套入式结肠直肠黏膜吻合保肛术对青年男性低位直肠癌术后性功能的影响

目的 探讨套入式结肠直肠黏膜吻合保肛术对青年男性低位直肠癌患者术后性功能的影响.方法 对68例低位直肠癌青年男性患者行套入式结肠直肠黏膜吻合术,分别于术前及术后调查其性功能.结果 68例患者中术后性功能障碍共发生22例,发生率32.35%,其中勃起障碍15例,射精障碍7例.6例Dukes A期患者均未发生性功能障碍,Dukes B期及C期患者术后性功能障碍发生率分别为26.67%及38.30%,两者差异有统计学意义(P＜0.05).结论 套入式结肠直肠黏膜吻合术可以很好地保护青年男性低位直肠癌患者的性功能,是一安全、有效的保肛术式.     

低位直肠癌保肛术式的选择

目的 对低位直肠癌保肛术式的选择方法进行探讨.方法 2003年1月至2008年1月期间,对137例低位直肠癌按无瘤原则行保肛术,术中将血供良好的结肠断端无张力拉下吻合,恢复肠道肛管的连续性.结果 行双吻合器低位前切除术102例中,91例直肠癌基底距肛缘6～8 cm,11例直肠癌基底距肛缘5～6 cm,后者肿瘤均位于直肠后壁;行Parks术或改良Bacon术35例中,直肠癌基底距肛缘均为5～6 cm.Parks术19例均为乙状结肠与肛管吻合;改良Bacon术16例均行降结肠经肛管拖出手术.结论 对肿瘤基底距肛缘6～8 cm和少数较瘦患者、基底距肛缘5～6 cm、且肿块位于直肠后壁的低位直肠癌可以采用双吻合器低位前切除术.对肿瘤基底距肛缘5～6 cm的低位直肠癌,可以行Parks术或改良Bacon术,其中乙状结肠较长时可以行乙状结肠与肛管吻合的Parks术;乙状结肠长度不够时可以游离结肠脾曲或左半结肠,行降结肠经肛管拉出的改良Bacon术.     

Colon and rectal surgery without mechanical bowel preparation: a randomized prospective trial

OBJECTIVE: To assess whether elective colon and rectal surgery can be safely performed without preoperative mechanical bowel preparation. SUMMARY BACKGROUND DATA: Mechanical bowel preparation is routinely done before colon and rectal surgery, aimed at reducing the risk of postoperative infectious complications. However, in cases of penetrating colon trauma, primary colonic anastomosis has proven to be safe even though the bowel is not prepared. METHODS: Patients undergoing elective colon and rectal resections with primary anastomosis were prospectively randomized into two groups. Group A had mechanical bowel preparation with polyethylene glycol before surgery, and group B had their surgery without preoperative mechanical bowel preparation. Patients were followed up for 30 days for wound, anastomotic, and intra-abdominal infectious complications. RESULTS: Three hundred eighty patients were included in the study, 187 in group A and 193 in group B. Demographic characteristics, indications for surgery, and type of surgical procedure did not significantly differ between the two groups. Colo-colonic or colorectal anastomosis was performed in 63% of the patients in group A and 66% in group B. There was no difference in the rate of surgical infectious complications between the two groups. The overall infectious complications rate was 10.2% in group A and 8.8% in group B. Wound infection, anastomotic leak, and intra-abdominal abscess occurred in 6.4%, 3.7%, and 1.1% versus 5.7%, 2.1%, and 1%, respectively. CONCLUSIONS: These results suggest that elective colon and rectal surgery may be safely performed without mechanical preparation.     

Could laparoscopic colon and rectal surgery become the standard of care? A review and experience with 750 procedures

INTRODUCTION: The benefits of the laparoscopic approach to colon and rectal surgery do not seem as great as for other laparoscopic procedures. To study this further we decided to review the current literature and the 10-year experience of a surgical group from university teaching hospitals in Montréal, Québec and Toronto in performing laparoscopic colon and rectal surgery. METHODS: The prospectively designed case series comprised all patients having laparoscopic colon and rectal surgery. The procedures were carried out by a group of 4 surgeons between April 1991 and November 2001. We noted intraoperative complications, any conversions to open surgery, operating time, postoperative complications and postoperative length of hospital stay. RESULTS: The group attempted 750 laparoscopic colon and rectal procedures of which 669 were completed laparoscopically. Malignant disease was the indication for surgery in 49.6% of cases. Right hemicolectomy and sigmoid colectomy accounted for 54.5% of procedures performed. Intraoperative complications occurred in 8.3%, with 29.0% of these resulting in conversion to open surgery. The overall rate of conversion to open surgery was 10.8%, most commonly for oncologic concerns. Median operating time was 175 minutes for all procedures. Postoperative complications occurred in 27.5% of procedures completed laparoscopically but were mostly minor wound complications. Pulmonary complications occurred in only 1.0%. The anastomotic leak rate was 2.5%. The early reoperation rate was 2.4%. Postoperative mortality was 2.2%. No port site metastases have yet been detected. The median postoperative length of stay was 5 days. CONCLUSIONS: The clinical outcomes of laparoscopic colon and rectal surgery in this 10-year experience are consistent with numerous cohort studies and randomized clinical trials. Laparoscopic colon and rectal surgery in the hands of well-trained surgeons can be performed safely with short hospital stay, low analgesic requirements and acceptable complication rates compared with historical controls and other reports in the literature. Evidence from published randomized clinical trials is emerging that under these conditions laparoscopic resection represents the better treatment option for most benign conditions, but concerns regarding its appropriateness for malignant disease are still to be resolved.     

Elective colon and rectal surgery differ in risk factors for wound infection: results of prospective surveillance

OBJECTIVE: The objective of this study was to clarify the incidence and risk factors for developing incisional surgical site infection (SSI) in both elective colon and rectal surgery. SUMMARY BACKGROUND DATA: SSI is a frequent complication after elective colorectal resection. The National Nosocomial Infection Surveillance system surveys all colorectal surgeries together, without differentiating the type of colorectal surgery performed. However, rectal surgery may have a higher risk for SSI, and identifying risk factors that are more specific to each procedure would be more predictive. METHODS: We conducted prospective SSI surveillance of all elective colorectal resections performed by a single surgeon in a single institution from November 2000 to July 2004. The data for colon and rectal surgeries were collected separately. The outcome of interest was incisional SSI. Univariate and multivariate analyses were performed to determine the predictive significance of variables in each type of surgery. RESULTS: A total of 556 colorectal resections, consisting of 339 colon and 217 rectal surgeries, were admitted to the program. The incisional SSI rates in colon and rectal surgeries were 9.4% and 18.0%, respectively (P = 0.0033). Risk factors for developing incisional SSI in colon surgery were ostomy closure (OR = 7.3) and lack of oral antibiotics (OR = 3.3), while in rectal surgery, risk factors were preoperative steroids (OR = 3.7), preoperative radiation (OR = 2.8), and ostomy creation (OR = 4.9). CONCLUSIONS: Colon and rectal surgeries differ with regard to incidence and risk factors for developing incisional SSI. SSI surveillance for such surgeries should be performed separately, as this should lead to more efficient identification of risk factors and a reduction in SSI.     

Low incidence of adhesion-related bowel obstruction after laparoscopic colorectal surgery

BACKGROUND: Postoperative adhesions are a major cause of morbidity, accounting for approximately 5% of the readmissions of surgical patients. Bowel obstruction is attributed to adhesions in more than half of the cases, many of which are following colon and rectal surgery. Laparoscopic surgery has the potential advantage of reduced adhesion formation owing to attenuated surgical trauma, less tissue handling, and smaller scars. However, the translation of these advantages to a reduced rate of bowel obstruction has not been sufficiently demonstrated. The aim of this study was to assess the rate of adhesion-related bowel obstruction after laparoscopic colon and rectal surgery. METHODS: Data regarding all cases of laparoscopic colon and rectal surgery were prospectively collected. Information relative to demographics, surgical procedures, and follow-up was analyzed, and patients who were readmitted for bowel obstruction were identified. RESULTS: Over a period of 8 years, 306 patients, at a mean age of 63 years, had a laparoscopic colon and rectal operation in our department-122 for benign conditions and 184 for malignant disease. The mean length of follow-up was 38 months. Six cases (2%) of bowel obstruction, which were unrelated to hernia or advanced cancer, were identified. Two patients had a history of open surgery, in addition to the laparoscopic procedure, so adhesions could be attributed solely to the laparoscopic procedure in 4 patients, which consisted of 1.3% of the total study group. Obstruction occurred within 2 weeks of surgery in 2 patients, and one early reoperation was required. CONCLUSIONS: The incidence of adhesion ileus after laparoscopic colon and rectal surgery appears to be very low. This long-term benefit of laparoscopic surgery should be considered when comparing this technique to its open counterpart.     

Informed consent for colorectal cancer surgery

There are two issues in informed consent for colorectal cancer surgery. One is the actual surgical technique. Recently intersphincteric resection (ISR) has been performed to avoid permanent colostomy, although it is not standard procedure. Regarding QOL score, Patients with colostomies do not necessarily have lower quality of life scores than patients who undergo sphincter-preserving surgery because of frequent bowel movements. Lateral lymphadenectomy for lower rectal cancer was standard procedure; however, its indications became limited due to urinary and sexual dysfunction. Preoperative radiotherapy is considered instead of lateral lymphadenectomy, as in the Western concept of the local recurrence of rectal cancer. Now laparoscopic surgery is accepted for stage I colon cancer according to the guidelines of the Japan Society for Cancer of the Colon and Rectum. The other issue is postoperative complications like anastomotic leakage, intestinal obstruction, etc. Frequent bowel movements and urinary and sexual dysfunction should also be explained before rectal cancer surgery.     

Standardized surgery for colonic cancer: complete mesocolic excision and central ligation – technical notes and outcome

Objective  Total mesorectal excision (TME) as proposed by R.J. Heald more than 20 years ago, is nowadays accepted worldwide for optimal rectal cancer surgery. This technique is focused on an intact package of the tumour and its main lymphatic drainage.
This concept can be translated into colon cancer surgery, as the mesorectum is only part of the mesenteric planes which cover the colon and its lymphatic drainage like envelopes. According to the concept of TME for rectal cancer, we perform a concept of complete mesocolic excision (CME) for colonic cancer. This technique aims at the separation of the mesocolic from the parietal plane and true central ligation of the supplying arteries and draining veins right at their roots.
Method  Prospectively obtained data from 1329 consecutive patients of our department with RO-resection of colon cancer between 1978 and 2002 were analysed. Patient data of three subdivided time periods were compared.
Results  By consequent application of the procedure of CME, we were able to reduce local 5-year recurrence rates in colon cancer from 6.5% in the period from 1978 to 1984 to 3.6% in 1995 to 2002. In the same period, the cancer related 5-year survival rates in patients resected for cure increased from 82.1% to 89.1%.
Conclusion  The technique of CME in colon cancer surgery aims at a specimen with intact layers and a maximum of lymphnode harvest. This is translated into lower local recurrence rates and better overall survival.     

Ischaemic colitis following aortoiliac surgery

Ischaemic colitis following aortoiliac surgery is a feared complication. Its frequency varies from 7% after repair of ruptured abdominal aortic aneurysm (AAA) to 0.6% after bypass for aortoiliac occlusive disease (AOD). In order to analyse predisposing factors and outcome of ischaemic colitis, the authors reviewed their clinical experience from 1988 to 1998. It concerns 28 cases (16 ruptured AAA, 7 elective AAA, 5 OAD) of clinically evident colonic ischaemia. This means an incidence of 7% after repair of ruptured AAA, 0.6% after elective AAA repair, and 0.8% after bypass for AOD. Transmural necrosis (grade 3) was observed in 21 patients, grade 2 ischaemia in 5 patients, and grade 1 ischaemia in 2 patients. Fifteen patients with grade 3 ischaemia underwent colectomy (Hartmann's procedure) with a mortality rate of 66%. All non operated grade 3 patients died. Overall, 16 of the 28 patients died at hospital (57% mortality rate). None of the patients with mild (grade 2 or 1) colonic ischaemia died. Profound hypovolaemic shock and inflammatory AAA were the only significant predisposing factors leading to colonic ischaemia. Associated colon revascularization could not avoid the evolution to colon necrosis in four patients. Reimplantation of a patent inferior mesenteric artery or an internal iliac artery was performed in only 4.8% of all aortoiliac reconstructions, and did not influence the development of ischaemic colitis. The authors conclude that a more liberal use of postoperative sigmoidoscopy could allow detecting colonic ischaemia at an earlier stage and reduce ensuing mortality. A reinforced effort to restore or preserve colonic vascularization could lower the incidence of colonic ischaemia following aortoiliac surgery.     

Laparoscopic Colorectal Training Gap in Colorectal and Surgical Residents

Methods:We examined the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Colorectal Surgeons (ABCRS) operative statistics for graduating general surgery and colon and rectal surgery residents.Results:Although the number of advanced laparoscopy cases had increased for general surgery residents, there was still a significant gap in case volume between the average number of laparoscopic colorectal operations performed by graduating general surgery residents (21.6) and those performed by graduating colon and rectal surgery residents (81.9) in 2014.Conclusion:There is a gap between general surgery and colon and rectal surgery residency training for laparoscopic colorectal surgery. General surgery residents are not meeting the volume of cases necessary for proficiency in colorectal surgery. This deficit represents a structural difference in training.     

Duhamel术治疗先天性巨结肠临床体会

目的探讨直肠后结肠拖出,侧侧吻合术的临床应用价值,评价Duhamel术式的优缺点。方法对3例先天性巨结肠的患儿实行Duhamel术式。结果 3例患儿一般情况可,恢复良好,术后排便通畅。结论 Duhamel术式手术较简单,膀胱及生殖系神经损伤的发生率明显减少,术后排便佳,吻合口破裂的发生率较低,对婴幼儿手术相当安全。     

加强结肠癌手术规范化实施

全直肠系膜切除手术是直肠癌规范化手术的重大进步,手术规范化使直肠癌预后得到提高。但是,结肠癌手术方式进展并不显著,尽管化疗药物不断更新,进展期结肠癌病人预后并无较大改善。随着临床实践的积累, 人们逐渐认识到结肠癌手术尚需进一步科学化、规范化。完整结肠系膜切除（complete mesocolic excision,CME）是进展期结肠癌手术方式的新理念,初步研究认为可改善进展期结肠癌预后。但无论何种结肠癌手术方式均需遵循如下原则：依胚胎解剖学基础,直视下精细操作;切实按照肿瘤学原则进行手术,最大程度降低复发转移率;重视多学科协作,促进结肠癌手术的规范化。结肠癌手术规范化是结肠肿瘤获得根治的保证,是结肠癌病人获益于手术的必要条件。     

Treatment of colon and rectal cancer

This article discusses multimodal treatment of noncomplicated colon and rectal cancer, considerations for specific types of colon cancer, considerations that may modify the extent and technique of surgery, the role of adjuvant chemotherapy for colon adenocarcinoma and rectal cancer, and surgical treatment of complicated colorectal cancer.     

Constructing a sound anastomosis

Formation of intestinal anastomosis is a commonly encountered procedure in abdominal surgery, and construction of these anastomoses should be considered an essential and basic aspect of the art of colon and rectal surgery. This chapter covers specific technical and physiological details relevant to the construction of sound intestinal anastomoses, discusses operative considerations for some specific anastomosis types commonly encountered and colon and rectal surgery, and reviews intraoperative testing and troubleshooting of anastomotic construction. Intraoperative assurance of a well perfused, tension-free, and technically secure anastomosis is the first and most essential principle for a good anastomotic outcome.     

Interpretation of the Randomized EVAR Trials

Purpose : Laparoscopic surgery for colon cancer has been proven safe, but controversy continues over implementation of laparoscopic technique for rectal cancer. The aim of this study was to compare the long-term outcomes of laparoscopically assisted and open surgery for nonmetastatic colorectal cancer.

Material and methods : From January 2001 to December 2006 all patients with nonmetastatic adenocarcinoma of the colon and rectum were considered for inclusion in this prospective non-randomised trial. The primary endpoint was overall survival, disease free survival and recurrence rate. Analysis was by intention to treat.

Results : A total of 365 resections were performed for nonmetastatic adenocarcinoma of the colon and rectum during the study period. Of those resections, 220 were colonic and 145 were rectal. In the patients with colon cancer 119 (54.1%) were operated laparoscopically and 101 (45.9%) by open surgery, in the patients with rectal cancer 75 (51.7%) were treated by laparoscopy and 70 (48.3%) by open technique. No statistically significant difference was found between the laparoscopic and open group regarding 5-year overall survival (p = 0.17 for colon cancer, p = 0.60 for rectal cancer), 5-year disease free survival (p = 0.25 for colon cancer, p = 0.81 for rectal cancer) and overall recurrence (p = 0.78 for colon cancer, p = 0.79 for rectal cancer). With respect to the tumor stage, in rectal cancer the probability of 5-year disease free survival was significantly higher in the laparoscopic group in stage III (p = 0.03).

Conclusion : Laparoscopic surgery for colorectal cancer is an oncologically safe procedure that is associated with a survival and recurrence rate equal to open surgery.     

pHi monitoring of the sigmoid colon after aortoiliac surgery. A five-year prospective study.

OBJECTIVES: to determine whether sigmoid-pHi diagnose colon ischaemia after aortoiliac surgery?Design: single-centre, non-randomised, prospective study. PATIENTS AND METHODS: of 83 patients operated on between 1994 and 1998, 41 with risk factors for the development of colon ischaemia were monitored peri- and/or postoperatively with sigmoid-pHi. Peri-operative mortality was 26% (8/31) after operation for a ruptured abdominal aortic aneurysm (AAA), nil after operation for non-ruptured AAA. Thirty-five postoperative colonoscopies were performed. All non-survivors were examined post-mortem. RESULTS: of six patients developing colon ischaemia after emergency operations (five for ruptured AAA) all had pHi-values <7.1 for 16-80 h. In two patients with transmural gangrene, and who had pHi-values below 6.6, pHi-monitoring permitted early diagnosis, colectomy and recovery. Three patients with mucosal gangrene were treated conservatively and recovered. Nine patients without ischaemic lesions had pHi-values <7.1, during 1-5 h, without adverse outcome. Bilateral ligation of the internal iliac arteries increased the risk of colon ischaemia (p<0.0001). CONCLUSIONS: pHi-monitoring was diagnostic for colon ischaemia. Mucosal and transmural gangrene were distinguished. The importance of the internal iliac circulation was demonstrated. The low mortality rate, and the fact that no patient died from bowel ischaemia, suggests that sigmoid pHi-monitoring may improve survival after ruptured AAA.     

The occurrence of severe epithelial dysplasia and its bearing on treatment of longstanding ulcerative colitis.

One hundred twenty-four patients with extensive ulcerative proctocolitis were operated upon with proctocolectomy. The mean observation time was 10.3 years. Before surgery rectal biopsies were taken in all patients. The relationship between precancerous lesion in rectal biopsies and the presence of precancer and/or cancer in the rectum or colon in the removed specimen was evaluated. Thirteen out of 14 patients showed evidence of severe rectal dysplasia as well as severe dysplasia in the large bowel specimen, and five of these patients had a carcinoma as well. The 14th patient showed severe dysplasia only in the rectum as well as a rectal carcinoma. Of 110 patients without severe rectal dysplasia, 36 showed evidence of severe colon dysplasia, and three of these patients had a large bowel carcinoma as well. Only one patient had a large bowel carcinoma without evidence of severe dysplasia in the rectum or colon. Thus, nine patients out of ten with large bowel carcinoma showed severe dysplasia in rectum and/or colon. Four of these carcinomas were unknown before surgery. Although severe dysplasia in the rectal biopsy is a strong indication of a large bowel carcinoma (6/14), a negative rectal biopsy does not exclude a large bowel carcinoma (4/110). Proctocolectomy cannot be looked upon only as a prophylactic procedure in patients with severe dysplasia in the rectal biopsy, but also as an attempt to curative surgery, as large bowel carcinoma may have already developed in a considerable number of patients where precancer is diagnosed in biopsies.     

Feasibility of Single-Port Laparoscopic Surgery for Sigmoid Colon and Rectal Cancers and Preoperative Assessment of Operative Difficulty

Purpose

Single-port laparoscopic surgery is more difficult for sigmoid colon and rectal cancers than for right-sided colon cancer. We sought to analyze the feasibility of this procedure for sigmoid colon and rectal cancers and to estimate its difficulty.

Methods

We analyzed prospectively collected data from 63 consecutive patients with sigmoid colon or rectal cancers who underwent single-port laparoscopic surgery at our institution from June 2009 to December 2011. Patient and tumor characteristics, including patients’ pelvic anatomy which was assessed on CT scan imaging, were evaluated to elucidate what factors would affect the difficulty of the procedure and the necessity of using an additional trocar.

Results

Overall, the median operative duration was 190 min and blood loss was 20 ml, with no postoperative complications. The median number of lymph nodes harvested was 17 and the distal margin was 58 mm. The tumor was located significantly closer to the anus in cases in which an additional trocar was required in the right lower quadrant (9.5 vs 18 cm, p?<?0.0001). Procedural difficulty was significantly increased in cases in which the sacral promontory protruded ventrally (odds ratio 0.779 [95 % confidence interval 0.613 to 0.945], p?=?0.0236).

Conclusions

Depending on tumor location and sacral promontory shape, the introduction of an additional trocar might render single-port laparoscopic surgery feasible for sigmoid colon and rectal cancer resection.     

Die Operationsmethodik bestimmt die Rezidivhäufigkeit colorectaler Carcinome Ein Vergleich der Ergebnisse von 2 chirurgischen Kliniken

INTRODUCTION: In order to investigate whether operative technique determines the 5-year recurrence and survival rates, we analysed the results obtained by two surgical departments using two different operative techniques. Department A: Removal of the tumour and a number of lymph nodes; department B: En-bloc resection in accordance with the requirements of standardised tumour surgery. PATIENTS AND METHODS: The surgical results obtained with all patients with colorectal carcinoma operated on between 1984 and 1988 (department A: 152 colon and 53 rectal carcinomas; department B: 124 colon and 177 rectal carcinomas). RESULTS: The local recurrence rate achieved by department A was significantly higher (colon carcinoma: department A 25 %; department B 10 %; rectal carcinoma: department A 54 %; department B 16 %). The 5-year survival rate for colon carcinoma was 65 % in department A, and 66 % in department B, the corresponding figures for rectal carcinoma being 49 % and 72 %, respectively. CONCLUSION: The results indicate that carcinoma of the colorectum should be operated on only at an institution that complies with the standards required for surgery of colorectal carcinoma.     

Syncope,seizures and stress

The episodic attack may reflect either cardiogenic or neurogenic mechanisms and not all seizures are due to epilepsy but rather can be caused by acute cerebral ischaemia. Cerebral ischaemia may result from vaso-vagal syncope or vago-vagal syncope, the latter being associated with an abrupt fall in blood pressure. Many events may precipitate syncope and convulsions: rectal examinations, micturition syndrome, tussive syncope, ingestion of food and liquids (i.e. the Banquet Syndrome) are some examples. Sudden death may occur due to stress, the causal mechanisms usually involving the cardiovascular system. Cardiac dysrhythmia is frequently implicated. Stress may incude a broad variety of autonomic responses mediated often through the vagal system resulting in syncope, seizures and fatal collapse. The higher nervous system may also modify autonomic electrical activity of the heart with the same consequences.