摘要:

INTRODUCTION:Sound surgical technique is based on accurate anatomic knowledge. In surgery for cancer, the anatomy of the perirectal fascia and the retrorectal plane is the basis for correct mobilization of the rectum to ensure clear surgical margins and to minimize the risk of local recurrence.METHODS:This review of the literature on the perirectal fascia is based on a translation of the original description by Thoma Jonnesco and a later account by Wilhelm Waldeyer. The Jonnesco description, first published in 1896 in French, is compared with the German account of 1899. These were critically analyzed in the context of our own and other techniques of mobilizing the rectum.CONCLUSIONS:Mobilization of the rectum for cancer can be performed along anatomic planes with minimal blood loss, preservation of the pelvic autonomic nerves and a low prevalence of local recurrence. Different techniques including total mesorectal excision are based on the same anatomic principles, however, popular words have been used to replace accepted, established terminology. In particular, the description of total mesorectal excision has been confusing because of its emphasis on the words “total” and “mesorectum.” The use of the word “mesorectum” anatomically is inaccurate and the implication that total excision of all the perirectal fat contained within the perirectal fascia “en bloc” in all patients with rectal cancer will minimize local recurrence remains contentious.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PURPOSE:Preoperative staging of rectal tumors is considered essential to tailor treatment for individual patients. The aim of the present study was to evaluate the accuracy of endorectal ultrasonography in preoperative staging of rectal tumors.METHODS:Eleven hundred eighty‐four patients with rectal adenocarcinoma or villous adenoma underwent endorectal ultrasonography evaluation at a single institution during a ten‐year period. We compared the endorectal ultrasonography staging with the pathology findings based on the surgical specimens in 545 patients who had surgery (307 by transanal excision, 238 by radical proctectomy) without adjuvant preoperative chemoradiation. Comparisons between groups were performed using chi‐squared tests and logistic regression analysis.RESULTS:Overall accuracy in assessing the level of rectal wall invasion was 69 percent, with 18 percent of the tumors overstaged and 13 percent understaged. Accuracy depended on the tumor stage and on the ultrasonographer. Overall accuracy in assessing nodal involvement in the 238 patients treated with radical surgery was 64 percent, with 25 percent overstaged and 11 percent understaged.CONCLUSION:The accuracy of endorectal ultrasonography in assessing the depth of tumor invasion, particularly for early cancers, is lower than previously reported. The technique is more precise in distinguishing between benign tumors and invasive cancers and between tumors localized to the rectal wall and tumors with transmural invasion. Differences in image interpretation may in part explain discrepancies in accuracy between studies.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PURPOSE:This study was performed to determine whether endoanal ultrasound could be used to accurately stage patients with squamous‐cell carcinoma of the anal canal and to determine the response of these tumors to multimodality therapy.METHODS:Thirteen consecutive patients with biopsy‐proven squamous‐cell carcinoma of the anal canal between 1996 and 1999 were included in the study. All patients underwent a pretreatment staging endoanal ultrasound with a B&K 3535 ultrasound machine using the 1850 rotating 360° probe with a 10‐MHz transducer. Tumors were staged using our own modification of a 1984 TNM staging system. For our study, a uT1 tumor was confined to the submucosa; a uT2a lesion invaded only the internal anal sphincter; a uT2b lesion penetrated into the external anal sphincter; a uT3 lesion invaded through the sphincter complex into the perianal tissues; and a uT4 lesion invaded adjacent structures. After the initial study, patients decided on a course of treatment, either primary surgery or chemoradiation. For patients choosing chemoradiation, a clinical examination with biopsies and a repeat endoanal ultrasound was performed after completion of therapy. Findings on physical examination and biopsy results were compared with the follow‐up endoanal ultrasound. For those choosing surgery, the pathology specimen from the abdominoperineal resection was reviewed and compared with the initial endoanal ultrasound interpretation to determine the accuracy of endoanal ultrasound staging.RESULTS:One patient died of complications from acquired immunodeficiency syndrome before undergoing definitive treatment for his anal cancer. Of the remaining 12 patients who comprised the study, the endoscopic staging was as follows: 1 uT1, 5 uT2a, 3 uT2b, 2 uT3, and 1 uT4. Five of the 12 patients selected surgery as the primary treatment modality for their disease. The other seven patients underwent a full course of chemoradiation. In all five patients who had an abdominoperineal resection, the surgical staging correlated with the endoanal ultrasound staging (2 T2a tumors and 3 T2b tumors). In the remaining seven patients, six to eight weeks after completion of therapy, there was no evidence of residual tumor by clinical examination and biopsies. In one of the seven patients, no abnormalities were detected on endoanal ultrasound, and it was interpreted as normal with no evidence of disease. In the remaining six patients, endoanal ultrasound revealed abnormalities that were judged to represent radiation‐induced changes rather than residual disease. A repeat endoanal ultrasound was done in these patients two to four months after the biopsies. Complete resolution of the postradiation changes occurred in all patients, and the scans were interpreted as showing no evidence of disease.CONCLUSIONS:Endoanal ultrasound can accurately determine the depth of penetration of squamous‐cell carcinoma into the sphincter complex and can be used to gauge accurately the response of these tumors to chemoradiation therapy. Our newly proposed ultrasound staging system may be more useful in choosing treatment options; future studies should be aimed at using endoanal ultrasound in identifying early lesions that may be amenable to less aggressive therapy as well as determining the utility of ultrasound in the surveillance of patients after successful treatment of their initial tumors.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PURPOSE:This study was designed to show, in certain patients, that colonic epithelial cells can be present in peripheral blood while absent in portal venous blood.METHODS:The circulating colorectal epithelial cells were detected by a reverse transcriptase‐polymerase chain reaction assay, which involved amplifying guanylyl cyclase C transcripts. Portal venous and peripheral blood samples were obtained at intervals from 58 patients undergoing colorectal cancer surgery.RESULTS:Circulating colonic epithelial cells were more frequently detected in portal venous blood than in peripheral blood only before mobilization of the tumor‐bearing colon segment in patients with tumors of Stage B. In five other patients, before mobilization of their tumor‐bearing colon segments, and in another three patients, during the mobilization, colorectal epithelial cells were detected in peripheral blood but not in portal venous blood. These eight patients had Stage C or D tumors.CONCLUSION:In 8 of 58 patients, colorectal epithelial cells were detected in peripheral but not in portal venous blood. Metastatic deposits in lymphatic vessels or liver might be the source of these cells.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PURPOSE:Infliximab has been reported to improve fistulizing Crohn's disease. Moreover, prompt healing of mucosal ulcers has been described. Whether fistulas disappear or remainders of fistulas persist is unknown. This study documents fistulous tracts before and after infliximab therapy by means of hydrogen peroxide‐enhanced endosonographyMETHODS:Eight patients with perianal, vaginal, or perineal fistulas were treated with a triplet of infliximab 5 mg/kg infusions. At baseline, and at Week 4 after the last infusion, fistulas were documented by local inspection, digital examination, and hydrogen peroxide‐enhanced anal or vaginal endosonography.RESULTS:Patients with vaginal or perineal fistulas did not respond clinically to therapy, whereas patients with perianal fistulas improved considerably. However, in all patents remainders of fistulous tracts were demonstrated by endosonographic techniques.CONCLUSIONS:Short‐term treatment of Crohn's disease‐associated fistulas with infliximab does not induce disappearance of fistulous tracts, irrespective of therapeutic response.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PURPOSE:Segmental resection for Crohn's colitis is controversial. Compared with subtotal colectomy, segmental resection is reported to be associated with a higher rate of re‐resection. Few studies address this issue, and postoperative functional outcome has not been reported previously. This study compared segmental resection to subtotal colectomy with anastomosis with regard to re‐resection, postoperative symptoms, and anorectal function.METHODS:Fifty‐seven patients operated on between 1970 and 1997 with segmental resection (n = 31) or subtotal colectomy (n = 26) were included. Reoperative procedures were analyzed by a life‐table technique. Segmentally resected patients were also compared separately with a subgroup of subtotally colectomized patients (n = 12) with similarly limited colonic involvement. Symptoms were assessed according to Best's modified Crohn's Disease Activity Index and an anorectal function score.RESULTS:The re‐resection rate did not differ between groups in either the entire study population (P= 0.46) or the subgroup of patients with comparable colonic involvement (P= 0.78). Segmentally resected patients had fewer symptoms (P= 0.039), fewer loose stools (P= 0.002), and better anorectal function (P= 0.027). Multivariate analysis revealed the number of colonic segments removed to be the strongest predictive factor for postoperative symptoms and anorectal function (P= 0.026 andP= 0.013, respectively).CONCLUSION:Segmental resection should be considered in limited Crohn's colitis.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PURPOSE:Several alterations of the enteric nervous system have been described as an underlying neuropathologic correlate in patients with idiopathic slow‐transit constipation. To obtain comprehensive data on the structural components of the intramural nerve plexus, the colonic enteric nervous system was investigated in patients with slow‐transit constipation and compared with controls by means of a quantitative morphometric analysis.METHODS:Resected specimens were obtained from ten patients with slow‐transit constipation and ten controls (nonobstructive neoplasias) and processed for immunohistochemistry with the neuronal marker Protein Gene Product 9.5. The morphometric analysis was performed separately for the myenteric plexus and submucous plexus compartments and included the quantification of ganglia, neurons, glial cells, and nerve fibers.RESULTS:In patients with slow‐transit constipation, the total ganglionic area and neuronal number per intestinal length as well as the mean neuron count per ganglion were significantly decreased within the myenteric plexus and external submucous plexus. The ratio of glial cells to neurons was significantly increased in myenteric ganglia but not in submucous ganglia. On statistical analysis, the histopathologic criteria (submucous giant ganglia and hypertrophic nerve fibers) of intestinal neuronal dysplasia previously described in patients with slow‐transit constipation were not completely fulfilled.CONCLUSION:The colonic motor dysfunction in slow‐transit constipation is associated with quantitative alterations of the enteric nervous system. The underlying defect is characterized morphologically by oligoneuronal hypoganglionosis. Because the neuropathologic alterations primarily affect the myenteric plexus and external submucous plexus, superficial submucous biopsies are not suitable to detect these innervational disorders.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

INTRODUCTION:Rectocele may be associated with both chronic constipation and anal incontinence. Several different surgical procedures have been advocated for rectocele repair. The aim of the present study was to evaluate anorectal function and clinical outcome in a consecutive series of patients who underwent selected endorectal or transperineal surgery for rectocele for whom operative treatment was determined by clinical and proctographic features. Attention was paid to the cohort of rectocele patients presenting with incontinence as a leading symptom.METHODS:Sixty consecutive patients with symptomatic rectocele underwent surgical treatment at our institution. Fifty‐eight of the patients were female (mean age 56; range, 21‐70 years). Incontinence was graded according to a previously reported scoring system that accounts for the type and frequency of incontinence episodes. Preoperative anorectal manometry was performed using an open perfused polyethylene probe. Rectal sensation was recorded by balloon distention. Endoanal ultrasonography was performed with a 7.5‐MHz probe. Preoperative defecography was performed at rest and on maximal squeeze and straining. Patients with obstructed defecation as their principal symptom, with associated mucosal rectal prolapse, underwent an endorectal procedure. For patients with associated anal incontinence (Grade B2 or greater), and without a rectal mucosal prolapse, a transperineal approach was performed with either an anterior external overlapping sphincteroplasty or levatorplasty. The median follow‐up was 48 (range, 9‐122) months.RESULTS:There was no operative mortality. Postoperative complications occurred in 18 patients (30 percent). Of 43 patients with incontinence, 34 (79 percent) were available for postoperative evaluation. None were fully continent. However, in 25 patients (73.5 percent), continence improved after surgery; half had only mucus soiling or loss of gas. Incontinence scores decreased (i.e., improved) from 4.8 ± 0.9 to 3.9 ± 0.9 (P = 0.002). A significant improvement was found both after transanal and perineal procedures. Only ten initially continent patients were available for postoperative assessment. All patients stated that they had clinical improvement in constipation. Their preoperative mean anal resting pressure was 62.5 ± 3.9 (standard error of the mean) mmHg, with a postoperative mean of 75.5 ± 7 mmHg. The preoperative mean squeeze pressure was 83.1 ± 8.5 mmHg, with a mean postoperative squeeze pressure of 88.5 ± 7.9 mmHg (P = not significant). The maximal tolerable volumes were all within normal limits, confirming the proctographic evidence that there were no cases of megarectum in our patient series. The pudendal nerve terminal motor latency was abnormal in all but two patients with incontinence (mean pudendal nerve terminal motor latency = 3.1; range, 1.2‐4 milliseconds). Rectoceles recurred in six patients (10 percent): five after a Block procedure and one after a Sarles‐type operation. The postoperative endosonographic appearance varied according to the nature of the procedure performed.CONCLUSION:There are few data concerning patients with rectocele who have associated anal incontinence, however, surgical decision analysis resulted in improvement in both constipation and incontinence in the majority of our patients with rectocele. Nevertheless, because none of the patients gained full continence postoperatively, pelvic floor rehabilitation might be also needed to achieve better sphincter function in patients with incontinence.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PURPOSE:Hemorrhoidectomy is the treatment of choice for patients with third‐degree or fourth‐degree hemorrhoids. However, whether the closed or open technique yields better results is unknown. The purpose of this study was to compare these techniques with respect to operating time, analgesic requirement, hospital stay, morbidity rate, duration of inability to work, healing time, and follow‐up results.METHODS:In this prospective and randomized study, 80 patients with third‐ degree or fourth‐degree hemorrhoidal disease were allocated to either the open‐ hemorrhoidectomy (Group A, n = 40) or the closed‐procedure group (Group B, n = 40). Open hemorrhoidectomy was performed according to the St. Mark's Hospital technique, whereas the Ferguson technique was used for the closed procedure under general anesthesia with the patient in the jackknife position.RESULTS:Mean operating time was significantly shorter in Group A (35 ± 7vs.45 ± 8 minutes,P< 0.001). Analgesic requirement on the day of surgery and the first postoperative day was also significantly lower (P< 0.05). The morbidity rate was higher in Group B (P< 0.05). Length of hospital stay and duration of inability to work were similar in both groups (P> 0.05). Healing time was significantly shorter in Group B (2.8 ± 0.6vs.3.5 ± 0.5 weeks,P< 0.001). Median follow‐up time was 19.5 (range, 4‐40) months. The only late complication (anal stenosis) was observed in one patient in Group B.CONCLUSIONS:Although the healing time is longer, the open technique is more advantageous with respect to shorter operating time, less discomfort in the early postoperative period, and lower morbidity rate. Gençosmanoğlu R, Şad O, Koç D, İnceoğlu R. Hemorrhoidectomy: open or closed technique? A prospective, randomized clinical trial. Dis Colon Rectum 2002;45:70‐75.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PURPOSE:A small 6‐cm colonic J‐pouch improves stool frequency and continence, without stool evacuation problems. However, the reservoir function is not improved on physiologic studies. Hence, a scintigraphy technique was devised to study the transit of solid and liquid colonic contents in these patients.METHODS:Patients were randomly assigned to straight or colonic J‐pouch anal anastomoses after ultralow anterior resection. At 1 year after surgery, they were studied by bowel questionnaire, anorectal manometry, and technetium TC 99m tin‐colloid liquid test meal/I‐131 microcapsule scintigraphy. In the latter, technetium TC 99m tin‐colloid was ingested orally to image the colonic liquids. I‐131 microcapsules taken simultaneously imaged the solid stools. After ingestion of the radioisotopes, imaging was performed at intervals of 7 to 8, 24, and 56 hours later. Two independent observers noted the presence of technetium TC 99m tin‐colloid liquid and I‐131 microcapsules in various areas of interest drawn over the colon.RESULTS:There were six patients (5 males, mean age, 61.5 (SE mean, 1.9) years) in the straight, and six patients (5 males, mean age, 63.2 (4.5) years) in the colonic J‐pouch group. Stool frequency was more in the straight group (4.8 (0.4)vs.3 (0.2) stools/day;P< .001). Continence, evacuation problems, and anorectal physiologic findings were not different. Technetium TC 99m tin‐colloid (imaging liquids) transited significantly faster than I‐131 microcapsules (imaging solids), at various areas of interest in the colon. In the colonic J‐pouch patients, technetium TC 99m tin‐colloid liquid was retained significantly longer in the descending colon at 24 hours (P< .05). Stool frequency was higher when technetium TC 99m tin‐colloid was not retained in the descending colon at 56 hours (3.3 (0.5)vs.4.3 (0.4) stools/day) but this did not reach statistical significance. There were no significant differences in the distribution of the ingested I‐131 microcapsules between colonic J‐pouch and straight groups.CONCLUSIONS:Reduced stool frequency after colonic J‐pouch may be related to factors causing better retention of liquid stools in the distal colon. No difference in solid stool transit could possibly account for minimal evacuation problems in small pouches.

ISSN:0012-3706    

出版商:OVID    

年代:2002

数据来源: OVID