (100 percent).CONCLUSION:Persistent rectovaginal fistula presents a difficult management problem. Choice of operation must be tailored to the underlying pathology and type of repair previously done. Advancement flap repair is generally not recommended for persistent complex fistulas or for simple fistulas that have failed a previous advancement flap repair.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:Because evacuation of effusion or collection could depend on the type of drainage, we compared the effects of closed suction drainage with passive drainage through tubes or undulated drains after abdominoperineal rectal excision for carcinoma on early and late perineal wound healing.METHODS:Of 234 consecutive patients undergoing abdominoperineal rectal excision for carcinoma between January 1983 and August 1990, unsatisfactory hemostasis or gross intraoperative septic contamination were recorded in 48 patients who were not included in the trial. After rectal excision and closure of the perineum, the remaining 186 patients were randomized to receive passive drainage (PD; n=96) or closed suction drainage (SD; n=90). Eighteen patients were withdrawn because of protocol violation, and three were lost to follow‐up, leaving 165 (89 PD and 76 SD) patients for analysis. Preoperative factors (sex, age, degree of obesity, weight loss, anemia, or presence of ascites), intraoperative and pathologic findings (Dukes stage), and postoperative courses (recurrence, late mortality) were similar in both groups. All patients were followed up for 12 months or until death.RESULTS:The rate of perineums healed at one month was significantly lower(P<0.05) in PD (55/89=61 percent) compared with SD (54/72=75 percent) patients. At three months, the rate of healed perineums no longer differed between the two groups (70/87=81 percentvs.60/72=84 percent). The number of vaginal fistulas, secondary reopenings, and perineums not healed at 12 months was similar in both groups. Median duration to complete healing was similar in both groups (23vs.21 days, respectively). On the other hand, three retained drains were seen in PD patients only. The median duration of hospital stay was identical in both groups (22 days). Seven patients died in the early postoperative period, including one in the PD group and six in the SD group. There was no significant difference in the number of late deaths (3vs.7) in PD and SD patients, respectively.CONCLUSION:These results suggest that closed suction drainage should be used after abdominoperineal rectal excision with satisfactory hemostasis or absence of gross intraoperative septic contamination.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:Abrupt discontinuation of total parenteral nutrition (TPN) has been recommended but is not widely practiced because of fear of hypoglycemia.METHODS:To determine whether hormonal counterregulatory mechanisms prevent hypoglycemia, we studied 12 patients (10 with inflammatory bowel disease, of which 6 received dexamethasone) after both abrupt and tapered discontinuation of 3:1 TPN solution in a clinical research facility. Venous blood was drawn before reduction of TPN rate in the tapered group or 15 minutes before and at abrupt discontinuation in the abrupt group and every 15 minutes for 1.5 hours.RESULTS:Glucose decreased from 152±56 (baseline) to 100±22 mg/dl 90 minutes after gradual discontinuation of TPN, compared with 135±45 to 96±15 mg/dl at 90 minutes after abrupt discontinuation, with no significant differences in mean glucose values. Mean epinephrine, norepinephrine, insulin, glucagon, growth hormone, cortisol, symptom score, and vital signs were not statistically different between the two groups.DISCUSSION:Hypoglycemia does not occur after abrupt discontinuation of TPN. The same changes in counterregulatory hormones were seen whether discontinuation was tapered or abrupt. In stable patients, TPN solutions can be abruptly discontinued.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSES:In this study we present our experience with treating persistent sacral and perineal defects secondary to radiation and abdominoperineal resection with or without sacrectomy.METHODS:Fifteen consecutive patients were treated with an inferiorly based transpelvic rectus abdominis muscle or musculocutaneous flap.RESULTS:Fourteen of the 15 patients achieved healing, and 7 patients had no complications. The remaining eight patients required one or more operative debridements and/or prolonged wound care to accomplish a healed wound. Our technique for the dissection and insetting of the transpelvic muscle flap is presented.CONCLUSION:The difficult postirradiated perineal and sacral wounds can be healed with persistent surgical attention to adequate debridement, control of infections, and a well‐vascularized muscle flap. The most satisfying aspects for patients are the discontinuance of foul‐smelling discharge, discontinuation of multiple, daily dressing changes, and reduction in the degree of chronic pain.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:This study was designed to investigate and quantify trophic alterations in the defunctioned, atrophic rat colon after short chain fatty acid (SCFA) treatment was administered in a clinically relevant way.METHODS:Diverting colostomy with exclusion of distal colon was performed on adult female rats (58), and treatment was started four weeks later. Enemas of either a SCFA solution of sodium‐acetate, sodium‐propionate and sodium‐butyrate (concentration, 780 mM), or isotonic saline (placebo) were instilled through the anus into the defunctioned colon. This was done twice daily for 7 or 14 days before death.RESULTS:After SCFA instillation for 14 days, the colonic wet weight was 18 percent higher compared with placebo(P<0.01), and there was a similarly significant difference in dry weight(P<0.05). Using stereologic assessment to determine the histologic composition of defunctioned colon, we found significant increases among SCFA‐treated rats in the weight of the mucosa(P<0.05), the submucosa(P<0.05), and the muscularis propria(P<0.05) and a 30 percent increase in the mucosal surface area compared with placebo‐treated rats(P<0.05). Measurements of breaking strength and hydroxyproline content showed no differences between treatment groups.CONCLUSIONS:SCFA enemas have a transmural trophic effect and preserve mucosal surface area of defunctioned and atrophic colon in rats.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:A prospective study was made of the prevalence and associations of pudendal neuropathy in 96 patients with fecal incontinence (72 females and 24 males).METHODS:Clinical exploration, perineal level measurement, anorectal manometry, and electrophysiologic evaluations (pudendal nerve terminal motor latency (PNTML) and external sphincter fiber density (FD)) were performed.RESULTS:Pudendal neuropathy (defined as PNTML>2.2 ms or FD>1.65) was found in 67 patients (69.8 percent) and was more common in females (75 percent) than in males (50 percent;P= 0.05). Pudendal neuropathy was also more frequent in patients with pathologic perineal descent (85 percentvs.55 percent;P<0.01) or exhibiting risk factors such as difficult labor or excessive defecatory straining(P<0.01). Perineal level at straining correlated inversely with both PNTML and FD(P<0.01). Manometric findings suggested greater external anal sphincter damage in patients with pudendal neuropathy than in those suffering fecal incontinence but no neuropathy(P<0.05). Pressure caused by the striated anal sphincter was also inversely correlated to PNTML. Pudendal neuropathy was encountered in 37 of 63 (58.7 percent) patients with sphincter injuryvs.in 31 of 33 (93.9 percent) patients with idiopathic fecal incontinence(P< 0.01).CONCLUSIONS:Pudendal neuropathy is an etiologic or associated factor often present in patients with fecal incontinence. In this sense, clinical, perineometric, and manometric findings correlate with pudendal neuropathy, though such explorations do not suffice to detect it.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:This study was undertaken to clarify the indications for endoscopic treatment.METHODS:Clinical and pathologic features of 191 lesions in 180 patients with early rectal carcinoma were examined, including 110 intramucosal carcinomas and 81 carcinomas with submucosal invasion (submucosal carcinomas). All lesions had been endoscopically or surgically resected at the National Cancer Center Hospital between 1976 and 1990.RESULTS:Metastasis to regional lymph nodes (LN metastasis) was seen in 0 percent (0/39) of intramucosal carcinomas and 9.2 percent (6/65) of submucosal carcinomas in the surgically treated patients. The incidence of LN metastasis was higher for lesions larger than 10 mm in diameter, for those showing massive submucosal invasion, and for moderately differentiated adenocarcinomas. LN metastases were associated significantly with lymphatic invasion.CONCLUSIONS:These results suggest that early rectal carcinomas should be resected surgically if they 1) show massive submucosal invasion, 2) are classified as moderately differentiated adenocarcinomas, and 3) are larger than 10 mm in diameter. In patients with both scanty submucosal invasion and features of well‐differentiated adenocarcinoma or intramucosal carcinoma and if no other risk factors for LN metastasis are present, such as lymphatic invasion by the primary lesion, surveillance may suffice after endoscopic resection.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID