摘要:

PURPOSE:The study contained herein used the database of the American Board of Colon and Rectal Surgery to demonstrate trends in colorectal practice from 1989 to 1996 and to compare the one‐year technical experience of a colorectal resident with the five‐year totals of a general surgery resident.METHODS:Complete case lists from applicants for the American Board of Colon and Rectal Surgery's qualifying examination have been entered into a database. Similar data have been compiled from the Residency Review Committee for Surgery.RESULTS:From 1989 through 1996, 446,082 procedures have been listed by 417 colorectal residents, an average of 1,060 cases per resident. When contrasted with the operative experience of a general surgery resident, the colorectal resident performs substantially more anorectal operations, more endoscopic procedures, and more index abdominal operations in one year than the average general surgery resident performs in five years.CONCLUSIONS:When added to the required general surgery experience, one year of training in colorectal surgery trains a true subspecialist with unique expertise in the treatment of disorders of the colon, rectum, and anus.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

&NA;When colorectal cancer complicates chronic ulcerative colitis or familial adenomatous polyposis, the role of ileal pouch‐anal anastomosis is uncertain because of concerns that the procedure may compromise oncologic therapy and that oncologic therapy may compromise ileal pouch‐anal anastomosis function.AIM:This study was undertaken to investigate the impact both of ileal pouch‐anal anastomosis on cancer outcomes and of cancer treatments on ileal pouch‐anal anastomosis function.PATIENTS AND METHODS:Of 1,616 patients undergoing ileal pouch‐anal anastomosis for chronic ulcerative colitis or familial adenomatous polyposis (1981‐1994), 77 patients were identified with adenocarcinoma of the colon (56), rectum (17), or both (4). Data were obtained from an ileal pouch‐anal anastomosis registry, case notes, and postal and telephone surveys.RESULTS:Mean age of the 77 index patients was 37 (range, 13‐60) years. Stage distribution was as follows: Stage 0, 9; Stage I, 31; Stage II, 15; Stage III, 22 patients. Twelve patients died with systemic disease (6 with a local component) after a mean follow‐up of 6 (range, 2‐15) years. Twenty‐two patients received adjuvant therapy (chemotherapy, 16; radiotherapy, 2; both, 4 patients). Chemotherapy complications requiring dose reduction or interruption occurred in three (15 percent) patients. One patient developed radiation enteritis (17 percent). Pouch failure occurred in 16 percent of cancer patients, compared with 7 percent for the overall registry. There were no differences between cancer and non‐cancer groups in operative complications, median stool frequency, incontinence, pad usage, or pouchitis.CONCLUSIONS:Although pouch failure is more common, ileal pouch‐anal anastomosis can be performed in the setting of colorectal cancer without significant impact on oncologic outcome or long‐term ileal pouch‐anal anastomosis function.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:Whether primary anastomosis should be performed after segmental resection with intraoperative colonic irrigation or subtotal colectomy is not yet established in the surgical treatment of obstructive left colon carcinoma. In this prospective, nonrandomized study, we present the results of 66 patients undergoing one‐stage surgery for obstructed left colon carcinoma.PATIENTS AND METHODS:We compared two techniques, subtotal colectomy (35 patients) and intraoperative colonic irrigation with segmental resection and immediate anastomosis (31 patients).RESULTS:The mortality rate was similar in both groups, 8.5 percent in the subtotal colectomy group and 3.2 percent in the intraoperative colonic irrigation group. The surgical complication rate was significantly higher in the intraoperative colonic irrigation group (41.9 percent) than in the subtotal colectomy group (14.2 percent;P<0.05). Mean operating time was significantly lower in the subtotal colectomy group than in the intraoperative colonic irrigation group (P<0.05). Both groups had a similar mean duration of hospital stay. Ten patients who underwent subtotal colectomy (31.2 percent) presented with diarrhea in the immediate postoperative period, which disappeared spontaneously or with antidiarrheal medication; a disabling diarrhea persisted in two patients only (6.2 percent).CONCLUSION:We believe that subtotal colectomy is the treatment of choice for obstructed left‐sided colonic carcinoma. Segmental resection with intraoperative colonic irrigation is more appropriate than subtotal colectomy only in patients with carcinomas of the rectosigmoid junction or with previous anal incontinence to avoid the appearance of postoperative diarrhea.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:The study contained herein was undertaken to verify if immediate resection with anastomosis with on‐site lavage in emergency treatment of left colon obstruction is a safe alternative to the multistage procedure, to look for solutions to practical problems outlined by previous authors, and to check the hospital stay.METHOD:Between 1991 and 1995, all patients (61) admitted with left colon obstruction were treated with intraoperative colonic lavage and primary anastomosis. Personal development of Dudley's technique is reported. Complications and mortality are pointed out. Later, endoscopy was performed to check the status of all survivors.RESULT:Low mortality (2 percent) and major complications rates (3 percent) and short hospital stay (11 days, except for patients with major complications) are reported in our series.CONCLUSION:One‐stage surgery with intraoperative lavage is a safe procedure. Patients have a better quality of life (no stoma occurred) with an effective cost‐savings.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:The purpose of this study was to analyze a single surgeon's experience with one‐stage resection with primary anastomosis in acute obstruction of the left colon, emphasizing intraoperative decompression before the anastomosis.METHOD:From January 1986 to September 1996, 91 patients received one‐stage resection with primary anastomosis for acute obstruction of the left colon. Eighty‐five of these 91 patients were operated on for carcinoma of the colon and rectum. Subtotal colectomies were performed in 20 patients, left hemicolectomies in 21 patients, sigmoid colectomies in 34 patients, and anterior resections in 16 patients. The preoperative serum albumin level was less than 3 gm/dl in 17 patients (less than 2.5 gm/dl in 10 patients). Four patients had associated abscesses, and one patient had colonic perforation with peritonitis before operative colonoscopy. Neither antegrade nor retrograde irrigation was performed.RESULTS:Operative mortality rate was 2.2 percent. There were two cases (2.2 percent) of anastomotic leakages. Other common complications included wound infection (11 cases), urinary tract infection (5 cases), intestinal obstruction (6 cases), and respiratory failure (3 cases).CONCLUSION:This experience suggests that an anastomosis can be performed more safely in patients with acute obstruction of the left colon than in those with an anastomosis in the nondiverted colon. Neither intraoperative irrigation nor routine subtotal colectomy was found to be necessary. Anastomosis below the peritoneal reflection is also not a contraindication.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:To gain recent epidemiologic information about inflammatory bowel disease in The Netherlands, a prospective study over four years (1991‐1995) was performed.METHODS:The incidence of inflammatory bowel disease and its subgroups was examined using standardized reports of newly diagnosed patients. A separate study compared the Inflammatory Bowel Disease Registration and computerized diagnostic files of a subgroup of general practitioners with the aim of estimating completeness of case ascertainment.RESULTS:The following mean incidence rates (per 100,000 inhabitants and year) were found: 6.9 (95 percent confidence interval, 5.9‐7.9) for Crohn's disease, 10 (95 percent confidence interval, 8.7‐11.2) for ulcerative colitis (23 percent of these with ulcerative proctitis), and 1.1 (95 percent confidence interval, 0.7‐1.5) for indeterminate colitis. In the age category 20 to 29 years, the incidence rate of Crohn's disease with small‐bowel involvement was higher in females than in males. In extended ulcerative colitis, a male preponderance was observed in the older age groups. Estimated case ascertainment was 78 percent.CONCLUSIONS:Compared with recent studies in neighboring countries, the observed age and gender standardized incidence rates are high in the south of The Netherlands. Completeness of case ascertainment might have contributed to this observation; however, case ascertainment was low in ulcerative proctitis. In the study area, differences in age and gender standardized incidence rates and in disease localizations could be compatible with an influence of environmental risk factors.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:Ileal pouch‐anal anastomosis is widely claimed to have replaced total proctocolectomy with ileostomy as the “procedure of choice” for ulcerative colitis, largely on the basis of a perceived improved quality of life. There exists relatively little support for this assertion in the literature. Our aim was to determine if educated patients choosing total proctocolectomy with ileostomy have a similar quality of life as with ileal pouch‐anal anastomosis.METHODS:All patients with ulcerative colitis referred to a single surgeon and deemed an appropriate surgical candidate were educated and then offered ileal pouch‐anal anastomosis or total proctocolectomy with ileostomy. Age, gender, and complications (including pouchitis) were recorded prospectively, and all patients were questioned regarding functional outcome and level of satisfaction. They were then asked to complete a slightly modified Inflammatory Bowel Disease Questionnaire, which was analyzed by categoric and overall scores.RESULTS:Sixty‐seven patients underwent elective surgery for ulcerative colitis during the study period. Fifty‐five patients chose ileal pouch‐anal anastomosis, and 12 had total proctocolectomy with ileostomy. The groups were similar except for younger age and longer follow‐up in the ileal pouch‐anal anastomosis group. Patients undergoing ileal pouch‐anal anastomosis had significantly more short‐term or long‐term complications (49vs.8 percent), with pouchitis being the most frequent complication. There was no difference in level of satisfaction between the two groups, and no patient in either group wishes they had undergone the other procedure. There was no difference in the overall or any categoric Inflammatory Bowel Disease Questionnaire score.CONCLUSION:Patient satisfaction with both procedures was similarly high. Patients who undergo ileal pouch‐anal anastomosis can expect a high level of satisfaction, with a good quality of life. However, educated patients choosing an ileostomy can achieve the same quality of life, without the higher complication rate associated with a pelvic pouch.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:Objectives of this study were to describe the technique of laparoscopic‐assisted resection rectopexy and audit the clinical outcomes, including review of functional results.METHODS:Data were prospectively collected for duration of operation, time to passage of flatus and feces postoperatively, hospital stay, morbidity, and mortality. Follow‐up was performed by an independent assessor using a standardized questionnaire. Patients were also assessed by clinical review or telephone interview.RESULTS:During a four‐year period, 34 patients underwent laparoscopic repair for rectal prolapse, of which 30 patients underwent laparoscopic‐assisted resection rectopexy. Median duration of the operations was 185 minutes, median time for passage of flatus was two days postoperatively, and median length of hospital stay was five days. Morbidity was 13 percent and mortality rate was 3 percent. Comparison between the first ten patients who underwent laparoscopic‐assisted resection rectopexy and the last ten revealed a significant reduction in both median duration of operating time (224vs.163 minutes;P<0.005) and length of stay (6vs.4 days;P<0.015). Follow‐up study conducted at a median time of 18 months revealed that most patients (92 percent) felt that the operation had improved their symptoms, that incontinence was improved in 14 of 20 patients with impaired continence (70 percent), and that constipation was improved in 64 percent. Symptoms of incomplete emptying and the need to strain at stool were both improved in 62 and 59 percent of patients, respectively. No full‐thickness recurrences have occurred, but two patients have had mucosal prolapse detected (7 percent) and treated.CONCLUSION:Laparoscopic‐assisted resection rectopexy is feasible and safe, with acceptable recurrence rates and functional results compared with the open procedure in the surgical literature. There is rapid return of intestinal function associated with an early discharge from hospital.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:The most common recurrence after curative resection of rectal carcinoma originates from tiny, undetectable residual foci within the pelvic cavity. The significance and methods used to predict the presence of extramural and extranodal microscopic cancer foci discontinuous with the main lesion of rectal cancers were investigated.METHODS:Four hundred twenty‐seven patients who underwent resection of rectal carcinoma were studied. All resected specimens were examined for histologic evidence of extramural cancer separate from the main lesion.RESULTS:Extramural cancers not in continuity with the main rectal lesion were classified as follows: 1) extranodal microscopic cancers; 2) large tumor nodules; 3) lymph node metastases. Each classification was found to influence long‐term prognosis. Among them, microscopic cancer was thought to be especially relevant because, by virtue of its microscopic nature, it may be left in the pelvic cavity, causing local recurrence. The existence of large tumor nodules and metastatic lymph nodes correlated closely with the presence of microscopic cancer. Because large tumor nodules and lymph node metastases are possibly detectable during the operation by palpation and may be analyzed by microscopic frozen sections, they might be useful predictors of the presence of microscopic cancers.CONCLUSIONS:In cases with extensive local rectal cancer spread, the nerve‐sparing rectal resection that omits lateral dissection may be insufficient for local control because of incomplete removal of occult microscopic cancer, resulting in local recurrence. Presence of microscopic cancer correlates closely with large tumor nodules and metastatic lymph nodes. Intraoperative frozen section investigations may, thus, help in deciding on extent of location resection.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

PURPOSE:This study examines the effect of 5‐fluorouracil administration during preoperative irradiation on rectal cancer tumor proliferation.PATIENTS AND METHODS:One hundred and fifty‐three patients with locally advanced rectal cancer received 45 to 50 Gy of preoperative irradiation with (103 patients) and without (50 patients) concurrent 5‐fluorouracil, followed by surgery. Pretreatment tumor biopsies and postirradiation surgical specimens were scored for proliferative activity by assaying the extent of Ki‐67 and proliferating cell nuclear antigen immunostaining and the number of mitoses per ten high‐powered fields. Postirradiation specimens were also assessed for downstaging.RESULTS:Although 5‐fluorouracil did not improve downstaging rates, marked decreases in the activity of all three markers of proliferation (mitotic counts, Ki‐67, and proliferating cell nuclear antigen immunostaining) were seen in rectal cancers of patients receiving the drug. No significant decreases were noted in patients undergoing irradiation only.CONCLUSION:The addition of 5‐fluorouracil to preoperative irradiation resulted in a more complete inactivation of the proliferating population. Frequency of downstaging, however, was unaffected. Thus, the quiescent cell population appears to represent a substantial barrier to further downstaging. New treatment strategies should be aimed at controlled recruitment of quiescent tumor cells at the time of irradiation.

ISSN:0012-3706    

出版商:OVID    

年代:1998

数据来源: OVID