摘要:

&NA;Laparoscopic surgery has evolved rapidly since 1989. The American Society of Colon and Rectal Surgeons, the Society of American Gastrointestinal Endoscopic Surgeons, and the American College of Surgeons Commission on Cancer jointly sponsored a registry to identify as early as possible the patterns of practice and acute complications of laparoscopic colectomy.METHODS:Cases were voluntarily registered by community and academic surgeons. Information was entered in the EPI‐5 database.RESULTS:One thousand fifty‐six cases were contributed by 118 surgeons; 763 patients were completed laparoscopically. The most common indication for surgery was cancer in 453 patients. The right colon (n=364) and sigmoid (n=294) were most frequently resected. Respondents felt adequate cancer resections were performed. Although several unique complications were noted, intraoperative complications were similar in type and frequency to open cases.CONCLUSION:Laparoscopic colorectal surgery can be performed with acceptable complications. It remains unclear if this approach is adequate for long‐term management of colon and rectal cancer.

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 whether any method of hemorrhoid therapy has been shown to be superior in randomized, controlled trials.METHOD:A meta‐analysis was performed of all randomized, controlled trials assessing two or more treatment modalities for symptomatic hemorrhoids. Outcome variables included response to therapy, need for further therapy, complications, and pain.RESULTS:A total of 18 trials were available for analysis. Hemorrhoidectomy was found to be significantly more effective than manual dilation of the anus(P=0.0017), with less need for further therapy(P=0.034), no significant difference in complications(P=0.60), but significantly more pain(P<0.0001). Patients undergoing hemorrhoidectomy had a better response to treatment than did patients treated with rubber band ligation(P=0.001), although complications were greater(P=0.02) as was pain(P<0.0001). Rubber band ligation was better than sclerotherapy in response to treatment for all hemorrhoids(P=0.005) as well as for hemorrhoids stratified by grade (Grades 1 to 2;P=0.007; Grade 3 hemorrhoids,P=0.042), with no difference in the complication rate(P=0.35). Patients treated with sclerotherapy(P=0.031) or infrared coagulation(P=0.0014) were more likely to require further therapy than those treated with rubber band ligation, although pain was greater after rubber band ligation(P=0.03 for sclerotherapy;P<0.0001 for infrared coagulation).CONCLUSION:Rubber band ligation is recommended as the initial mode of therapy for Grades 1 to 3 hemorrhoids. Although hemorrhoidectomy showed better response rates, it is associated with more complications and pain than rubber band ligation, thus should be reserved for patients who fail to respond to rubber band ligation.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:This study was designed to determine the accuracy of physical examination (as judged by four‐contrast defecography) for women with pelvic floor relaxation disorders.METHODS:Sixty‐two women (mean age, 59 years) who had obstructed defecation or constipation, vaginal prolapse, urinary difficulty, or pelvic pain underwent four‐contrast defecography. Oral, vaginal, bladder, and rectal contrast were administered selectively and fluoroscopy was performed. Radiographic findings were compared with physical examination diagnosis.RESULTS:Four‐contrast defecography changed the diagnosis in 46 patients (75 percent); 26 percent of presumed cystoceles, 36 percent of enteroceles, and 25 percent of rectoceles were not present on defecography. Defecography also revealed unsuspected coexisting defects in addition to known abnormalities detected on physical examination. In contrast, when physical examination was negative for these defects, 63 percent of patients were found to have cystoceles, 46 percent to have enteroceles, and 73 percent to have rectoceles on four‐contrast defecography. The discovery of Grade 2 or 3 unsuspected abnormalities was significant, especially so for enteroceles. For posterior vaginal eversions extending to or past the introitus, physical examination was accurate in only 61 percent. Physical examination of large anterior defects was more accurate, with 74 percent of patients being correctly diagnosed.CONCLUSIONS:Physical examination diagnosis of pelvic floor relaxation disorders is frequently inaccurate, especially for large vaginal eversions. Four‐contrast defecography improves diagnostic accuracy, helps to identify all pelvic floor defects before surgery, and can assist with planning the correct operative approach.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:This study was designed to investigate the effect of lateral sphincterotomy on internal anal sphincter function in patients with chronic anal fssure.METHODS:Using an eight‐channel perfusion catheter and computerized data analysis, a prospective manometric study was performed on patients with chronic anal fissure undergoing lateral sphincterotomy (LS).RESULTS:Mean resting pressure (MRP) in patients with anal fissure (85.1 mmHg) was significantly higher(P=0.012) than control subjects (63.3 mmHg). One week following LS there was a significant reduction in MRP (50.0 mmHg;P=0.0014), and this was maintained when reassessed five weeks later (MRP=56.4 mmHg;P=0.0019). There was no significant difference in coefficent of variation (a measure of the degree of manometric asymmetry of the anal canal) in the control group (mean, 8.9 percent) and in patients with anal fissure (mean, 7.7 percent;P=0.43). LS created a significant increase in anal canal resting manometric asymmetry when assessed at one (mean, 17.3 percent;P=0.0013) and six weeks (mean, 11.7 percent;P=0.027) after the procedure.CONCLUSION:LS produces a global and symmetric decrease in anal canal resting pressure. In addition, it produces a significant increase in manometric asymmetry of the resting anal canal by creating a detectable segmental defect.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:The extent of lymph node dissection optimal for the prognosis of right colon cancer is investigated.METHODS:Between 1946 and 1991, 275 patients had curative operation for right colon cancer. A retrospective analysis of rate and degree of lymph node metastasis was performed in each of the 275 patients, and survival rate was estimated in 197 patients who could be followed over a period of three years or more.RESULTS:In most of the curative operative cases of right colon cancer, metastasis to epicolic and paracolic nodes was restricted up to 10 cm proximal or distal to the tumor margin, and metastasis in the central direction was restricted up to main nodes. When cancer metastasized to infrapyloric lymph nodes, dissection of the nodes resulted in a higher rate of long‐term prognosis. The five‐year cumulative survival rates showed no statistically significant difference between any two of the N0 to N3 lymph node metastasis groups.CONCLUSION:The dissection procedure for right colon cancer involved removal of 10 cm of normal bowel both proximal and distal to the lesion and, in the central direction, dissection of regional lymph nodes along the main trunk artery up to main nodes,i.e.,nodes situated anterior to the surgical trunk, which was confirmed to have a therapeutically satisfactory benefit. Infrapyloric lymph nodes must be dissected when metastasis to the nodes is suspected. In cases of cecal or ascending colon cancer in which the middle colic artery is no longer the main trunk artery, a right hemicolectomy with resection of only the right branch of the middle colic artery will usually suffice.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:The inflammatory process associated with Crohn's disease often makes dissection difficult, even in “open” surgery. This study was undertaken to determine if dissection and resection could be performed laparoscopically and whether it would benefit this group of patients.METHODS:Between November 1992 and November 1994, laparoscopic‐assisted intestinal resection was attempted in 18 patients with Crohn's disease and was successfully completed in 14. One patient had ileal disease, requiring ileal resection with ileoileal anastomosis. The remainder had disease requiring ileocolic resections. Muscle‐splitting incisions averaging 5 cm in length were made to facilitate removal of specimens.RESULTS:Commencement of oral alimentation was possible at an average of 3.6 (range, 1‐7) days postoperatively. Discharge occurred at an average of 6.6 (range, 4‐9) postoperative days. In comparison, 14 patients operated on by the authors for the same disease in the open manner during the past six months stayed an average of 8.5 (range, 5‐14) postoperative days. Postoperative complications were minimal.CONCLUSIONS:On the basis of this initial study, it appears that laparoscopic‐assisted intestinal resection can be readily performed in patients with Crohn's disease. In our early experience, we have found that laparoscopic mobilization and resection may be difficult or impossible in patients with large fixed masses, multiple complex fistulas, or recurrent Crohn's disease. Extraction incisions are frequently so large in these patients that they do not derive the same benefits from laparoscopic surgery that are enjoyed by patients without these findings. Most patients having laparoscopic resections eat earlier, may require fewer narcotics, and are able to be discharged from the hospital an average of two days earlier than patients operated on in an open manner. In addition, it appears that laparoscopic‐assisted intestinal resection results in a shorter, easier convalescence and an earlier return to full activity.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:A variety of adjuvant treatments and cytoprotective agents have been proposed to lessen the toxicity of radiation therapy. The following study was designed to evaluate the benefit of six agents or combinations using anastomotic bursting strength as a measure of transmural radiation injury.METHODS:The 40‐Gy study consisted of the following. Seventy‐two male Sprague‐Dawley rats were divided into eight equal groups: nonradiated control, radiated untreated control, and six radiated treated groups. The radioprotective treatments included ribose‐cysteine (RibCys), WR‐2721, glutamine, vitamin E, MgCl2/adenosine triphosphate, and RibCys/glutamine in combination. Radiated animals received 40 Gy to the abdomen. Two weeks after radiation, all animals underwent small bowel and colonic resection with primary anastomosis. Animals were sacrificed one week postoperatively, at which time anastomoses were evaluated and bursting strengths determined. The 70‐Gy study consisted of the following. The same protocol was repeated for five groups of nine rats divided into nonradiated, radiated untreated, and three radiated treated groups receiving RibCys (8 mmol/kg), RibCys (20 mmol/kg), and WR‐2721. All radiated animals received 70‐Gy doses.RESULTS:In the 40‐Gy group, there were 10 radiation‐related deaths and 6 anastomotic leaks among 70 rats studied. None of the differences between groups were significant. Nonradiated control group small bowel and large bowel anastomotic bursting pressures were significantly elevated compared with all radiated groups. Compared with radiated controls, there were significant improvements in small bowel bursting strength in the RibCys, WR‐2721, RibCys‐glutamine, and vitamin E groups and significant improvement in colonic bursting strength in MgCl2/adenosine triphosphate, WR‐2721, and RibCys groups. In the 70‐Gy group, all nine nonradiated control rats survived. All eight untreated radiated control rats died, four of eight WR‐2721 animals died (P=0.03), all RibCys (8 mmol/kg) animals died (P=0.03), and three of nine treated with RibCys (20 mmol/kg) survived (P=0.08).CONCLUSIONS:WR‐2721 and RibCys gave consistent protection against large and small bowel radiation injury. The lower incidence of treatment‐related toxicity and potentially equal or greater radioprotective effects may make RibCys more clinically useful than WR‐2721.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:A survey was undertaken to assess the impact of laparoscopy on the practice of colorectal surgery.METHODS:A total of 1,520 questionnaires were mailed to all members of the American Society of Colon and Rectal Surgeons; 635 (42 percent) surgeons responded, 50 percent, and indicated that one questionnaire represented their entire group practice.RESULTS:Two hundred seventy‐eight (47 percent) respondents currently perform laparoscopic colorectal surgery; 62 percent (171) use the laparoscope for ≤20 percent of their bowel resections. Conversely, only 6 percent (16) use the laparoscope in over 50 percent of resections. The percentage of surgeons who perform various procedures were right colectomy, 78 percent; left colectomy, 57 percent; stoma creations, 52 percent; anterior resection, 44 percent; Hartmann's closure, 42 percent; abdominoperineal resection, 27 percent; rectopexy, 18 percent; and total colectomy, 14 percent. If the preoperative diagnosis is known to be carcinoma, 196 (71 percent) surgeons attempted laparoscopic colorectal surgery, but 55 percent of surgeons (108) operated only for early lesions and 35 percent (68) only for palliation. To enable the procedure to be laparoscopically performed, 87 percent (243) of surgeons stated that they have changed their practice to include routine use of ureteral stents (23 percent), preoperative colonoscopic marking of small lesions (40 percent), or intraoperative colonoscopy. Despite increased use of endoscopy, there were 18 patients in whom the wrong segment of colon was removed. Moreover, nine patients had early local recurrence after resection of colon cancer, nine had early local recurrence after rectal cancer resection, and five had early port‐site recurrence. Although 255 (40 percent) surgeons surveyed would themselves undergo laparoscopic colorectal surgery for a rectal villous adenoma, only 38 (6 percent) would have a laparoscopic anterior resection for cancer.CONCLUSIONS:Several important problems exist including early port‐site recurrence and a dual surgical standard. Although many surgeons are eager to practice laparoscopic colorectal surgery on their patients with carcinoma, they are reluctant to have the new technique applied to themselves.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

PURPOSE:Controversy exists as to whether fissure patients have elevated resting pressures when compared with control patients. The diameter of manometry catheters used in past studies varies widely (1.5‐25 mm) and may have contributed to differences observed in resting pressures. A prospective study was undertaken to determine the influence of manometry catheter diameter on maximum resting pressure in patients with idiopathic chronic anal fissures.METHODS:A total of 28 fissure patients and 28 control patients had manometry performed with both a 1.8‐mm and a 4.8‐mm (external diameter) water‐perfused catheter.RESULTS:Mean maximum resting pressure (RP) for fissure patients as measured with the 1.8‐mm catheter was 86 (range, 65‐115) mmHg and 83 (range, 47‐117) mmHg with the 4.8‐mm catheter(P=0.65). Mean maximum RP for control patients with the 1.8‐mm catheter was 70 (range, 30‐108) mmHg and 72 (range, 35‐109) mmHg with the 4.8‐mm catheter(P=0.07). When fissure and control patients were compared, a significantly higher mean RP was observed in the fissure group for both the 1.8‐mm catheter (86vs.70 mmHg, respectively;P=0.01) and the 4.8‐mm catheter (83vs.72 mmHg, respectively;P=0.03). There was no significant difference in length of the high‐pressure zone within each group or when the fissure group and controls were compared, regardless of catheter used. For both groups of patients, there was a significantly higher incidence of ultraslow waves (USWs) observed with the 4.8‐mm catheter when compared with the 1.8‐mm catheter. The USW frequency was not significantly different when fissure and control groups were compared with either catheter type.CONCLUSIONS:Catheter size did not influence measured maximum RP in fissure patients. The maximum RP was significantly greater for fissure patients overall when compared with the control group, regardless of catheter used. There was an increased frequency of USWs noted with the larger catheter size in all patients; however, these USWs only became apparent when catheter was left at each station until a true baseline RP was obtained.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

&NA;Diminished levels for fecal short chain fatty acids (SCFAs) have been linked to occurrence of ulcerative colitis, colorectal polyps, and colon cancer, diseases that are rare or uncommon in African populations.PURPOSE:The aim of this study was to determine fecal SCFA concentrations and fecal pH values in groups of black South Africans (African) and white South Africans (white) subjects.METHODS:Twenty healthy Africans (all women; mean age, 35 years) and 17 healthy whites (7 women; 10 men; mean age, 32 years) were tested.RESULTS:Mean total concentrations of SCFAs in the two groups were 142.1 (±53.9) and 69.2 (±26.0) mmol/kg wet feces, respectively(P=0.0001). Mean values for Africans were significantly higher in all subfractions except butyrate. There was a significant inverse correlation between fecal pH value and total fecal SCFA concentration(r=0.704;P=0.001).CONCLUSION:High concentrations of fecal SCFAs in the African group could protect against chronic bowel diseases.

ISSN:0012-3706    

出版商:OVID    

年代:1995

数据来源: OVID