共查询到20条相似文献,搜索用时 15 毫秒
1.
Pigot F Bouchard D Mortaji M Castinel A Juguet F Chaume JC Faivre J 《Diseases of the colon and rectum》2003,46(10):1345-1350
PURPOSE: Transanal excision of rectal villous adenomas is a widely used surgical technique, because it is a one-step procedure, requiring no sophisticated instrumentation, and allowing complete histologic analysis of the excised tumor. Therefore, it ranks alongside radical surgery and palliative destructive procedures, but its results are highly variable in the published series. This discrepancy may be explained by the variable completeness of tumor excision because of potential dissection difficulties. Because intraoperative exposure may be a major limiting factor, one of us (JF) has developed a tractable cutaneomucous flap procedure to lower the rectal tumor to the anal verge, where control of the dissection line is easier. This retrospective review of consecutive patients operated on during ten-year period reports long-term results after transanal excision for large rectal villous adenomas with the tractable flap technique. PATIENTS: From 1978 to 1988, 207 consecutive patients (100 males), mean age 68 (range, 24-90) years, were operated on for an apparently benign villous rectal adenoma. Twenty-one patients (10 percent) were referred after failure of previous treatments: 11 endoscopic, 8 surgical, 1 laser, 1 radiotherapy. Mean distance of lower tumor edge from anal margin was 5.6 (range, 0-13) cm and was <10 cm in 82 percent. RESULTS: Three patients (1.5 percent), including one with a Tis carcinoma, underwent a secondary treatment for immediate gross failure of resection: one further local excision and two palliative laser destructions. Immediate postoperative course was uneventful for 96 percent; there was one death from perineal gangrenous infection, four cases of hemorrhage, and three urinary retentions. Subsequently one case of transient fecal incontinence and 11 medically managed stenoses were noted. Mean size of resected tumor was 5.4 (range, 1-17) cm. Deep excision margins concerned the rectal muscular layers in 199 patients (96 percent) and perirectal fat in 8 (4 percent). Specimen margins were negative for cancer in 175 (85 percent) and positive or unknown in 32 cases. Histologic evaluation demonstrated in situ cancer in 28 (14 percent) and invasive carcinoma in 9 (4 percent). In three patients (1 percent), two abdominoperineal resections were immediately performed (one T2 with a mucinous contingent, one T3) and one adjuvant radiotherapy (one undifferentiated T2). Four patients (2 percent) did not return for postoperative evaluation. For the remaining 198 patients, mean follow-up was 74 +/- 34 (median, 75; range, 1-168) months. Forty-four died from unrelated causes. Recurrence occurred in seven (3.6 percent) and was malignant in two, who subsequently died. Specific recurrence-free probability was 99.5 percent at one year, 96 percent at five years, and 95 percent at ten years. A lesion size >6 cm (10 vs. 1 percent for smaller tumors) and the presence of an invasive carcinoma (20 vs. 3 percent without invasive carcinoma) were significantly associated with an increased probability of recurrence at five years. CONCLUSION: Providing that adequate intraoperative exposure is obtained and advanced malignant tumors receive immediate secondary treatment, transanal resection of clinically benign, large rectal villous adenomas is safe and effective. It is an alternative to rectal resection, which exposes the patient to potentially adverse effects, and also to destructive procedures, which preclude any histologic evaluation of the tumor. 相似文献
2.
Total Mesorectal Excision Results in Low Local Recurrence Rates in Lymph Node-Positive Rectal Cancer 总被引:11,自引:2,他引:11
PURPOSE: Most series report lymph node involvement as the main predictor for local recurrence. The principal lymphatic drainage of the rectum is to nodes in the mesorectum and then nodes along the superior rectal and inferior mesenteric arteries. If total mesorectal excision provides adequate block dissection of the lymphatics of the rectum, good local control with low rates of local recurrence should be achieved even in node-positive disease.METHODS: Prospective data on all rectal cancers have been collected since 1978; 170 patients with Dukes C rectal cancer have undergone anterior resection and total mesorectal excision. We did not perform any internal iliac node dissections. Follow-up data were analyzed for local recurrence and distant recurrence.RESULTS: The local recurrence rate was 2 percent for Dukes A cases, 4 percent for Dukes B, and 7.5 percent for Dukes C (P = 0.0127). The systemic recurrence rate was 8 percent for Dukes A, 18 percent for Dukes B, and 37 percent for Dukes C (P = 0.0001).CONCLUSIONS: If surgical priority is given to the difficult task of excision of the whole mesorectum, anterior resection with total mesorectal excision in node-positive rectal cancer, local recurrence rates of < 10 percent can be achieved.Presented at the Association of Colorectal Surgeons of Great Britain and Ireland, Harrogate, United Kingdom, June 25 to 27, 2001. 相似文献
3.
Jin-Tung Liang M.D. Ph.D. Horng-Shiee Lai M.D. Ph.D. Po-Huang Lee M.D. Ph.D. 《Diseases of the colon and rectum》2006,49(4):517-518
Introduction More and more colorectal surgeons believe that total mesorectal excision can achieve favorable oncologic results for the treatment
of rectal cancers. The present study is a feasibility study aiming to evaluate if total mesorectal excision can be safely
performed by laparoscopic approach with beneficial functional recovery.
Methods A total of 44 patients (from January 2004 to February 2005) with middle rectal cancer (the average distance from anal verge
was 7.8 cm, ranging from 5.0 to 10.0 cm) without preoperative chemoradiation therapy were selected to undergo laparoscopic
total mesorectal excision. Before the study entry, all patients underwent pelvic magnetic resonance imaging or multislice
spiral computed tomography to evaluate the circumferential resection margin of rectal cancer. Only patients whose circumferential
resection margin was not involved by rectal cancer were considered as potentially curable by total mesorectal excision procedures
and were enrolled for this study. The operation procedures were conducted according to the guidelines advocated by Heald et al.1 and were shown in the video. Posteriorly, the dissection was along the ‘holy plane’ downward to the level of levator ani
muscle. Anteriorly, the dissection plane was at the anterior part of Denonvilliers fascia. Laterally, the lateral ligaments
were sharply cauterized at the medial part. The resected bowel was reconstructed with stapled end-to-end anastomosis. The
surgical outcomes of this procedure were prospectively evaluated.
Results The laparoscopic total mesorectal excision was performed with acceptable operation time (234.4±44.4 minutes, mean±standard
deviation) and little blood loss (80.0±24.0 ml) through a small wound (5.0±0.5 cm). Histopathology showed that all patients
were able to get adequate distal section margins (mean: 2.8 cm; range: 1.6–5.4 cm) and negative circumferential resection
margins (mean: 8.4mm; range: 2–14 mm). The number of dissected lymph nodes was 16.0±4.0. The pathologic tumor–node–metastasis
stages were as follows: Stage I: n= 4; Stage II: n = 22; Stage III: n = 18. Two patients (4.5 percent) were diverted by protective
ileostomy. There was no mortality within 30 days after operation. However, anastomotic leakage occurred in 3 patients. The
patients have quick functional recovery, as evaluated by the length of postoperative ileus (48.0±12.0 hours), hospitalization
(9.0±1.0 days) and degree of postoperative pain (3.5±0.5, visual analog scale). Besides the expenses covered by the National
Bureau of Health Insurance in Taiwan, the patient had to pay an extra expense of NT$ 65000.08000.0 (1.0US dollars = 32.0 NT$).
During the follow-up periods (median: 14 months, range. 2 to 27 months), three patients of Stage III and 1 patient of Stage
II developed a recurrent disease (lung metastasis: n = 2; liver metastasis: n = 1, and pelvic recurrence, n = 1).
Conclusion By laparoscopic approach, the total mesorectal excision for rectal cancers can be safely performed with good functional recovery.
However, with only a median follow-up of 14 months in this case series, the long-term oncologic outcomes for these patients
remain a question. Further randomized prospective study is thus mandatory to provide solid evidence of this approach.
This multimedia article (video) has been published online and is available for viewing at . Its abstract is presented here. As a subscriber to Diseases of the Colon & Rectum you have access to our SpringerLink electronic service, including Online First.
Video presentation in Yonsei Colorectal Cancer International Symposium, Seoul, South Korea, May 28, 2005.
Grant support from 94S040, National Taiwan University Hospital.
Reprints are not available. 相似文献
4.
To date no studies have examined the relationship between cholesterol levels and the occurrence of specific colonic polyp histologies. Villous histology has a greater predilection for subsequent malignancies than other histologies. Consequently, we examined the effect of cholesterol levels on the occurrence of villous adenomas. Just under one in 10 (9.5%, 15/158) patients had polyps with villous histologies. Cholesterol levels were positively and nonlinearly associated with a greater likelihood of villous histology, suggesting that a threshold exists for the effect of cholesterol level on the likelihood of having polyps with villous histology [odds ratios (OR) for combined two variable quadratic effect: cholesterol OR, 1.18; 95% confidence interval (CI), 1.02–1.37 and cholesterol squared OR, 1.004; 95% CI, 1.00–1.02]. Our data suggest that, in patients with polyps, higher cholesterol levels increase the likelihood of having polyps with villous histology, but that the effect of cholesterol level reaches a threshold. 相似文献
5.
Bonadeo FA Vaccaro CA Benati ML Quintana GM Garione XE Telenta MT 《Diseases of the colon and rectum》2001,44(3):374-379
PURPOSE: This study was designed to assess the local recurrence rate and prognostic factors for local recurrence in patients undergoing curative anterior or abdominoperineal resections without radiotherapy. METHODS: From January 1980 to December 1996, 514 consecutive patients underwent curative resections for rectal cancer. We excluded those with preoperative radiotherapy (n=23), postoperative radiotherapy (n=27), local resection (n=36), and 11 (2.1 percent) patients who died postoperatively. The remaining 417 patients (249 males) with a median age of 64 (range, 21–90) years were analyzed. For upper third lesions, mesorectal tissue was excised down to at least 5 cm below the tumor. Total mesorectal excision was performed for lower and middle tumors. Postoperative chemotherapy was limited to patients with Stage III lesions. Median follow-up (and 95 percent confidence interval) was (5.2 4.3–5.9) years, with 87.7 percent of patients followed up longer than 24 months. Local recurrence was defined as any recurrence within the field of resection, regardless of the presence or absence of distant metastasis. RESULTS: Five-year local recurrence rate(and 95 percent confidence interval) was 9.7 (6.4–13) percent, with a median time to diagnosis of 15 (10–23) months. Local recurrence rates in Stages I, II, and III were: 3.1, 4.1, and 24.1 percent, respectively (P < 0.0001). In relation to node status, local recurrence rates were N0, 4.1 (1.7–6.5) percent; N1, 12.6 (4.6–20.6) percent; N2, 32.1 (12.1–52.1) percent; and N3, 59.3 (22.5–96.1) percent; (P < 0.00001). Lower third tumors had a higher local recurrence rate than middle and upper third tumors: 17.9, 7.1, and 5.1 percent, respectively (P=0.002). Adjusted by stage, this difference was maintained only in Stage III tumors. Among lower tumors, those at 6 and 7 cm from the anal verge had a lower local recurrence rate than those below 6 cm (6.7vs. 26.2 percent, respectively;P=0.02). Accidental rectal perforation at or near the tumor site occurred in 12 cases (2.9 percent), showing a strong correlation with local recurrence (P < 0.0001). Multivariate analysis showed significant higher risk for lower third tumors (hazard ratio, 2.98) and positive nodes (hazard ratio, 4.78). CONCLUSIONS: Appropriate surgery without irradiation achieves excellent local control in N0 rectal cancers. Node metastasis, lower third localization (especially below 6 cm), and accidental rectal perforation at or near the tumor site are significantly associated with a higher local recurrence rate. 相似文献
6.
Nano M Marchisio F Ferronato M Breatta AD Solej M Barbero S Dei Poli M Gandini G 《Diseases of the colon and rectum》2006,49(12):1897-1904
Purpose For many years, poor vascularization of the short rectal stump has been considered the main cause of leakage. The purpose
of this study was to evaluate the vascularization of the rectal stump after total mesorectal excision.
Methods We studied the iliac vascularization on 28 volunteers with healthy rectum to have an anatomic basis. Then, we studied the
vascularization of the rectal stumps after total mesorectal excision by using angio computed tomography at seven and three
months after operating on 22 patients; we validated this technique by studying the vascularization using angio computed tomography
in 18 rectal specimens from cadavers.
Results Both in healthy rectums and in rectal stumps after total mesorectal excision, there is good vascularization substained by
middle and inferior rectal arteries. The former is more important and frequent as described in previous literature.
Conclusions The vascularization of the short rectal stump is generally well represented even after total mesorectal excision.
Reprints are not available. 相似文献
7.
Beveridge IG Swain DJ Groves CJ Saunders BP Windsor AC Talbot IC Nicholls RJ Phillips RK 《Diseases of the colon and rectum》2004,47(1):123-126
A restorative proctocolectomy or ileal pouch procedure is one of the main surgical options for patients with familial adenomatous polyposis. The main premise underlying the recommendation of a pouch procedure rather than an ileorectal anastomosis is that it minimizes the risk of rectal cancer. Several studies have evaluated the risk of developing pouch adenomas. There also have been reports of pouch cancers, although the long-term risk of malignancy cannot yet be quantified. Most pouch polyps reported have been small tubular adenomas with mild dysplasia. A 19-year-old female with familial adenomatous polyposis had a colectomy and ileorectal anastomosis. Progressive rectal polyposis led to a restorative proctocolectomy at aged 38 years. Four years later, a large, 3-cm × 2-cm, villous adenoma was identified in the mid pouch, which was resected endoscopically. A 32-year-old male with familial adenomatous polyposis had a restorative proctocolectomy. Ten years after surgery, pouch endoscopy revealed several large, villous adenomas arising from the pouch mucosa. These advanced polyps may present a significant risk for cancer development and require close endoscopic surveillance. These findings strengthen the recommendation for careful regular endoscopic surveillance of familial adenomatous polyposis pouches and the evaluation of management and treatment strategies for pouch adenomas. 相似文献
8.
Weiser MR Landmann RG Wong WD Shia J Guillem JG Temple LK Minsky BD Cohen AM Paty PB 《Diseases of the colon and rectum》2005,48(6):1169-1175
PURPOSE This study examines surgical salvage of locally recurrent rectal cancer following transanal excision of early tumors.METHODS Through retrospective review of a colorectal database we identified 50 patients who underwent attempted surgical salvage for local recurrence following initial transanal excision of T1 or T2 rectal cancer. Eight patients had resectable synchronous distant disease. Clinicopathologic variables were associated with extent of surgery required for salvage and outcome.RESULTS Salvage procedures included abdominoperineal resection (31), low anterior resection (11), total pelvic exenteration (4), and transanal excision (3). One patient had unresectable disease at exploration, requiring diverting ostomy. Of the 49 patients who underwent successful salvage, 27 (55 percent) required an extended pelvic dissection with en bloc resection of one or more of the following structures: pelvic sidewall and autonomic nerves (18); coccyx or portion of sacrum (6); prostate (5); seminal vesicle (5); bladder (4); portion of the vagina (3); ureter (2); ovary (1); and uterus (1). Complete pathologic resection (R0) was accomplished in 47 of 49 patients. Of the eight patients with distant and local recurrence, two underwent synchronous resection and six had delayed metastasectomy. With a median follow-up of 33 months, 29 patients had recurred or died of disease at the time of this analysis. Five-year disease-specific survival was 53 percent. Factors predictive of survival included evidence of any mucosal recurrence on endoscopy, low presalvage carcinoembryonic antigen, and absence of poor pathologic features (lymphovascular and perineural invasion). Patients who required an extended pelvic resection had a worse survival rate.CONCLUSION Pelvic recurrence following transanal excision of early rectal cancer is often locally advanced, requiring an extended pelvic dissection with en bloc resection of adjacent pelvic organs to achieve salvage. The long-term outcome in patients undergoing resection is less than expected, considering the early stage of their initial disease. When contemplating local excision for early rectal cancer, the risk of local recurrence, the extent and morbidity of surgery required for salvage, and the modest cure rate following salvage should be considered.Read at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004.Reprints are not available. 相似文献
9.
Fenech DS Takahashi T Liu M Spencer L Swallow CJ Cohen Z Macrae HM McLeod RS 《Diseases of the colon and rectum》2007,50(5):598-603
Purpose The purpose of this study was to determine the functional outcomes and health-related quality of life of patients after transanal
excision of rectal cancers or polyps and to assess the relationship between functional outcomes and health-related quality
of life.
Methods All patients having a transanal excision at the Mount Sinai Hospital from 1989 to 2002 were included if the indication for
surgery was a benign or malignant neoplasm. Physician charts were reviewed, and patients and their physicians were contacted
to obtain follow-up information. Continence was assessed by using the Continence Score described by Jorge and Wexner and the
Fecal Incontinence Quality of Life instrument by Rockwood and Lowry.
Results Eighty-two patients fit the inclusion criteria (42 males; mean age, 71 ± 13.7 years). Of these, 29 had villous adenomas, 2
had carcinoids, and 1 had a hyperplastic polyp. Fifty had cancers, including 34 with T1, 14 with T2, and 2 with T3 cancers.
Seven patients had a low anterior resection or abdominoperineal resection within two months of transanal excision because
of advanced features of cancer. Five patients had salvage abdominoperineal resections or low anterior resections for local
recurrences. Five patients died of rectal cancer (including 3 who had salvage surgery) and an additional seven patients died
of other causes. Functional results were assessed in 58 of 61 eligible patients. The mean Continence Score postoperatively
was 3.5 ± 3.9 compared with 2.4 ± 3.7 preoperatively (P = 0.03). The mean Fecal Incontinence Quality of Life scores after surgery in all patients were 3.9 ± 0.3, 3.6 ± 0.6, 3.7 ± 0.3,
3.7 ± 0.6 in the domains of lifestyle, coping, depression, and embarrassment, respectively, after surgery, indicating high
quality of life. Using Spearman’s correlation, we found that the continence scores after surgery correlated well with the
Fecal Incontinence Quality of Life scores. In the domains of lifestyle (Spearman’s correlation = −0.69), coping and behavior
(Spearman’s correlation = −0.7), and embarrassment (Spearman’s correlation = −0.61) but did not correlate well with the domain
of depression (Spearman’s correlation = −0.17).
Conclusions Although functional results are worsened in a minority of patients after transanal excision, quality of life is high in the
majority of patients.
Read at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003. 相似文献
10.
Total Mesorectal Excision for Rectal Cancer: Difference in Outcome for Low and High Rectal Cancer 总被引:3,自引:0,他引:3
Faerden AE Naimy N Wiik P Reiertsen O Weyessa S Trønnes S Andersen SN Bakka A 《Diseases of the colon and rectum》2005,48(12):2224-2231
PURPOSE This prospective study was designed to assess the outcome through the first five years after the introduction of total mesorectal
excision in 1993 in a Norwegian central hospital, with special regard to the difference between low (≤6 cm from anal verge)
and high (>6 cm) rectal cancers.
METHODS A total of 140 patients (81 males; median age, 64 (range, 29–87) years) underwent surgery for rectal cancer under curative
intention.
RESULTS Local recurrence rates were 8 of 44 (18 percent) for the low cancers and 5 of 96 (5 percent) for the high, a statistically
significant difference (P = 0.0014). Corresponding numbers when the R1 resections are excluded were 5 of 36 (13 percent) for the low and 4 of 92 (4
percent) for the high cancers (P = 0.002). The five-year survival after R0 resections of cancers <6 cm was significantly reduced compared with those >6 cm.
The five-year overall survival for the whole material was 72 percent.
CONCLUSIONS Surgery alone for rectal cancer can achieve overall good results, with five-year overall survival of 72 percent. The prognosis
of the cancers of the lower rectum seems to be inherently different from the tumors of the higher level, both concerning local
recurrence and five-year survival, suggesting different biologic behavior of the two cancers.
Presented at the meeting of the Norwegian Surgical Society, Oslo, Norway, October 18 to 22, 2004. 相似文献
11.
Shigemi Onoue Takehito Katoh Haruhiko Chigira Masaomi Suzuki Yoshihisa Shibata Koji Matsuo Matsuyoshi Maeda 《Journal of hepato-biliary-pancreatic sciences》1997,4(4):469-473
We report a case of villous tumor of the papilla of Vater associated with hypopotassemia. The patient was a 73-year-old woman who presented with jaundice and fever. She had a history of diabetes mellitus and liver dysfunction. Laboratory studies revealed that levels of total bilirubin, alkaline phosphatase, and C-reactive protein, and the white blood cell count were elevated (suggestive of cholangitis) and that the serum potassium level was markedly reduced, to 1.9 mEq/l (normal value 3.5–5.0 mEq/l). Duodenoscopy showed a villous tumor arising in the papilla of Vater. Percutaneous transhepatic biliary drainage was performed. Approximately 700–1500 ml of bile with viscous mucoid fluid was drained daily. Percutaneous transhepatic cholangioscopy showed a papillary lesion in the distal common bile duct. Biopsied specimens from both percutaneous transhepatic cholangioscopy and duodenoscopy disclosed tubulovillous adenoma. Endoscopic ultrasonography showed that the tumor had spread to the main pancreatic duct as well as to the common bile duct. The patient underwent pylorus-preserving pancreaticoduodenectomy. Pathology examination disclosed well differentiated adenocarcinoma, carcinoma in situ, in tubulovillous adenoma. The cancer cells were observed at the bottom of the tumor spreading in the common bile duct. This is a rare case of a patient presenting with hypopotassemia associated with a tubulovillous tumor of the papilla of Vater that secreted mucoid material. 相似文献
12.
Local Excision of Distal Rectal Cancer: An Update of Cancer and Leukemia Group B 8984 总被引:2,自引:0,他引:2
Greenberg JA Shibata D Herndon JE Steele GD Mayer R Bleday R 《Diseases of the colon and rectum》2008,51(8):1185-1194
Purpose The efficacy of local excision in the treatment of some early-stage distal rectal cancers is still being debated, because
few high-quality, long-term prospective data on outcomes are available.
Methods Fifty-nine patients with T1 lesions were treated with local excision alone, whereas 51 patients with T2 lesions received external
beam irradiation (5,400 cGY) and 5-fluorouracil (500 mg/m2 intravenously Days 1–3, Days 29–31) after local excision. Kaplan-Meier curves were used to estimate the primary outcomes.
The log-rank test and Cox’s proportional hazards model were used to compare subgroups relative to these outcomes.
Results With a median follow-up of 7.1 (range, 2.1–11.4) years, ten-year rates of overall survival were 84 percent for patients with
T1 and 66 percent for T2 rectal cancer. Disease-free survival was 75 percent for T1 and 64 percent for T2 disease. Local recurrence
rates for patients with T1 and T2 lesions were 8 and 18 percent, respectively, and rates of distant metastases were 5 percent
for T1 and 12 percent for T2 lesions. T stage was a statistically significant predictor of overall survival (P = 0.04) and approached statistical significance as a predictor of disease-free survival (P = 0.07).
Conclusions Local excision alone for T1 rectal adenocarcinomas is associated with low recurrence and good survival rates that remain durable
with long-term follow-up. T2 lesions treated via local excision and adjuvant therapy are associated with higher recurrence rates.
Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007. 相似文献
13.
Michael E. C. McFarlane 《Journal of hepato-biliary-pancreatic sciences》2001,8(1):107-109
Villous tumors of the duodenum are rare tumors which have been infrequently reported in the literature. Surgical treatment options include wide local excision and radical pancreaticoduodenectomy. A case of duodenal villous adenoma presenting with bilious vomiting is presented here. 相似文献
14.
Transanal Excision vs. Major Surgery for T1 Rectal Cancer 总被引:14,自引:0,他引:14
Endreseth BH Myrvold HE Romundstad P Hestvik UE Bjerkeset T Wibe A;Norwegian Rectal Cancer Group 《Diseases of the colon and rectum》2005,48(7):1380-1388
PURPOSE The purpose of this national study was to examine the long-term results of transanal excision compared with major surgery of T1 rectal cancer.METHODS This prospective study from the Norwegian Rectal Cancer Project included all 291 patients with a T1M0 tumor within 15 cm from the anal verge treated by anterior resection, abdominoperineal resection, Hartmann’s procedure, or transanal excision in the period from November 1993 to December 1999.RESULTS Two hundred fifty-six patients were treated by major surgery and 35 patients by transanal excision. None of the patients had neoadjuvant therapy. Macroscopic tumor remnants (R2) occurred in 17 percent (6/35) of the transanal excisions, while major surgery obtained 100 percent R0 resections. Eleven percent of the patients treated with major surgery had glandular involvement. There were no significant differences according to tumor localization, size, or differentiation between Stage I and Stage III tumors. Patients treated with transanal excision were older than patients having major surgery (mean age, 77 vs. 68 years, P < 0.001). After curative resection (R0, R1, Rx) the five-year rate of local recurrence was 12 percent (95 percent confidence interval, 0–24) in the transanal excision group compared with 6 percent (95 percent confidence interval, 2–10) after major surgery (P = 0.010). The overall five-year survival was 70 percent (95 percent confidence interval, 52–88) in the transanal excision group compared with 80 percent (95 percent confidence interval, 74–85) in the major surgery group (P = 0.04) and the five-year disease-free survival was 64 percent (95 percent confidence interval, 46–82) in the transanal excision group compared with 77 percent (95 percent confidence interval, 71–83) in the major surgery group (P = 0.01).CONCLUSIONS The main problem of transanal excision for early rectal cancer in the present study was the inability to remove all the malignancy. Patients treated with transanal excision had significantly higher rates of local recurrence compared with patients who underwent major surgery. Patients who had transanal excision had inferior survival, but they were older than those who had major surgery.From the Norwegian Gastrointestinal Cancer Group and the Norwegian Rectal Cancer Group.This work was supported by a grant from the Norwegian Cancer Society.Presented at the XXth Biennial Congress of the International Society of University Colon and Rectal Surgeons, Budapest, Hungary, June 6 to 10, 2004. 相似文献
15.
Landmann RG Wong WD Hoepfl J Shia J Guillem JG Temple LK Paty PB Weiser MR 《Diseases of the colon and rectum》2007,50(10):1520-1525
Successful selection of patients with rectal cancer for local excision requires accurate preoperative lymph node staging.
Although endorectal ultrasound is capable of detecting locally advanced disease, its ability to correctly identify nodal metastases
in early rectal lesions is less well described. This study examines the accuracy of endorectal ultrasound in determining nodal
stage based on depth of penetration of the primary lesion (T stage). Between 1998 and 2003, endorectal ultrasound was performed
on 938 consecutive patients; 134 had biopsy-proven rectal cancers and were treated with radical resection, without neoadjuvant
therapy. Lymph node metastases were measured pathologically and correlated with endorectal ultrasound and clinicopathologic
features. Accuracy and specificity of endorectal ultrasound nodal staging was determined. The overall accuracy of endorectal
ultrasound nodal staging for the study cohort was 70 percent, with a 16 percent false-positive rate and 14 percent false-negative
rate. Endorectal ultrasound was more likely to overlook small metastatic lymph node deposits. The size of lymph node metastasis
and accuracy of endorectal ultrasound nodal staging was related to T stage. The specificity of endorectal ultrasound nodal
staging, or the ability to identify patients who were node-negative, was dependent on T stage. Early rectal lesions are more
likely to have lymph node micrometastases not detected by endorectal ultrasound. The ability of endorectal ultrasound to correctly
identify patients without lymph node metastasis is dependent on the T stage of the primary lesion. The limitations of endorectal
ultrasound in accurately staging nodal disease in early rectal lesions may, in part, explain the relatively high recurrence
rates seen after local excision.
Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April
30 to May 5, 2005.
Reprints are not available. 相似文献
16.
BACKGROUND AND AIM: Transanal endoscopic microsurgery (TEM) was a technique developed to allow the excision of adenomas and early-stage cancers from the rectum and distal sigmoid colon. The aim of this project was to prospectively study surgical morbidity, mortality and the local recurrence rate of all patients treated with this technique. METHODS: All patients undergoing TEM were prospectively evaluated. Endpoints to assess the surgical morbidity and mortality were defined before the study commenced. All patients underwent regular follow up to determine treatment efficacy in terms of the local recurrence rate and survival. RESULTS: The study involved 113 patients, with a mean age of 69 years (standard deviation 14 years, range 30-94 years), and a male to female ratio of 1.4:1. The mean polyp area was 20.5 cm(2) (range 1-169 cm(2)) and the mean height above the anal verge was 9.5 cm (range 4-25 cm). Histology of the tumors found 62 adenomas, 20 carcinomas in situ, and 31 adenocarcinomas. There were no unplanned returns to theater or postoperative deaths. Four patients required readmission within 30 days because of bleeding, and nine patients underwent more radical surgical procedures following histological evaluation of the resected specimens. During a mean follow up of 1.5 +/- 0.8 years (maximum 3.2 years), there have been two recurrences of villous adenomas. The actuarial local recurrence rate at 2 years is 2.4% (95% confidence interval 0.8-4.0%). CONCLUSION: TEM was demonstrated to be a safe surgical procedure, and early follow up has shown it to be an efficacious treatment for benign rectal adenomas and early rectal cancers. 相似文献
17.
Neoadjuvant Therapy and Anastomotic Leak After Tumor-Specific Mesorectal Excision for Rectal Cancer 总被引:1,自引:0,他引:1
Martel G Al-Suhaibani Y Moloo H Haggar F Friedlich M Mamazza J Poulin EC Stern H Boushey RP 《Diseases of the colon and rectum》2008,51(8):1195-1201
Purpose This study was designed to evaluate whether neoadjuvant therapy is a risk factor for anastomotic leakage after rectal cancer
surgery.
Methods A retrospective review of 220 patients who underwent tumor-specific mesorectal excision for rectal cancer from 2000 to 2005
was performed. Risk factors for leak were identified by using a multivariable regression model.
Results A total of 54 patients received neoadjuvant chemoradiation therapy and surgery, whereas 166 received surgery alone. No difference
in clinically significant leaks was observed between the two groups (5.6 vs. 6.6 percent, P = 1). A diverting ileostomy was performed in 26.4 percent of patients who received neoadjuvant therapy compared with 9.7
percent for surgery alone (P = 0.0021). Neoadjuvant patients were more likely to have ultralow anastomoses (17.6 vs. 2.5 percent, P < 0.0001). On multivariate analysis, smoking (odds ratio, 6.37 (1.8, 22.2), P = 0.004), difficult anastomosis (odds ratio, 7.66 (1.8, 31.5), P = 0.0048), and low level of anastomosis (≤4 cm from the verge; odds ratio, 5.28 (1.05, 26.6), P = 0.044) were independently associated with anastomotic leakage.
Conclusions Significant predictors of anastomotic leak include smoking, difficult anastomosis, and level of anastomosis (≤4 cm). Neoadjuvant
chemoradiation therapy was not found to be significantly associated with leakage after tumor-specific mesorectal excision
for rectal cancer.
Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007. 相似文献
18.
Outcome of Local Excision of Rectal Carcinoma 总被引:6,自引:2,他引:6
Gopaul D Belliveau P Vuong T Trudel J Vasilevsky CA Corns R Gordon PH 《Diseases of the colon and rectum》2004,47(11):1780-1788
PURPOSE This study was designed to determine the results of patients with rectal adenocarcinoma treated with local excision.METHODS A retrospective, chart review was conducted for all patients treated with local excision for rectal adenocarcinoma from 1984 to 1998.RESULTS Sixty-four patients were retained for analysis. The median follow-up was 37 (range, 9–125) months. There were 15 local failures with a median time to local failure of 12 months. Seven patients were salvaged with further operation (4 by repeat local excision, 4 by abdominoperineal resection, and 1 by low anterior resection). The incidence of local recurrence increased with advancing stage of the carcinoma (T1, 13 percent; T2, 24 percent; T3, 71 percent), histologic grade of differentiation, (well, 12 percent; moderately, 24 percent; poorly, 44 percent), and margin status (negative, 16 percent; close (within 2 mm), 33 percent; positive, 50 percent). Sixteen percent of carcinomas 3 cm failed compared with 47 percent for carcinomas > 3 cm. Nine percent (1/11) of T2 patients treated with adjuvant radiation therapy recurred locally compared with 36 percent (5/14) without radiation therapy. Three of four T3 patients who received radiation therapy failed locally compared with two of three who did not. Using the Kaplan-Meier method, the overall survival at five years was 71 percent, and disease-free survival was 83 percent. Actuarial local failure was 27 percent and freedom from distant metastasis was 86 percent. The sphincter preservation rate was 90 percent at five years.CONCLUSIONS Local excision alone is an acceptable option for well-differentiated, T1 carcinomas, 3 cm. Adjuvant radiation is recommended for T2 lesions. The high local recurrence rate in patients after local excision of T3 lesions with or without adjuvant radiotherapy would mandate a radical resection.Reprints are not available.Poster presentation at the meeting of The American Society Colon Rectal Surgeons, Boston, Massachusetts, June 24 to 29, 2000. 相似文献
19.
Endorectal Ultrasound in the Follow-Up of Rectal Cancer Patients Treated by Local Excision or Radical Surgery 总被引:2,自引:0,他引:2
de Anda EH Lee SH Finne CO Rothenberger DA Madoff RD Garcia-Aguilar J 《Diseases of the colon and rectum》2004,47(6):818-824
PURPOSE: This study was designed to investigate the role of a scheduled follow-up protocol using endorectal ultrasonography for the diagnosis of local recurrence after local excision and radical surgery for rectal cancer.METHODS: A selected group of 275 patients with invasive rectal cancer followed prospectively by endorectal ultrasonography after curative-intent local excision (n = 108) or radical surgery (n = 167) was reviewed. For the radical-surgery group, results were compared with a group of 176 rectal cancer patients who had similar operations during the same period of time and were not entered in follow-up protocol. Excluded were patients with invasive cancers removed by snare excision, male patients treated by abdominoperineal resection, and patients treated by endocavitary radiation. Students unpaired t-test was used to compare tumor and patient characteristics. Survival curves were estimated using the Kaplan-Meier method and compared using the log-rank test.RESULTS: In the local-excision group, 32 patients developed local recurrence, 26 (81 percent) were asymptomatic, and 10 of them (31 percent) were diagnosed only by endorectal ultrasound. We found no difference in the rates of salvage surgery or survival between patients diagnosed of recurrence by ultrasound or other methods. In the radical-surgery group, 12 patients developed local recurrence, 5 (42 percent) were asymptomatic, and 4 of them (33 percent) were diagnosed only by endorectal ultrasound. More patients with isolated local recurrence in the follow-up group underwent salvage surgery (4/9 patients; 44 percent) compared with patients without follow-up (3/13 patients; 23 percent), but the differences were not significant.CONCLUSIONS: Endorectal ultrasound identifies one-third of asymptomatic local recurrences that were missed by digital examination or proctoscopic examination. However, the impact of the earlier diagnosis in patient survival can only be determined by a larger, prospective, randomized trial.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeon, San Diego, California, June 2 to 7, 2001. 相似文献
20.
Lee SH Hernandez de Anda E Finne CO Madoff RD Garcia-Aguilar J 《Diseases of the colon and rectum》2005,48(12):2249-2257
PURPOSE A positive circumferential resection margin is associated with a high risk of local recurrence and distant metastasis after
total mesorectal excision for rectal cancer. The mesorectum is thinner anteriorly than posteriorly, and the risk of a positive
resection margin may be higher for anterior than for posterior tumors. We sought to determine the effect of the tumor's position
in the circumference of the rectum on the treatment and outcomes of rectal cancer patients treated by total mesorectal excision.
METHODS We retrospectively analyzed 401 patients with rectal cancer staged by preoperative endorectal ultrasound and treated by sharp
mesorectal excision with or without neoadjuvant therapy. Tumors were classified into four groups (anterior, posterior, lateral,
and circumferential) according to the location of deepest point of penetration on endorectal ultrasound. Differences in recurrence
and survival rates were analyzed with logistic regression analysis.
RESULTS Of the 401 tumors, 27 percent were anterior, 26 percent posterior, 32 percent lateral, and 15 percent circumferential. The
groups did not differ in age, gender, tumor distance from the anal verge, or tumor grade. The ultrasound and pathology stages
were more advanced in the circumferential group, and the proportion of uT4 tumors was higher in the anterior group. Circumferential
and anterior tumors were more likely to receive preoperative adjuvant radiation. After an average follow-up of 44 months,
20 percent of patients had developed recurrence (13 percent distant, 6 percent local, and 1 percent distant and local). Recurrence
was associated with advanced tumor stage, tumor proximity to the anal verge, and no preoperative adjuvant therapy. Early tumor
stage and preoperative chemoradiation were associated with lower recurrence and improved survival. When tumor stage was controlled
for, patients with poor or undifferentiated tumors and male patients with anterior tumors were shown to have a higher risk
of recurrence or death. The estimated five-year disease-free survival for the entire group was 73 percent.
CONCLUSIONS Tumor stage is the main criterion to estimate prognosis in rectal cancer patients. The position of the tumor within the circumference
of the rectum may provide valuable clinical information. Anterior tumors tend to be more advanced and, at least in male patients,
has a higher risk of recurrence and death than tumors in other locations.
Presented at the meeting of the Minnesota Surgical Society, St. Paul, Minnesota, April 27, 2001. 相似文献