摘要:

&NA;Pelvic floor outlet obstruction is a rare cause of severe constipation. Anal myectomy, subtotal colectomy, and medical therapy have limited success. The purpose of this study was to develop a short outpatient treatment using biofeedback techniques. Nine patients with severe constipation and straining resulting from pelvic floor outlet obstruction underwent complete investigation of the pelvic floor musculature and anal sphincter mechanism. Patients were unable to expel a 60‐cc rectal balloon and had nonrelaxing puborectalis on defecography. The treatment protocol utilized anal surface electromyography to document improper straining and retrain pelvic floor muscles to relax during defecation. Sensory retraining with a rectal balloon, behavioral relaxation techniques, and defecation of simulated stool using a 120‐cc Metamucil®(Procter & Gamble, Cincinnati, OH) slurry in the rectum allowed re‐establishment of normal defecation in all nine patients. Repeat training was required in three patients during follow‐up. Treatment of pelvic floor outlet obstruction with outpatient retraining techniques is possible.

ISSN:0012-3706    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

&NA;Anorectal pressures in patients with fecal incontinence have been investigated. With anal manometry, 34 percent of patients with fecal incontinence had maximal resting pressure and 39 percent had maximal squeeze pressure within the normal range. When a pressure gradient was calculated as the pressure difference between maximal resting pressure and rectal pressuring during filling of a rectal balloon, patients with fecal incontinence could be better distinguished from controls: 20 percent of patients with fecal incontinence had values within the normal range when the rectal pressure at the earliest defecation urge was used(P<0.05), and 12 percent had values within the normal range when the rectal pressure at maximal tolerable volume was used(P<0.01). Anorectal pressure gradient measurements seem to distinguish patients with fecal incontinence from controls better than maximal resting pressure or maximal squeeze pressure alone.

ISSN:0012-3706    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

&NA;To compare the clinical and functional results of ileorectostomy (IR) and ileal pouch‐anal anastomosis (IPAA) in patients with familial adenomatous polyposis (FAP), we reviewed the results of 94 IPAA patients and 21 IR patients who were operated upon between 1978 and 1988. The groups were similar with respect to age and sex. None of the patients died postoperatiyely. Postoperative complications occurred in 28 percent of the IPAA group and in 17 percent of the IR group(P>0.1). Seven percent of IPAA patients described symptoms compatible with pouchitis. Sixty‐one percent of IR patients required subsequent fulguration of rectal polyps at least once. IR patients had a mean (±SD) of 4 (±2) stools per day, while IPAA patients had 5 (±2) stools per day(P>0.05). No significant difference in daytime soiling was present between IR (6 percent) and IPAA (4 percent). Nighttime spotting was also similar between the two groups. Nighttime soiling, however, was reported by 4 percent of IPAA patients but not by IR patients(P<0.05). One IPAA patient (1 percent) required pouch excision for a desmoid tumor, while two IR patients (11 percent) required proctectomy and ileostomy for recurrent dysplastic polyps(P<0.05). Adhesions and a shortened ileal mesentery prevented the construction of an ileoapal procedure in these latter patients. In conclusion, the postoperative complication rate and functional results are similar after IR and IPAA in patients with FAP; however, IR does not eradicate rectal polyps and may indeed preclude IPAA for those requiring subsequent proctectomy.

ISSN:0012-3706    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

&NA;During a three‐year period, 27 patients with the diagnosis of adenocarcinoma of the rectum were referred to the Department of Radiation Oncology and accepted for preoperative radiation therapy. The referral was based solely on endoluminal ultrasound staging (ELUS) of an unfavorable lesion (n=12) or ultrasound staging with the clinical impression of a fixed (n=9) or tethered (n=6) lesion. High‐dose (4,500‐5,600 cGy) preoperative radiation was followed by definitive surgery in four to seven weeks. The gross and microscopic pathology observed in 23 specimens of this group of patients formed the basis of this report. The microscopic findings that persist after radiation allow an accurate determination of the tumor stage existing prior to radiation. Correlations are made between the original evaluation of the tumor, including ELUS, and the microscopic findings. ELUS accurately predicted the depth of tumor penetration in 20 to 23 of 23 specimens and the lymph node status in 16 of 23 specimens. In the context of the pathologic findings as described, downstaging was not demonstrated. Following this radiation protocol, a marked reduction in tumor mass was demonstrated, as well as evidence of tumor destruction in the remaining mass, varying from minimal to total elimination of viable tumor. The concept that radiation fibrosis exists only as it approximates or replaces neoplasm is offered. In the context of this pathologic finding, improved resectability occurred for certain tumors. It is recommended that ELUS be added to the clinical evaluation of rectal adenocarcinoma. It is also recommended that the pathologic findings described be used when reporting the stage of rectal tumors that have received high‐dose preoperative radiation therapy.

ISSN:0012-3706    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

&NA;The prevalence of gallstone disease in 145 consecutive patients with colorectal cancer was compared with gallstone prevalence in 4,159 subjects randomly selected from a population. The group of patients had a significantly higher prevalence of gallstone disease than the population (odds ratio=1.59,95 percent confidence limits 1.04‐2.45), whereas cholecystectomies occurred with equal frequency in the two groups. There was a nonsignificant trend toward more right‐sided cancers in patients with gallstones than in patients without. These results, together with available literature, give substantial evidence for an association between gallstones and colorectal cancer, an association which is not due to cholecystectomy being a predisposing factor to colorectal cancer. Sporadic findings of an association between cholecystectomy and colorectal cancer can be explained by the above relationship.

ISSN:0012-3706    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

&NA;Forty of 416 patients with familial adenomatous polyposis were noted to have intra‐abdominal desmoid tumors, and a subgroup of 16 were treated with noncytotoxic drug therapy. Drugs used were sulindac (14 patients), sulindac plus tamoxifen (3 patients), indomethacin (4 patients), tamoxifen (4 patients), progesterone (DEPO‐PROVERA®; Upjohn Co., Kalamazoo, MI) (2 patients), and testolactone (1 patient). Therapy with these drugs for continuous periods of six months or more resulted in three complete and seven partial remissions. When treated patients were compared with untreated patients (n=12), there were significant benefits for the treated group, both in reduction of desmoid size and in improvement of symptoms, despite the inherent selection bias against this. Sulindac was the only drug used in enough patients to permit independent evaluation of its effect, with one complete and seven partial reductions of tumor size. Some patients had a delayed response to sulindac, with tumor shrinkage occurring after an initial period of tumor enlargement. When using sulindac for the treatment of desmoid tumors, this phenomenon should be considered.

ISSN:0012-3706    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

&NA;We made use of hematoxylin and eosin (H&E) stain, Verhoeff van‐Gieson stain for elastic tissue (EVG), and factor VIII‐related antigen (FVIII‐RA) to stain tissues excised from 94 patients with colorectal carcinoma. Of these 94, 49 died of disease within two years (Group I), and 45 survived for five years or longer (Group II) after surgery. In the tissues from both groups, the use of EVG stain revealed a higher incidence of vascular invasion than was seen with H&E stain. In Group I, the rates were 28.6 percent and 61.2 percent with H&E and EVG, respectively, and those in Group II were 4.4 percent and 31.1 percent, respectively. Conversely, the FVIII‐RA stain showed a decrease in the incidence of vascular invasion in both groups. In Group I, when vascular invasion was examined in EVG‐stained tissues, the incidence was 81.3 percent in cases of hematogenous metastases and 23.5 percent in those without hematogenous metastases(P< 0.01). These differences were not evident with H&E. When observing the site of vascular invasion in tissues of the colorectal wall stained with EVG, intramural and extramural types of vascular invasion were seen in 20 percent and 80 percent of cases in Group I and in 93 percent and 7 percent of those in Group II, respectively. Thus, not only the frequency, but also the site, of vascular invasion into the colorectal wall evidenced with EVG stain provides a more precise prediction of the recurrence of hematogenous metastases.

ISSN:0012-3706    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

&NA;Sixty‐nine patients were operated upon in a three‐stage procedure. Early complications occurred in 29 percent after colectomy‐ileostomy, in 25 percent after proctomucosectomy with ileoanal anastomosis and loop ileostomy, and in 9 percent after closure of loop ileostomy. Only three of these were considered serious. Seventy‐one percent of the patients were readmitted into the hospital between the three operations or after the last one. Total hospital stay was 49 days (median); the range was 20 to 345 days. Reconstruction of the reservoir was performed in four patients owing to defecation problems, with satisfying functional results in two patients, while two emptied by catheter. There was no postoperative mortality or pelvic sepsis, and no pouches were excised. Ileostomy was re‐established in two patients. At histopathologic reevaluation of colectomy specimens, the diagnosis was changed from ulcerative colitis to Crohn's disease in three patients and to indeterminate colitis in five. Median follow‐up was 4.3 years. Continent anal defecation without ileostomy was achieved in 67 patients (97 percent), with 4.1 bowel movements per day and 0.6 per night. Perfect continence was achieved in 55 percent in the daytime and in 43 percent at night. The low rate of reservoirthreatening complications is attributed to the three‐stage procedure and the technical details in the surgical procedures.

ISSN:0012-3706    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

&NA;The effect of abdominal rectopexy on bowel function is difficult to assess in retrospective studies because preoperative bowel habit cannot be determined accurately. This study examined bowel symptoms and physiologic tests of anorectal function prospectively in 23 patients before and at three months after rectopexy. Rectopexy eliminated complete prolapse in all and stopped bleeding in 16 of 18 patients. Incontinence improved significantly. Constipation (<3 bowel actions per week or straining for more than 25 percent of defecation time) was relieved in 4 of 11 affected patients but developed in 5 of the 12 who were not constipated preoperatively. Since the median bowel frequency was 21 motions per week before surgery and 17 afterward, the main determinant of constipation was straining. Abdominal pain was relieved after rectopexy in 6 of 12 patients but developed in 3 of 13 who were pain‐free before surgery. Three patients (13 percent) had a first‐degree relative with rectal prolapse. Perineal descent decreased significantly. Maximal anal resting pressure increased significantly, but this did not correlate significantly with improved continence. Twenty‐one patients (91 percent) could expel a 50‐ml balloon preoperatively; 18 of those 21 could still do so postoperatively. The two patients who could not expel the balloon preoperatively were able to do so postoperatively. This study shows that rectal prolapse is associated with profoundly abnormal defecation and abdominal pain. While abdominal rectopexy improved continence, it may improve or worsen other bowel symptoms, including constipation.

ISSN:0012-3706    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

&NA;Patients on chronic hemodialysis for end‐stage renal disease (ESRD) may develop anorectal problems necessitating surgery. From January 1984 to December 1987, 18 ESRD patients underwent anorectal surgery. During this period, a mean of 215 patients underwent dialysis. Patients with ESRD present with characteristic problems: chronic constipation, need for dialysis pre‐ and postoperatively with heparin infusion, anemia, anticoagulation secondary to the consequences of uremia, and significant medical problems including coronary artery disease, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease (COPD). Two patients had concomitant anal fissure, two had fistula‐in‐ano, and one had an acute perianal abscess. In two patients, the postoperative course was complicated by hemorrhage and, in one patient, by abscess formation. There was no delay in wound healing compared with a cohort group. The essentials of perioperative management are discussed with respect to timing of dialysis, methods of anesthesia and pain management, coagulation screening, and complications. Patients on well‐managed chronic dialysis will tolerate anorectal surgery without undue jeopardy.

ISSN:0012-3706    

出版商:OVID    

年代:1992

数据来源: OVID