ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:The aim of this study was to determine the effect of eversion of the anorectum during restorative proctocolectomy (RP) for ulcerative colitis on functional outcome.METHODS:One hundred seventeen patients underwent RP with stapled end‐to‐end ileal pouch‐anal anastomosis (EEA), without resection of the anal mucosa. Sixty‐four underwent EEA with eversion of the anorectum, and 53 underwent EEA without eversion. Each patient underwent paired studies of anorectal function before and a median of 12 months after RP.RESULTS:One year after RP, median (interquartile range) maximum resting pressure was 69 (range, 51‐88) cmH2O in those patients who underwent eversionvs. 80 (range, 64‐90) cmH2O in patients without eversion(P(>0.04). Threshold sensation in the upper, middle, and lower thirds of the anal canal were 9.1, 7.4, and 6.8 mA after eversionvs.6.9, 4.9, and 3.8 mA without eversion(P=0.003,P<0.001,P<0.001, respectively). Before operation, all patients had a rectoanal inhibitory reflex; however, after RP, 54 of 64 patients in the eversion group and 50 of 53 patients with a stapled EEA without eversion had an inhibitory reflex(P=not significant). Leakage of mucus was experienced by 11 patients who underwent eversion, compared with 9 patients without eversion. Fifty‐six of 64 patients with eversion could defer defecation for more than 30 min compared with 43 of 53 patients without eversion. Twenty‐two of 64 patients in the eversion group retained perfect discrimination between flatus and feces compared with 38 of 54 without eversion(P<0.001). Level of the anastomosis was 1 (range, 0.5‐3) cm above dentate line after eversion compared with 1.5 (range, 0‐6) cm without eversion.CONCLUSION:Clinical outcome after RP with eversion was not as good as outcome after stapled EEA without eversion. Such a conclusion requires confirmation in a prospective control trial.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:The aim of this study was to obtain additional biologic determinants that may be of use in segregating into subgroups with different prognosis patients with similarly staged colorectal cancers.METHODS:Between 1989 and 1991, a prospective study of prognostic factors has been performed in a group of 98 consecutive, unselected patients who underwent curative resections for primary untreated large bowel carcinoma. The fate of all patients is known at three years after operation. Clinical and pathologic data were recorded at the time of presentation and operation, and patients have been the subjects of regular follow‐up. Tumor DNA content was determined by flow cytometry, and cell proliferative activity was determined by autoradiography with tritiated thymidine labeling index (LI).RESULTS:Univariate analysis revealed that the most important predictors of survival(P<0.001) were the presence of positive lymph nodes, the presence of preoperative complications, Dukes stage, and LI. The multivariate analysis showed that Dukes stage(P<0.002) and LI(P<0.0001) were the only factors significantly related to survival. Disease‐free survival was influenced significantly by Dukes stage(P<0.001), LI, according to the classification in the two groups of high and low proliferative activity, respectively, (P<0.0001), LI, calculated as a continuous variable(P<0.0002), and the presence of lymph node metastases(P<0.003). Outcome (favorable/unfavorable) was influenced significantly by Dukes stage(P<0.0001) and LI(P<0.0001). Concordance for each patient between Dukes stage and outcome was 73.1 percent and between LI, calculated as a continuous variable, and outcome was 74.1 percent. If, on the other hand, Dukes stage and LI are used together, concordance with outcome reaches 89.2 percent.CONCLUSION:We can conclude that, from a practical point of view, LI is an essential factor that must be combined with pathologic variables for a better prediction of patient outcome.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

BACKGROUND:Long‐term steroid therapy predisposes to postsurgical complications, especially in patients with inflammatory bowel disease.PURPOSE:This study was undertaken to determine incidence of early septic complications after ileal pouch‐anal anastomosis (TPAA) in patients who are undergoing prolonged steroid therapy.METHODS:We reviewed charts of 692 patients undergoing restorative proctocolectomy and IPAA to treat ulcerative colitis. Incidence of early (within 30 days) septic complications and sepsis‐related reoperations, in patients who were having high‐dose (>20 mg of prednisone per day) and low‐dose steroid therapy (<20 mg of prednisone per day) for more than one month before surgery, was compared with patients who were not receiving steroid therapy. Follow‐up included an annual questionnaire and physical examination.RESULTS:Patients without steroid dose data recorded were excluded (n=21). Of the 671 remaining patients, 310 received no steroids, 169 received low‐dose steroids, and 192 received high‐dose steroids. These three groups were similar in gender composition, age at surgery, types of anastomosis (stapled or handsewn), and incidence of diabetes mellitus, peripheral vascular disease, and obesity. Early septic complications were found in 18 (6 percent), 14 (8 percent), and 12 (6 percent) patients without steroid therapy, those having low‐dose steroid therapy, and those having high‐dose steroid therapy(P=0.57), respectively. Sepsis‐related reoperation rate(P=0.73) and number of sepsis‐related pouch excisions(P=0.79) did not differ between groups. In patients undergoing IPAA without ileostomy, early septic complications were found in one (3.8 percent), two (20 percent), and five (50 percent) patients without steroid treatment, low‐dose steroid therapy, and high‐dose steroid therapy(P=0.004), respectively.CONCLUSION:In patients who are undergoing IPAA with diversion for ulcerative colitis, prolonged systemic steroid therapy before surgery is not associated with increased septic complications.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:Patterns of metastatic spread are difficult to determine with routine postoperative follow‐up. This study was undertaken to evaluate two selected populations of colorectal cancer patients injected and screened with antitumor antibody.METHODS:Eighty‐six evaluable patients with colorectal cancer underwent exploratory laparotomy with both traditional surgical exploration and radioimmunoguided surgery (RIGS) following injection of125I‐labeled CC49 monoclonal antibody. RIGS‐positive tissue detectable with a handheld gamma‐detecting probe was defined as tissue involved with the disease process. Comparisons were made between extent of disease using traditional exploration and extent using RIGS.RESULTS:In 41 patients with primary disease, traditional exploration detected 45 sites of disease (1.1 sites/patient) compared with 153 RIGS‐positive sites (3.7 sites/patient). In 45 patients with recurrent disease, traditional exploration found 116 sites (2.6 sites/patient)vs.184 RIGS‐positive sites (4.1 sites/patient). Involvement by selected anatomic sites is shown below.Table. No Caption available.CONCLUSION:RIGS detected more tissue involved in disease process for all sites in both primary and recurrent disease except liver metastases. Areas with highest proportion of RIGS‐positive tissue, the gastrohepatic ligament and celiac nodes, are rarely resected and are not pathologically examined. Positive RIGS localization of tumor antigen in these areas suggests more extensive dissemination of disease process.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:In a blinded fashion, radiolabeled B72.3 was investigated in operative cases of recurrent colorectal cancer to determine if diagnostic accuracy would be improved to ultimately maximize curability and minimize interventional morbidities.METHODS:Study patients underwent conventional evaluation including history, physical examination, abdominal/pelvic computed tomographic scan (CT), colon examination, and carcinoembryonic antigen (CEA) determination, with select magnetic resonance imaging and ultrasonographic imaging as indicated. Murine monoclonal antibody B72.3 was labeled with indium‐111(111In‐CYT‐103 provided by Cytogen) and scans obtained at 48 hours and, selectively, at 72 and 96 hours. Unlike previous studies, the operating surgeon was blinded to111In‐CYT‐103 abdominal scan results until surgical exploration was complete.RESULTS:Of 15 study patients (10 male; 5 female), average age was 57 years, and average CEA was 10 ng/ml (with eight elevated CEA levels). A single patient did not undergo surgery because of presence of pulmonary metastases identified on CT scan but not identified on a111In‐CYT‐103 scan. Laparotomies included resection and intraoperative radiation (10), resection alone (1), and biopsy only (3). CT and111In‐CYT‐103 scans were compared with operative findings. CT scans had an accuracy and positive predictive value of 47 and 100 percent, respectively, whereas those of111In‐CYT‐103 scan were 60 and 82 percent, respectively. Contribution of the scan to diagnosis and management was graded by the surgeon as no effect (67 percent), beneficial effect (13 percent), or negative effect (20 percent).CONCLUSIONS:111In‐CYT‐103 was more accurate compared with CT scan, but when value of the scan was examined with respect to its potential contribution to patient management, it was beneficial in only 13 percent of patients. Further refinements may enhance the value of antibody imaging techniques.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:We report the results of biofeedback (BF) on patients with outlet obstruction defecation (OOC), including those with and without measurable paradoxical puborectalis contractions (PP). Clinical and anorectal physiologic parameters (ARP) were assessed one week before and after a standardized course of BF.METHODS:Sixty‐two consecutive patients (24 men, 38 women; mean age, 48 (standard error of the mean, 2.3) years) were recruited. All had persistent constipation despite six weeks of dietary fiber supplements. Colonic inertia was excluded by transit marker studies. Defecating proctography excluded anatomic abnormalities causing outlet obstruction. Patients underwent four outpatient sessions of biofeedback, each session lasting one hour.RESULTS:After BF, 56 patients (90.3 percent) were subjectively improved. Frequency of spontaneous bowel movements were significantly increased(P=0.003). Frequency of laxative‐induced(P=0.004) and enema‐induced(P=0.005) stools were reduced. Anal resting(P=0.04) and squeeze(P=0.002) pressures were increased. Number of patients with PP was reduced from 40 to 31(P=0.004). Presence of PP did not affect response to BF. There were no differences in ARP between the 56 patients who improved and the 6 who did not. There were no side effects or clinical regressions after a mean follow‐up of 14.9 (standard error of the means, 0.9) months.CONCLUSIONS:BF effectively treated OOC in 90.3 percent, regardless of PP. Anal pressures were increased, and PP was decreased.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:The aim of this study was to identify the overall long‐term causes of death in a large series of patients who were undergoing proctocolectomy with ileal pouch‐anal anastomosis (IPAA).METHODS:Records of patients who underwent proctocolectomy with IPAA at the Mayo Clinic affiliated hospitals between January 1981 and October 1994 were reviewed to determine overall mortality, cause, and timing of death.RESULTS:A total of 1,603 patients underwent proctocolectomy with IPAA reconstruction (1,407 for chronic ulcerative colitis (CUC), 187 for familial polyposis (FAP), and 9 for other diagnoses). Thirty‐two patients have died, with an overall mortality rate of 2 percent. Mean age at time of death was 40 (23‐60) years. There was no significant difference in overall mortality between patients with CUC and patients with FAP. Three deaths occurred postoperatively (0.2 percent) because of pulmonary embolism, perforated gastric ulcer, and subarachnoid hemorrhage. Late deaths occurred in 29 patients (1.8 percent), 10 months to 10.4 years after the operation. The most common cause of late death was cancer, including colon and rectal carcinoma (10 patients), hematologic malignancies (4 patients), cholangiocarcinoma (3 patients), and germ‐cell carcinoma (1 patient). Four patients died from unrelated sepsis, two died following myocardial infarction, two patients died from complications of subsequent orthopedic surgery, and one patient died of cirrhosis. Two additional patients committed suicide. No late deaths were directly attributable to the IPAA procedure.CONCLUSIONS:Proctocolectomy with IPAA is a safe procedure. Operative mortality is low, and late deaths are related to carcinogenic and extracolonic manifestations of underlying or unrelated coexisting diseases and events.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:This study relates our experience with local surgical management of perianal Crohn's disease.METHOD:Of 1,735 patients with Crohn's disease seen between 1980 and 1990, records of 66 patients (3.8 percent) with symptomatic perianal Crohn's disease treated by local operations were retrospectively reviewed to study outcome of local surgical intervention.RESULTS:All patients had intestinal disease that was limited to the colon in 32 patients (48 percent), ileocolonic region in 22 patients (33 percent), and ileum in 12 patients (18 percent). Types of perianal disease encountered included perianal suppuration (57), anal fistula (47), anal fissure (21), anal stenosis (5), gluteal abscess (3), scrotal abscess (2), and anovaginal fistula (2). A total of 321 episodes of anal complications necessitated 256 local surgical interventions. Local anorectal operations performed included simple incision and drainage of abscess (57), fistulotomy (35), incision and drainage of complex anorectal abscesses and fistulas and insertion of seton (24), internal sphincterotomy (6), fissurectomy (1), and anal dilation (3). Of 24 patients with horseshoe abscesses and fistulas managed with insertion of a seton and 35 patients who underwent fistulotomy as a primary procedure or in conjunction with drainage of an abscess, none experienced fecal incontinence as a direct result of the operation. Thirteen patients required proctectomy to control perianal disease, and a similar number underwent total proctocolectomy for extensive intestinal disease. Forty patients (61 percent) continue to retain a functional anus.CONCLUSION:Patients with symptomatic low anal fistula involving minimum sphincter musculature can be treated safely with fistulotomy. In treatment of patients with horseshoe abscesses and high fistulas, aggressive local surgical intervention using a seton permits preservation of the sphincter and good postoperative function.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:Colorectal malignancies are less common in developing than developed nations because of lowerper capitaincome and higher dietary fiber consumption. This clinicopathologic study attempts to determine changes in the pattern of these neoplasms in Ibadan, Nigeria, during the last two decades.METHODS:The present study is based on the clinical Cancer Registry records and gross and morphologic surgical pathology findings of 526 patients with histologically verified malignant colorectal neoplasms received in the Department of Pathology, University College Hospital, Ibadan, between 1971 and 1990.RESULTS:Colonic malignancies increased by 81 percent, whereas rectal malignancies decreased 16.1 percent in frequency(P<0.05). The modal ages were 55 to 60 years and 45 to 50 years for colonic and rectal neoplasms, respectively, in contrast to reported peak occurrence in the seventh decade among Caucasians. Colonic neoplasms were predominantly right‐sided (34.3 percent cecal), abdominal mass and pain being major clinical manifestations. This differs from the pattern in American Negroes, among whom colonic carcinomas are predominantly left‐sided, dyschezia being an important presentation. As in most other studies, adenocarcinomas were the predominant neoplasms.CONCLUSIONS:Further work is required to determine prognostically significant features of colorectal cancer in our environment.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID