摘要:

PURPOSE:Dynamic graciloplasty has been used for intractable fecal incontinence, and good results have been reported. The aim of this study was to assess prospectively the safety and efficacy of dynamic graciloplasty for intractable fecal incontinence in a prospective, multicenter trial.METHODS:A total of 123 adults were treated with dynamic graciloplasty at 20 institutions. Continence was assessed preoperatively and postoperatively by use of 14‐day diaries.RESULTS:There was one treatment‐related death. One hundred eighty‐nine adverse events occurred in 91 patients (74 percent). Forty‐nine patients (40 percent) required one or more operations to treat complications. One hundred seventy (90 percent) events were resolved. Sixty‐three percent of patients without pre‐existing stomas recorded a 50 percent or greater decrease in incontinent events 12 months after dynamic graciloplasty, and an additional 11 percent experienced lesser degrees of improvement. Twenty‐six percent were not improved, worsened, or exited. In patients with pre‐existing stomas, 33 percent achieved successful outcomes at 12 months. This number increased to 60 percent at 18 months. Seventy‐eight percent of patients had increased enema retention time, and mean anal canal pressures improved significantly at 12 months. Significant changes in quality of life were also observed.CONCLUSIONS:Objective improvement can be demonstrated in the majority of patients with end‐stage fecal incontinence treated with dynamic graciloplasty. Reduction in incontinence episodes can be correlated with improved quality of life. Adverse events are frequently encountered, but most resolve with treatment.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Locally advanced primary and recurrent rectal cancers treated with external beam radiation therapy, intraoperative radiation therapy, and chemotherapy represent a complex group of patients in the setting of extensive pelvic surgery and sphincter preservation. We sought to define functional outcome and quality of life in this subset of patients.METHODS:We retrospectively reviewed our experience with locally advanced primary and recurrent rectal cancer patients who underwent intraoperative radiation therapy with either low anterior resection (n=12) or coloanal anastomosis (n=6) between 1991 and 1998. Current functional outcome and quality of life were evaluated by a detailed questionnaire.RESULTS:Median time from operation to assessment was 24 (range, 6‐93) months. Using a standardized Sphincter Function Scale, incorporating the number of bowel movements per day and degree of incontinence, patients were graded as poor, fair, good, or excellent function. Of all patients, 56 percent reported unfavorable (poor or fair) function. Of the subset of patients with coloanal anastomosis or very low low anterior resection, 88 percent had unfavorable function as compared with 30 percent with standard low anterior resection. (P=0.02; Fisher's exact probability test). A quality‐of‐life satisfaction score based on social, professional, and recreational restrictions demonstrated 56 percent of patients to be dissatisfied with their bowel function.CONCLUSIONS:The majority of patients with advanced rectal cancers who require external beam radiation therapy, extensive pelvic surgery, and intraoperative radiation therapy report unfavorable functional and quality‐of‐life outcomes after sphincter preservation. In this setting patients being considered for coloanal anastomosis or very low anterior resection may be better served by permanent diversion.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:The purpose of this study was to evaluate the clinical efficacy of positron emission tomography with 2‐[18F] fluoro‐2‐deoxy‐D‐glucose compared with computed tomography plus other conventional diagnostic studies in patients suspected of having metastatic or recurrent colorectal adenocarcinoma.METHODS:The records of 105 patients who underwent 101 computed tomography and 109 2‐[18F] fluoro‐2‐deoxy‐D‐glucose positron emission tomography scans for suspected metastatic or recurrent colorectal adenocarcinoma were reviewed. Clinical correlation was confirmed at time of operation, histopathologically, or by clinical course.RESULTS:The overall sensitivity and specificity of 2‐[18F] fluoro‐2‐deoxy‐D‐glucose positron emission tomography in detection of clinically relevant tumor were higher (87 and 68 percent) than for computed tomography plus other conventional diagnostic studies (66 and 59 percent). The sensitivity of 2‐[18F] fluoro‐2‐deoxy‐D‐glucose positron emission tomography in detecting mucinous cancer was lower (58 percent; n=16) than for nonmucinous cancer (92 percent; n=93). The sensitivity of 2‐[18F] fluoro‐2‐deoxy‐D‐glucose positron emission tomography in detecting locoregional recurrence (n=70) was higher than for computed tomography plus colonoscopy (90vs.71 percent, respectively). The sensitivity of 2‐[18F] fluoro‐2‐deoxy‐D‐glucose positron emission tomography in detecting hepatic metastasis (n=101) was higher than for computed tomography (89vs.71 percent). The sensitivity of 2‐[18F] fluoro‐2‐deoxy‐D‐glucose positron emission tomography in detecting extrahepatic metastases exclusive of locoregional recurrence (n=101) was higher than for computed tomography plus other conventional diagnostic studies (94vs.67 percent). 2‐[18F] fluoro‐2‐deoxy‐D‐glucose positron emission tomography altered clinical management in a beneficial manner in 26 percent of cases (26/101) when compared with evaluation by computed tomography plus other conventional diagnostic studies.CONCLUSION:2‐[18F] fluoro‐2‐deoxy‐D‐glucose positron emission tomography is more sensitive than computed tomography for the detection of metastatic or recurrent colorectal cancer and may improve clinical management in one‐quarter of cases. However, 2‐[18F] fluoro‐2‐deoxy‐D‐glucose positron emission tomography is not as sensitive in detecting mucinous adenocarcinoma, possibly because of the relative hypocellularity of these tumors.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Operating room time and anastomosis‐related morbidity of laparoscopic‐assisted sigmoid resection with anastomosis performed in an open fashion through a horizontal suprapubic incision or laparoscopically after re‐establishing pneumoperitoneum were compared.METHODS:A randomized trial was performed on patients with recurrent uncomplicated diverticulitis of the sigmoid colon during a 14‐month period. Inclusion criteria were persistence of symptoms despite medical treatment and two previous admissions. Exclusion criteria included complicated diverticulitis, suspected cancer, and previous extensive abdominal surgery. Because skin incisions were similar and patients were randomly assigned in the operating room, the trial was performed as double blind.RESULTS:There were no deaths. Two patients were excluded before randomization. Three patients were not treated as allocated because of conversion to open surgery. Aside from previous abdominal‐surgery rates, 16 patients with laparoscopic‐assisted sigmoid resections after re‐establishing pneumoperitoneum and 15 patients with laparoscopic‐assisted sigmoid resections with anastomosis performed in an open fashion through a horizontal suprapubic incision were well‐matched for age, gender, weight, American Society of Anesthesiology class, previous admissions, skin‐incision length, size of circular stapler, and mobilization of splenic flexure. There were no significant differences in morbidity rates (3/16vs.3/15), complete doughnuts (16/16vs.15/15), blood loss (300vs.200 ml), flatus (4vs.4 days), solid‐food resumption (5vs.6 days), stay (8.5vs.9 days) in laparoscopic‐assisted sigmoid resection after re‐establishing pneumoperitoneum and laparoscopic‐assisted sigmoid resection with anastomosis performed in an open fashion through a horizontal suprapubic incision groups, respectively. Patients with laparoscopic‐assisted sigmoid resection after re‐establishing pneumoperitoneum had statistically longer operating room time (295vs.190 minutes;P<0.01). Median follow‐up was 12 and 10 months in 10 patients with laparoscopic‐assisted sigmoid resection after reestablishing pneumoperitoneum and 11 patients with laparoscopic‐assisted sigmoid resection with anastomosis performed in an open fashion through a horizontal suprapubic incision, respectively. One patient with laparoscopic‐assisted sigmoid resection with anastomosis performed in an open fashion through a horizontal suprapubic incision had an anastomotic stenosis endoscopically dilated.CONCLUSIONS:Nonrestoration of pneumoperitoneum after laparoscopic‐assisted sigmoid resection allows a decrease in operating room time and a similar outcome.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:It has recently been demonstrated that the tumor growth rate is a stronger determinant of survival than the extent of the growth in local recurrence of rectal cancer. We studied which factors controlled the tumor growth rate using modern immunohistochemical methods.METHODS:In 51 patients who underwent extended resection for this condition, paraffin‐embedded specimens were examined for 1) tumor angiogenesis by CD31 staining and microvessel counting, 2) apoptosis by terminal deoxynucleotide transferase‐mediated deoxyuridine triphosphate‐biotin nick end‐labeling staining, and 3) cellular proliferative activity using anti‐proliferative cell nuclear antigen antibody. The results were compared with carcinoembryonic antigen doubling time and survival.RESULTS:The five‐year survival rate was 20 percent. The postoperative carcinoembryonic antigen doubling time, which was the strongest predictor of survival, correlated highly with proliferative cell nuclear antigen labeling index, but did not correlate with the apoptotic index or microvessel counts.CONCLUSION:Our study shows that cancer cell proliferation rather than apoptosis or angiogenesis is a major determinant of tumor growth rate and survival in patients with locally recurrent rectal cancer.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:The aim of this study was to re‐evaluate the clinicopathologic features of flat adenomas with special reference to the role of central depression found in flat adenomas.METHODS:Clinicopathologic features, such as grade of atypia by size, site, central depression, coexisting lesions, gender, and family history of cancer, were evaluated in 236 flat adenomas from 183 patients selected retro‐spectively and prospectively.RESULTS:Of the 236 flat adenomas, 175 had mild, 33 had moderate, and 28 had severe (i.e., intramucosal carcinoma) atypia. The frequency of severe atypia correlated positively with size. Severe atypia were significantly more frequent in females (21 percent in females and 10 percent in males;P<0.05). Sixteen percent of flat adenomas in patients with coexisting cancer showed severe atypia, which was significantly more than those without coexisting cancer (P<0.05). The frequency of multiple flat adenomas in patients with two or more family members with cancer was 53 percent, which was significantly higher than in patients with one or no family members with cancer (P<0.05). Central depression was observed in 19 percent of flat adenomas. The rate of severe atypia (22 percent) of flat adenomas with central depression was significantly higher than that (9 percent) of flat adenoma without central depression (P<0.05). Patients who had flat adenomas with central depression had a higher incidence of coexisting cancer and cancer in the family (P<0.05 andP<0.01).CONCLUSION:At colonoscopic examination consideration should be given for the increased potential to become malignant in flat adenomas, especially those with central depression and in patients with a history of malignancy or with a family history of malignancy.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Neosphincter procedures may prove to be the treatment of choice for patients with neuropathic fecal incontinence but are rarely proposed for milder forms of the disease. Biofeedback may prove beneficial to these patients but is yet unproven. The objectives of this study were to develop a method of performing biofeedback using transanal ultrasound to teach the patient to contract repetitively and to determine biologic measures of sphincter function using transanal ultrasound in healthy and incontinent patients.METHODS:Initial uncontrolled studies were performed to determine the compliance, normal values, biologic measures of external sphincter strength (isotonic and isometric fatigue times), and early efficacy data using continence scores and visual analog scale scores.RESULTS:Forty‐four patients were assessed during three months, with relative improvements in continence scores (St. Mark's Hospital, 40 percent; Pescatori, 20 percent) and patient and investigator visual analog scale scores (38 percent for both) and measurable increase in biologic fatigue times measured by transanal ultrasound.CONCLUSIONS:Transanal ultrasound seems to be a method of teaching external sphincter contraction and measuring sphincter strength with good initial compliance. Clinically and statistically significant improvements in incontinence scores, visual analog scale scores, and biologic strength of the external sphincter were detected in the short‐term follow‐up with uncontrolled data. The randomized, controlled trial that we have begun will either confirm or refute these results.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Bowel function after ultralow anterior resection may be improved by a colonic J‐pouch. The aim of this study was to compare the bowel function and ambulatory manometry in patients randomly assigned to straight coloanal anastomosis or colonic J‐pouch.METHODS:Forty‐seven consecutive patients underwent ultralow anterior resection for adenocarcinoma. The colonic J‐pouch was constructed with 6‐cm limbs. A bowel function questionnaire was administered at one year after surgery. Ambulatory manometry was performed before and at one year after surgery.RESULTS:Values are expressed below as mean and (standard error of the mean). Patients with colonic J‐pouch were found to have less frequent stools (4.6 (0.3)vs.7.1 (0.9) stools/day;P<0.05) and stool clustering (35vs.63.2 percent;P<0.05) and were less unlikely to soil when passing flatus (85vs.35.3 percent;P<0.05). The ambulatory anorectal pressure gradient was better preserved in the colonic J‐pouch group (30.3 (3.7)vs.18 (2.6) mmHg;P<0.05). Stool frequency was predicted by the mean rectal pressures (t=3.368;P=0.003). However, higher mean rectal pressures were tolerated by the colonic J‐pouch for each daily bowel movement (6.7 (0.6)vs.4.4 (0.5) mmHg/stool;P=0.008). Anal sampling episodes and slow wave activity were impaired postoperatively in both groups. The minimal anal pressures were lower in patients unable pass flatus without soiling (12.4 (5.3)vs.26 (2.3) mmHg;P=0.004). Large contraction waves were not seen, and this may be related to the absence of severe defecation problems with 6‐cm colonic J‐pouches.CONCLUSIONS:A colonic J‐pouch resulted in better bowel function and more favorable ambulatory manometric findings at one year of follow‐up.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Patients with chronic anal fissures are known to have high resting anal pressures that return to normal after successful surgical treatment. Internal anal sphincter activity is increased by sympathetic excitatory innervationviaalpha adrenoceptors. The objective of this study was to determine the effect of alpha‐1 adrenoceptor blockade on anal sphincter pressure in patients with and without chronic anal fissures.METHODS:The effect on the anal canal pressure profile of a single oral 20 mg dose of indoramin, an alpha‐1 adrenoceptor antagonist, on seven patients with chronic anal fissure and six healthy patients without a fissure was investigated.RESULTS:Indoramin reduced anal resting pressures in those with anal fissure by a mean of 35.8 percent, from 106.9 ± 22.15 cm H2O to 68.6 ± 20.35 cm H2O, and in those without anal fissure by a mean of 39.9 percent, from 84.17 ± 27.46 cm H2O to 52.17 ± 24.78 cm H2O, after one hour. This pressure reduction persisted at three hours, and its magnitude is comparable to that obtained after internal sphincterotomy. The pressure reduction occurred over the whole length of the anal canal.CONCLUSION:It is proposed that alpha‐1 adrenoceptor antagonists could be a suitable treatment for chronic anal fissure and other painful conditions where reduction in anal pressure is warranted.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID