ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:Stapling of the ileal pouch‐anal anastomosis with preservation of the anal transitional zone remains controversial because of concerns about the potential risk of dysplasia and cancer. The natural history and optimal treatment of anal transitional zone dysplasia ten or more years after surgery are unknown. This study establishes the risk of dysplasia in the anal transitional zone and the outcome of a conservative management policy for anal transitional zone dysplasia, with a minimum of ten years' follow‐up after ileal pouch‐anal anastomosis.METHODS:A total of 289 patients undergoing anal transitional zone‐sparing stapled ileal pouch‐anal anastomosis for inflammatory bowel disease between 1986 and 1990 were studied. Patients undergoing anal transitional zone‐sparing ileal pouch‐anal anastomosis who were studied with serial anal transitional zone biopsies for at least ten years postoperatively were included (n = 178). Median follow‐up was 130 (range, 120‐157) months.RESULTS:Anal transitional zone dysplasia developed in 8 patients 4 to 123 (median, 9) months after surgery. There was no association with gender, age, preoperative disease duration, or extent of colitis, but the risk of anal transitional zone dysplasia was significantly associated with cancer or dysplasia as a preoperative diagnosis or in the proctocolectomy specimen. Dysplasia was high grade in two patients and low grade in six. Two patients with low‐grade dysplasia on two or more occasions after detection of low‐grade dysplasia underwent completion mucosectomy and perineal pouch advancement with neo‐ileal pouch‐anal anastomosis. One patient with high‐grade dysplasia on two occasions was to undergo completion mucosectomy, but this was not technically feasible. Partial mucosectomy with vigorous anal transitional zone biopsy was performed with close postoperative surveillance. Biopsies were negative for dysplasia. The second recently diagnosed patient with high‐grade dysplasia underwent examination under anesthesia with negative anal transitional zone biopsies and will be kept under close surveillance. No cancer in the anal transitional zone was found during the study period. The 4 other patients with low‐grade dysplasia on 1 or 2 occasions were treated expectantly and have been dysplasia free for a median of 119 (range, 103‐133) months.CONCLUSIONS:Anal transitional zone dysplasia after stapled ileal pouch‐anal anastomosis is infrequent and is usually self‐limiting. Anal transitional zone preservation did not lead to the development of cancer in the anal transitional zone with a minimum of ten years of follow‐up. Long‐term surveillance is recommended to monitor dysplasia. If repeat biopsy confirms persistent dysplasia, mucosectomy with perineal pouch advancement and neo‐ileal pouch‐anal anastomosis is recommended.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:We aimed to assess objectively the integrity of the parasympathetic neural pathway that controls the inflow choke vessels to the corpora cavernosa in a group of male patients with postproctectomy erectile dysfunction.METHODS:The study group was male patients with erectile dysfunction after proctectomy for rectal cancer and inflammatory bowel disease identified by sexual function questionnaire. The group underwent two consecutive nights of home nocturnal penile tumescence monitoring with the Nocturnal Electrobioimpedance Volumetric Assessment device. The control group was also monitored. It comprised preoperative potent patients with rectal cancer and inflammatory bowel disease who had not yet undergone a variety of surgical procedures. Demographics and nocturnal penile tumescence parameters were recorded, including number, duration, and percentage increase in penile volume of tumescent events.RESULTS:Thirty‐four impotent study group and 28 potent control group patients underwent nocturnal penile tumescence monitoring. The groups were well matched for mean age (difference, 1.4 years; 95 percent confidence interval, −5.8 to 8.6 years) and proportion with rectal cancer (difference, 6 percent; 95 percent confidence interval, −1 to 13 percent). The number of nocturnal penile tumescent events was greater for the potent group than for the control group (mean rank, 40.4vs. 24.2; P = 0.0004). There was no significant difference between the mean duration (difference, 2.6 minutes; mean rank, 27.9vs. 34.4;P= 0.16) or the mean penile volume increase (difference, 5.4 percent increase; mean rank, 30.6vs. 32.6;P= 0.66) for tumescent events between the study and control groups. Mean age was significantly higher in complete than in partial impotence (60.9vs. 53.1 years; difference, 7.8 years; 95 percent confidence interval, 0.1 to 15.5 years). There was a nonsignificant trend to a lower mean number of tumescence events among sildenafil responders than among nonresponders (3.5vs. 4.8 events; mean rank, 11.2vs. 17.3;P= 0.14).CONCLUSION:Nocturnal penile tumescence activity is diminished but not ablated by the trauma of surgical dissection. This suggests that some of the cavernous nerves that govern inflow to the corpora cavernosa are intact after surgery and that the nerve lesion responsible for erectile dysfunction is partial, and it explains why the response to sildenafil in such patients is surprisingly high.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:This study was designed to define the different types of strictures, the factors favoring their occurrence, and their treatment after ileal pouch‐anal anastomosis.METHODS:Between January 1981 and June 1996, 1,884 ileal pouch‐anal anastomoses were constructed at the Mayo Clinic in Rochester, Minnesota. Data were collected prospectively and included age, gender, type of underlying diseases (chronic ulcerative colitisvs.familial adenomatous polyposis), proctologic antecedents, technique of anastomosis, intraoperative difficulties, and postsurgical complications. Strictures were categorized as nonfibrotic and fibrotic on the basis of the presence or absence of a fibrotic segment at the anal canal anastomosis that was responsible for pouch‐outlet obstruction requiring at least one dilation.RESULTS:Strictures occurred in 213 patients (11.2 percent; 11 percent for chronic ulcerative colitis and 12 percent for familial adenomatous polyposis;P= not significant). Strictures were nonfibrotic in 86.4 percent of patients and fibrotic in 13.6 percent. A greater number of strictures were observed after a handsewn anastomosis (12 percent) than after a stapled anastomosis (4 percent;P= 0.03). Intraoperative technical difficulties were associated with 13 percent of all strictures regardless of the type of stricture (fibrotic, 7.5 percent; nonfibrotic, 14 percent;P= 0.4). Postoperative complications such as abscess, fistula, and pouch retraction were found in 13 percent of cases and were primarily associated with fibrotic strictures. Treatment included dilation, which was successful in 95 percent of nonfibrotic strictures but in only 45 percent of fibrotic strictures (P= 0.0001). Surgical treatment was required in 25 strictures (12 percent), including excision of the strictured segment with mucosal advancement flap (5 patients), excision of the pouch with permanent ileostomy (9 patients), or redo pouch (3 patients). With one exception, all excised pouches were associated with other perianastomotic complications, such as abscess, fistula, and pouch retraction. The remaining eight patients had other surgical procedures because of abscess (n = 3), division of an obstructive bridge (n = 2), and débridement and curettage of a fistula (n = 3) with dilation for associated strictures.CONCLUSIONS:Strictures were observed in 11.2 percent of the patients in this study. Nonfibrotic strictures responded well to anal dilation, whereas fibrotic strictures were more commonly associated with intraoperative or postoperative complications, often necessitated surgical therapy to salvage pouch function, and were eventually responsible for pouch failure in nine patients.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:Emergency surgery for colon cancer is widely thought to be associated with increased likelihood of surgical morbidity and mortality; however, other coexistent factors such as advanced disease, the age of the patient, and medical comorbid conditions may also influence these outcomes. The primary purpose of this study was to identify the relative risk for surgical morbidity and/or mortality conferred by emergency surgery compared with elective surgery for patients with colon cancer.METHODS:An Institutional Review Board‐approved, case‐control study was performed. During the period from January 1, 1995, to June 30, 2001, a total of 184 primary surgeries for colon cancer were performed. Emergency indications for surgery were defined as peritonitis, intra‐abdominal abscess, or complete bowel obstruction at presentation (defined as emesis, distention on examination, and confirmatory plain radiograph films). By this definition, 29 patients (15.7 percent) met the criteria for inclusion. These patients were age and stage matched with 29 patients derived from the remaining 155 patients. Information was collected on surgical morbidity and mortality, length of stay, and survival.RESULTS:Age, medical comorbidities, and stage of disease were well matched between groups. The indications for the 29 emergency surgeries were as follows: 6 for peritonitis, 2 for abscesses, and 21 for complete obstructions. Nine patients did not have their primary tumor removed. Sixteen patients underwent resection and anastomosis; the remaining four patients underwent a Hartmann's procedure. Overall surgical morbidity (64vs. 24 percent; odds ratio, 5.1; 95 percent confidence interval, 1.7‐16) and mortality (34vs. 7 percent; odds ratio, 7.1; 95 percent confidence interval, 1.4‐36.2) were significantly higher for patients undergoing emergency surgery. Among patients surviving surgery, there was no difference in overall survival between patients undergoing emergency compared with elective operation.CONCLUSIONS:Emergency surgery has a strong negative influence (beyond that which is expected based on stage of disease) on immediate surgical morbidity and mortality. The similarity between the two groups in overall survival for patients surviving the perioperative period suggests that the negative impact of emergency surgery is confined to the immediate postoperative period.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:We retrospectively analyzed prognostic factors for surgical resection and intraoperative radiation therapy to identify indicators for this treatment strategy.METHODS:Thirty‐nine consecutive patients with locally recurrent colorectal cancer who underwent surgical resection with intraoperative radiation therapy from January 1, 1987, to June 30, 1999, were analyzed. The mean electron energy was 10.5 MeV and the mean intraoperative radiation dose was 22.6 Gy. Kaplan‐Meier survival estimates were obtained for the 37 patients who recovered postoperatively. Prognostic factors were analyzed univariately by log‐rank test and multivariately by Cox's proportional hazards model.RESULTS:Three‐year cumulative survival was 44 percent (standard error = 11) for 26 patients free of unresectable distant metastasis who underwent surgical resection and intraoperative radiation therapy for pelvic recurrence of colorectal cancer, but none of the 11 patients with unresectable distant metastasis survived 3 years. Preoperative prognostic factors which were significant on univariate and multivariate analysis were unresectable distant metastasis (P= 0.001) and elevated preoperative serum CA 19‐9 (P= 0.02). Patients with synchronous resection of local recurrence and distant metastasis had a significant survival advantage over those without resection of metastases (P= 0.02). Univariate analysis in a subgroup of 26 patients without unresectable distant metastasis revealed pain (P= 0.0003) to be a useful preoperative prognostic indicator, whereas tumor fixation (P= 0.01) and amount of residual tumor after surgical resection (P= 0.01) were significant intraoperative and postoperative factors, respectively. Fluorouracil‐based postoperative systemic chemotherapy produced a significant survival benefit (P= 0.04).CONCLUSIONS:Patients with unresectable distant metastasis are not suitable candidates for surgical resection and intraoperative radiation therapy, whereas those with resectable metastasis are potential candidates. Intraoperative radiation therapy may be less useful for patients with pain, elevated preoperative CA19‐9, fixed tumors, or gross residual tumor after surgical resection. Multimodal treatment strategies combining preoperative and/or postoperative external beam radiation therapy and intraoperative radiation therapy with fluorouracil‐based systemic chemotherapy are recommended for patients with these indicators.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:The aim of this study was to determine why colorectal tumors confined to submucosa rarely metastasize. Under normal conditions, the submucosa contains many large lymphatic vessels with thin walls that would presumably favor the spread of cancer cells through the lymphatic system.METHODS:Specimens of colorectal cancer tissue, the border between tumor and normal tissue, and normal tissue were obtained from patients undergoing radical resection of colorectal cancer. The material was embedded in methacrylate resin for light microscopy and Epon® for transmission electron microscopy examination. Light microscopy observations were routinely performed on serial sections.RESULTS:No lymphatic vessels were ever found in the tumor mass. The border area contained peritumoral inflammatory infiltrate of variable thickness. Where submucosal lymphatic vessels came into contact with peritumoral inflammatory infiltrate, they were profoundly altered: their endothelium was fragmented, and their walls were disrupted. These altered lymphatic vessels were almost always accompanied by mast cells, which were observed in the process of degranulating toward the lymphatic endothelium. No such alterations were detected in blood vessels.CONCLUSION:Our results suggest that mast cells, probably influenced by inflammatory infiltrate and/or colorectal cancer cells, destroy lymphatic vessels, which prevents cancer cells from spreading through the lymphatic system.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:Enteroscopy during laparotomy for Peutz‐Jeghers syndrome was introduced in our unit in 1987. Its aim is to achieve more complete polyp clearance and thereby reduce the number of subsequent laparotomies for small intestinal polyps.METHODS:All patients with Peutz‐Jeghers syndrome who had undergone intraoperative enteroscopy since its introduction into our unit in 1987 were identified. The numbers of polyps identified by palpation and transillumination and by enteroscopy were recorded. The timing of, indications for, and findings of all subsequent laparotomies were analyzed and compared with data from our unit before the introduction of intraoperative enteroscopy.RESULTS:Twenty‐five patients (14 females) were studied. Enteroscopy identified 350 (median 12, range 0‐35) polyps not detected by palpation and transillumination. All impalpable polyps were removed endoscopically by snare or biopsy. The median follow‐up was 53 (interquartile range, 13‐133) months. Six patients have had an additional laparotomy (1 urgent relaparotomy for small‐bowel perforation after endoscopic polypectomy, 4 polypectomies, and 1 adhesion obstruction). No patient has required operative polypectomy within 4 years of polyp clearance by intraoperative enteroscopy, compared with registry data of 4 (17 percent) of 23 patients who had more than 1 laparotomy within 1 year.CONCLUSION:Intraoperative enteroscopy for Peutz‐Jeghers syndrome improves polyp clearance without the need for additional enterotomies and may help to reduce the frequency of laparotomies.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:Colorectal cancer is a major cause of death worldwide. To reduce the incidence and mortality from rectal cancer, an individual quantitative risk‐assessment model (hereafter referred to as the Attributive Degree Value) and reverse passive hemagglutination fecal occult blood test were used in a randomized, controlled, population‐based trial that was conducted in Jiashan County, People's Republic of China.METHODS:All residents of Jiashan County aged 30 years or older were enrolled in the study, and 21 townships in the county were randomized to either a screening (n = 10 townships) or control (n = 11 townships) group. Participants in the screened group submitted a one‐article‐per‐slide stool sample and completed a structured risk‐assessment questionnaire from which their attributive degree value was computed. According to study protocol, 4,299 participants were defined as high risk and underwent diagnostic evaluation with 60‐cm flexible sigmoidoscopy and, in some cases, an additional screening with colonoscopy.RESULTS:From 1989 to 1996, cumulative mortality from colon cancer was 90 (95 percent confidence interval, 83‐97) per 100,000 in the screened group and 83 (95 percent confidence interval, 76‐90) per 100,000 in the control group (log‐rank = 1.49,P= 0.222). Mortality from rectal cancer during this time was 110 (95 percent confidence interval, 102‐118) per 100,000 in the screened group, which differed significantly from the control group mortality rate of 161 (95 percent confidence interval, 152‐170) per 100,000 (log‐rankP= 0.003).CONCLUSION:Mass screening with a reverse passive hemagglutination fecal occult blood test along with an individual attributive degree value score was effective in reducing mortality from rectal cancer but not in reducing mortality from colon cancer or the incidence of colorectal cancer.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:Patients with unresectable, locally advanced rectal cancer are reported to have a dismal prognosis. The aim of this study was to analyze the effect of combined‐modality therapy on clinical outcome.METHODS:From March 1990 to December 1997, 43 patients (28 males; median age, 62 years; median follow‐up, 74 months) with locally advanced (T4 and/or N3) nonmetastatic rectal cancer received external‐beam radiation (23.6 plus 23.6 Gy (split course), 8 patients; 45 Gy, 35 patients) plus 5‐fluorouracil (96‐hour continuous infusion, Days 1‐4, at 1,000 mg/m2/day) and mitomycin C (10 mg/m2, intravenous bolus, Day 1). Concomitant chemotherapy was repeated at the beginning of the second course (split‐course group) or in the last week of radiotherapy (continuous‐course group). After 6 to 8 weeks, patients were evaluated for surgical resection and intraoperative radiation therapy (10 to 15 Gy). Thereafter, adjuvant chemotherapy (5‐fluorouracil plus leucovorin, 6‐9 courses) was prescribed.RESULTS:During chemoradiation, 5 patients (11.6 percent) developed Grade 3 to 4 hematologic toxicity. After chemoradiation, 29 patients (67.4 percent) had an objective clinical response (complete response, 2.3 percent; partial response, 65.1 percent). Thirty‐eight patients underwent radical surgery (anterior resection, 24 patients; abdominoperineal resection, 14 patients; intraoperative radiation therapy boost on the tumor bed, 19 patients), and 2 patients had partial tumor resection. No perioperative deaths occurred in the patient group. Five‐year survival and local control rates were 59.9 and 69.1 percent, respectively. Distant metastasis occurred in 44.2 percent of patients. Statistically significant relationships between intraoperative radiation therapy and local control (P= 0.0104), radical surgery and survival (P= 0.0120), and adjuvant chemotherapy and disease‐free survival (P= 0.0112) were observed.CONCLUSIONS:Our data suggest that combined‐modality therapy was relatively well tolerated and resulted in good local control and survival. With regard to the impact of surgical resection on survival, additional studies aimed at improving the local response rate are necessary, whereas the positive impact of intraoperative radiotherapy on local control appears to justify the inclusion of this therapeutic modality in prospective multi‐institutional trials.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID