摘要:

PURPOSE:Fissure‐in‐ano and acutely thrombosed external hemorrhoids are common, benign anal conditions, usually characterized by severe anal pain. Internal anal sphincter hypertonia appears to play a role in the etiology of this pain. Nitric oxide has recently been identified as the “novel biologic messenger” that mediates the anorectal inhibitory reflex in humans. This report documents a therapeutic role for nitroglycerin, a nitric oxide donor, in the treatment of acutely thrombosed external hemorrhoids and anal fissure.METHODS:Five patients with thrombosed external hemorrhoids and fifteen patients with anal fissure or ulcer were identified. A treatment regimen that included 0.5 percent nitroglycerin ointment applied topically to the anus was instituted. After one week of therapy, all patients were re‐examined and questioned regarding pain relief and side effects of treatment. Fissure patients were followed for eight weeks or until healing occurred.RESULTS:All patients reported dramatic relief of anal pain following application of nitroglycerin. Pain relief lasted from two to six hours. Complete healing of fissures occurred within two weeks in ten patients and within one month in two patients. One patient, whose fissure had not healed completely within two weeks requested surgical sphincterotomy. Two patients remained with persistent anal ulcers despite two months of therapy. Both, however, were pain‐free. Side effects were limited to transient headache in 7 of 20 patients.CONCLUSION:Topically applied nitroglycerin ointment appears to have a therapeutic role in the treatment of thrombosed external hemorrhoids and anal fissure.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:Our aim was to determine manometric status and functional outcome of the ileoanal pouch procedure in a subset of patients with defunctionalized anal sphincters as a result of long‐term fecal diversion.METHODS:The anal manometric profiles of 12 patients defunctionalized for one year or more were compared with 26 patients with nondefunctionalized anal sphincters. Functional data were obtained from the Lahey Clinic Ileoanal Pouch Registry.RESULTS:Preoperative manometric data revealed a mean resting pressure of 91.5 mmHg in the nondefunctionalized groupvs.68.7 mmHg in the defunctionalized group; mean squeezing pressure was 171.7 mmHg (nondefunctionalized group)vs.102.3 mmHg (defunctionalized group); and squeezing pressure volume was 1,283,000 mmHg3(nondefunctionalized group)vs.585,000 mmHg3(defunctionalized group). Functionally both groups had a mean of 6.1 bowel movements in a 24‐hour period and could defer defecation for a mean of 2 hours. Leakage occurred in 22 percent of the defunctionalized group and 17 percent of the nondefunctionalized group (P=0.35).CONCLUSION:Despite physiologic perturbations, the long‐term, defunctionalized anal sphincter can adequately support a restorative procedure without regard to timing of pouch creation.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

BACKGROUND:One of the main concerns in colon carcinoma therapy is local recurrence of the malignancy at the site of resection. Previous studies have shown that morphologically normal‐appearing mucosa adjacent to colon carcinoma is different from mucosa distant from carcinoma. Mucosa adjacent to a carcinoma is characterized by crypt lengthening, cell hypertrophy, and change in production of mucopolysaccharides from sulfomucin in normal mucosa to sialomucins in carcinomas and adjacent mucosa. Recently there have been reports suggesting that there is an upward extension of the proliferative compartment in colonic crypts of this adjacent mucosa.METHODS:Immunoblot analysis using antibodies to retinoblastoma, statin, c‐Fos, c‐Jun, and Cdc‐2 proteins was used for our study on the expression of early cell cycle genes in carcinoma and its adjacent mucosa. In all, 15 tissue samples obtained from patients with colon carcinoma were analyzed. Tissue specimens were collected and immediately dissected as tumor, 0 to 1, 1 to 2, 2 to 3, 3 to 4, and 4 to 5 cm from the primary lesion. Dissected pieces were homogenized separately and subjected to immunoblot analysis.RESULTS:We found upregulation of c‐Fos, c‐Jun, and Cdc‐2 expression in carcinoma and adjacent mucosa up to 4 cm from the edge of the carcinoma. The phosphorylated form of retinoblastoma is present in the carcinoma as well as in adjacent mucosa up to 4 cm from the margin of the carcinoma. Furthermore, we observed that the level of statin, a nonproliferation‐specific nuclear protein, is very low in the primary lesion and in adjacent mucosa up to 3 cm.CONCLUSIONS:These results indicate that adjacent tissue up to 3 to 4 cm from the carcinoma has elevated levels of expression for cell cycle traverse‐associated genes and down‐regulation of nonproliferation‐specific gene expressions such as statin. This imbalance indicates that within 3 to 4 cm from the edge of the carcinoma, colonic epithelial cells are already abnormal and may be in the hyperproliferative and preneoplastic state, susceptible to further steps leading to eventual malignant transformation.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:A prospective defecographic study was performed to evaluate the anorectal physiology of dynamic graciloplasty (gracilis muscle transposition and subsequent implantation of an electric stimulator) for treatment of fecal incontinence.METHODS:From November 1986 until May 1993, 38 consecutive patients with incapacitating fecal incontinence were treated with “anal dynamic graciloplasty.” Defecography was performed before and after surgical procedures. Defecographic data (anorectal angle, perineal descent, anal canal length, anal canal width, and anal leakage) were correlated with respect to clinical outcome and anal manometry.RESULTS:Fecal continence was achieved in 24 patients, which correlated significantly with no leakage of barium contrast during defecography(P<0.01, Kruskal‐Wallis one‐way analysis of variance). In addition, minimum anal canal width decreased from 7 mm before surgery to 1 mm after dynamic graciloplasty(P<0.01, paired Student'st‐test).CONCLUSION:Defecography is an efficient method to evaluate dynamic graciloplasty for fecal incontinence.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:Emergency surgery for fulminant colitis is often complicated by high‐dose steroid therapy, poor nutrition, and psychologic maladjustment. Cyclosporine is effective for fulminant ulcerative colitis in adults, resulting in avoidance of immediate surgery in 75 percent of patients and a 55 percent long‐term remission rate. Over the last five years, we studied the effectiveness of cyclosporine in children with fulminant colitis.METHODS:Fourteen patients with ulcerative colitis (age, 7‐20 years) received cyclosporine after satisfying the following criteria: 1) greater than five bloody diarrheal stools per day; 2) severe abdominal pain; 3) no improvement after ten days of bowel rest, 4) intravenous methylprednisolone (1‐2 mg/kg/day); and 5) parenteral nutrition. Treatment was begun with oral cyclosporine (4.6‐9.6 mg/kg/day), and the dose was adjusted to achieve whole blood trough levels measured with a monoclonal radioimmunoassay between 150 and 300 ng/ml. If improved, patients were discharged on oral cyclosporine, prednisone, and a regular diet.RESULTS:Eleven of 14 patients (78 percent) responded within two to nine days and were able to consume a normal diet, had three or less soft stools per day, and had no pain. One did not respond after ten days and underwent an ileal pouch‐anal anastomosis procedure. Two patients elected surgery after 20 days of therapy and a partial response. Of 11 patients who left the hospital, 4 had recurrent symptoms after 2 to 11 months of taking therapeutic doses of cyclosporine and 3 flare ups while weaning from cyclosporine after 4 to 8 months. Three patients have been weaned from cyclosporine after 8 to 13 months and have remained in remission from six months to five years. One patient is about to complete a six‐month course of cyclosporine. Overall ten (72 percent) have undergone surgery, including 7 of 11 who responded initially to cyclosporine and left the hospital. Weight(P<0.001), albumin(P<0.01), erythrocyte sedimentation rate(P>0.05), and prednisone dose(P<0.001) improved significantly in the seven patients on cyclosporine who responded initially, left the hospital, and subsequently underwent surgery.CONCLUSIONS:Cyclosporine is effective in achieving clinical remission in 80 percent of children with refractory fulminant colitis; however, within one year, most initial responders will require colectomy because of a flare up of the disease. In a majority of patients, the role of cyclosporine therapy is to rapidly ameliorate symptoms and prevent precipitous colectomy, improve nutrition and psychologic adaptation, and reduce the steroid dose leading to surgery in a well‐prepared patient.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:The aim of this study was to report the prevalence of postoperative complications and mortality of patients with colorectal cancer when treated by conventional surgery.METHODS:Morbidity and mortality following open resection for colorectal cancer were analyzed in 1,846 patients whose clinical, operative, and pathology data were prospectively documented over a 20‐year period.RESULTS:Mortality following elective resection of the left and right colon was low, whereas overall morbidity was high (37.2 percent). Respiratory and cardiac complications were especially common. Incidence of clinically significant leakage was similar following right (0.5 percent) or left (1.1 percent) hemicolectomy. Incidence of anastomotic leakage was significantly higher after emergency right hemicolectomy (4.3 percent). Overall morbidity following excision of the rectum was high (40.2 percent). Respiratory and cardiac complications predominated. Incidence of clinically significant anastomotic leakage following anterior resection was low (2.9 percent). Over the years, there has been a decline in the number of patients with tumor demonstrated histologically in a line of resection, suggesting an improved local surgical clearance.CONCLUSIONS:These results following conventional surgery may be useful when evaluating new techniques.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:Acute pouchitis is a troublesome complication after restorative proctocolectomy. Deficiency of fuel, especially short chain fatty acids (SCFA), produced by anaerobic bacterial fermentation of saccharides, is implicated in ulcerative and diversion colitis. Our hypothesis was that SCFA deficiency occurs in acute pouchitis, and correction of the deficiency is associated with resolution of pouchitis.METHODS:Thirty‐two patients were studied, 10 with histologically confirmed acute pouchitis and 22 with healthy pouches. Stool concentrations of SCFA (acetic, propionic, butyric, and valeric acids) were determined by gas‐liquid chromatography. Quantitative bacteriologic studies of stool were carried out, and four‐quadrant pouch biopsies were assessed by a pathologist who was unaware of the clinical state. Patients with pouchitis were treated for six weeks with metronidazole and given dietary advice to increase their intake of fermentable saccharides.RESULTS:Stool concentrations of SCFA were significantly less in pouchitis patients compared with patients with healthy pouches (340μmol/g (range, 124‐492)vs.93 (range, 44‐136)P<0.01). No differences in anaerobic or aerobic counts were seen. Resolution of pouchitis was associated with a significant increase in SCFA, but anaerobic counts fell.CONCLUSION:Deficiency of SCFA is implicated in acute pouchitis

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:The aim of this study was to prospectively evaluate the role of laparoscopic‐assisted surgery in patients presenting for routine colorectal surgical procedures.METHODS:Two hundred consecutive patients were assessed for the possible use of laparoscopic surgery. The decision regarding suitability of the patient for the procedure was made by the operator. For the purpose of analysis, patients were assigned to open, converted, and laparoscopic groups.RESULTS:Ninety‐five of 200 patients were considered appropriate for laparoscopic surgery, 62 (65.3 percent) being successfully completed. These completed operations included right colectomy (24/30), sigmoid colectomy (22/36), appendectomy (9/10), anterior resection (3/8), abdominoperineal resection (3/5), and left colectomy (1/2). Complications attributable to laparoscopy were infrequent (6.3 percent) and were not responsible for any deaths. Patients in the laparoscopic group required less analgesia, tolerated oral intake earlier, and were discharged from the hospital earlier than those who were converted or who had open procedures.CONCLUSIONS:Laparoscopic assisted surgery is safe, effective, and applicable to many of the standard colorectal procedures. Observed benefits include less postoperative pain and shorter hospital stay.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:This study was designed to investigate rectal reservoir function and anal pressures in patients with fecal incontinence using anorectal manovolumetry and to evaluate the reproducibility of the investigation.METHODS:Forty‐eight patients with fecal incontinence were investigated with respect to anal pressures and rectal volume changes and sensibility in response to stepwise increased rectal pressures (5‐60 cm of H2O). Patients with known rectal wall diseases were excluded. Results were compared with those of 25 control subjects investigated in a similar manner. In ten individuals in the latter group, investigation was repeated after 5 minutes and 24 hours.RESULTS:Resting pressure (RP), squeezing pressure (SP), and the difference between SP and RP was lower in patients than in controls(P<0.0001). There was no significant difference between patients and controls concerning rectal sensibility or compliance(P>0.05), but there was a correlation between RP and rectal compliance(r=0.25;P<0.05) and between SP and rectal compliance(r=0.30;P<0.01). There was good reproducibility of RP and SP after five minutes(r=0.88‐0.92;P<0.001). The day‐to‐day variation was larger for RP(r=0.52;P>0.05) compared with SP(r=0.89;P<0.001). Rectal compliance at 40 cm of H2O was reproducible after 5 minutes(r=0.98;P<0.0001) and 24 hours(r=0.88;P<0.01).CONCLUSIONS:These results indicate that the primary defect in incontinent patients is a sphincter dysfunction. Any reduction in rectal compliance is likely to be a secondary phenomenon.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:This study was designed to investigate neural and muscular features of the colonic wall in patients with severe idiopathic constipation.METHODS:By using quantitative immunohistochemistry, resected specimens from 14 patients with idiopathic chronic constipation and 17 nonobstructed cancer controls were studied.RESULTS:Routine histology revealed no significant histologic abnormality throughout the colon apart from four cases of melanosis coli. Ratio of the thickness of circular to longitudinal muscle was significantly lower in the left colon in constipated subjects. The myenteric plexus appeared morphologically normal in all subjects. S‐100 protein, which stains neuronal supporting tissues, demonstrated an increase in the proportion of neural tissue in the myenteric plexus. There was an increased number of PGP‐9.5 immunoreactive nerve fibers in the muscularis propria in constipated patients, and this was significantly higher in the ascending and descending colon.CONCLUSION:Intractably constipated patients have alterations in the neural composition of the colonic myenteric plexus and innervation of the circular muscle.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID