摘要:

PURPOSE:The stimulated gracilis neosphincter is accepted as a viable option in select patients with fecal incontinence. The aim of this study was to review the initial problems and complications.METHODS:A prospective analysis of all patients who underwent this procedure was undertaken. Stage I consisted of the distal vascular delay of the muscle and creation of a temporary stoma. Stage II was the transposition of the muscle and implantation of the stimulator and electrodes. Low frequency electrical stimulation was applied to the muscle for 12 weeks, after which Stage III (stoma closure) was undertaken.RESULTS:From March 1993 to December 1995, 17 patients (9 females and 8 males) with a mean age of 42.2 (range, 19‐72) years underwent the procedure. One patient died from pancreatitis and another from small‐bowel adenocarcinoma, three and six months after the procedure, respectively. Two patients (one with Crohn's disease) required permanent stomas. One additional patient required a permanent stoma because of lead fibrosis. Other complications noted during ascent of the learning curve included seroma of the thigh incision, excoriation of the skin above the stimulator, fecal impaction, anal fissure, parastomal hernia, rotation of the stimulator, premature battery discharge, fracture of the lead, perineal skin irritation, perineal sepsis, rupture of the tendon, tendon erosion, muscle fatigue during programming sessions, and electrode displacement from the nerve or fibrosis around the nerve. However, ultimately after rectification of these problems, 13 of the 15 eligible patients had stoma reversal. Manometric results showed an average basal pressure of 43 mmHg and an average maximum squeeze pressure that increased from 36 mmHg before surgery to 145 mmHg by stimulation(P<0.01). Based on objective functional questionnaires, 9 of 15 (60 percent) evaluable patients reported improvement in continence, social interactions, and quality of life. Three of these nine patients require daily use of enemas.CONCLUSION:Although the stimulated gracilis operation is a feasible procedure for selected patients with severe incontinence, the learning curve is steep. Although the ultimate outcome in a selected group of patients can be very gratifying, major technical modifications are required before use beyond a research protocol setting. Furthermore, patients must have the psychological strength, emotional commitment, and financial resources that may be necessary for multiple revisional surgeries or ultimate device failure.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

BACKGROUND:The optimum management of large‐bowel cancer in patients with previous spinal cord injury (SCI) is uncertain.PURPOSE:The aim is to determine the outcome of patients with SCI who are undergoing colectomy or proctectomy for cancer.METHODS:A population‐based study of patients receiving care at hospitals in the Department of Veterans Affairs system from 1987 to 1991 was performed. Patients with ICD‐9 codes for SCI and colon and rectal cancer were identified. Patients with previous SCI who underwent colectomy or proctectomy for their cancer comprised the study population. Data were compiled from national computerized Veterans Affairs datasets, supplemented by individual operative reports and discharge summaries.RESULTS:Forty‐four patients were evaluable. Mean age was 65 (range, 40‐80) years, and mean time since SCI was 24 (range, 1‐50) years. Mean follow‐up was 4.6 years after resection. Distribution of tumors was 39 percent rightsided, 43 percent left‐sided, and 18 percent rectal. All 32 patients with colonic tumors underwent resection; 26 of 32 patients (81 percent) had an anastomosis. Seven of eight (88 percent) rectal lesions were treated by abdominoperineal resection. Twenty‐six of 44 patients (59 percent) presented with Stage III or IV disease. Twelve of 44 (27 percent) died, 8 of 12 from cancer. Overall 30‐day mortality rate was 4.5 percent (2/44). In‐hospital morbidity rate (pulmonary, cutaneous, and urinary tract only) was 34 percent. Among those who received postoperative chemotherapy, 80 percent completed treatment.CONCLUSIONS:Patients with previous SCI tolerate resection well. Tumor distribution and stage are similar to those of neurally intact patients. Morbidity is commonly related to pre‐existing complications of SCI. Adjuvant therapy is well tolerated.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:This study was undertaken for the comparison of local resection for early rectal carcinomas using transanal endoscopic microsurgery or anterior resection.METHODS:Data from 50 of 52 patients with proven adenocarcinoma (GI/II) and intraluminal ultrasound with Stage uT1 N negative (uTNM) were evaluated in a prospective randomized study with two therapeutic arms: transanal endoscopic microsurgery (TEM; n=24) or anterior resection (AR; n=26), performed under general anesthesia.RESULTS:Patients' ages and rectal tumor locations showed insignificant differences of distribution in comparison of TEM with AR (Welsh's alternatet‐test;t‐test). Local recurrence (4.2 percent) and five‐year survival rates (96 percent) differed insignificantly (log‐rank test). Early postoperative mortality was zero. Significant differences were found comparing time of hospitalization, loss of blood, operation time, and opiate analgesia (Welsh's alternatet‐test; Wilcoxon's test; eachP< 0.05). Early and late morbidity differed considerably.CONCLUSIONS:Lower morbidity, similar local recurrence, and survival rates favor the TEM technique. Comparable results in survival rate to the gold standard (AR) are objective arguments for choosing the adequate surgical procedure. For early rectal cancer, the minimum invasive TEM technique should be preferred because of superior overview during operation with safer suturing after meticulous full wall thickness excision.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:We report the indications, technique, and results of conversion of the ileoanal pouch to the Kock's pouch in five patients. The indication was functional disturbance that could not be corrected by operation. Aim of the conversion operation was re‐establishment of fecal control and complete preservation of existing ileal surface.METHODS:The ileal pouch was used again, and in one case an augmentation was made. The continence valve was made three times from the afferent loop and in two cases from a higher ileal segment.RESULTS:Following conversion, function was excellent in three patients with ulcerative colitis and in one patient with familial adenomatous polyposis. One woman who underwent proctocolectomy for slow‐transit constipation needed a Brooke ileostomy for continuous abdominal distention pain.CONCLUSION:We conclude that conversion to a continent ileostomy is a rewarding method of safely eliminating dysfunction of the ileoanal pouch that cannot be corrected by operation. Presumption is, however, that the surgeon is familiar with both methods and that the primary disease is suitable for pouch surgery.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:Bone marrow transplantation (BMT) is often associated with profound neutropenia. Allogeneic transplant recipients also have defects in both humoral and cellular immunity and thus are subject to increased risk of serious, often life‐threatening, infection even beyond the period of granulocyte recovery. The current study was undertaken to evaluate patients who required operative intervention for perianal sepsis following BMT.METHODS:The bone marrow transplant database at a single institution was used to identify all patients diagnosed with perianal infections after autologous or allogeneic BMT. Charts were reviewed in a retrospective manner.RESULTS:Over a ten‐year period ending in November 1993, 963 BMT were performed at the City of Hope National Medical Center. Twenty‐four patients were diagnosed with perianal infections foEowing their transplants. Fifteen patients did not have purulent collections requiring drainage and were treated with antibiotics and supportive measures alone. Nine patients (37.5 percent) required surgical intervention between 10 and 380 days following transplantation. At the time of surgical intervention, seven patients had purulent collections and two patients had acute and chronic inflammation, tissue necrosis, and fibrosis. Of the two patients with an absolute neutrophil count less than 1,000, a purulent collection was found in one of the patients. Cultures taken from perianal abscesses were almost all polymicrobial, and the most common organisms wereEscherichia coli, Bacteroides, Enterococcus,andKlebsiella.For those patients undergoing surgical intervention, mean time to complete wound closure by secondary intention was 37.6 days; five patients healed in less than 15 days, two patients healed at 93 and 114 days, and two patients had persistent, open wounds at time of death, which was unrelated to their perianal disease. Five patients were receiving systemic steroids at time of surgical intervention; this did not appear to affect time to wound healing.CONCLUSIONS:Perianal infections are a rare complication of BMT. Majority of these infections are polymicrobial, and organisms isolated are similar to those seen in the perianal infections of nonimmunosuppressed patients. Despite steroid use, granulocytopenia does not exclude the possible presence of purulent collections, and clinical examination should guide the decision for surgical drainage. In general, perianal wound healing is not prolonged in BMT patients.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:Functional outcome after low anterior resection with ultralow coloanal anastomosis for rectal cancer is improved by construction of a colonic J‐pouchvs.straight anastomosis. Optimum size of this pouch has yet to be determined. Therefore, we initiated a prospective, randomized trial using 5‐cm and 10‐cm pouches to determine this size.METHODS:Patients with tumors 5 to 10 cm from the anal verge were included in the study. Before a low anterior resection anastomosis was performed, patients were randomized to either a 5‐cm J‐pouch group (5‐J group) or a 10‐cm J‐pouch group (10‐J group). Functional assessments were performed one year postoperatively. Clinical functions were evaluated using a functional scoring system. Physiologic functions, such as sphincter and reservoir function, were evaluated by anorectal manometry and evacuation function by the balloon expulsion and saline evacuation tests.RESULTS:Forty patients among 43 randomized patients were assessed for functional outcome one year postoperatively (5‐J group, n=20; 10‐J group, n=20). The functional score was similar for the two groups, although reservoir function in the 5‐J group was significantly less than in the 10‐J group. Sphincter function was similar between the two groups. Evacuation function in the 5‐J group was significantly superior to that in the 10‐J group.CONCLUSIONS:The 5‐cm J‐pouch conferred adequate reservoir function without compromising evacuation.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:This study was undertaken to assess biofeedback treatment (active sphincter exercises under direct electromyography vision) in neurogenic fecal incontinence.METHODS:Twelve patients with neurogenic fecal incontinence have been studied prospectively. External sphincter contractions were exercised under direct electromyographic vision twice per day for 30 minutes during 12 weeks. Manometry was done at the beginning and after 12 weeks of training to evaluate objectively changes in sphincter functions.RESULTS:No patient experienced any improvement in fecal control. Mean resting pressure increased from 7 to 9 kPa and mean squeeze pressure from 3.9 to 4.9 kPA, which was of no statistical significance(P=0.20 andP=0.46, respectively).CONCLUSIONS:External sphincter contraction exercises under direct electromyographic vision are not effective in neurogenic fecal incontinence. Degree of continence does not improve, and external sphincter function is not increased significantly.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:A survey was conducted to document current perioperative steroid use in colorectal patients.METHODS:A mail survey was sent to 1,400 members and fellows of The American Society of Colon and Rectal Surgeons.RESULTS:Three hundred seven questionnaires (21.9 percent) were returned. Twenty‐four respondents had retired or lacked accurate data. The remaining 283 surgeons averaged 43.5 (range, 31‐71) years in age and had been in practice an average of 11 (range, 1‐39) years. Ninety‐seven percent were certified by the American Board of Surgery, 87 percent by the American Board of Colon and Rectal Surgery, and 85 percent by both. Eighty‐six percent of respondents manage the perioperative steroids and 85 percent manage the postoperative steroid taper of their patients. In patients receiving preoperative steroids, 84 percent of respondents administer 100 mg of hydrocortisone phosphate intravenously before surgery. The most common postoperative dosage (used by 62 percent) was 100 mg of hydrocortisone phosphate intravenously every eight hours, which was tapered to 50 mg intravenously every 8 to 12 hours. Most patients (49 percent) received 20 mg of prednisone per day when their oral intake was resumed. The most common taper regimen was a 5 mg reduction per week (61 percent of respondents).CONCLUSION:Despite lack of scientifically established requirements or proven physiologic guidelines, perioperative steroid use by colorectal surgeons appears relatively consistent.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:This study was designed to compare complications and functions following either radical extended right colectomy without colonic decompression or radical segmental left colectomy with intraoperative decompression for obstructed left‐sided colonic carcinomas.METHODS:One hundred three patients with obstructed left‐sided colonic carcinoma undergoing primary resection and anastomoses were studied.RESULTS:There were 57 males and 46 females with a median age of 65 (range, 24‐98) years and who had a median follow‐up of 31 (range, 2‐59) months. There were no leaks or intra‐abdominal sepsis in the extended right colectomy group (44 patients) compared with one anastomosis leak in the segmental left colectomy (59 patients) group. Median hospital stay was 14 days in both groups, with a range of 8 to 36 days in the segmental left colectomy group and 7 to 44 days in those with extended right resection. One month after surgery, the patients who underwent segmental left colectomy had a median bowel movement of 3 (range, 1‐6) per 24 hours compared with those with extended right colectomies who had a median of 5 (2‐11) bowel movements per 24 hours. Bowel frequency decreased to four or less episodes per 24 hours in all patients in both groups at six months.CONCLUSION:There was no significant difference between bowel function or complications between the two groups.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

&NA;Although sporadic colorectal cancer (CRC) is relatively uncommon in the young, it may constitute an elevated genetic risk for CRC in these individuals.PURPOSE:This study was designed to determine extent of colorectal cancer in families of probands under 40 years of age.METHODS:Medical records of all consecutive patients, 40 years of age or younger at the time of CRC surgery, during the time period 1986 to 1994 were examined. Cases of familial adenomatous polyposis and ulcerative colitis were excluded.Viainterviews of surviving probands or nearest relatives, dates of birth and death, causes of death, and diagnosis of cancer were recorded on all first‐degree relatives (parents, siblings, and offspring), second‐degree relatives (grandparents, aunts, and uncles), and any other relatives.RESULTS:A total of 128 patients, 40 years of age or less at time of CRC resection, were identified. Of these, 45 probands/families were reached by phone, and 45 detailed family histories were obtained. Age range of these 45 probands was 19 to 40 (mean, 33.1) years. In 25 families there was no history of CRC in first‐degree, second‐degree, or third‐degree relatives. Eight of 45 probands (17.8 percent) had at least one first‐degree relative with CRC, and three of these eight families fulfilled the Amsterdam criteria for hereditary nonpolyposis colorectal cancer (HNPCC). In all three families, inheritance of CRC appeared to segregate with the maternal side of the family. In addition, 5 of 43 non‐HNPCC probands had at least one first‐degree, second‐degree, or third‐degree relative less than 40 years of age, at time of CRC diagnosis.CONCLUSION:Ascertainment of a detailed family history in early age of onset CRC patients identifies frequent familial clustering of CRC and HNPCC in 17.8 percent of cases.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID