摘要:

&NA;One of the earliest references to heredity in colorectal cancer dates to Aldred Warthin's now‐famous recollection of his seamstress' distress regarding “cancer excess” in her family history. her predication of an early demise secondary to cancer of the female organs, colon, or stomach proved true. The slow, arduous investigation that ensued followed a tortuous route of nearly eight decades before the implications of such family histories were widely acknowledged through the degisnation of hereditary nonpolyposis colorectal cancer or Lynch Syndrome Variants I and II. The story of hereditary nonpolyposis colorectal cancer is one of chance meetings, the selfless sharing of information, perseverance in the face of adversity, meticulous scientific documentation, and ultimate vindication by a scientific process that yielded molecular genetic evidence through the identification of the culprit mutations (hMSH2, hMLH1, hPMS2, and hMSH6). Our purpose is to provide a brief outline of the course charted by the study of the genetics of hereditary nonpolyposis colorectal cancer. This should be of particular interest to the readers of this Journal as we celebrate 100 years of dedication to the diagnosis and treatment of diseases of the colon, rectum, and anus through the efforts of The American Society of Colon and Rectal Surgeons.

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

PURPOSE:Recent experimental studies suggest that laparoscopic surgery for abdominal malignancy may be associated with increased tumor implantation. This study investigated the influence of cytotoxic agents (administered intraperitoneally or intramuscularly) on implantation of a tumor cell suspension after laparoscopic surgery in an experimental model.METHODS:Thirty‐three Dark Agouti rats underwent laparoscopy with CO2insufflation and instillation of a tumor cell suspension into the abdominal cavity. Rats were randomly allocated to one of the following study groups (9 rats in the control group, 6 rats in all other groups): 1) control (no intraperitoneal instillation); 2) intraperitoneal normal saline (0.9 percent); 3) intraperitoneal povidoneiodine (Betadine® to normal saline 1:10 dilution); 4) intraperitoneal methotrexate (2 doses of 0.125 mg/kg body weight in normal saline administered 24 hours apart); 5) intramuscular injection of 2 doses of 0.125 mg/kg body weight administered 24 hours apart (no intraperitoneal agent). Rats were killed 7 days after the procedure, and the peritoneal cavity and port sites were examined for the presence of tumor.RESULTS:A significant reduction in tumor implantation and port‐site metastases was observed in all treatment groups (povidone‐iodine and intramuscular and intraperitoneal methotrexate).CONCLUSIONS:This study suggests that tumor implantation after laparoscopic surgery and port‐site metastases might be prevented by the intraperitoneal or systemic administration of cytotoxic agents. Further studies are needed to determine whether these findings can be applied to clinical practice.

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

PURPOSE:The aim of this study was to assess any differences between the inclusion or omission of medical bowel confinement relative to postoperative morbidity and patient tolerance after anorectal reconstructive surgery.METHODS:Between January 1995 and February 1997 a prospective randomized trial was conducted for patients without stomas who underwent anorectal reconstructive surgery. All patients were randomly assigned either to medical bowel confinement (a clear liquid diet with loperamide 4 mg by mouth three times per day and codeine phosphate 30 mg by mouth four times per day until the third postoperative day) or to a regular diet, beginning the day of surgery. All patients in both groups underwent the identical preoperative oral mechanical preparation, preoperative oral and parenteral antibiotics, and postoperative antibiotics. Wound closure and wound care were identical in both groups.RESULTS:Fifty‐four patients (46 females) were prospectively, randomly assigned to medical bowel confinement (n=27; 50 percent) or a regular diet (n=27; 50 percent); the mean ages were 51.0 (range, 28‐80) and 47.2 (range, 23‐87) years, respectively. Indications for surgery were fecal incontinence in 32 patients, complicated fistulas in 17 patients, anal stenosis in 4 patients, a Whitehead deformity in 1 patient, and a chronic unhealed fissure in 1 patient. Fifty‐four patients underwent 55 procedures: 32 patients underwent sphincteroplasty, 18 patients underwent transanal advancement flaps, and 5 patients underwent anoplasties. There were no differences between the two groups in the incidence of either septic or urologic complications. Nausea and vomiting were recorded in seven (26 percent) medical bowel confinement and three (11 percent) regular‐diet patients. The first postoperative bowel movement occurred at a mean of 3.9 days in the medical bowel confinement group and 2.8 days in the regular diet group (P<0.05). Fecal impaction occurred in seven (26 percent) of the patients in the medical bowel confinement group and two (7 percent) of the patients in the regular diet group. Hospital charges analysis showed a mean cost of hospitalization of $12,586.00 (range, $3,436.00−$20,375.00) for the medical bowel confinement group and $10,685.00 (range, $3,954.00−$18,574.00) in the regular diet group, representing a mean difference of $1,901.00 (P=0.06). Mean follow‐up was 13 months for both groups (range, 1‐24 months in the regular diet group and 2‐25 months in the medical bowel confinement group). No statistical difference was shown in the functional outcome of sphincteroplasties between the medical bowel confinement group and the regular diet group.CONCLUSIONS:The outcome of reconstructive anorectal surgery was not adversely affected by the omission of medical bowel confinement. Moreover, cost savings can be achieved by the omission of routine bowel confinement.

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

PURPOSE:Cytomegaloviral enterocolitis is an uncommon disorder that can complicate inflammatory bowel disease. It is more common in patients with acquired immunodeficiency syndrome and can occur in patients on immunosuppressive therapy for autoimmune or inflammatory diseases and in allograft recipients. Mortality rates of up to 71 percent have been reported for cytomegaloviral enterocolitis. The aims of this study were 1) to identify the presentation, underlying medical conditions, treatment, and outcome of patients with cytomegaloviral enterocolitis and 2) to determine the prevalence of this infection in patients undergoing intestinal resection for inflammatory bowel disease.METHODS:A retrospective chart review of patients with pathologic evidence of cytomegaloviral enterocolitis from 1985 through 1996 was performed. To determine the prevalence of this condition, the hospital discharge database was searched for the diagnoses of ulcerative colitis and Crohn's disease in patients who underwent bowel resection.RESULTS:93 patients (mean age, 44 years; 66 percent males) had cytomegaloviral infection in the small intestine (n=6), large intestine (n=86), or appendix (n=1). Patients with acquired immunodeficiency syndrome (n=42), with ulcerative colitis (n=11), with Crohn's disease (n=11), receiving organ transplant (n=12), receiving bone marrow transplant (n=8), and in other immunosuppressed states (n=11) comprised this study. Seventeen patients (18 percent) underwent intestinal resection, and the remaining 76 patients were treated medically. Abdominal pain (77vs.37 percent;P<0.01) and gastrointestinal bleeding (65vs.34 percent;P<0.05) were more common presenting symptoms in patients who required resection than patients in the medically managed group. Mortality was 17.6 percent in the surgically managed group and 14.5 percent in the patients who were managed medically. The median duration of ulcerative colitis in patients with coexisting cytomegaloviral infection was 12 months. The prevalence of cytomegaloviral enterocolitis was 4.6 percent in patients with ulcerative colitis and 0.8 percent in patients with Crohn's disease.CONCLUSIONS:These data suggest that cytomegaloviral infection more frequently complicates ulcerative colitis than Crohn's disease. Furthermore, a short and fulminant course of ulcerative colitis may indicate coexisting cytomegaloviral infection. The overall low mortality in this retrospective study suggests that aggressive medical and surgical treatment improves survival in patients with cytomegaloviral enterocolitis.

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

PURPOSE:We describe a patient who had precancerous colonic symptoms and a positive family history of multiple occurrences of early‐onset colorectal cancer in her first‐degree and second‐degree relatives consistent with hereditary nonpolyposis colorectal cancer. Hereditary nonpolyposis colorectal cancer diagnosis had not been made before her diagnosis of carcinoma of the cecum with liver metastasis. She died at age 20, leading to litigation. Controversies about standards of care, their malpractice implications, and pertinent legal issues are discussed.METHODS:Review of the medical and family history was made by the expert witness (HTL) with appropriate documentation of the chronology of symptoms, as derived from depositions. These documents revealed that the patient's mother had repeatedly discussed with the caregivers her concern about the family history of colon cancer and the need for appropriate surveillance.RESULTS:The patient's colonic symptoms progressed for a period of three years. Flexible sigmoidoscopy was performed by a nonphysician. The physician who ordered the procedure considered this appropriate because isolated polyps were reported in the patient's father and paternal uncle, which apparently led him to believe that the diagnosis was familial adenomatous polyposis. During litigation procedures, a pedigree was constructed and found to be consistent with hereditary nonpolyposis colorectal cancer. The case was settled in favor of the plaintiff before trial.CONCLUSION:It is essential to understand the natural history of hereditary nonpolyposis colorectal cancer, inclusive of the need for surveillance colonoscopy in patients at increased risk by virtue of their position in their family pedigree.

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

PURPOSE:Although the criteria for clinical diagnosis of hereditary nonpolyposis colorectal cancer are not fully agreed on, young age seems to be a common trait. The purpose of this study is to identify clinicopathologic features of hereditary nonpolyposis colorectal cancer in early age‐of‐onset colorectal cancer patients stratified as a function of family cancer history.METHODS:Two hundred thirty consecutive colorectal cancer patients 40 years or older at time of diagnosis were registered into an ongoing database during a ten‐year period. Accurate family history was obtainedviamedical records, telephone calls, and questionnaires on 146 patients. According to extent of family history of cancer, patients were stratified into seven groups: 1) fulfilling Amsterdam criteria, 2) fulfilling less strict criteria, 3) having at least one first‐degree relative with colorectal cancer, 4) having at least one distant relative with colorectal cancer, 5) having at least one first‐degree relative with any cancer, 6) having at least one distant relative with any cancer, 7) having no family history of cancer.RESULTS:Twenty‐two of 146 patients fulfilled Amsterdam and less strict hereditary nonpolyposis colorectal cancer criteria (15 percent). These hereditary nonpolyposis colorectal cancer patients were significantly younger (31vs.35 years;P=0.0003) and had more metachronous colorectal cancer (27 percentvs.2 percent;P=0.007) and less colorectal cancer with nodal or metastatic spread than the non‐hereditary nonpolyposis colorectal cancer patients (35 percentvs.65 percent;P=0.01).CONCLUSION:Precise familial cancer assessment in early age‐of‐onset colorectal cancer increases the yield of hereditary nonpolyposis colorectal cancer diagnosis. Because of the frequent development of metachronous colorectal cancer and favorable prognosis, extensive rather than segmental surgery should be considered in early age‐of‐onset colorectal cancer patients belonging to hereditary nonpolyposis colorectal cancer families.

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

PURPOSE:There is currently no knowledge of the prognostic value of echogenicity of colorectal liver metastases in patients receiving no treatment, hepatic cryotherapy, or any other treatment modality. We sought to determine whether differences in echogenicity of colorectal liver metastases predict prognosis after hepatic cryotherapy.METHODS:Between April 1990 and May 1997 the echogenicity of liver metastases was assessed intraoperatively in 48 patients undergoing cryotherapy forin situdestruction of colorectal liver metastases, with use of an Aloka machine with a 5‐MHz scanner. Survival time was calculated by the Kaplan‐Meier method, and the prognostic value of echogenicity and several other possible prognostic factors was tested with the log‐rank test.RESULTS:Thirty‐three patients were found to have hyperechoic metastases. These patients had a favorable outcome, with a median survival time of 50 months, as compared with a median survival time of 24 months in the 15 patients with hypoechoic metastases (P=0.0074). Regarding the remaining prognostic factors that were tested, only age less than 51 years, absence of involved nodes at primary resection, small diameter of liver metastases, and low preoperative serum carcinoembryonic antigen levels were associated with a favorable outcome.CONCLUSION:We believe that this is an original description of the prognostic importance of echogenicity of colorectal liver metastases. Differences in echogenicity may be related to tumor biology. This will be addressed in further studies.

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

PURPOSE:This retrospective study was undertaken to evaluate immunohistochemically the expression of CD44 standard protein and CD44v5 and CD44v6 isoforms in colorectal adenomas and early invasive cancers developing within adenomas as possible markers characterizing colorectal polyps with a more aggressive biologic potential.METHODS:Archival tissues of 81 consecutive locally resected colorectal polyps, comprising 57 colorectal adenomas and 24 carcinomas‐in‐adenomas, were stained immunohistochemically with the use of commercially available mouse monoclonal antibodies: SFF‐2 for CD44 standard protein, VFF‐8 for CD44v5, and VFF‐7 for CD44v6.RESULTS:Sixtythree percent of the colorectal polyps were positive for CD44 standard protein, 59 percent were positive for CD44v5, and 27 percent were positive for CD44v6. Ninetythree percent of the low‐grade adenomas were CD44 standard protein‐positive, in contrast to 50 percent of the high‐grade adenomas and only 42 percent of the carcinomas‐in‐adenomas (Kendall's Tau =−0.42;P<0.0001). CD44v6 expression was more frequently found in early invasive cancers (54 percent) than in high‐grade adenomas (25 percent) and low‐grade adenomas (7 percent). This difference also was statistically significant (Kendall's Tau‐b =0.39;P=0.00003). Surprisingly, a downregulation of CD44 standard protein expression was observed in the adenoma tissue adjacent to carcinomas (62 percent) and areas with high‐grade atypia (71 percent), compared with low‐grade adenomas (93 percent; Kendall's Tau‐b =−0.28;P=0.004).CONCLUSIONS:Our data suggest that CD44 standard protein and CD44 isoform v6 expression differs considerably in benign and malignant colorectal polyps. Clinical studies with larger patient groups could clarify the prognostic potential of CD44 further

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

PURPOSE:The aim of the present study was to study whether patients developing anastomotic leakage after colorectal resections for colorectal cancer have laboratory signs of an altered hemostatic balance in the systemic circulation, preoperatively and postoperatively, causing an impaired healing process.METHODS:Patients operated on for colorectal cancer were studied. Seventeen consecutive patients with anastomotic leakage and 17 patients without anastomotic leakage were matched according to age, gender, tumor stage, and localization of tumor. Hemostatic balance was estimated preoperatively and at one, two, and seven days and at three months after surgery by plasma levels of sensitive markers of coagulation activation and fibrinolysis,i.e., prothrombin fragment 1+2, thrombin‐antithrombin complexes, soluble fibrin, tissue‐type plasminogen activator activity, and plasminogen activator inhibitor Type 1.RESULTS:Preoperatively, the hemostatic balance was comparable in patients with and without anastomotic leakage. In the early postoperative period, patients developing anastomotic leakage exhibited signs of systemic coagulation activation,i.e., elevated plasma levels of prothrombin fragment 1+2, thrombin‐antithrombin complexes, soluble fibrin, and plasminogen activator inhibitor Type 1. The observed coagulation activation appeared before the anastomotic leakage became clinically evident. More patients with anastomotic leakage received perioperative blood transfusions than patients without leakage, despite the fact that duration of surgery and intraoperative blood loss were comparable in the two groups.CONCLUSIONS:Enhanced coagulation activity was observed postoperatively in patients developing anastomotic leakage after colorectal resections for colorectal cancer. Such a hypercoagulable state may contribute to the development of anastomotic leakage by facilitating formation of microthromboses in the perianastomotic area.

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

PURPOSE:Similar to findings obtained for most carcinomas, the pathogenesis of colorectal cancer is considered to be multifactorial. There is strong evidence for an inherited, genetic predisposition to disease in patients with familial adenomatous polyposis and hereditary nonpolyposis colorectal cancer. There is still debate, however, about the contribution of genetic factors to the pathogenesis of sporadic colorectal cancer. The present study was undertaken to search for human leukocyte antigen associations in a group of patients with colorectal cancer and to correlate the findings with both the histology of the disease and family history.SUBJECTS AND METHODS:The allele frequencies of serologically defined human leukocyte antigen class I and II antigens were studied in 101 patients with a recent, histologically confirmed diagnosis of colorectal cancer. All individuals in this study were unrelated to each other. After surgical treatment, all patients were grouped according to the stage (Dukes Stages A, B, C, and D), differentiation (Grades 1, 2, and 3), and the site of the tumor. Patients were also classified with regard to family history for colorectal cancer. The results obtained for human leukocyte antigen frequencies were compared with those of 105 healthy control subjects (control group).RESULTS:An increased frequency of human leukocyte antigen‐B18 (27.72vs.14.28 percent;P<0.025; odds ratio =2.3) and of human leukocyte antigen‐DQ5 (43.56vs.22.5 percent;P<0.01; odds ratio =2.65) was observed for patients with colorectal cancervs.control subjects, respectively. In addition, human leukocyte antigen‐B18 was present with increased frequency (30.76 percent;P<0.05; odds ratio =2.66; and 26.67 percent;P<0.05; odds ratio =2.18) among patients with rectal and colon carcinoma, respectively. A higher frequency of human leukocyte antigen‐DQ5 (45.33 percent;P<0.01; odds ratio =2.84) was observed among patients with colon carcinoma. Remarkably, human leukocyte antigen‐DQ5 (50vs.22.5 percent;P<0.05; odds ratio =3.43) and human leukocyte antigen‐A1 (41.66vs.12.38 percent;P<0.01; odds ratio =5.05) were found to be strongly associated with a family history of colorectal cancer.CONCLUSION:The observation of specific human leukocyte antigen associations with particular subsets of colorectal cancer strongly suggests that genetic susceptibility for the development of colorectal cancer exists. Although the multifactorial pathogenesis of colorectal cancer must be considered, human leukocyte antigens may have useful predictive and diagnostic value.

ISSN:0012-3706    

出版商:OVID    

年代:1999

数据来源: OVID