摘要:

PURPOSE:Intra‐abdominal desmoid tumors occur in 12 percent of patients with familial adenomatous polyposis. A minority grow quickly and are lethal, most are relatively inert, and some cause problems by obstructing adjacent organs. Desmoid tumors may be estrogen‐dependent, and estrogen‐blocking drugs are part of the usual treatment of these tumors. This study was performed to examine the effect of pregnancy on the course of patients with familial adenomatous polyposis and intra‐abdominal desmoids.METHODS:All females with familial adenomatous polyposis and an intra‐abdominal desmoid treated or followed up at this institution were eligible. Stable, asymptomatic desmoids were followed up yearly with examination and CT scan. Growing or symptomatic desmoids were followed up at least every six months. Maximum tumor size was grouped as follows: <10 cm, 10 to 20 cm, and >20 cm. A change in tumor size was defined as a change of ±50 percent or more of maximum diameter. Stable tumors showed no change in diameter during the study period; variable growth was defined as a significant change in either direction that was followed by a return to previous dimensions or a stabilization of growth. Rapid growth was a doubling of diameter within three months. Pregnant females were compared with nonpregnant females. Subgroups of females were matched for age at diagnosis of desmoid.RESULTS:Twenty‐two females had never been pregnant, whereas 25 had been pregnant at least once. Eleven pairs were matched for age. There were no differences between groups in the incidence of extracolonic manifestations of familial adenomatous polyposis, family history of desmoids, number or type of surgeries done for familial adenomatous polyposis, length of follow‐up, or time from surgery to desmoid diagnosis. Desmoids in pregnant females had a significantly more benign course: 18 were stable (vs.6 nonpregnant females), 2 had variable growth (vs.10), 1 had rapid growth (vs.5), and 4 disappeared (vs.1). There were also trends to smaller, less symptomatic tumors requiring treatment less often in pregnant females.CONCLUSIONS:Pregnancy seems to ameliorate the course of abdominal desmoid tumors significantly in females with familial adenomatous polyposis. This finding raises questions about the most appropriate hormonal treatment for these tumors. Perhaps progesterone or prolactin therapy should be tried, alone or in combination with estrogen. If further studies confirm these findings, females with a family history of desmoid tumors should not be advised against pregnancy.

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 determine the biologic significance of tumor response and the prognostic value of molecular markers in a group of patients with rectal cancer treated with preoperative radiation therapy and radical surgery.METHODS:Microsatellite instability, microvessel count, and immunohistochemistry for proliferating cell nuclear antigen, p53, p21, bcl‐2, and vascular endothelial growth factor were performed in the preradiation biopsy specimen of 72 patients with rectal cancer treated by preoperative radiation therapy and radical curative surgery. Preoperative tumor stage by endorectal ultrasound was compared with pathology stage of the resected specimen. Mean follow‐up was 50 months.RESULTS:Twenty‐eight patients (39 percent) responded to radiation therapy. The response was complete in 8 (12 percent) and partial in 20 patients (27 percent). Tumors with positive nodes in the surgical specimen were less likely to have responded to preoperative radiation (P=0.03). Only p21 expression was individually associated with response to radiation (56vs.30 percent;P=0.03). Tumors that were p53‐negative/p21‐positive or p21‐positive/bcl‐2‐positive were also more likely to respond to radiation (83vs.35 percent;P=0.03 and 71vs.31 percent;P=0.01, respectively). The tumor relapsed in 21 patients (29 percent): locally in 7 (10 percent) and distally in 14 (19 percent). Recurrence was associated with lack of response to radiation, female gender, distal tumor location, high proliferating cell nuclear antigen labeling index, and low microvessel count. Probability of survival was greater for patients with well or moderately differentiated tumors and tumors that responded completely to radiation.CONCLUSIONS:Tumor response to radiation is associated with improved tumor control and overall survival rate, and p21 expression is a marker of tumor radiosensitivity in patients with rectal cancer. Furthermore, a high proliferating cell nuclear antigen labeling index and a low microvessel count in the preradiation biopsy specimen may be prognostic indicators for tumor recurrence.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:The role of extended resections for locally advanced carcinomas of the right colon infiltrating duodenum and pancreas remains unclear. This investigation was undertaken to review our experience with pancreatic head or duodenal resections for advanced right‐sided colon cancer.METHODS:The clinical, pathologic, and follow‐up details of eight patients with bulky primary carcinomas of the right colon infiltrating the duodenum (n=4) or pancreatic head (n=4) surgically managed at Memorial Sloan‐Kettering Cancer Center between 1986 and 1998 were reviewed.RESULTS:Six patients presented with anemia, and one patient each with epigastric pain and an abdominal mass. All patients had T4 lesions, whereas five had lymph node metastases at presentation. All patients were resected with clear pathologic margins either by right colectomy anden blocduodenectomy (n=4), oren blocpancreaticoduodenectomy (n=4). The 30‐day mortality rate was zero. Six patients remained alive and free of disease at a median follow‐up of 26 months, and there was one long‐term survivor who was alive and free of disease at 84 months after resection.CONCLUSION:Extended resection for localized primary colonic carcinoma invading pancreas or duodenum can be undertaken safely and is associated with prolonged survival time.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Recent prospective studies have recommended primary repair for all penetrating colon injuries. We evaluated our management trends given these recommendations and assessed our results of primary repair.METHODS:A retrospective review was conducted of 145 patients with penetrating colon injuries received between January 1, 1991, and December 31, 1997. The patients were characterized according to demographics and severity of injury. Morbidity was defined as failure of a primary repair, abscess, fistula, wound dehiscence, fasciitis, sepsis, organ failure, or coagulopathy. The periods 1991 to 1993 (early period) and 1994 to 1997 (late period) were chosen for comparison.RESULTS:Primary repairs were performed in 53 of 75 patients (71 percent) during the early period and in 61 of 70 patients (87 percent) during the late period (P=0.03). No significant differences in demographics or injury severity were found to account for the increased rate of primary repairs. The number of suture repairs was nearly equal in both periods (59vs.61 percent). The number of resections and anastomoses for destructive colon injuries was significantly higher in the late period (26 percent) compared with the early period (12 percent;P=0.05). Morbidity was equal (24 percent) in the two periods. There were no failures of resections and anastomoses and one failure of suture repair.CONCLUSIONS:Increased primary repair occurred because of more liberal use of resection and anastomosis for destructive injuries. Suture repair was performed for the amenable colonic injury throughout the study period. Risk factors for failure of resection and anastomosis cannot be defined from our study. Further investigation is needed to determine if resection and anastomosis is safe for the most severely injured patients.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:A study was performed to evaluate the early morphologic and functional consequences of vaginal delivery on the anal sphincter in primiparous females.METHODS:Among a cohort of 197 primiparous females who agreed to participate in a clinical evaluation of fecal incontinence and in a transanal ultrasound examination 12 weeks after delivery, 52 also underwent anal manometry using a radial six‐port catheter, of whom 10 were asymptomatic and had a normal sphincter at ultrasound and the remaining 42 had clinical signs of anal incontinence or ultrasonographic defects of the anal sphincter or both. Anal sphincter pressures and asymmetry index were analyzed at rest and during voluntary squeeze. Manometric and ultrasound results were compared, together with clinical symptoms.RESULTS:Fourteen patients with clinical signs of anal incontinence had lower resting and squeeze anal pressures than continent patients (P<0.05), but similar anal asymmetry indexes. Patients with incontinence and an anal defect had the lowest resting and squeeze anal pressures (P<0.05). Forceps assistance to delivery was not associated with a higher frequency of anal sphincter lesions. Resting and squeeze anal pressures were lower in the forceps group (P<0.005), but anal asymmetry indexes were similar. Finally, manometric results were identical in the presence or absence of anal sphincter endosonographic defects.CONCLUSIONS:Anal sphincter defects are frequent after the first vaginal delivery, but are not always associated with functional or clinical abnormalities. Resting and squeeze anal pressures were significantly decreased in patients with incontinence and an anal defect and after forceps‐assisted deliveries. Anal asymmetry index was not found useful in this population of young primiparous females.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:The findings of paradoxical puborectalis contraction, rectocele, sigmoidocele, intussusception, and abnormal perineal descent often coexist in constipated patients, as noted by defecographic study. Moreover, some of these conditions are often found in asymptomatic patients. Biofeedback is the treatment of choice for constipated patients with paradoxical puborectalis contraction; the main determinant of successful biofeedback is patient compliance. The significance of coexistent and highly prevalent variants, such as rectocele, intussusception, sigmoidocele, or abnormal perineal descent, on the success of biofeedback is unknown. This review was designed to assess whether these coexisting defecographic findings have any prognostic significance for the outcome of biofeedback.METHODS:From July 1988 to December 1996, 209 constipated patients with paradoxical puborectalis contraction underwent biofeedback treatment after defecography. A total of 173 patients (120 females) who had more than one biofeedback session after defecography formed the study group. Defecographic findings included concomitant rectoceles, 40 (23 percent); evidence of circumferential intussusception, 17 (10 percent); sigmoidocele, 13 (8 percent); and abnormal perineal descent, 109 (63 percent).RESULTS:Whereas 65 patients failed to complete the course of biofeedback therapy, 108( 62.4 percent) patients completed the course of biofeedback and were discharged by the therapist. Within the completed group 59 (55 percent) improved, and 49 (45 percent) patients failed biofeedback therapy. In the improved group 14 (23.7 percent) had a rectocele, 5 (8.5 percent) had intussusception, 5( 8.5 percent) had a sigmoidocele, and 37 (62.7 percent) had abnormal perineal descent. In the failure group 9 (18.4 percent) had a rectocele, 5 (10.2 percent) had an intussusception, 2 (4.1 percent) had a sigmoidocele, and 31 (63.3 percent) had abnormal perineal descent (P=not significant). The success of biofeedback was then analyzed relative to the number of coexisting conditions. Specifically, the outcome in patients with paradoxical puborectalis contraction alone and with one, two, and three other defecographic findings were compared. No statistically significant difference was found among these four groups.CONCLUSION:Although other defecographic findings frequently coexist with paradoxical puborectalis contraction, none of the concomitant findings adversely affected the outcome of biofeedback treatment. Therefore, biofeedback can be recommended to patients with coexistent defecographic findings, with expectation of success in over 50 percent of individuals who complete the course of therapy.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:Local recurrence of rectal cancer after curative surgery appears in 5 to 30 percent of all cases. It is necessary to detect local recurrence in a resectable stage to have an opportunity for currative reintervention or palliative prevention of those symptoms. Because most local recurrences occur extraluminally, conventional follow‐up fails to detect them at an early stage. Therefore, a prospective study was performed to assess the diagnostic potential of endorectal and endovaginal ultrasound to detect asymptomatic resectable local recurrence.METHODS:In 338 patients 721 endoluminal ultrasound examinations were added to routine follow‐up of rectal and left colonic cancer, with a mean of 2.1 (range, 1‐10) endoluminal ultrasound examinations for each patient.RESULTS:A total of 116 patients (34.3 percent) were shown to have local recurrence, which was suggested by endoluminal ultrasound and proven by endoluminal ultrasound‐guided needle biopsy in all cases of unclear pararectal structures that could not be verified by endoscopic biopsy. Digital examination failed to detect local recurrence in 91 patients, endoscopy failed to detect local recurrence in 80 patients, and the levels of tumor markers were normal in 25 patients with confirmed local recurrence. In 33 cases of local recurrence, both digital examination and endoscopy results were normal. Twenty‐five patients, in whom carcinoembryonic antigen levels, digital examination, and endoscopy results were normal, underwent potential curative reoperation, with total resection of the local recurrence. All 25 patients were still alive at the end of the study period, and 21 were free from disease. On the other hand, only 6 of 67 patients with local recurrence detectable by conventional follow‐up could be operated on with curative intention.CONCLUSION:Postoperative endoluminal ultrasound is able to detect local recurrence at an earlier and asymptomatic stage and can be verified by endosonography‐guided needle biopsy. Routine use in follow‐up may raise the ratio of curative retreatment by early detection of extramural local recurrence.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

OBJECTIVE:There are significant differences in patient outcome after potentially curative surgery for colorectal cancer that relate to the surgeon performing the procedure. The reasons for these differences remain obscure. The aim of this study was to examine the effect of the surgeon's specialty on patient outcome after potentially curative colorectal cancer surgery and to identify factors that may help explain differences in outcome among specialty groups.METHODS:Between 1990 and 1993, 378 patients underwent potentially curative surgery for colorectal cancer by surgeons with different specialty interests, vascular or transplant, general, and colorectal surgeons, in a large teaching hospital. Information on operative details, including the length of the resection specimen, resection margins, whether the tumor was removed withen blocresection of adjacent clinically involved organs, number of lymph nodes removed, and stage was collected. Factors affecting both local and overall recurrence rates were analyzed using logistic regression analysis at both univariate and multivariate levels.RESULTS:At a median follow‐up of 45 months the only factors associated with a significantly reduced local recurrence rate were the length of the resection specimen (odds ratio, 0.56; 95 percent confidence interval, 0.31‐0.99) and colorectal specialty (P=0.04). Patients operated on by a general surgeon were 3.42 times (95 percent confidence interval, 1.32‐8.9) more likely to develop a local recurrence than those operated on by a colorectal surgeon. For overall recurrence, early stage disease (P<0.0001), absence of vascular invasion (0.005), and colorectal specialty (0.025) were the only factors associated with significantly improved outcome at multivariate analysis.CONCLUSIONS:These data show that surgeons with an interest in colorectal cancer achieve lower local and overall recurrence rates compared with vascular or transplant or general surgeons. Differences in local recurrence rates seem to be predominantly related to the extent of resection performed and demonstrate the need to remove an adequate specimen when performing potentially curative colorectal cancer surgery.

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 evaluate the efficacy of photodynamic therapy in the management of residual neoplasms of the perianal skin.METHODS:This is a retro‐spective review. Five patients with pathologic confirmation of residual perianal neoplasms were treated with photodynamic therapy. There were three females. The mean age was 52 (range, 33‐79) years. Pathology consisted of Bowen's disease in two patients, squamous‐cell carcinoma in two patients, and extramammary Paget's disease in one patient. Four patients received one photodynamic therapy treatment and one patient received two treatments three months apart.RESULTS:Treatment was followed by immediate perianal erythema, subsequent blister formation in 36 to 48 hours, and sloughing of the treated area in 72 hours. With a mean follow‐up of 5.2 (range, 1‐8) years, there were two recurrences. One recurrence was in a patient four years after treatment for Paget's disease, and the other was in a patient nine months after treatment for Bowen's disease. The latter was managed successfully with wide local excision. Treatment‐related toxicities included significant perianal pain in four patients, controlled with analgesia management.CONCLUSIONS:Photodynamic therapy can successfully be used after wide local excision for residual neoplasms of the perianal skin. Treatment can be rendered with acceptable morbidity.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

PURPOSE:A prospective, randomized trial was performed between 1979 and 1981 comparing anal dilation and hemorrhoidectomy for hemorrhoidal disease at the Maastricht University Hospital. The aim of this study was to update that trial to assess long‐term outcome and complications such as fecal incontinence.METHODS:A total of 138 patients with second‐degree and third‐degree hemorrhoids entered the study. Median follow‐up was 17 (range, 8.4‐18.3) years and was achieved for 118 (86 percent) patients. Group A (n=35) underwent hemorrhoidectomy and Group B (n=39) was treated with anal dilation and aftertreatment (original Lord's procedure), whereas Group C (n=44) had dilation only. Fourteen of these patients died.RESULTS:Recurrent hemorrhoids were noted for 26 percent of the patients treated with hemorrhoidectomy, for 46 percent with operative dilation with the postoperative dilation program, and for 39 percent with operative dilation without the postoperative program. The percentage of repeated treatment for the three subgroups was 11, 23, and 18 percent, respectively. The continence status remained more or less the same during the first year. However, 17 years later the anal stretch procedures caused various incontinence disorders in 52 percent of these patients. Significance was found for incontinence of flatus (from 11 to 30 patients;P=0.04) in the anal dilation groups.CONCLUSIONS:Hemorrhoidectomy can be considered to be a safe procedure for treatment of hemorrhoidal disease, with excellent long‐term results. Anal dilation is associated with a high percentage of complaints of fecal incontinence. The procedure should be abandoned.

ISSN:0012-3706    

出版商:OVID    

年代:2000

数据来源: OVID