摘要:

PURPOSE:To provide local control and palliation of pain, a multimodality approach, including external beam radiation therapy, surgical resection, and intraoperative electron irradiation (IOERT), has been used for patients with locally advanced anal or recurrent rectal cancers involving the sacrum.METHODS:Sixteen consecutive patients (11 males; 5 females; ages, 44‐76) underwent surgical exploration, sacrectomy, and IOERT, between 1990 and 1994.RESULTS:Proximal extent of resection was S2‐3 in four patients, S3‐4 in five, and S4‐5 in five. Two patients had resection of the anterior table of the sacrum. Margins were clear in 11, close in 3, and microscopically involved in 2 patients. Operative times ranged from 6 to 17 (median, 12.5) hours, and blood loss ranged from 300 to 12,600 (median, 3,350) ml. No operative deaths resulted. Major postoperative complications occurred in eight patients (50 percent): posterior wound infections and dehiscence, urinary leak, and ileal fistula. Five (31 percent) and 3 (19 percent) patients developed no or minor complications, respectively. Intensive Care Unit stay was one night for all patients, and overall hospital stay ranged from 11 to 30 (median, 16.5) days. Follow‐up was available on all 16 patients. Kaplan‐Meier survival was 68 percent at one year and 48 percent at two years. At the time of analysis, 9 of 16 patients were alive. Of the nine alive patients who responded to a questionnaire, eight reported a reduction in pain and improved quality of life postoperatively.CONCLUSIONS:Sacropelvic resection, in conjunction with IOERT, provides palliation and offers potential for cure in patients with locally advanced or recurrent anorectal cancer.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

&NA;Transanal rectal advancement flap (TRAF) is a surgical option in the management of rectovaginal and other complicated fistulas involving the anorectum. Most reported series have a short follow‐up.PURPOSE:This study was undertaken to determine the long‐term success, safely, applicability, and factors affecting recurrence in patients managed with TRAF, including patients with Crohn's disease.METHODS/MATERIALS:Retrospective analysis of all patients undergoing endorectal advancement flaps at a single institution between 1988 and 1993 was performed. One hundred one patients were identified (70 percent female; 30 percent male). Included were 52 patients with rectovaginal, 46 with anal perineal, and 3 with rectourethral fistulas. Causes were obstetric injury in 13 patients, Crohn's disease in 47, cryptoglandular in 19, mucosal ulcerative colitis in 7, and surgical trauma or undefined causes in 15 patients.RESULTS:No mortality occurred. Median follow‐up was 31 (range, 1‐79 months). Immediate failure (within one week of the repair) was seen in 6 percent of patients. Statistically(tP<0.001) higher recurrence rates were observed in patients who had undergone previous repairs. Mean hospital stay was four days. Overall recurrence was seen in 29 patients (29 percent). Seventy‐five percent of all recurrences occurred within the first 15 months; however, recurrence was noted for up to 55 months after repair. Etiology of fistula, use of constipating medications, antibiotic use, and most importantly associated Crohn's disease did not statistically affect recurrence rates. Failure rate was only influenced by previous number of repairs.CONCLUSION:TRAF is a safe technique for managing complicated anorectal and rectovaginal fistulas, including patients with Crohn's disease. Long‐term follow‐up is essential to accurately report recurrence rates.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

OBJECTIVE:The purpose of this study was to compare laparoscopy with minilaparotomy approaches to colorectal diseases.METHOD:Outcomes after minilaparotomy and laparoscopy were prospectively compared for a 12‐month period.RESULTS:Minilaparotomy was performed in 35 patients to achieve right colectomy (14), left colectomy (8), total colectomy (2), low anterior resection (6), abdominoperineal resection (2), colostomy (1), and ileal resection (1). Laparoscopic techniques were used in 52 patients to perform right colectomy (20), left colectomy (11), low anterior resection (5), abdominoperineal resection (7), total colectomy (3), ileal resection (1), colostomy (3), transverse colectomy (1), and colostomy closure (1). Mean operative times were 69 minutes for minilaparotomy (range, 33‐180) and 173 minutes for laparoscopy (range, 60‐300). Mean incision lengths were 12 (range, 8‐18) cm and 8 (range, 0‐25) cm; mean time to bowel movement was four (range, 1‐7) days and 3‐9 (range, 0‐8) days; mean day of discharge was 6.9 (range, 3‐15) days, and 6 (range, 1‐15) days postoperatively, respectively. Laparoscopy procedures were completed in 39 of 52 patients (75 percent); mean time to bowel movement was 3‐5 (range, 0‐6) days, and mean day of discharge was 5.3 (range, 1‐14) days(P=<0.005).CONCLUSION:The use of a small incision, whether by minilaparotomy or by laparoscopy, results in similar early return of function and discharge.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:This study assesses the outcome of a standardized operation performed by two surgeons for severe idiopathic slow transit constipation that was resistant to laxative treatment.METHODS:Fifty‐nine consecutive patients, 4 men and 55 women, with a mean age of 42.3 years, underwent colectomy with ileorectal anastomosis. Slow colonic transit was demonstrated in each case. Fifty‐two patients were available for follow‐up, with median time to follow‐up being 42 (range, 3‐81) months.RESULTS:Median bowel frequency was 4 per 24 hours. Sixty‐nine percent had four or less bowel movements daily. Ten percent used antidiarrheal medication regularly. One patient had a stoma for recurrent severe constipation. Mean continence score was 1.8 (on a scale of 0‐20); six patients were incontinent, and four of these six had normal preoperative anal manometry. Fourteen patients (27 percent) had difficulty with rectal evacuation. Preoperative defecating proctography was a poor predictor of postoperative evacuation difficulties. Twenty‐seven patients (52 percent) had persisting abdominal pain, but there was a significant improvement in the degree of pain(P<0.00001). Forty‐seven patients (90 percent) were satisfied with the outcome of the operation (and would elect to have it done again). Dissatisfied patients had recurrent constipation or diarrhea and incontinence.CONCLUSION:Colectomy with ileorectal anastomosis produces a satisfactory functional outcome in the majority of patients undergoing surgery for severe constipation with proven slow colonic transit.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:Stapled anastomoses are currently an established technique in colorectal surgery. Larger series about the use of circular staplers in rectal anastomoses within daily clinical routine are rare.METHODS:We evaluated the morbidity, clinical leakage rate, and mortality in an unselected population of a teaching hospital after elective, left‐sided colorectal resections with stapled rectal anastomoses. In the course of our study, manually sewn rectal anastomoses were not performed. All anastomoses were tested intraoperatively by instillation of liquid.RESULTS:A total of 615 elective colorectal resections with stapled rectal anastomoses was performed by 18 surgeons from 1984 to 1993. A protective colostomy was created in 2.9 percent (n=16) of all patients. Clinical anastomotic leakage occurred in nine patients (1.5 percent). The mortality rate was 1 percent (n=6).CONCLUSION:Use of the stapling technique facilitates the performance of anastomoses, particularly in regions with difficult anatomy. The rate of local complications is low, and protective colostomy can thus be dispensed with in most cases.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:The purpose of this study was to determine the incidence of human papillomavirus deoxyribonucleic acid (HPV DNA) in anal squamous carcinoma.METHODS:HPV DNAin situhybridization for HPV Types 6, 11, 16, 18, 31, 33, and 35 was performed on the formalin‐fixed, paraffinembedded tissue from 53 perianal and anal squamous carcinomas and 10 controls.RESULTS:HPV DNA sequences were identified in 18 of 53 anal squamous carcinomas (34 percent). All 10 controls were negative for HPV DNA. Of the 18 positive patients, 10 were perianal squamous carcinomas, and 8 were anal canal squamous carcinomas. Six of the perianal carcinomas were positive for HPV Types 6 and 11. The remaining four perianal carcinomas and all eight of the anal canal carcinomas were positive for HPV Types 16 and 18.CONCLUSION:HPV DNA sequences can be identified in anal squamous carcinomas. Anal squamous epithelium is another site where HPV infection may carry a risk for malignant transformation. One‐third of anal squamous carcinomas may be associated with prior HPV infection. Patients with anogenital HPV infection should be routinely screened for anal squamous lesions.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:The majority of recent American articles on management of colon trauma promote liberal use of primary repair. The extent to which Canadian surgeons have embraced such recommendations is unknown.METHOD:To determine the current attitude of Canadian surgeons toward the use of primary repair, we surveyed the members of The Canadian Association of General Surgeons regarding their management of three fictitious cases of penetrating and blunt colon trauma.RESULTS:Three hundred seventeen members of The Canadian Association of General Surgeons responded. Ninety‐two percent managed a fictitious case of early, uncontaminated stab wounds by primary repair. Delay in treatment or fecal contamination was associated with a significantly reduced number of respondents choosing primary repair(P<0.001).Surgeons were less likely to choose primary repair for management of a case of blunt colon injury (35 percent;P<0.001), and only 25 percent considered primary repair an option for a case of low velocity bullet wounds; 2 percent chose it for high velocity bullet wounds. Overall, the most common response to colon trauma scenarios was colostomy. However, 96 percent of respondents selected primary repair as the treatment of choice for at least one clinical situation depicted in the questionnaire. The likelihood of choosing primary repair was independent of surgeons' experiences or the level of the surgeons' trauma center.CONCLUSIONS:Although there are still settings in which many Canadian surgeons consider colostomy the appropriate treatment for colon injuries, primary repair has definitely established a foothold in all levels of Canadian general surgery practice.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:This study was undertaken to assess the accuracy and ability of endorectal ultasound (ERUS) to predict changes in rectal tumor stage after a preoperative chemoradiation protocol.METHODS:Since December 1990, all rectal malignancies at our institution have been preoperatively staged with ERUS. ERUS has been an essential tool in preoperative staging of rectal cancer patients, possessing an overall accuracy of 84 percent for T stage and 81 percent for lymph node status in our hands (Williamson PR, unpublished data). Beginning in July 1992, all patients staged with T3 or T4 lesions on initial ERUS have been entered into a protocol consisting of preoperative chemoradiation therapy (CRT). This protocol consists of patients receiving 4,500 to 5,040 rads for five to eight weeks and concomitantly receiving sensitizing doses of 5‐fluorouracil and/or leucovorin. All patients were scheduled for sphincter‐saving or abdominoperineal resections six to eight weeks following completion of CRT. A repeat ERUS was performed on each patient one week before surgery.RESULTS:The study group consisted of 15 patients who completed CRT, including 12 males and 3 females. Evidence of tumor shrinkageviaERUS measurement was seen in all patients. Average tumor shrinkage as assessed by ERUS was 16 percent by width and 32 percent by depth of invasion. Sonographic level of invasion and nodal status were each downstaged in 38 percent of patients. Pathologic evaluation comparison revealed that the level of invasion was downstaged in 47 percent and nodal status in 88 percent compared with initial ERUS staging. Of those patients downstaged, 4 of 11 (36 percent) revealednotumor in the pathology specimen.CONCLUSIONS:We conclude from our early experience that although ERUS offers a method for assessing degree of shrinkage and downstaging of T3 and T4 lesions after CRT, presently it does not closely predict the pathologic results. Results are strongly related to the experience of the ultrasonographer. The ability to distinguish tumor from radiation‐induced changes to perirectal tissues is under continued investigation, and a new method of interpreting the data obtained by ERUS after CRT will need to be established.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

PURPOSE:Urinary stone formation is a widely recognized complication of inflammatory bowel diseases and the surgical management of these conditions. Previously the fecal volume and chemistry after restorative proctocolectomy with J‐pouch were found to be similar to conventional panproctocolectomy with permanent ileostomy. The purpose of this study was to investigate whether the relative risks of urinary stone formation were less following J‐pouch than following conventional ileostomy.METHODS:The risk of urinary stone formation was determined from the chemical composition of two consecutive 24‐hour urine samples in 13 patients with well‐functioning ileostomies, 15 patients with well‐functioning J‐pouches, and 17 control volunteers.RESULTS:Compared with controls, ileostomy and J‐pouch patients had significantly lowered urinary volumes and pH, higher concentrations of calcium and oxalate, and an increased risk of forming uric acid stones. In addition there was an increased risk of forming calcium stones in the conventional ileostomy group. This risk was found not to be present in the J‐pouch group.CONCLUSIONS:The risks of forming uric acid stones are high for both ileostomy and J‐pouch patients, but our results suggest that there will be a reduction in calcium stone formation after J‐pouch.

ISSN:0012-3706    

出版商:OVID    

年代:1996

数据来源: OVID