摘要:

INTRODUCTION:Surgeons have been reluctant to apply laparoscopic techniques to Crohn's disease surgery because of concerns with evaluating and excising inflamed tissue using laparoscopic methods Additionally in Crohn's disease surgery, laparoscopic techniques have not been demonstrated to have clear advantages over conventional ones.METHOD:We conducted a prospective, randomized trial in one surgical department comparing laparoscopic vs. conventional techniques in 60 patients (25 males), median age 34.4 (range 10‐60.1) years, undergoing elective ileocolic resection for refractory Crohn's disease. Postoperatively, all patients underwent measurement of pulomnary function tests every 12 hours, and were treated identically on a highly controlled protocol with regard to analgesic administration, feeding, and postoperative care.RESULTS:Of the 31 patients assigned to laparoscopic and 29 to the conventional group, all had isolated Crohn's disease of the terminal ileum plus or minus the cecum. Median length of the incision was 5 cm in the laparoscopic group and 12 cm in the conventional group. Overall recovery of 80 percent of forced expiratory volume (one second) and forcec vital capacity was a median of 2.5 days for laparoscopic and 3.5 days for conventional (P=0.03). There was no difference in the amount of morphine equivalents used between groups postoperatively. Flatus and first bowel movement returned a median of 3 and 4 days, respectively, after conventional roscopicvs.3.3 and 4 days, respectively, after conventional surgery (P=0.21). Median length of stay was five (range, 4‐30) days for laparoscopic, and six (range, 4‐18) days for conventional surgery. Major complications occurred in one patient in each group. Minor complications occurred in four laparoscopic and eight conventional patients (P<0.05). There were no deaths. Two laparoscopic patients were converted to conventional as a result of adhesions or inflammation. All patients recovered well and there were no clinical resurrences in the follow‐up period (median, 20; range, 12‐45 months).CONCLUSIONS:Within a single insititution, single surgical team, prospective, randomized trial, laparoscopic techniques offered a faster recovery of pulomary function, fewer complications, and shorter length of stay compared with conventional surgery for selected patients undergoing ileocolic resection for Crohn's disease.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:To compare the outcome after laparoscopicversusopen resection for colorectal adenocarcinoma.METHODS:A retrospective cohort analysis of all patients undergoing elective resection for colorectal adenocarcinoma between November 1992 and June 1999 at a university‐affiliated hospital. These included 219 open (mean age, 68.3 years) and 98 laparoscopic (mean age, 70.3 years) resections. Data from converted cases (n=12) were included in the laparoscopic group using the intention‐to‐treat principle.RESULTS:Operative time, lymph node yield, resection margins and postoperative morbidity and mortality were similar between laparoscopic and open technique. Parenteral analgesic use was less in the laparoscopic group (laparoscopic, 2.7; open, 3.2 days;P=0.021). Time to first flatus (laparoscopic, 1.8; open, 3 days;P<0.0001) and first bowel movement (laparoscopic, 3.5; open, 4.9 days;P<0.0001) was shorter in the laparoscopic group. Resumption of an oral liquid diet (laparoscopic, 2.1; open, 4 days;P<0.0001) and solid diet (laparoscopic, 5.2; open, 7.1 days;P<0.0001) was also quicker in the laparoscopic patients. Length of hospitalization was significantly shorter in the laparoscopic patients (laparoscopic, 6.9; open, 10.9 days;P<0.001). There were less minor complications in the laparoscopic group (laparoscopic, 11.2; open, 21.5 percent;P=0.029) but no difference in major complications or perioperative mortality. Recurrence, disease‐free and overall survival were similar between the two groups. No port site recurrences ocurred in the laparoscopic group but there were three wound recurrences in the open group.CONCLUSIONS:Laparoscopic resection for colorectal cancer can be performed safely and effectively in tertiary centers. Earlier discharge from hospital, quicker resumption of oral feeds and less postoperative pain are clear advantages. No adverse effect on recurrence or survival was noted, but results of prospective, randomized trials, currently underway, are needed before laparoscopic resection for colorectal cancer becomes the standard of practice.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:Preanastomotic recurrence and stricturing after surgery for ileocolic Crohn's disease is a frequent, unexplained phenomena that may lead to prompt reoperation. The aim of this study was to determine whether a wide‐lumen stapled anastomosis (side‐to‐side, functional end‐to‐end) provides better outcome than a conventional sutured end‐to‐end anastomosisMETHOD:A case‐control comparative analysis of patients with Crohn's disease from two inflammatory bowel disease centers treated with wide‐lumen stapled anastomosis and a matched (age and gender) group treated with conventional sutured end‐to‐end anastomosis was performed.RESULTS:A total of 138 patients with Crohn's disease were treated, 69 with wide‐lumen stapled anastomosis and 69 with conventional sutured end‐to‐end anastomosis. Preoperative therapy, number of previous resections, indication for operation, and length of bowel resected were similar in both groups. Fewer complications occurred after wide‐lumen stapled anastomosis (P=0.048). A total of 55 patients developed recurrent Crohn's disease symptoms, 39 (57 percent) in the conventional sutured end‐to‐end anastomosis and 16 (24 percent) in the wide‐lumen stapled anastomosis group. Median follow‐up was 70 and 46 months, respectively. After conventional sutured end‐to‐end anastomosis 18 reoperations were required, 15 for anastomotic stricture and 3 for fistulization. After wide‐lumen stapled anastomosis three reoperations were necessary, two for stricture and one for fistulization. The cumulative reoperation rate for anastomotic recurrence was significantly lower (P=0.017; log‐rank test) for the wide‐lumen stapled anastomosis group.CONCLUSION:Wide‐lumen stapled anastomosis is as safe as conventional sutured end‐to‐end anastomosis and results in a lower incidence of symptomatic recurrent Crohn's disease and need for reoperation. Further prospective study of the wide‐lumen stapled anastomosis technique is necessary to define the precise role of this operation in patients with Crohn's disease.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:Although sphincter‐preservation procedures have replaced abdominoperineal resection as the treatment of choice for rectal cancer, a subset of patients with rectal cancer will still require abdominoperineal resection. The use of adjuvant radiotherapy has been shown to reduce local recurrence, and combined modality therapy (chemoradiation) improves survival. Sharp mesorectal excision compared with the classic teaching of blunt retrorectal dissection is also an important component of local control. The primary aim of the present study was to evaluate the postoperative complications associated with neoadjuvant therapy in patients requiring complete rectal excision. Oncologic outcomes for all patients with abdominoperineal resection are also provided.METHODS:A prospective database of 5,634 patients who underwent surgery for colorectal cancer at Memorial Sloan‐Kettering Cancer Center between the years 1987 and 1997 was reviewed. Patients with primary adenocarcinoma of the rectum who underwent abdominoperineal resection were identified. In 1,622 patients who were operated on for primary rectal cancer, 292 patients (18 percent) underwent abdominoperineal resection and the rest had a sphincter‐preserving procedure. Ten patients were excluded from the study because of prior pelvic irradiation for other cancer (8 patients) and insufficient radiation dose (<4,000 cGy; 2 patients). Neoadjuvant radiotherapy was given to 123 patients and postoperative adjuvant radiotherapy to 65 patients, whereas 94 did not receive radiotherapy. Intraoperative radiotherapy combined with preoperative radiotherapy was administered to 23 of the 123 patients given neoadjuvant radiotherapy.RESULTS:The duration of the operation was significantly longer in both neoadjuvant radiotherapy and intraoperative radiotherapy groups compared with the nonradiotherapy group (P=0.01 andP<0.0001, respectively). Estimated blood loss, mean number of blood units transfused per patient, and the percentage of patients being transfused were similar among the groups. Early postoperative complications were significantly higher in the neoadjuvant radiotherapy groups compared with the nonradiotherapy group. Late complications, overall survival, disease‐free survival, and local recurrence were not significantly different among the groups.CONCLUSIONS:In patients with cancer of the lower one‐third of the rectum, sharp pelvic dissection can result in a low rate of local recurrence even without radiotherapy. The role of preoperative radiotherapy, although associated with higher perineal wound complications, is important in increasing resectability and sphincter‐preservation rate. Randomized, prospective trials will be needed to establish the role of adjuvant radiotherapy in patients undergoing sharp mesorectal excision for rectal cancer.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:After resection of the distal rectum with a straight reanastomosis, poor bowel function can occur. This is felt to be because of the loss of the rectal reservoir. To overcome this, a neoreservoir using a colonic J‐pouch has been advocated in low colorectal and coloanal anastomosis. However, difficulties in reach, inability to fit the pouch into a narrow pelvis, and postoperative evacuation problems can make the colonic J‐pouch problematic. Coloplasty is a new technique that may overcome the poor bowel function seen in the straight anastomosis and the problems of the colonic J‐pouch. The purpose of this study was to compare the functional results after a low colorectal anastomosis among patients receiving a coloplasty, colonic J‐pouch, or straight anastomosis.METHODS:Twenty patients underwent construction of a coloplasty with a low colorectal anastomosis. Postoperative manometry and functional outcome of these patients was compared with a matched group of 16 patients who had a colonic J‐pouch and low colorectal anastomosis and 17 patients who had a straight low colorectal anastomosis.RESULTS:Maximum tolerated volume was significantly favorable in the coloplasty (mean, 116.9 ml) and colonic J‐pouch group (mean, 150 ml)vs.the straight anastomosis group (mean, 83.3;P<0.05) The compliance was also significantly favorable for the coloplasty (mean, 4.9 ml/mmHg) and the colonic J‐pouch group (mean, 6.1 ml/mmHg)vs.the straight anastomosis group (mean, 3.2 ml/mmHg;P<0.05) The coloplasty (mean, 2.6; range, 1‐5) and colonic J‐pouch (mean, 3.1; range, 2‐6) had significantly fewer bowel movements per day than the straight anastomosis group (mean, 4.5; range, 1‐8;P<0.05). Similar complication rates were noted in the three groups.CONCLUSIONS:Patients with a coloplasty and low colorectal anastomosis seem to have similar functional outcome along with similar pouch compliance compared with patients with colonic J‐pouch and low colorectal anastomosis. However, the coloplasty may provide an alternative method to the colonic J‐pouch for a neorectal reservoir construction when reach or a narrow pelvis prohibits its formation. Technically it also may be easier to construct.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:During ileal pouch‐anal anastomosis, both conservation of the anal transitional zone during the stapled technique and incomplete mucosectomy in the standard Park's procedure may expose the patient to disease recurrence. We propose here an technique whose aim is to solve both problems by performing handsewn ileal pouch‐anal anastomosis on the dentate line after rectal eversion and total proctectomy.METHODS:We reviewed the records of 172 consecutive patients who had undergone ileal pouchanal anastomosis since 1984 for chronic ulcerative colitis (n=80), familial adenomatous polyposis (n=48), selected cases of Crohn's disease (n=42), or other causes (n=2).RESULTS:One patient (0.5 percent) died postoperatively. Operative morbidity was similar to that reported after the Park's and stapled procedures. Of our 128 patients with a five‐year follow‐up, anastomotic stricture occurred in 15 (12 percent), and 4 patients (3 percent) had to have pouch removal. Stool frequency per 24 hours was 4.8±1.6 (range, 1‐11), continence was perfect in 104 patients (81 percent), and sexual activity was estimated to be unchanged in 120 (94 percent). No evidence of disease recurrence was noted in the patients with familial adenomatous polyposis or ulcerative colitis.CONCLUSIONS:During ileal pouch‐anal anastomosis, Park's procedure carries the risk of incomplete mucosectomy and disease recurrence, and the stapled procedure requires a long‐term follow‐up of the anal transitional zone. Our alternative technique with total proctectomy avoids both problems and gives similar long‐term functional results.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID