ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

PURPOSE:Colorectal surgery, a high‐volume procedure, has been targeted for performance improvement to reduce length of stay. Specific postoperative quality indicators and readmission rates should be analyzed concomitantly to assure that adverse events are not associated with earlier discharge.METHODS:From July 1, 1990, to June 30, 1997, 1,218 consecutive patients who underwent transabdominal colorectal surgery were analyzed for length of stay, mortality, morbidity, and discharge disposition. Each patient was assigned an Admission Severity Group rating 0 to 4 using a hospital‐based state‐legislated software system (Atlas™) to validate comparative performance internally and externally. Readmission data within 120 days of discharge were available for the last 678 consecutive patients from July 1, 1993, to June 30, 1997, using Lastword™ (computerized medical records).RESULTS:The annual frequencies of the 1,218 procedures were 173, 183, 175, 146, 167, 189, and 185, respectively, from July 1990 through June 1997. Severity distribution was 32 for Admission Severity Group 0, 517 for Admission Severity Group 1, 540 for Admission Severity Group 2, 128 for Admission Severity Group 3, and 1 for Admission Severity Group 4, with no annual difference (P=0.012). There was a significant reduction in total length of stay of 3.1 (12.9‐9.8) days during the seven years (P=0.001). The overall operative mortality rate was 1.4 percent, and the morbidity was 2.6 percent, with no annual differences (P=0.655 andP=0.033, respectively). The disposition to home did not change (P=0.21). Of the 678 patients followed up for readmission, 100 (14.7 percent) were readmitted within 120 days, with no annual difference (P=0.302).CONCLUSION:Mortality, morbidity, disposition, and readmission rates were not affected by a decreased length of stay after colorectal surgery.

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

PURPOSE:The aim of this study was to compare four methods of biofeedback for patients with constipation.METHODS:Thirty‐six patients were prospectively, randomly assigned to one of four protocols: 1) outpatient intra‐anal electromyographic biofeedback training; 2) electromyographic biofeedback training plus intrarectal balloon training; 3) electromyographic biofeedback training plus home training; or 4) electromyographic biofeedback training, balloon training, and home training. All 36 patients received weekly one‐hour outpatient biofeedback training. Success was measured by increased unassisted bowel movements and reduction in cathartic use. In all instances patients maintained a daily log in which documentation was maintained regarding each bowel evacuation and the need for any cathartics.RESULTS;There was a statistically significant increase in unassisted bowel movements for Groups 1, 2, and 4 (P<0.05) and a reduction in the use of cathartics in Groups 1, 2, and 3 (P<0.05).CONCLUSION:There was a significant improvement in outcome after all four treatment protocols for constipation; however, no significant difference was found among the treatments. Therefore, electromyographic biofeedback training alone is as effective as with the addition of balloon training, home training, or both.

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

PURPOSE:The aim of this study was to investigate any possible relation between the severity of anorectal dysfunction in diabetes mellitus and duration of disease and presence of microangiopathy or neuropathy or both.METHODS:Standard multiport anorectal manometry was performed in 25 healthy control subjects (10 males; age (mean±1 standard deviation), 62±14 years) and 38 patients with diabetes mellitus. Patients were divided into two groups according to the duration of the disease: Group A (19 patients) with a duration less than 10 years (7.2±2.5; 8 males; age, 57±18) and Group B (19 patients) with a duration longer than 10 years (19.8±5.6; 6 males; age, 62±15).RESULTS:Results are reported as mean ± one standard deviation. Patients showed lower resting and squeeze anal pressures (P<0.01), impaired rectoanal inhibitory and anocutaneous reflexes, and reduced sensitivity in rectal distention (P=0.004) as compared with controls. In addition, Group B showed a significantly increased incidence of microangiopathy (P=0.04) and autonomic and peripheral neuropathy (P=0.002), significantly reduced basal and squeeze anal pressures (52±16vs.64±24 mmHg;P=0.03 and 98±39vs.124±54 mmHg;P=0.04, respectively), reduced amplitude of slow waves (7.3±3vs.9.5±3.7 mmHg;P=0.03), anal leak in smaller rectal volumes (P=0.003), and reduced response of the anal sphincter at the anocutaneous reflexes (29±14vs.39±14 mmHg;P=0.05) compared with Group A. The former group of patients exhibited a significantly higher incidence of fecal incontinence (P=0.008).CONCLUSION:Patients with long‐standing diabetes mellitus have increased incidence of fecal incontinence and severely impaired function of both the anal sphincters and the rectum. These findings could be attributed to the increased incidence of microangiopathy and autonomic and peripheral neuropathy observed in this subset of diabetic patients.

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

PURPOSE:This study was designed to evaluate symptoms and clinical findings in a prospective series of patients with chronic constipation.METHODS:A total of 155 consecutive patients with intractable constipation underwent detailed symptom registration, anorectal manometry, electromyography, colonic transit time measurement, and defecography.RESULTS:All investigations were completed by 134 patients (112 females) with a median age of 52 (range, 17‐79) years. Whole‐gut transit time was delayed in 55 patients (41 percent), pelvic floor dysfunction was diagnosed in 59 patients (44 percent), but in 35 percent of patients both transit time and pelvic floor function were found to be normal. Three symptoms were shown to have an independent value for the diagnosis of slow‐transit constipation. Patients with slow transit more often reported two or fewer stools per week (84vs.46 percent), laxative dependence (87vs.44 percent), and a history of constipation since childhood (58vs.22 percent) than did those with normal transit. Pelvic floor dysfunction was associated with a higher prevalence of backache (53vs.33 percent) and a lower prevalence of normal stool frequency (19vs.36 percent), heartburn (12vs.27 percent), and a history of anorectal surgery (7vs.21 percent) compared with those with normal pelvic floor function. All four symptoms retained an independent value in the logistic regression analysis for pelvic floor dysfunction. Two symptoms characterized the group with normal transit and normal pelvic floor function: normal stool frequency and alternating diarrhea and constipation.CONCLUSIONS:Symptoms are good predictors of transit time but poorer predictors of pelvic floor function in patients with constipation.

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

PURPOSE:This study compared conventional water‐perfused and vector volume anal manometry in female patients with neurogenic fecal incontinence and chronic anal fissure and in healthy female volunteers. We used endoanal magnetic resonance (MR) imaging to measure internal and external sphincter lengths and thicknesses and contrasted these with the manometric findings in the different anorectal conditions.METHODS:One hundred thirty‐three female subjects were studied over an eight‐month period, including 33 control volunteers, 83 patients with neurogenic fecal incontinence, and 17 patients with chronic anal fissure. Conventional manometry was contrasted with automated vector volume‐derived parameters. Endoanal magnetic resonance images were obtained using a previously described internal coil with a 0.5 T Asset™ scanner measuring quadrantal internal sphincter thickness and averaged coronal internal and external sphincter lengths.RESULTS:There was a statistically significant relationship between parameters measured by conventional manometry and those variables derived from vector volume manometry at rest and squeeze. There was no difference in sectorial vector‐derived pressures within any anorectal condition and no correlation between quadrantal internal sphincter thickness measurements and sectorial pressures at rest. Patients with chronic anal fissure and neurogenic fecal incontinence had constitutionally shorter superficial and subcutaneous external sphincters than healthy control subjects (P<0.001).CONCLUSIONS:There is no association between manometric findings and morphologic sphincter measurement; however, the shorter distal external sphincter in patients with fissure might render the lower anal canal relatively unsupported after internal sphincterotomy in the female patient.

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

OBJECTIVE:The purpose of this study was to evaluate the healing rate of transsphincteric perianal fistulas after transanal advancement flap repair and to examine the impact of this procedure on fecal continence.METHODS:Between January 1992 and January 1997, 44 consecutive patients with a transsphincteric perianal fistula passing through the middle or upper third of the external anal sphincter underwent transanal advancement flap repair. There were 34 male patients, and the median age was 44 (range, 19‐72) years. Twenty‐four patients (55 percent) had previously undergone one or more prior attempts at repair. With the patient in prone jackknife position, the internal opening of the fistula was exposed using a Parks retractor. The crypt‐bearing tissue around the internal opening and the overlying anoderm was excised. A layer of mucosa, submucosa, and internal sphincter fibers was mobilized 4 to 6 cm proximally. The base of the flap was approximately twice the width of its apex. The flap was advanced and sutured to the anoderm below the level of the internal opening. The median follow‐up was 12 months. Fecal continence was evaluated in 43 patients by means of a questionnaire.RESULTS:Transanal advancement flap repair was successful in 33 patients (75 percent). Success was inversely correlated with the number of prior attempts. In patients with no or only one previous attempt at repair the healing rate was 87 percent. In patients with two or more previous repairs the healing rate dropped to 50 percent. In 15 patients (35 percent) continence deteriorated after transanal advancement flap repair. Twenty‐six patients (59 percent) had a completely normal continence preoperatively. Ten of these patients (38 percent) encountered soiling and incontinence for gas after the procedure, whereas three subjects (12 percent) complained of accidental bowel movements. Eighteen patients (41 percent) had continence disturbances at the time of admission to our hospital. In two of these patients (11 percent), incontinence deteriorated.CONCLUSIONS:The results of transanal advancement flap repair in patients with no or only one previous attempt at repair are good. In patients who have undergone two or more previous attempts at repair the outcome is less favorable. Remarkably, the number of previous attempts did not adversely affect continence status.

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

PURPOSE:Operative techniques commonly used for fissure‐in‐ano include anal stretch, open lateral sphincterotomy, closed lateral sphincterotomy, posterior midline sphincterotomy, and to a lesser extent dermal flap coverage of the fissure. Reports of direct comparisons among these techniques are variable in their results and for the most part underpowered. A rigorous analysis of the combined reports was therefore undertaken to determine whether a preferred technique for fissure surgery can be elucidated.METHODS:MEDLINE was searched for all published reports using the key words “surgery” and “anal fissure.” All reports in which there was a direct comparison between at least two operative techniques were reviewed, and when more than one report existed for any given pair, that report was included in the meta‐analysis. If crude data were not presented in the report, the authors were contacted, and crude data were obtained. The two most commonly used end points in these reports were persistence of the fissure and postoperative incontinence of flatus. These are the only two end points included in the meta‐analysis. The meta‐analysis was performed using Epi‐Info software obtained from the Centers for Disease Control and Prevention (www.cdc.gov).RESULTS:Seventeen publications fulfilled the criteria of the study, encompassing 2,727 patients. Significant differences were found for both persistence and incontinence to flatus when comparing anal stretch to all forms of sphincterotomy. No significant difference was found comparing open to closed lateral internal sphincterotomy for persistence or incontinence. Posterior midline sphincterotomy was not significantly different from lateral sphincterotomy related to persistence or incontinence.CONCLUSION:Internal anal sphincterotomy is superior to anal stretch and should probably be performed in the lateral location, although both the open and closed techniques seem equally efficacious.

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID