ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:Infliximab (anti‐TNF &agr;) has been used for the treatment of fistulizing Crohn's disease with variable efficacy. The aim of this study was to evaluate the efficacy of infliximab combined with selective seton drainage in the healing of fistulizing anorectal Crohn's disease.METHODS:This was a retrospective chart review of all patients with fistulizing Crohn's disease treated with infliximab between March 2000 and February 2002.RESULTS:Twenty‐nine patients (12 male; mean age, 31 years) received a mean of 3 (range, 1‐5) doses of infliximab 5 mg/kg. Twenty‐one patients had perianal fistulas; eight had rectovaginal fistulas, four with combined rectovaginal/perianal fistula. Fourteen of 21 patients (67 percent) with perianal fistula had a complete response (mean follow‐up, 9 months), 4 of the 14 relapsed (mean, 6 months), but all had a complete response to retreatment (mean, 9 months). A partial response occurred in four patients (19 percent), defined by decreased drainage (2 patients) or infliximab dependence (2 patients) requiring repeated dosing every six to eight weeks. Three patients (14 percent) had no response. Seton drainage was used before infusion in 13 perianal patients for perianal infection and 17 were treated with maintenance azathioprine or methotrexate. Of eight patients with rectovaginal fistula, complete response occurred in one, partial response in five, and no response in two. Two partial responders became infliximab dependent. A complete response was observed in one patient with isolated rectovaginal fistula, a partial response in five. No patient with a combined rectovaginal/perianal fistula had a complete response. Five rectovaginal fistula patients were taking maintenance immunosuppressive agents and two had seton drainage before infusion.CONCLUSIONS:Selective seton placement combined with infliximab infusion and maintenance immunosuppressives resulted in complete healing in 67 percent of Crohn's patients with perianal fistula and partial healing in 19 percent. Relapse was successfully treated with repeat infusion. Concomitant rectovaginal fistula was a poor prognostic indicator for successful infliximab therapy.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:The surgical management of complex perineal fistulas, such as high transsphincteric and suprasphincteric fistulas, or those associated with Crohn's disease, radiotherapy, surgical trauma, or cavity or a secondary tract, is associated with the risk of sphincter injury and significant discomfort. Fibrin glue may close fistula tracts without muscle division. Therefore, the aim of this study was to evaluate the use of fibrin glue sealing in treatment of perineal fistulas.METHODS:A retrospective chart review of all patients in whom fibrin glue was used for the treatment of perineal fistula was performed. Patients were contacted by telephone to establish follow‐up.RESULTS:Thirty‐seven patients underwent injection of fibrin glue for complex perineal fistulas. Twenty‐four patients had fibrin glue injection as the principal treatment for the perineal fistula, and 13 had fibrin glue in conjunction with an endorectal advancement flap. The fistula was of cryptoglandular origin in 16 (42 percent) cases and associated with Crohn's disease and trauma in 7 (19 percent) and 14 (38 percent) patients, respectively. At a mean follow‐up of 12.1 months, healing occurred in only 15 (41 percent) patients. The healing rate was 33 percent when fibrin glue was the principal treatment, and 54 percent when used with an endorectal advancement flap. Fistulas of noncryptoglandular origin had a higher success rate, although this difference did not reach statistical significance. There was no morbidity associated with the injection of fibrin glue.CONCLUSION:In this study, fibrin glue had moderate success in the definitive treatment of perineal fistulas. However, 33 percent of the patients in whom fibrin glue was the only treatment used were able to avoid more extensive surgery. Fibrin glue is associated with minimal risk, therefore its application should be considered in patients with complex anal fistulas.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:Currently, rectal sensation may be measured by balloon distention or mucosal electrostimulation. This study investigated the application of a graded heat stimulus to the rectum using a novel thermal probe as a further method of evaluating rectal sensory afferent mechanisms.METHODS:A thermal probe specially designed in our institution was used to test rectal heat sensitivity in 31 healthy subjects. This was compared with all other standard anorectal physiologic measurements. Repeatability studies were also performed.RESULTS:Heat stimulation of the mid rectum elicited sensory responses in all subjects. The most common reported response was not heat but a sharp or prickling sensation. The median rectal heat threshold was similar in males (median, 47°C; range, 44‐50°C) compared with females (median, 45°C; range, 43‐50°C;P> 0.05). There was a high degree of repeatability with rectal heat and balloon distention thresholds, but not electrostimulation thresholds. A strong correlation was found between rectal heat thresholds and defecatory desire (r= 0.71;P< 0.001) and maximum tolerable volumes (r= 0.8;P< 0.001) measured with balloon distention.CONCLUSION:This is the first demonstration of a repeatable sensory response to heat stimulation in the rectum of normal subjects. Strong correlation between heat thresholds and balloon distention to maximum tolerable volumes and defecatory desire suggest common sensory afferent pathway excitation. Heat stimulation is a simple technique that has a high degree of repeatability and may be an objective assessment of polymodal nociceptor function in the rectum.

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 review our results in patients undergoing treatment with 4 percent formalin for radiation‐induced injury to the rectum.METHODS:A retrospective review of office charts was performed, identifying all patients undergoing formalin treatment. Patient gender, initial malignancy, prior treatments, response to treatment with formalin, complications, and length of follow‐up were reviewed. All patients had flexible endoscopy to assess for proximal sources of bleeding. The indication for treatment was a symptomatic patient with endoscopic evidence of radiation injury. A cotton pledget was used for direct application of 4 percent formalin to the affected areaviaa rigid proctoscope or anoscope. The treatment was repeated if blanching did not occur or if bleeding continued. Patients were followed up at three‐week to four‐week intervals and treatment was repeated based on the above indications. Treatments were continued until cessation of bleeding occurred or, when treatment failed, operative treatment was required.RESULTS:Thirty‐six patients were identified. Three were lost to follow‐up. Symptoms included bleeding in all but one patient, who presented with an ulcer. There were 33 (26 male) patients. Seventeen (51.5 percent) patients had prior treatment. The number of formalin treatments ranged from 1 to 13, with a mean of 3.4. The follow‐up ranged from 1 to 60 months, with a mean of 18 months. Twenty‐nine (88 percent) patients had improvement or cessation of symptoms. Four (12 percent) patients failed treatment. Two patients were noted to have full‐thickness ulcers and both failed formalin treatment. No complications were noted related to formalin treatment.CONCLUSION:We conclude that formalin therapy is a safe and effective form of treatment that can be performed in the office with minimal discomfort and no complications. It can be performed multiple times until results are achieved. Formalin therapy may be useful as a first‐line treatment for chronic radiation proctitis, however, a prospective controlled trial comparing modalities is required to prove this to be true.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:The aim of this study was to define the long‐term oncologic outcomes of laparoscopic resections for colorectal cancer.METHODS:We analyzed our experienceviaa prospective, nonrandomized, longitudinal cohort study. The period of study extended from April 1991 to May 2001. Laparoscopic resection was offered selectively in the absence of a large mass, invasion into abdominal wall or adjacent organs, and multiple prior abdominal operations. Every laparoscopic resection performed with curative intent for adenocarcinoma was included. Twenty percent of patients whose procedures were converted to open resection were included in the laparoscopic‐resection group because of intention to treat. Oncologic outcome measures of this group were compared with a computerized, case‐matched, open‐resection group, the case‐matching variables being age, gender, site of primary tumor (colonvs.rectum), and TNM stage. The laparoscopic‐resection group was followed up prospectively, and data were updated regularly. The follow‐up techniques consisted of a combination of office visits, telephone calls, and the United States Social Security Death Index database.RESULTS:The laparoscopic‐resection group consisted of 172 patients with a mean age of 67 (range, 27‐85) years. The open‐resection group consisted of 172 patients with a mean age of 69 (range, 30‐90) years. Mean follow‐up was 52 (range, 3‐128) months. Complete (100 percent) follow‐up data were available. The TNM stage distribution was 63 Stage I (37 percent), 51 Stage II (30 percent), 47 Stage III (27 percent), and 11 Stage IV (6 percent) tumors for the laparoscopic‐resection group and 65 Stage I (38 percent), 48 Stage II (28 percent), 51 Stage III (29 percent), and 8 Stage IV (5 percent) tumors for patients in the open‐resection group (P= 0.75, not significant). Thirty‐day mortality was 1.2 percent (2 deaths) in the laparoscopic‐resection group and 2.4 percent (4 deaths) in the open‐resection group (P> 0.05, not significant). Early and late complication incidences were comparable. Local recurrence was observed in three patients (1.7 percent) in the laparoscopic resection group with the primary tumor in the colon and in three patients (1.7 percent) with the primary tumor in the rectum, for a total incidence of local recurrence in the laparoscopy group of 3.5 percent (6 patients). In the open‐resection group, local recurrence was observed in two patients (1.2 percent) among those with primary tumor site in the colon and in three patients (1.7 percent) in the group with primary tumor in the rectum, for a total incidence of local recurrence in the open‐resection group of 2.9 percent (5 patients). One of the local recurrences in the laparoscopy group occurred in the port/extraction site, for an incidence of 0.6 percent. Metastasis occurred in 18 patients (10.5 percent) in the open group and in 21 (12.2 percent) in the laparoscopy group. Stage‐for‐stage overall five‐year survival rates were similar in the two groups. The Kaplan‐Meier statistical analysis performed for colonicvs.rectal primary adenocarcinoma confirmed that TNM stage for stage‐overall survival was similar in the laparoscopic and open‐resection groups (log‐rankP= 0.22).CONCLUSIONS:Notwithstanding the drawbacks of a nonrandomized study, no adverse long‐term oncologic outcomes of laparoscopic resections for colorectal cancer were observed in a single center's experience during a ten‐year period.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:Extramammary Paget's disease of the perianal region is a rare finding that often results in delayed diagnosis and treatment. Although the natural history of the disease is not well characterized, it historically has been associated with other cancers. This study summarizes the history and treatment of all patients diagnosed with perianal Paget's disease at a single institution.METHODS:Charts of all patients with a diagnosis of extramammary Paget's disease of the perianal region confirmed or treated at Memorial Sloan‐Kettering Cancer Center between 1950 and 2000 were reviewed. Patients with vulvar Paget's disease or Bowen's disease were excluded except when Paget's disease of the perianal region was diagnosed first. Whenever possible, follow‐up information was updated. Estimates of overall and disease‐free survival were made by the method of Kaplan and Meier.RESULTS:Twenty‐seven patients with a median age of 63 years were diagnosed with perianal Paget's disease. Most patients (74 percent) were treated with wide excision. Local recurrence occurred in 37 percent of all patients treated and in 30 percent of patients (6/20) undergoing a wide excision as part of their treatment. An invasive component was identified in 44 percent of patients (12/27) with perianal Paget's disease. Six patients (22 percent) required a colostomy as part of the treatment for their disease. Adjuvant chemoradiotherapy was used in 22 percent of patients (6/27) who had more aggressive disease. At a median follow‐up of 67 months, 56 percent (15/27) had no evidence of disease, and two patients had died of metastatic disease. The overall and disease‐free survival at five years was 59 and 64 percent, respectively, which decreased to 33 and 39 percent, respectively, by ten years.CONCLUSIONS:Perianal Paget's disease is a rare finding even at a large referral center. The disease process is generally a prolonged one marked by frequent recurrences, and the treatment of first choice is wide excision. Patients with invasive malignancies require more extensive surgery. The role of chemoradiotherapy remains undefined in this disease.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

INTRODUCTION:The phenotype of hereditary nonpolyposis colorectal cancer includes an 80 percent lifetime risk of colorectal cancer, a predominance of lesions proximal to the splenic flexure, and a high incidence of synchronous and metachronous neoplasia. Although prophylactic colectomy is rarely advised for patients with a hereditary nonpolyposis colorectal cancer genotype and a normal colon, the presence of advanced neoplasia in the context of a qualifying family history or a hereditary nonpolyposis colorectal cancer genotype has led to such recommendations. We performed this study to document the patterns of colorectal surgery performed for cancer‐bearing patients who are part of an Amsterdam criteria‐positive family and to compare rates of metachronous cancers that follow index total or segmental colectomy.METHODS:Family trees fulfilling the classic Amsterdam criteria for hereditary nonpolyposis colorectal cancer were identified, and all patients for whom surgical and pathology records were available were included in the study. Type of surgery and the outcome of subsequent follow‐up were abstracted. Patients were divided into those treated at the Cleveland Clinic and those treated elsewhere.RESULTS:There were 39 families with 93 affected patients. These patients had 127 colorectal cancers, 76 (60 percent) of which were right sided (proximal to the splenic flexure). Median age at diagnosis of the index cancer was 47 (range, 26‐81) years. Sixteen patients (17 percent) had metachronous cancers and multiple surgeries, whereas four (4 percent) had synchronous cancers. Median follow‐up for patients who underwent surgery at the Cleveland Clinic was 13 (range, 4‐49) years, whereas that for those who underwent surgery elsewhere was 14 (range, 1‐42) years. Sixteen (48 percent) of the 33 patients who underwent surgery at the Cleveland Clinic had a total colectomyvs.7 (12 percent) of the 60 who had surgery elsewhere (Fisher's exact test,P< 0.001). Only one patient who had surgery at the Cleveland Clinic had a second operation for a metachronous cancer (1/17 patients having a segmental resection). Fifteen patients who underwent surgery elsewhere needed a second resection for metachronous cancer (15/53 patients having a segmental resection; Fisher's exact test,P= 0.094).CONCLUSION:We conclude that there is high risk of metachronous colorectal cancer if an index cancer in a hereditary nonpolyposis colorectal cancer patient (defined according to Amsterdam criteria) is treated by partial colectomy. However, this risk can be lowered by performing a total colectomy at the time of index surgery, or possibly by effective postoperative surveillance.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:Given the improvement in oncologic outcome after the introduction of total mesorectal excision for the treatment of rectal cancer, the objective of the present study was to determine the frequency of identification and preservation of the pelvic autonomic nerves and to identify a possible link between postoperative micturition disturbances and the extent of the radical resection.METHODS:Between March 1997 and December 2001, 150 patients with adenocarcinoma of the rectum (≤16 cm from the anal verge) underwent surgery, with sphincter preservation in 112 cases (74.7 percent). Sixty‐three patients (42 percent) were classified as American Society of Anesthesiologists Stage III and two (1.3 percent) as Stage IV. The number of cases with complete identification, partial identification, or nonidentification of the autonomic nerves (superior hypogastric plexus, hypogastric nerve, and inferior hypogastric plexus) was documented and correlated with micturition disturbances (need for a long‐term urinary catheter). Urine volumes were measured by ultrasound before and after surgery.RESULTS:The pelvic autonomic nerves were identified completely in 108 patients (72 percent), partially in 16 (10.7 percent), and not at all in 26 (17.3 percent). After the initial phase of the study (n = 50 patients), complete identification was realized in 78 percent of cases. Multivariate analysis showed that of the predetermined parameters (learning curve for Group Ivs.Groups II or III, gender, T stage, blood loss, curative surgery, and previous surgery), gender (P= 0.006), learning curve (P= 0.019), and depth of penetration of the rectal wall (T1/T2vs.T3/T4;P= 0.028) exerted an independent influence on achievement of complete pelvic nerve identification. Sixteen patients (10.7 percent) were discharged from the hospital with a urinary catheter. Identification and preservation of the pelvic autonomic nerves was associated with low bladder dysfunction rates (4.5vs.38.5 percent;P< 0.001). In the evaluation of preoperative and postoperative bladder function, a urologic history and residual urine volume measurements by ultrasound were essential. The information obtained from urodynamic studies was of no relevance.CONCLUSIONS:Identification and preservation of the pelvic autonomic nerves was achieved in the majority of patients and led to the prevention of urinary dysfunction. Gender (P= 0.006), learning curve (P= 0.019), and T stage are independent parameters that influence outcome.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:This study was undertaken to identify prognostic factors that can be used to predict prognosis after surgery for lung metastases from colorectal carcinoma.METHODS:We reviewed retrospectively the clinical course of 37 patients who underwent surgical resection of primary colorectal cancer and metastatic lung disease at the National Defense Medical College Hospital between September 1986 and July 1999. We analyzed the prognostic factors with special reference to the clinicopathologic factors of primary tumors.RESULTS:Multivariate analysis indicated that the existence of an extranodal cancer deposit in the primary lesion (hazard ratio = 4.55,P= 0.009) and three or more lung metastases (hazard ratio = 2.9,P= 0.04) were significant indicators for poor prognosis. We divided the patients into two groups: Group A (n = 12) had neither of these two parameters, and Group B (n = 25) comprised all other patients. This two‐ranked classification was significantly related to both survival rates (3‐year and 5‐year survival rate, 90.9 and 90.9 percent in Group A and 16.1 and 8.1 percent in Group B, respectively;P= 0.0003) and disease‐free survival after thoracotomy (3‐year and 5‐year disease‐free survival rate, 52.9 and 39.7 percent in Group A and 5.3 and 5.3 percent in Group B, respectively;P= 0.002).CONCLUSION:An extranodal cancer deposit at the primary tumor site is a new significant prognostic factor after resection of lung metastases from colorectal cancer. A two‐ranked classification by extranodal cancer deposit and the number of pulmonary lesions can provide useful prognostic information for the treatment of lung metastasis. Surgical resection of pulmonary metastasis is expected to be very useful for patients in Group A.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID