摘要:

PURPOSE:In terms of functional outcome, there is evidence of the superiority of the colonic J‐pouch over a straight coloanal anastomosis. Even though the colonic J‐pouch was created to restore a neorectal reservoir, manometric data show that the volume of a short colonic J‐pouch does not differ from a straight coloanal anastomosis. We speculate that the advantage of the colonic J‐pouch is not in creating a larger neorectal reservoir, but rather related to decreased motility. Maurer and Z'graggen recently described a new colonic pouch design, performing a “transverse coloplasty” pouch. The purpose of this pilot study was to compare the feasibility and functional outcome of the 5‐cm colonic J‐pouchvs.the coloplasty pouch.METHODS:From February 2000 to June 2001, we randomized 40 consecutive patients with distal rectal cancer (<12 cm from the anal verge) into the J‐pouch or coloplasty group. A low rectal resection and coloanal anastomosis was performed in all patients. Functional data were collected by a standardized questionnaire and anorectal manometry, preoperatively and six months postoperatively. Primary end points of the study were potentially differences of both groups regarding technical feasibility, stool frequency, and anorectal manometry.RESULTS:The construction of a coloplasty pouch was feasible in all cases of the coloplasty group, but not in 5 of 20 (25 percent) patients of the J‐pouch group, because of colonic adipose tissue. Six months after operation or stoma closure, respectively, stool frequency was 2.75 ± 1 per day in the J‐pouch group and 2 ± 2 per day in the coloplasty group. There was no significant difference in resting and squeeze pressure and neorectal volume between both groups, but an increased neorectal sensitivity in the coloplasty group.CONCLUSION:We found similar functional results in the coloplasty group compared to the J‐pouch group. The neorectal sensitivity was increased in the coloplasty group. Therefore, the colonic coloplasty seems to be an attractive pouch design because of its feasibility, simplicity, and effectiveness.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:A prospective trial was conducted to establish long‐term healing of complex idiopathic anorectal fistula, without extension, after fibrin glue treatment, with clinical assessment and magnetic resonance imaging to determine tract healing.METHODS:Twenty‐two patients undergoing glue instillation after fistula curettage and irrigation were followed up for a median of 14 months. Clinical assessment, short tau inversion recovery sequence magnetic resonance imaging, and combined short tau inversion recovery and dynamic contrast‐enhanced magnetic resonance imaging were performed at a median of three months postoperatively, and their ability to predict outcome in the presence of early skin healing was determined.RESULTS:Of 22 patients, 19 (86.5 percent) had transsphincteric fistulas, 1 (4.5 percent) had a suprasphincteric fistula, 1 (4.5 percent) had an extrasphincteric fistula, and 1 (4.5 percent) had a rectovaginal fistula. None had clinical or radiologic evidence of secondary extension. Despite skin healing in 17 (77 percent) of 22 patients at a median of 14 days after treatment, only 3 (14 percent) remained healed at 16 months. Magnetic resonance imaging with short tau inversion recovery sequences in combination with dynamic contrast‐enhanced magnetic resonance imaging predicted outcome in all 10 assessments (100 percent), compared with short tau inversion recovery sequence alone in 16 (94 percent) of 17 assessments or clinical examination in 12 (71 percent) of 17 (P= 0.02).CONCLUSIONS:The success rate of fibrin glue application for complex anorectal fistulas without extension is 14 percent. Magnetic resonance imaging predicts outcome at an earlier stage than clinical examination.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:One of the concerns with colectomy and ileorectal anastomosis as a prophylactic procedure for patients with familial adenomatous polyposis is the risk of metachronous rectal cancer, estimated at from 12 to 43 percent. These estimates are based largely on surgeries performed at a time when the only alternative option to ileorectal anastomosis for patients with severe familial adenomatous polyposis was proctocolectomy and ileostomy. This study was designed to test the hypothesis that in the pouch era severe polyposis is now treated by proctocolectomy and ileal pouch‐anal anastomosis. Ileorectal anastomosis is performed mostly in mildly affected patients and will therefore carry a very low risk of metachronous rectal cancer.METHODS:Patients undergoing primary prophylactic surgery for familial adenomatous polyposis between 1950 and 1999 were categorized according to the year of their surgery: prepouch era (before 1983) or pouch era (after 1983). Patients undergoing colectomy and ileorectal anastomosis were the focus of the study, and rate of proctectomy and the incidence of rectal cancer were recorded for each group. Data on the severity of the polyposis for each group were abstracted.RESULTS:A total of 197 patients underwent ileorectal anastomosis, 62 in the prepouch era (median follow‐up, 212 months; interquartile range, 148 months) and 135 in the pouch era (median follow‐up, 60 months; interquartile range, 80 months). Patients in the prepouch era came to surgery at the same median age as those in the pouch era (median age 23.0 years, interquartile ranges 15.5 years for prepouch and 17 years for pouch). Similar proportions of patients in the prepouch era had severe polyposis (49 percent) as in the pouch era (44 percent), although all severely affected patients had an ileorectal anastomosis in the prepouch eravs.39 percent in the pouch era. Twenty (32 percent) prepouch‐era patients underwent proctectomy compared with three (2 percent) pouch‐era patients. No pouch‐era patient had rectal cancer on follow‐up; eight (12.9 percent) prepouch‐era patients did.CONCLUSION:Although follow‐up is shorter, ileorectal anastomosis for familial adenomatous polyposis performed since 1983 carries a much lower rate of rectal cancer and proctectomy than ileorectal anastomosis performed before this time, when restorative proctocolectomy was not an option. This is related, at least in part, to a greater number of patients with severe polyposis having their rectum initially spared.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

INTRODUCTION:The effect of pelvic radiotherapy on anorectal function is not clearly documented and is investigated in this prospective study.METHODS:Thirty‐one males (median age, 70 years) with carcinoma of the prostate (n = 28) and bladder (n = 3) completed proctitis/incontinence symptom score questionnaires and anorectal physiology studies before and six weeks after pelvic radiotherapy. At six months after completion of radiotherapy, 25 of these patients were studied again. The results were expressed as medians and ranges and compared by the Mann‐WhitneyUtest (2‐tailed).RESULTS:Six weeks and six months after treatment, respectively, the proctitis symptom scores (0 (0‐4)vs.2 (0‐7) (P< 0.001)vs.2 (0‐5) (P< 0.001)) and the incontinence symptom scores (0 (0‐5)vs.4 (0‐11) (P< 0.001)vs.3 (0‐14) (P< 0.001)) increased. Urgency, frequency of defecation, anorectal pain, incontinence to liquid stool and to flatus, and alteration in lifestyle were significant symptoms after treatment. The following measurements decreased: anal canal resting pressure (83 (35‐137)vs.79 (26‐152) (P= NS)vs.71 (29‐97) (P< 0.01) cm H2O), the squeeze increment (152 (51‐135)vs.162 (63‐321) (P= NS)vs.108 (45‐296) (P< 0.042) cm H2O), and the maximum tolerated rectal volume (245 (115‐450)vs.194 (112‐344) (P< 0.05)vs.200 (109‐350) (P< 0.138) ml). The rectal electrosensory threshold increased (20 (5.4‐44)vs.22 (9‐50.5) (P< 0.134)vs.31.5 (13.6‐76) (P< 0.001) mA).CONCLUSIONS:Anorectal symptoms at six weeks after pelvic radiotherapy are related to reduced rectal capacity and compounded at six months by diminished internal and external sphincter function and rectal mucosal sensitivity.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:The purpose of this study was to determine whether a complete pathologic response after neoadjuvant therapy in rectal cancer patients improves disease control and survival.METHODS:The study reviewed Stage II and III rectal cancer patients treated with preoperative chemoradiation and resected for cure. Complete pathologic response was defined as no cancer in the resected specimen. The main outcome measures were cancer‐specific and disease‐free survival in patients achieving a complete pathologic response and a noncomplete pathologic response. Kaplan‐Meier curves were evaluated using log‐rank analysis.RESULTS:Eighty‐nine rectal cancer patients received neoadjuvant chemoradiation followed by radical resection for cure. Twenty‐one patients (24 percent) achieved a complete pathologic response. Median follow‐up for the complete pathologic response group was 23.5 months and 31 months for the noncomplete pathologic response group. There were more Stage III patients in the noncomplete pathologic response group than the complete pathologic response group (P= 0.005). Complete pathologic response patients were less likely to receive postoperative adjuvant chemotherapy than noncomplete pathologic response patients (P= 0.004). Cancer‐specific and disease‐free survival were not statistically different between the two groups. However, a trend was noted toward improved survival and decreased recurrence in association with a complete pathologic response.CONCLUSION:Stage III patients were less likely to be in the complete pathologic response group than Stage II patients. Complete pathologic response patients were less likely to receive postoperative adjuvant chemotherapy than noncomplete pathologic response patients. Complete pathologic response after neoadjuvant chemoradiation for rectal cancer patients demonstrated a trend toward improved survival and decreased recurrence compared with noncomplete pathologic response patients.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:Eighty percent of local recurrence after resection of rectal adenocarcinoma classically occurs within two years of surgery. Pretherapeutic staging is frequently limited to clinical examination, although the accuracy of endoanal ultrasonography has been demonstrated. The aim of this study was to report the long‐term results of preoperative radiation therapy and resection of pretherapeutic endoanal ultrasonography‐staged T3 and T4 rectal adenocarcinoma.METHODS:This retrospective review analyzed a series of 113 patients who underwent radiation therapy followed by surgery. All patients underwent an endoanal ultrasonography. Median follow‐up was 75 months.RESULTS:Fifty‐seven percent of patients were pT3 or T4. Thirty‐six percent had involvement of lymph nodes. Five‐year rates of survival, local recurrence‐free survival, and disease‐free survival were 79, 73, and 68 percent, respectively. Ten‐year rates were 65, 63, and 62 percent, respectively. Median time to detection of local recurrence was 39 months. Eight of ten local recurrences occurred after two years of follow‐up. Eight of ten patients with local recurrence had pretherapeutic endoanal ultrasonography‐staged N+ tumors.CONCLUSION:These results appear to justify a follow‐up program for patients with pretherapeutic endoanal ultrasonography‐staged N+ tumor. However, a minimum of seven years of follow‐up is needed to obtain an accurate assessment of results.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

INTRODUCTION:A temporary loop ileostomy is often created to minimize the impact of peritoneal sepsis from an anastomotic dehiscence after a coloanal or low colorectal anastomosis. Such a stoma is usually closed after 6 to 12 weeks when the intestinal edema is reduced and the peristomal adhesions are less dense. This period is three to four times longer than necessary for assurance of anastomotic healing, which is usually achieved by the second week after surgery. With the use of a bioresorbable membrane to minimize the formation of peristomal adhesions, earlier closure is hypothetically possible at three weeks.METHODS:Patients undergoing creation of a defunctioning ileostomy were randomized in Phase I either to have an adhesion barrier membrane wrapped around the limbs of the ileostomy, with closure at three weeks, or to the control group, with no barrier membrane and closure after more than six weeks. In the subsequent Phase II, the efficacy of the barrier membrane was compared in a similar manner with a control group at ileostomy reversal after three weeks. Peristomal adhesions at the time of stomal mobilization were scored in a blinded manner.RESULTS:In Phase I, no statistically significant differences were noted in the mean adhesion scores between the two groups (7.42vs.7.28). However, in Phase II, when peristomal adhesions at closure were compared at three weeks for both groups, with and without adhesion barrier placement, there was a significant reduction in the overall mean adhesion scores (5.81vs.7.82, respectively). The number of patients with dense adhesions was also reduced in the adhesion barrier group. There was no significant difference in the time taken and the difficulty encountered during ileostomy closure in the two groups. A tendency to easier closure, as evidenced by a lower incidence of perioperative complications, was noted in the adhesion barrier group.CONCLUSION:An adhesion barrier membrane placed around the limbs of a defunctioning loop ileostomy reduces peristomal adhesion and facilitates early closure at three weeks with minimal complications.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:This review was designed to 1) critically examine the research design used in investigations of biofeedback for pelvic floor dyssynergia, 2) compare the various biofeedback treatment protocols for pelvic floor dyssynergia‐type constipation used in this research, 3) identify factors that influence treatment outcome, and 4) identify goals for future biofeedback research for pelvic floor dyssynergia.METHODS:A comprehensive review of both the pediatric and adult research from 1970 to 2002 on “biofeedback for constipation” was conducted using a Medline search in all languages. Only prospective studies including five or more subjects that described the treatment protocol were included. In addition, a meta‐analysis of these studies was performed to compare the outcome of different biofeedback protocols for treating constipation.RESULTS:Thirty‐eight studies were reviewed, and sample size, treatment protocol, outcome rates, number of sessions, and etiology are shown in a table. Ten studies using a parallel treatment design were reviewed in detail, including seven that randomized subjects to treatment groups. A meta‐analysis (weighted by subjects) was performed to compare the results of two treatment protocols prevalent in the literature. The mean success rate of studies using pressure biofeedback (78 percent) was superior (P= 0.018) to the mean success rate for studies using electromyography biofeedback (70 percent). However, the mean success rates comparing studies using intra‐anal electromyography sensors to studies using perianal electromyography sensors were 69 and 72 percent, respectively, indicating no advantages for one type of electromyography protocol over the other (P= 0.428). In addition to the varied protocols and instrumentation used, there also are inconsistencies in the literature regarding the severity and etiology of symptoms, patient selection criteria, and the definition of a successful outcome. Finally, no anatomic, physiologic, or demographic variables were identified that would assist in predicting successful outcome. Having significant psychological symptoms was identified as a factor that may influence treatment outcome, but this requires further study.CONCLUSION:Although most studies report positive results using biofeedback to treat constipation, quality research is lacking. Specific recommendations are made for future investigations to 1) improve experimental design, 2) clearly define outcome measures, 3) identify the etiology and severity of symptoms, 4) determine which treatment protocol and which component of treatment is most effective for different types of subjects, 5) systematically explore the role of psychopathology in this population, 6) use an adequate sample size that allows for meaningful analysis, and 7) include long‐term follow‐up data.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:Biofeedback is considered an effective treatment for anal incontinence, but a substantial proportion of patients fails to improve. The purpose of this study was to identify the key predictors of outcome.METHODS:We retrospectively analyzed the clinical and physiologic data of 145 patients consecutively treated in our unit for anal incontinence by biofeedback. Clinical evaluation was performed by means of a structured questionnaire that included previous history, symptoms of incontinence, and bowel habit. Anorectal evaluation measured anal pressure profiles, neural reflexes, defecatory dynamics, rectal compliance, and rectal sensitivity. Biofeedback treatment was performed by a manometric technique with reinforcement sessions scheduled every three months and daily exercising at home. Six months after the onset of biofeedback treatment the clinical response was evaluated as good (improvement of incontinence) or poor (no improvement or worsening).RESULTS:Of 126 patients (104 female; age range, 17‐82 years) with at least six‐month follow‐up, 84 percent had a good response to treatment. By univariate analysis, several factors, such as age, history of constipation, abnormal defecatory maneuver, and rectal compliance, were significantly related to treatment response, but by multivariate logistic regression only age and defecatory maneuver were independent predictors of the response. The association of both factors provided the best sensitivity and specificity; 48 percent of patients younger than age 55 years and with abnormal defecatory maneuver had negative response to treatment, whereas 96 percent of patients age 55 years or older with normal defecatory maneuver had a positive response.CONCLUSION:In patients with anal incontinence scheduled for biofeedback treatment, potential alterations of defecation should be first searched for and corrected, particularly in younger patients.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:This study was a retrospective analysis of complication rates, symptom recurrence, long‐term results, and patient satisfaction after outpatient excision (local anesthesia) of thrombosed external hemorrhoids.METHODS:From 1995 to 2000, 340 patients (166 males) underwent office‐based excision of thrombosed external hemorrhoids under local anesthesia. Data regarding complications, operations because of recurrence, residual symptoms, patient's satisfaction with anesthesia, and wound treatment were obtained by questionnaire. Response was solicited at a minimum of 9 months postprocedure.RESULTS:Complete follow‐up data was available in 88 percent of patients (mean follow‐up, 17.3 months). Recurrent thrombosed external hemorrhoid requiring a procedure developed in 22 (6.5 percent) patients. Other complications that required operative intervention were one (0.3 percent) incidence of postoperative bleeding and seven (2.1 percent) perianal abscess/fistula. The majority of patients (66 percent) had no anal complaints at follow‐up. Local anesthesia would be preferred if a repeat excision was required in 79 percent, whereas 11 percent would prefer another form of anesthesia and 10 percent were unsure.CONCLUSION:Outpatient excision under local anesthesia of a thrombosed external hemorrhoid can be safely performed with a low recurrence and complication rate while offering a high level of patient of acceptance and satisfaction.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID