摘要:

BACKGROUND:Recent pressures to decrease the cost of medical care have mandated preoperative outpatient bowel preparation (OBP) for elective colorectal surgery without any data documenting equivalent quality of care. This study examined the safety and efficacy of OBP compared with inpatient bowel preparation (IBP).METHODS:Records of all patients who underwent OBP for elective colorectal resection since the inception of the OBP program from July 1993 to June 1994 were compared with records of all patients who received IBP for elective procedures from January to June 1993.RESULTS:The two groups, 90 patients who underwent OBP and 98 patient who had IBP, were well matched for age, sex, diagnosis, and operations performed. The OBP group had a shorter length of hospital stay (median, 7vs.9 days;P< 0.0001; chi‐squared analysis), whereas the complication rate was similar (19 percent in the OBP groupvs.18 percent in the IBP group), including infectious complications (10 percent in the OBP groupvs.7 percent in the IBP group). Although operating time was similar (mean, 199vs.213 minutes) and estimated blood loss (mean, 528vs.536 ml), the OBP group had significantly higher perioperative fluid requirements: intraoperative fluids (median, 4300vs.3700 ml;P< 0.05; Student'st‐test), intraoperative colloid administration (48vs.29 percent;P< 0.0002; chi‐squared), 24‐hour postoperative fluids (3224vs.2700 ml;P< 0.0001; Student'st‐test), and postoperative fluid challenges (50vs.20 percent;P<0.0001; chi‐squared analysis).CONCLUSION:Outpatient bowel preparation for elective colorectal surgery is safe and effective. It offers shorter hospital stay, and, therefore, potentially reduces medical care cost. Patients with multiple medical problems may not tolerate extensive fluid shifts; therefore, other preoperative arrangements, such as inpatient or outpatient intravenous fluid therapy, need to be considered to minimize complications that may outweigh potential cost savings.

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 review our experience with patients with rectoceles using very selective criteria for operative repair and to critically review our surgical results.METHODS:This is a review of patients selected for rectocele repair between 1989 and 1994.RESULTS:Two hundred seventy‐nine patients were evaluated for pelvic outlet symptoms in our clinic. Defecography was performed in 180 patients; rectocele was seen in 143 patients (79 percent; 135 females and 8 males). On physical examination, 132 patients had a palpable rectocele (73 percent). Rectocele repair was recommended for 35 patients (13 percent); 33 (32 females and 1 male) underwent this procedure. Mean age was 55 (range, 16‐78) years. Although many patients complained of constipation, incontinence and pelvic pain, in these 33 patients criteria for repair included the sensation of a vaginal mass or bulge that required digital support and/or rectal digitizing for evacuation (58 percent), retention of barium in the rectocele on defecography (55 percent), or a very large rectocele with internal anterior rectal wall prolapse (6 percent). A hysterectomy had been performed previously in 47 percent of women repaired. Rectocele repair was performed by a standard transanal approach in 31 patients and transabdominally in 2 patients. Hospital stay averaged 3.7 (range, 1‐8) days. Few postoperative complications occurred; urinary retention was the most common (18 percent). All patients were followed postoperatively, and 26 patients (79 percent) answered a standardized questionnaire. Mean follow‐up was 31 (range, 5‐64) months. Eighty percent of patients questioned who initially complained of a vaginal mass or bulge reported complete resolution (significant improvement by the sign test,P< 0.5). Subjectively, 92 percent of patients questioned reported improvement in their preoperative symptoms and satisfaction with the operation.CONCLUSION:Rectoceles are frequently identified during defecography, which is performed for pelvic floor complaints, yet are often asymptomatic. In contrast to other recent reports of rectocele repair, our data indicate that careful selection of patients using specific criteria may result in very good clinical results.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:Photodynamic therapy (PDT) is a relatively new alternative modality for palliation of rectal cancer. Current source of light for PDT are laser systems that are expensive and not necessarily needed for PDT. We evaluated a new nonlaser light source for PDT, Versa‐Light®.METHODS AND RESULTS:In vitroPDT—CT26 murine colon carcinoma cells were incubated with aluminum phthalocyanine (AlPcS4) for 48 hours and subjected to photoradiation using Versa‐Light®,and viability was assessed. There was a significant decrease in viability of treated cells compared with controls.In vivoPDT—BALB/c mice were injected either subcutaneously or intrarectally with CT26 cancer cells. IP AlPcS4(2.5 mg/kg) was injected when tumors were visible. After 24 hours, mice were subjected to photoradiation. Massive tumor necrosis in response to PDT was observed. PDT also prolonged survival of treated mice. Patient treatment—A 70‐year‐old woman with recurrent local rectal carcinoma received intravenous Photofrin II®(2 mg/kg). After 48 and 96 hours, she was subjected to direct photoradiation. After the first light session, there was complete macroscopic disappearance of the tumor. Biopsies up to 10 weeks after the treatment showed no cancer cells in the treated area. Sixteen weeks later, a randomized biopsy from previous tumor site showed carcinoma cells.CONCLUSIONS:We believe that Versa‐Light®,is a good light source for PDT. It was effective in bothin vitroand animal studies. It can also be safely used for clinical PDT.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

&NA;Widespread use of prophylactic colectomy has resulted in a reduction in the incidence of colorectal cancer in familial adenomatous polyposis (FAP) patients. A retrospective chart review of families registered at the Steve Atanas Stavro Familial Gastrointestinal Cancer Registry in Toronto was performed to determine whether the decrease in the number of patients developing colorectal cancer implies that causes of mortality in FAP patients are shifting to that of extracolonic manifestations of FAP. Information was available on 140 deaths within 158 families and among 461 individuals with FAP. When stratified by decade, from the 1930s to the 1990s, the ratio of deaths caused by extracolonic manifestations of FAP compared with deaths caused by colorectal cancer was noted to have risen. Even though most deaths in FAP patients are still from colorectal cancer, it appears that screening policies and prophylactic colectomy have resulted in a reduction in the number of FAP patients who develop colorectal cancer. Thus, in recent decades, a greater percentage of deaths in FAP patients appears to be attributable to extracolonic manifestations of the disease.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:The authors evaluate the effectiveness of routine colonoscopy and marker evaluation in diagnosis of intraluminal recurrent cancer.METHODS:Chart review was conducted on 481 patients who underwent curative resection for colorectal cancer between 1980 and 1990. Clinical visits were scheduled and carcinoembryonic antigen evaluation was performed every three months, and colonoscopy was performed preoperatively, 12 to 15 months after surgical treatment, and then with intervals of 12 to 24 months or when symptoms appeared.RESULTS:About 10 percent of patients developed intraluminal recurrences. More than one‐half of metachronous lesions arose within the first 24 months, and median time to diagnosis was 25 months. Patients with left‐sited tumors in the advanced stage had a higher risk of developing recurrent intraluminal disease. Twenty‐nine patients underwent a second surgical operation, of which 17 cases were radical. In this group, the five‐year survival was 70.6 percent, although no nonradically treated or nonresected patients survived longer than 31 months. Twenty‐two patients were asymptomatic at time of diagnosis of recurrence, and of these, 12 patients underwent radical operation; on the other hand, of the 24 symptomatic patients, only 5 were treated radically. Carcinoembryonic antigen was the first sign of recurrence in eight cases. Colonoscopy must be performed within the first 12 to 15 months after operation, whereas an interval of 24 months between examinations seems sufficient to guarantee early detection of metachronous lesions.CONCLUSION:Serial tumor marker evaluation is of help in earlier diagnosis of local recurrences. Asymptomatic patients more frequently undergo another operation for cure and thus have a better survival rate.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

&NA;Incidence of tuberculosis is sharply rising in the United States, and tuberculous peritonitis is often diagnosed late in the course of the disease, resulting in undue patient morbidity and mortality.PURPOSE:Purpose of this study was to better identify which clinical, laboratory, radiologic, and invasive procedures were most useful in diagnosing tuberculous peritonitis.METHODS:All cases of tuberculous peritonitis diagnosed between 1982 and 1994 were reviewed retrospectively to discern which laboratory, radiographic, and procedural tests were helpful in diagnosing the condition.RESULTS:Twenty‐eight cases of tuberculous peritonitis were diagnosed during the studied period. Two patients were not diagnosed until autopsy. Patients from all socioeconomic classes and multiple races ranged in age from 3 to 69 (mean, 29.5) years. Most patients presented with a chronic wasting illness, mild abdominal pain, and fever. Purified protein derivative was only positive in 5 of 16 patients. Chest radiographs were suggestive of pulmonary tuberculosis (TB) in five patients. Ultrasound examination of the abdomen was helpful in five patients, and computed tomographic scan was suspicious in 16 of 17 patients. Sputum for acid fast bacillus (AFB) smear was positive in 3 of 14 patients, and paracentesis for AFB smear was positive in 1 of 8 patients. Routine blood work was not helpful. Laparoscopy was diagnostic in five of seven patients. Laparotomy and tissue biopsy of characteristic tissue for AFB smear and culture was diagnostic in 20 of 20 patients. Once diagnosed, all patients responded rapidly to empiric antituberculous medical therapy, except one patient with miliary TB who died shortly after diagnosis. A trend in earlier diagnosis was noted in recent years and is felt to be the result of an elevated index of suspicion.CONCLUSIONS:TB peritonitis may be fatal but is medically cured if diagnosed in a timely fashion. It is essential that the clinician suspect the disease in appropriate patients. Tests frequently associated with TB such as chest radiograph and purified protein derivative are not sensitive in detection of TB peritonitis. Computed tomographic scan is the most useful radiographic study. Mini laparotomy with tissue biopsy for smear and culture is the most sensitive and specific diagnostic procedure.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

&NA;Chronic constipation is an extremely common problem in children. Many authors have advocated using anorectal manometric examination during evaluation of chronic childhood constipation and encopresis as a means of developing individualized modes of treatment.PURPOSE:This study was designed to prospectively examine frequency and severity of symptoms of childhood constipation and encopresis and associate these symptoms with anorectal manometric findings.METHODS:Forty‐four children with chronic constipation participated in the study. Before performing anorectal manometry, bowel‐related symptoms were collected for two consecutive weeks with a computerized voice mail system. Anorectal manometry was performed using a triple lumen catheter attached to a hydraulic manometry infusion system.RESULTS:Frequency of voluntary bowel movements did not correlate with any manometric parameters. Frequency of fecal soiling, age at onset of symptoms, and duration of symptoms were all highly correlated with degree of sphincter spasm during attempted defecation; however, none of these variables correlated with any other manometric parameter. Amount of pain associated with bowel movements correlated with frequency of soiling and was inversely correlated with maximum squeeze pressure but was not correlated with any other manometric parameter.CONCLUSIONS:In children with chronic constipation and encopresis, sphincter spasm demonstrated with anorectal manometry is highly correlated with frequency of fecal soiling, age at onset, and duration of symptoms; however, none of the other commonly measured manometric parameters appear to correlate with symptoms of chronic childhood constipation and encopresis.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

&NA;Carcinoma of the colon is the second most common cancer among men and women combined in the United States.PURPOSE:Ornithine decarboxylase (ODC) is the first and key regulatory enzyme in the polyamine biosynthesis pathway and is regulated by various factors. Polyamines are believed to participate in cellular proliferation and differentiation. High levels of polyamines and ODC activity are associated with rapid cell growth, particularly in tumor tissues. Regulation of this enzymein vivohas important clinical implications. In the present study, we used Northern analysis and mobility shift assay to investigate whether ODC gene expression is regulated by androgens in the three human colonic cell lines, SW620, HT‐29, and Caco‐2.METHODS:Cell lines were maintained in Dulbecco's Modified Eagle's medium/F12 supplemented with 5 percent fetal bovine serum. At 60 percent confluency, medium was replaced with steroid‐depleted medium, and incubation continued for 24 hours. Following this period, medium was replaced with fresh steroid‐free medium containing 1 nM dihydrotestosterone.RESULTS:Dihydrotestosterone stimulated ODC messenger ribonucleic acid expression only in HT‐29 colonic cell line. Studies using electrophoretic mobility shift assays of nuclear extracts also showed a binding pattern with SP1 and NF‐&kgr;B regulatory sequences only in testosterone‐treated HT‐29 cells.Conclusion:These results suggest that androgens may play an important role in the growth of HT‐29 colonic cell lines.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:To clarify neurologic function with respect to external anal sphincter and puborectalis muscles after J configuration ileal J‐pouch‐anal anastomosis for patients with ulcerative colitis and adenomatosis coli, we examined the terminal motor latency in the pudendal and sacral motor nerve (S2‐4).METHODS:Latency of the response in the external anal sphincter muscle following digitally directed transrectal pudendal nerve stimulation (PNTML) and in the puborectalis muscle following transcutaneous magnetic stimulation of the cauda equina at the levels S2‐4 (SMNLTSS) were measured in 12 patients with ileal J‐pouchanal anastomosis; they were divided into a group with continence (7 cases) and a group with soiling (5 cases). Results were compared with data obtained from 12 patients before operation and 15 controls.RESULTS:Conduction delay of PNTML and SMNLTSS in patients with soiling was longest, followed by delay in those without any soiling, then delay in patients before operation, and then controls. In addition, significant differences were also noted between conduction delay of PNTML in controls and those who are incontinent and experience soiling(P< 0.05 andP< 0.01, respectively), and there were significant differences also noted between conduction delay of PNTML in patients before operation and those who are incontinent and experiencing soiling(P< 0.05 andP< 0.01, respectively). Conduction delay of PNTML and SMNLTSS were found in patients before operation rather than in controls. No significant differences were noted between conduction delay of PNTML and SMNLTSS in patients before operation and controls. Significant differences were also noted between conduction delay of PNTML and SMNLTSS in patients who are incontinent and experiencing soiling(P< 0.01, respectively).CONCLUSION:These findings support the hypothesis that soiling after this procedure may be partially caused by damage to pudendal and sacral motor nerves (S2‐4).

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:Colorectal cancer is one of the tumors most refractory to treatment by chemotherapy. The chemosensitivity test should be performed to individualize the chemotherapy for patients with colorectal cancer, which is less sensitive for anticancer drugs. The present study was designed to determine the chemosensitivity in fresh human colorectal cancer, using highly purified tumor cells, and the correlation of this sensitivity with clinical response.METHODS:We determined the chemosensitivity for cisplatin, mitomycin C, adriamycin, and 5‐fluorouracilin vitroin 93 fresh human colorectal cancers using the MTT assay and performed chemotherapy according to results of the MTT assay.RESULTS:Inhibition rate of tumor cells for cisplatin was higher than those for other drugs. Fifteen patients who have evaluable lesions received chemotherapy according to results of the MTT assay. Clinical responses were obtained in 5 of 15 patients, and the inhibition rate for cisplatin was higher in responders than in nonresponders.CONCLUSIONS:It is suggested that the chemotherapy according to results of the MTT assay is effective in patients with colorectal cancer.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID