摘要:

PURPOSE:Surgical options for the treatment of rectal cancer may involve sphincter‐sparing procedures (SSP) or abdominoperineal resection (APR). We sought to examine variations in the surgical treatment of rectal cancer for a large, well‐defined patient population and specifically to determine if differences exist in management and survival based on hospital type and surgical caseload.METHODS:The Cancer Surveillance Program database for Los Angeles County was used to retrospectively retrieve data on all patients who underwent SSP or APR for rectal adenocarcinoma between 1988 and 1992.RESULTS:A total of 2,006 patients with adenocarcinoma of the rectum underwent SSP or APR during the study period. Overall, 55 percent underwent SSP, and the remaining 45 percent underwent APR. Use of SSP remained relatively constant for each year of the five‐year period. Substantial variability was seen in the use of SSP at various hospital types. For localized disease, this varied from as low as 52 percent at teaching hospitals to as high as 78 percent at hospitals approved by the American College of Surgeons(P=0.067). To examine the role of caseload experience, hospitals were divided into those completing an average of five or fewer rectal cancer cases per yearvs.those completing an average of more than five cases per year. For localized disease, hospitals with higher caseloads performed SSP in significantly more cases, 69vs.63 percent(P=0.049). Survival was seen to be significantly improved for patients operated on at hospitals with higher caseloads, in cases of both localized and regional diseases(P<0.001).CONCLUSION:Surgical choices in the treatment of rectal cancer may vary widely, even in a well‐defined geographic region. Although the reasons for this variability are multifactorial, hospital environment and surgical caseload experience seem to have a significant role in the choice of surgical procedure and on survival.

ISSN:0012-3706    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

PURPOSE:There is concern that patients with presumed ulcerative colitis and significant perianal disease may in fact have Crohn's disease. Moreover, prior perianal disease may be an independent factor for poor outcome of the pelvic pouch. The aim of this study was to evaluate the effect of prior perianal disease on pelvic pouch outcome.METHODS:Between 1982 and 1994, 52 of 753 patients (6.9 percent) who had a pelvic pouch procedure were prospectively identified as having perianal disease. Outcome of the pelvic pouch of these 52 patients (Group I) were compared with the outcome of 701 pelvic pouch patients with no prior perianal disease (Group II). The perianal diseases identified in Group I were fissure‐in‐ano (17), perianal abscesses (13), fistula‐in‐ano (7), rectovaginal fistula (3), and significant hemorrhoids/skin tags (25). Eleven patients (21 percent) had more than one type of perianal disease. Twenty‐seven patients (52 percent) required a total of 33 perianal operations for the different anal pathologies.RESULTS:Both groups were comparable for the following characteristics: age at time of pelvic pouch procedure, pathology (ulcerative colitis or indeterminate colitis), design of pouch, and type of ileoanal anastomosis (handsewn or stapled). An ileoanal anastomosis leak developed in 21 percent of patients (n=11) in Group Ivs.11.4 percent (n=80) in Group II(P<0.05). Perianal postoperative complications occurred in 11.5 percent of patients (n=6) in Group Ivs.1.7 percent (n=12) in Group II(P<0.05). Total pouch failure rate was not significantly different between the two groups (11.5vs.7.6 percent;P>0.05). Crohn's disease was subsequently diagnosed in 1.9vs.2.7 percent(P>0.05). Subgroup analysis of Group I patients showed no significant difference in outcome according to type of perianal lesion or a history of perianal surgery.CONCLUSION:Prior perianal disease significantly increases the risk of developing an ileoanal anastomotic leak and postoperative perianal complications. However, a pelvic pouch procedure may be an acceptable surgical alternative for selected ulcerative colitis patients with prior perianal disease because the overall pouch failure rate is not significantly increased.

ISSN:0012-3706    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

PURPOSE:In patients undergoing colectomy with ileal pouch‐anal anastomosis, controversy exists regarding the necessity for and appropriate extent of rectal mucosal resection. Our aim was to assess histologically the extent of anorectal smooth muscle resected at the time of mucosal proctectomy and to correlate this with postoperative bowel and anal sphincter function.METHODS:Surgical specimens of 79 patients undergoing colectomy, mucosal proctectomy, and ileal pouch‐anal anastomosis were examined histologically in a blinded fashion, and the content of smooth muscle in the mucosal proctectomy specimens was scored. Degree of smooth muscle resection was correlated with postoperative anorectal manometry and with functional outcomes, including stool frequency and nocturnal leakage of stool after 3 and 12 months of follow‐up.RESULTS:Degree of smooth muscle loss correlated with decreased resting pressure of the internal anal sphincter as early as three months after surgery(r=−0.26;P=0.03), and the correlation was even stronger after 12 months(r=−0.37;P=0.005). Decreases in resting pressure were related, in turn, to increased stool frequency at 12 months(r=0.32;P=0.02), but stool frequency was also inversely related to volume of the ileal pouch(r=−0.27;P=0.05). Multivariate analysis confirmed that resting pressure and pouch volume were both significant determinants of stool frequency. The likelihood of nocturnal stool leakage at 12 months was primarily a function of stool frequency(P<0.01) but also increased with patient age(P<0.02).CONCLUSIONS:These findings indicate that loss of resting pressure of the internal anal sphincter can be correlated with the extent of smooth muscle resection during rectal mucosectomy and that these factors, in turn, correlate with increased stool frequency and a greater likelihood of nocturnal stool leakage. Consequently, an optimum functional result requires care in identifying and preserving maximum anorectal smooth muscle during mucosectomy.

ISSN:0012-3706    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

PURPOSE:This study was designed to describe recurrence and survival rates after operative treatment for anorectal melanoma and to identify predictive factors for recurrence.METHODS:Records of 50 patients with anorectal melanoma from 1939 to 1993 were reviewed.RESULTS:Overall five‐year survival and disease‐free survival were 22 and 16 percent, respectively. At the time of diagnosis, 26 percent of patients had metastatic disease, and all died within 12 (mean, 6.3) months. Five‐year survival and recurrence rates were identical after either abdominoperineal resection (APR) or wide local excision, both with curative intent. Gender, size of tumor, presence of melanin, positive perirectal lymph nodes, or treatment were not predictive of recurrence. Anorectal melanoma was found incidentally after hemorrhoidectomy or polypectomy in five patients. Three other patients underwent an excisional biopsy of a lesion measuring less than 2 cm. Of these eight patients, five underwent APR and three underwent wide local excision with no microscopic residual tumor at pathology. All developed regional or systemic recurrence at a mean of 21 (range, 4‐88) months, and all died of their disease at a mean of 29 (range, 5‐98) months.CONCLUSION:Prognosis for anorectal melanoma is poor, irrespective of surgical treatment performed. No predictive factors for recurrence were identified in this series. Wide local excision with a negative margin of a least 1 cm is suggested as the treatment of choice. APR should be reserved for tumor not amenable to local excision or for palliative treatment of large obstructive lesion until effective adjuvant therapies are available.

ISSN:0012-3706    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

BACKGROUND:Staged resection of the sigmoid colon has been the traditional strategy for treating patients who require nonelective surgery to manage complications of diverticular disease. Resection and primary anastomosis has not generally been recommended when the clinical setting is compromised by contiguous inflammation or inadequate mechanical cleansing of the colon because of concerns regarding the potential risk of anastomotic dehiscence. Although many reports have confirmed that intraoperative colonic lavage (ICL) is a safe method for relieving fecal loading of the colon to facilitate primary intestinal anastomosis in patients with mechanical obstruction of the distal colon, there is very limited experience with the use of this technique in treating acute inflammatory disorders of the colon. In this report, we present our results with ICL in the nonelective treatment of patients with complications of diverticulitis.METHODS:Records of all patients undergoing urgent operations at the Lahey Clinic to treat complications of diverticular disease from July 1987 to January 1996 were reviewed.RESULTS:Of 62 patients who required nonelective operations, 33 underwent ICL in an attempt to perform primary anastomosis. In five patients, the operation included creation of a colostomy. The indication for surgery was obstruction in 13 patients (39 percent), persistent abscess or phlegmon in 13 (39 percent), perforation in 6 patients (18 percent), and hemorrhage in 1 patient (3 percent). According to Hinchey's classification system, 18 patients had Stage I disease, 10 had Stage II, and 5 patients had Stage III disease. There were no patients with Stage IV disease. The single anastomotic complication in the series was responsible for the sole operative mortality. The morbidity rate of 42 percent, included three intraoperative complications (2 splenic injuries and 1 ureteral laceration), two intra‐abdominal abscesses (6 percent), and six wound infections (18 percent).CONCLUSION:In our experience, ICL has proven to be a safe method for accomplishing single‐stage resection of the colon in selected patients with diverticulitis who require an urgent operation. When there is no evidence of diffuse purulent or feculent peritonitis, we believe this is the preferred method for treating patients who are hemodynamically stable.

ISSN:0012-3706    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

PURPOSE:This study was undertaken to describe our results in a series of patients undergoing total abdominal colectomy with ileorectal anastomosis (TAC/IRA) using laparoscopic techniques in patients with familial adenomatous polyposis (FAP) and rectal‐sparing. Young patients with FAP requiring TAC/IRA may be ideal candidates for minimally invasive surgery, because they are generally thin and have benign disease. They might benefit maximally from the theoretic advantages of these techniques.METHODS:We have performed laparoscopic TAC/IRA in 16 FAP patients (10 females; mean age, 18 years). Procedures were entirely intracorporeal, with a 3‐cm to 6‐cm specimen extraction incision.RESULTS:Median operative time was 232 (range, 156‐285) minutes, and blood loss 175 (range, 50‐675) ml. The only intraoperative complication, a twisted ileorectal anastomosis, was noted intraoperatively and revised. There were no conversions to conventional laparotomy. Median postoperative interval to passage of flatus was three days,1‐4and for bowel movements it was three days.1‐4Median hospital stay was five days.3‐11One case of early postoperative small‐bowel obstruction was treated nonoperatively, and one case of brachial plexus neuropraxia resolved spontaneously.CONCLUSIONS:Based on this preliminary experience, we believe laparoscopic TAC/ IRA can be a safe and effective treatment for selected patients with FAP. As techniques and instrumentation for laparoscopic colon surgery are perfected, this procedure will likely become an appealing option in the management of patients with FAP.

ISSN:0012-3706    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

PURPOSE:This study was designed to estimate the efficiency of the various methods used to treat familial adenomatous polyposis coli.METHODS:Three hundred ninety patients (219 males) underwent surgery for familial adenomatous polyposis coli; postoperative follow‐up was from 1 to 30 years.RESULTS:Coloproctectomy with preservation of the anal sphincter and coloproctectomy with ileoanal pull‐through procedures resulted in development of anal canal cancer in 3 (4.1 percent) of 74 patients. Follow‐up revealed development of cancer in the large bowel in 26 (10.7 percent) of 242 patients, in whom colectomy with preservation of various colonic segments was performed.CONCLUSIONS:The occurrence rate of cancer is not significantly related to patients' gender, age, length of preserved colonic segment, presence of cancer in the removed colonic segment, or postoperative follow‐up period; however, presence of polyps in the colonic segments preserved during surgery significantly increased the risk of development of cancer at a later time.

ISSN:0012-3706    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

BACKGROUND:Primary repair has become the most common method of treatment for civilian injuries of the colon. However, colostomy may still be required in selected patients.AIMS:This study was undertaken to identify factors for the performance of colostomy in patients with colon injuries.METHODS:During a 60‐month period, all penetrating injuries to the colon treated at Saint Louis University Hospital were evaluated. All patients underwent an operation within six hours of injury. Rectal injuries were excluded.RESULTS:One hundred thirty consecutive patients with injuries to the colon were identified. Primary repair was performed in 81 patients (62 percent). Fecal diversion was used in 49 patients (38 percent). No deaths occurred related to colon injury. Complications related to colon injury included wound infections in 22 patients (17 percent) and intra‐abdominal complications in 16 patients (abscess, 14; fecal fistula, 1). Wound complications were most closely related to whether the skin was closed primarily or left open (22vs.8 percent). Intra‐abdominal complications occurred in 7 percent of patients in whom the colon injury was closed primarily and in 20 percent of patients in whom a stoma was created(P>0.05). Patients chosen for colostomy had significantly greater blood loss, more associated injuries, and higher scores on the Abdominal Trauma Index (ATI) and Colon Injury Scale (CIS) and were more likely to have gross contamination(P<0.05). Stepwise regression analysis of 13 factors revealed that only gross contamination and ATI predicted the occurrence of intra‐abdominal complications and that CIS most closely predicted either wound or intra‐abdominal complications. Stratification of patients based on an ATI of ≥30 and a CIS of ≥4 revealed no difference in outcome between primary repair and colostomy in either the low‐risk or high‐risk groups. However, severity of injury was greater in patients treated with colostomy.CONCLUSIONS:Primary repair can be accomplished with low morbidity in the majority of civilians with penetrating injuries to the colon. Colostomy may be required in high‐risk patients as defined by an ATI of ≥30 in association with a CIS of ≥4.

ISSN:0012-3706    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

PURPOSE:The acute and long‐term effects of pelvic radiation on defecation were studied.METHOD:Anorectal function was assessed based on manometry and subjective symptoms in 31 patients with cervical cancer treated by radiotherapy alone. Sixteen of 31 patients were examined periodically before, during, and after radiotherapy (early group). Fifteen others were examined more than six months after completion of radiotherapy (late group).RESULTS:One‐third of patients in both groups had symptoms, mainly diarrhea and increased stool frequency. Patients in the late group also suffered from disturbed gas‐stool discrimination, urgency, a sense of residual stool, and soiling. Anal canal resting pressure was significantly higher after radiotherapy (47±15.5 mmHg) than before radiotherapy (36.3±12.5 mmHg;P<0.05). The maximum tolerable volume decreased with radiation, from 163.3±45 before to 119.2±41.4 ml during, 112.7±36.6 ml immediately after, and 94.6±34.4 ml in the late group(P<0.01). Rectal compliance also decreased over time and was lower in the early group (before, 5.7±1.3 ml/mmHg;P<0.01; during, 4.6±2.2 ml/mmHg,P<0.01; after, 3.7±1.4 ml/mmHg;P<0.05) than the late group (2.1±1.5 ml/mmHg) and lower before than after in the early group(P<0.01). Although rectal pressure initiating continuous desire to defecate did not change, the maximum tolerable pressure was significantly higher in the late group (81±19.5 mmHg) than during (59±16.8 mmHg) or after (59.9±16.9 mmHg) radiotherapy in the early group(P<0.05).CONCLUSION:Radiation reduces the capacity of the rectal reservoir, even in asymptomatic patients. These changes develop during radiotherapy and progress over time.

ISSN:0012-3706    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

PURPOSE:Total anorectal reconstruction with a double dynamic graciloplasty was performed after abdominoperineal reconstruction (APR) for low rectal cancer. In four patients an additional pouch was constructed to improve neorectal motility and capacity. The aim of this study was to evaluate the results in the first 20 patients and to report on the preliminary results of patients with an additional pouch.METHODS:Twenty patients with a mean age of 52 (range, 25‐71) years and a rectal tumor at a mean of 3 (range, 0‐5) cm from the anal verge were treated. In 14 patients the Miles resection, colon pull‐through, and construction of a neosphincter were performed in one session. Six patients had the double graciloplasty at an average of 4.1 (range, 1.1‐8.8) years after APR. In four patients a pouch was constructed with an isolated segment of distal ileum.RESULTS:After a mean follow‐up of 24 (range, 1‐60) months after APR, none of the patients developed local recurrence, whereas four patients developed distant metastasis. Fifteen of 20 patients were available for evaluation, and 5 patients were still in training. Of these 15 patients, 8 patients were continent (53 percent), 2 patients were incontinent, and in 5 patients the perineal stoma was converted to an abdominal stoma. Failures were attributable to necrosis of the colon stump (n=2) and incontinence (n=3). At 26 weeks mean resting pressure was 44 (standard deviation (SD), 28) mmHg, and mean pressure during stimulation was 90 (SD, 46) mmHg at a mean of 35 (SD, 1.2) volts at 52 weeks. Mean defecation frequency was three times per day (range, 1‐5). Of the eight patients who were continent, six used daily enemas. Mean time to postpone defecation was 11 (range, 0‐30) minutes.CONCLUSION:In experienced hands, the double dynamic graciloplasty is an oncologically safe procedure that can have an acceptable functional outcome in a well‐selected group of patients. However, to improve the outcome, further modifications will be necessary. So far, the addition of a pouch has not resulted in improved outcome.

ISSN:0012-3706    

出版商:OVID    

年代:1997

数据来源: OVID