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1.
Purpose Optimal treatment of mid to distal rectal cancers includes total mesorectal excision for oncologic clearance and, where reanastomosis
is feasible, a colonic J-pouch-anal anastomosis improves bowel function. There is recent interest in performing an ultralow
anterior resection laparoscopically.1–3 A technique is described that includes specimen extraction through the eventual routine defunctioning colostomy or ileostomy
site.
Methods Consecutive unselected patients who underwent laparoscopic ultralow anterior resection were recruited. Patients with adenocarcinoma
underwent preoperative endorectal ultrasound to individualize for neoadjuvant chemoradiotherapy, based on local extent and
lymph nodes seen. The operative procedures were as shown in the video. Posterior dissection along the “total mesorectal excision
plane” included incision of Waldeyer’s fascia. Bowel continuity was restored by an intracoporeal double-cross stapled colonic
J-pouch-anal anastomosis, but where not possible a coloplasty with pull-through handsewn coloanal anastomosis was performed.
Results Laparoscopic ultralow anterior resection was performed on 55 patients (35 men; median age, 63 (range, 33–90) years) from March
2004 to October 2006. The median body mass index was 26.3 (19–38); 14 patients (25 percent) had a body mass index >30. Ten
patients (18 percent) had an American Society of Anesthesiologists’ classification of III. The indications were adenocarcinoma
(n = 51), squamous-cell carcinoma of rectum (n = 1), dermoid tumor of mesorectum (n = 1), large villous adenoma (n = 1), and
carcinoid with local lymph node metastases (n = 1). The adenocarcinomas were a median distance of 6 (3–12) cm from the anal
verge. Neoadjuvant radiotherapy was given in 12 patients (24 percent) who had preoperative endoanal ultrasound findings of
tumor extension beyond the muscularis propria and chemoradiotherapy in 7 (14 percent) of these patients where the tumor was
more bulky and fixed. Laparoscopic ultralow anterior resection was completed at a median 180 (90–405) minutes, with 53.5 (2–2250)
ml of blood loss, and the specimen was extracted through a 4.5 (3.5–11) cm wound. The latter included three cases (5 percent)
that were converted. Significant adhesiolysis was required in 29 patients (52.7 percent) because of previous operations. The
histologic grading or the adenocarcinoma patients were: Stage I, n = 14; Stage II, n = 23; Stage III, n = 11; Stage IV, n = 3.
Of those who underwent curative resection (Stages I–III), the distal resection margin was 2.9 ± 0.7 cm (mean ± standard error)
and the radial resection margins were at least 2 mm in all patients. The level of the coloanal anastomosis was a median 3.5
(0–4.5) cm from the anal verge; a coloanal pull-through anastomosis was required in one patient who had a distal cancer. The
ileostomies functioned and patients tolerated free fluids at a median of two (1–9) days, and the median postoperative hospital
stay was seven (3–22) days. At a median follow-up of 14 (2–33) months, none of the adenocarcinoma patients who had undergone
curative resection had recurrences. Four patients (8 percent) had postoperative complications that required operative/invasive
intervention (anatomotic leak n = 1, proximal bowel ischemia n = 1, port site hernia n = 1, pelvic collection n = 1). Four
other patients had smaller pelvic collections that resolved with antibiotics; pelvic collections were associated with advanced
stage of cancer (P = 0.047). Discharge was delayed by acute gastric distension in 11 patients; the latter was associated with poorer American
Society of Anesthesiologists’ risk classification (P = 0.035). Erectile dysfunction occurred in ten men, and this was associated with adjuvant chemoradiotherapy (P = 0.042). One patient (2 percent) had persistent urinary retention that required catheterization at latest follow-up. The
ileostomy had been closed in 50 patients, and at last follow-up, the median stool frequency was two (1–8) bowel movements
per day.
Conclusions Laparoscopic ultralow anterior resection could be offered routinely and completed safely in Western populations, where obesity
and adhesions from previous abdominal surgery is common. A laparoscopic technique readily allowed visual identification of
the autonomic nerves in the abdomen over the aorta, which could then be followed down into the pelvis. If the pelvis was deep,
inversion of the 30° laparoscope in the “upside down” position fascilited incision of Waldeyer’s fascia. This brought the
rectum proximally and anteriorly, aiding with the laparoscopic stapler transection of the distal rectum, especially if the
cancer was distal, the patient was obese, and the pelvis was narrow. Extraction of the specimen at the eventual defunctioning
stoma site reduced the incisions required. Preoperative chemoradiotherapy may have a role in postoperative male sexual dysfunction.
Further randomized, controlled studies that include assessing five-year cancer survival/recurrence, pelvic nerve dysfunction,
and bowel function are needed before laparoscopic ultralow anterior resection becomes widely accepted.
Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users. 相似文献
2.
Purpose Adjuvant radiotherapy is currently recommended for all node-positive rectal cancers to reduce local recurrence. This study
evaluated if an adequate mesorectal excision can obviate the need for radiotherapy in early node-positive cancer.
Methods Stage IIIA rectal cancer patients were identified in a prospectively maintained database. Patients who received postoperative
radiotherapy (radiotherapy) and those who did not (no radiotherapy) were compared for recurrence, survival, bowel function,
and quality of life. Quality of life was assessed using the Short Form-36 Medical Outcomes Survey.
Results Eighty-six patients underwent proctectomy for T1-T2,N1 rectal cancers from 1978 to 2004. Patients receiving radiotherapy (n = 34)
were younger and had a higher percentage of T1 tumors than patients who did not receive radiotherapy (n = 52). Other tumor
characteristics, type of surgery, and number of involved lymph nodes were comparable. Estimated 5-year local recurrence was
radiotherapy 3.4 percent and no radiotherapy 4.7 percent; distant recurrence was radiotherapy 13.5 percent and no radiotherapy
16.5 percent; and disease-specific mortality rates were similar 13.5 vs. 11.3 percent, for radiotherapy and no radiotherapy (all P > .05). Patients receiving radiotherapy had higher frequency of daytime bowel movements, urgency, and usage of pads and antidiarrheal
medications. Age adjusted quality of life parameters were comparable between treatments.
Conclusion Postoperative radiotherapy did not reduce recurrence or mortality. Function but not quality of life was adversely affected.
Routine postoperative radiotherapy for Stage IIIA rectal cancer should be reconsidered.
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
3.
Risk Factors and Oncologic Impact of Anastomotic Leakage after Rectal Cancer Surgery 总被引:3,自引:0,他引:3
Jung SH Yu CS Choi PW Kim DD Park IJ Kim HC Kim JC 《Diseases of the colon and rectum》2008,51(6):902-908
Purpose The impact of anastomotic leakage on the long-term oncologic outcome is not clear. This retrospective study evaluated risk
factors and oncologic impacts of anastomotic leakage after rectal cancer surgery.
Methods Data were analyzed from 1,391 patients who underwent sphincter preservation for rectal cancer between January 1997 and August
2003. Operations were classified as anterior resection (n = 164), low anterior resection (n = 898), or ultralow anterior resection
(n = 329).
Results The anastomotic leakage rate was 2.5 percent. Multivariate analysis identified male (hazard ratio, 3.03), old age (hazard
ratio, 2.42), and lower anastomosis level (hazard ratio, 2.68) as risk factors for leakage. The local recurrence rates were
9.6 and 2.2 percent for the leakage and nonleakage groups, respectively but were not significant (P = 0.14). The overall five-year survival rates were 55.1 and 74.1 percent in the leakage and nonleakage groups, respectively
(P < 0.05), and the cancer-specific survival rates were 63 and 78.3 percent in the leakage and nonleakage groups, respectively
(P = 0.05). However, in subgroup analysis, significant differences were identified only in Stage III patients.
Conclusions Age, sex, and ultralow anterior resection were found to be risk factors for anastomotic leakage after rectal cancer surgery.
In addition, leakage was associated with poor survival.
Poster presentation at the meeting of The American Society Colon and Rectal Surgeons, Seattle Washington, June 3 to 7, 2006. 相似文献
4.
Nahas CS Shia J Joseph R Schrag D Minsky BD Weiser MR Guillem JG Paty PB Klimstra DS Tang LH Wong WD Temple LK 《Diseases of the colon and rectum》2007,50(9):1393-1400
Purpose This study was designed to evaluate one institution’s experience with treatment outcomes for rectal squamous-cell carcinoma.
Methods Using our prospective Colorectal Database, we identified patients diagnosed with rectal squamous-cell carcinoma at our institution
between 1983 and 2005. Pathology was rereviewed, tumor immunophenotype was compared to control cases of anal squamous-cell
carcinoma and rectal adenocarcinoma, treatment modalities and outcomes were analyzed.
Results Twelve patients were identified (10 females median age, 58 years). Median distal extent of tumors was 7 (range, 5–8) cm from
the anal verge. Treatment included chemotherapy only (n = 1), chemoradiation only (n = 2), induction chemotherapy followed
by chemoradiation and surgery (n = 2), chemoradiation followed by surgery (n = 5), and surgery followed by chemoradiation
(n = 2). The chemotherapy regimen was 5-fluorouracil-based. Radiotherapy total dose was 50.4 Gy (1.8 Gy/day, daily × 5) external
iliac and inguinal nodes were not included in the radiation field. Complete clinical responders to chemoradiation (n = 2)
received no further treatment. All seven partial responders underwent surgery; six had complete pathologic response; nodal
status in two of six was unknown because they had local excision. Immunophenotypical analysis showed similar keratin expression
profile between rectal squamous-cell carcinoma (n = 5) and rectal adenocarcinoma (n = 5), which is different from anal squamous-cell
carcinoma (n = 10). All patients were alive without evidence of disease at follow-up (median follow-up, 2.6 (range, 0.5–16) years).
Conclusions Our data suggest that most patients treated with upfront chemoradiation therapy followed by surgery did well. Sphincter-preserving
surgery is usually feasible. Clinical judgment of tumor response after chemoradiation is not completely reliable. Immunohistochemistry
suggests a common cellular origin for rectal squamous-cell carcinoma and rectal adenocarcinoma, which is different from anal
squamous-cell carcinoma.
Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 7,
2006.
Reprints are not available. 相似文献
5.
Vibert E Bretagnol F Alves A Pocard M Valleur P Panis Y 《Diseases of the colon and rectum》2007,50(11):1776-1782
Purpose Surgery of the primary tumor in patients with colorectal cancer and unresectable synchronous liver metastases remains controversial.
This study was designed to evaluate predictive preoperative factors of early postoperative death (<3 months) in such patients.
Methods This study included 80 patients who underwent colorectal resection (n = 56) or diversion stoma (n = 24) for colorectal cancer
with unresectable liver metastases. Twenty-two patients (28 percent) died during the first three months after surgery with
two (2.5 percent) in-hospital postoperative deaths. Analysis of predictive preoperative factors for three-month postoperative
death risk was performed.
Results In univariate analysis, age older than 75 years (P = 0.01), American Society of Anesthesiologists grade > II (P = 0.009), symptomatic patient (P = 0.01), bowel obstruction (P = 0.03), aspartate aminotransferase serum level >50 (1.5 N) IU/L (P = 0.008), and alkaline phosphatase >200 (2 N) IU/L (P = 0.02) were prognostic risk factors for three-month death after surgery. In multivariate analysis, age older than 75 years
(relative risk = 7.9; P = 0.04) and aspartate aminotransferase serum level >50 IU/L (relative risk = 8.3; P = 0.03) were independent risk factors.
Conclusions In patients with colorectal cancer and synchronous unresectable liver metastases, the three-month mortality rate was high
(28 percent). Thus, better knowledge of risk factors could help select patients who could possibly benefit from surgery. The
study suggested that age older than 75 years and liver cytolysis (>1.5 N) are associated with an increased three-month postoperative
death risk. In these patients, surgery should be avoided.
Read at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005. 相似文献
6.
Frasson M Braga M Vignali A Zuliani W Di Carlo V 《Diseases of the colon and rectum》2008,51(3):296-300
Purpose The purpose of this study was to evaluate the impact of laparoscopic colorectal resection on short-term postoperative outcome
in elderly patients.
Methods A series of 535 patients with colorectal disease who had been randomly assigned to laparoscopic (n = 268) or open (n = 267)
resection was analyzed. A total of 201 patients (37.6 percent) were elderly (aged 70 years or older) and 334 patients (62.4
percent) were younger than aged 70 years. Follow-up for postoperative morbidity was performed for 30 days after hospital discharge.
Results Elderly patients had a higher American Society of Anesthesiologists score compared with younger patients in both the laparoscopic
and open groups (P = 0.0001). In the open group, elderly patients had higher morbidity rate (37.5 vs. 23.9 percent; P = 0.02) and longer length of hospital stay (13 vs. 10.6; P = 0.007) compared with younger patients. In the laparoscopic group, morbidity rate (20.2 vs. 15.1 percent) and length of hospital stay (9.5 vs. 9.1) were similar in elderly and younger patients. In elderly patients, the laparoscopy-reduced morbidity rate (20.2 vs. 37.5 percent; P = 0.01) and length of hospital stay (9.5 vs. 13; P = 0.001) compared to the open approach. In younger patients, the advantages of the laparoscopic approach on morbidity rate
(15.1 vs. 23.9 percent; P = 0.06) and length of stay (9.1 vs. 10.6; P = 0.004) were less pronounced.
Conclusions Laparoscopy improved short-term postoperative outcome more in elderly than in younger patients. Advanced age was associated
with higher morbidity and longer length of stay only in patients who underwent open colorectal surgery.
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
7.
Quah HM Chou JF Gonen M Shia J Schrag D Landmann RG Guillem JG Paty PB Temple LK Wong WD Weiser MR 《Diseases of the colon and rectum》2008,51(5):503-507
Purpose Adjuvant therapy for Stage II colon cancer remains controversial but may be considered for patients with high-risk features.
The purpose of this study was to assess the prognostic significance of commonly reported clinicopathologic features of Stage
II colon cancer to identify high-risk patients.
Methods We analyzed a prospectively maintained database of patients with colon cancer who underwent surgical treatment from 1990 to
2001 at a single specialty center. We identified 448 patients with Stage II colon cancer who had been treated by curative
resection alone, without postoperative chemotherapy.
Results With median follow-up of 53 months, 5-year disease-specific survival for this cohort was 91 percent. Univariate and multivariate
analyses identified three independent features that significantly affected disease-specific survival: tumor Stage T4 (hazard
ratio (HR), 2.7; 95 percent confidence interval (CI), 1.1–6.2; P = 0.02), preoperative carcinoembryonic antigen >5 ng/ml (HR, 2.1; 95 percent CI, 1.1–4.1; P = 0.02), and presence of lymphovascular or perineural invasion (HR, 2.1; 95 percent CI, 1–4.4; P = 0.04). Five-year disease-specific survival for patients without any of the above poor prognostic features was 95 percent;
five-year disease-specific survival for patients with one of these poor prognostic features was 85 percent; and five-year
disease-specific survival for patients with ≥2 poor prognostic features was 57 percent.
Conclusions Patients with Stage II colon cancer generally have an excellent prognosis. However, the presence of multiple adverse prognostic
factors identifies a high-risk subgroup. Use of commonly reported clinicopathologic features accurately stratifies Stage II
colon cancer by disease-specific survival. Those identified as high-risk patients can be considered for adjuvant chemotherapy
and/or enrollment in investigational trials.
Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007.
Reprints are not avaliable. 相似文献
8.
Chessin DB Gorfine SR Bub DS Royston A Wong D Bauer JJ 《Diseases of the colon and rectum》2008,51(9):1312-1317
Purpose After restorative proctocolectomy, 7 to 8 percent of patients may have a pouch leak. Concern exists that pouch leak may be
associated with impaired functional outcome. We evaluated patients who underwent restorative proctocolectomy to determine
whether pouch leak adversely affected long-term functional outcome and quality of life.
Methods We queried our prospectively maintained database of patients who underwent restorative proctocolectomy for demographic and
clinical data. We sent a long-term outcome questionnaire to patients, including the validated Fecal Incontinence Severity
Index and Cleveland Global Quality of Life scores. Pouch leak was identified by clinical or radiographic evidence of leak.
Patients with leak were compared with those without to determine the impact on long-term functional outcome or quality of
life.
Results A total of 817 patients were available for follow-up and 374 patients (46 percent) completed questionnaires. The group with
(n = 60; 16 percent) and without (n = 314; 84 percent) leak had similar demographics. The median Fecal Incontinence Severity
Index score (15.3 vs. 14.7, P = 0.77), Cleveland Global Quality of Life score (0.79 vs. 0.81, P = 0.48), and bowel movements per 24 hours (7.92 vs. 7.88, P = 0.92) were similar. The pouch loss/permanent ileostomy rate was higher in those who leaked (13.3 vs. 0.9 percent, P < 0.001).
Conclusions Anastomotic leak after restorative proctocolectomy does not adversely affect long-term quality of life or functional outcome.
However, pouch loss/permanent ileostomy is significantly more likely in patients who have had an anastomotic leak.
Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, June 7 to 11, 2008.
Reprints are not available. 相似文献
9.
Araujo SE Bernardo WM Habr-Gama A Kiss DR Cecconello I 《Diseases of the colon and rectum》2007,50(11):1800-1810
Purpose In colorectal cancer, the negative effect of aneuploidy has been a controversy for more than 20 years. Studies to determine
a survival-deoxyribonucleic acid content relationship have conflicting results. A systematic literature search followed by
a meta-analysis of published studies addressing prognostic effect of aneuploidy for patients who underwent surgical treatment
of colon and rectal cancer was conducted.
Methods The main outcome measure was the five-year overall mortality rate after surgical resection. For the selected studies, we estimated
this outcome for three subsets of patients through separate meta-analyses: 1) for all patients with colorectal cancer; 2)
only between patients with Stage II colon cancer; and 3) only for studies in which follow-up losses were declared. The presence
of publication bias was assessed with a funnel plot for asymmetry.
Results A total of 5,478 patients with colorectal cancer were represented in 32 studies (Group 1), we estimated a reduction in the
five-year overall mortality from 43.2 percent for aneuploid tumors to 29.2 percent for diploid tumors (combined relative risk = 1.44;
95 percent confidence interval = 1.34–1.55; P < 0.001). In addition, 357 patients with Stage II colon cancer (Group 2) extracted from three studies had an absolute reduction
of 14.3 percent in five-year overall mortality favoring diploid tumors (combined relative risk = 1.93; 95 percent confidence
interval = 1.29–2.89; P = 0.001). Lastly, of 14 studies in which follow-up losses were declared (Group 3), 2,221 patients were represented and a
15.7 percent mortality reduction was measured favoring patients with diploid tumors (combined relative risk = 1.44; 95 percent
confidence interval = 1.3–1.61; P < 0.001).
Conclusions Patients who undergo an aneuploid colorectal cancer surgical resection have a higher risk of death after five years. This
finding may ultimately impact survival of patients with node-negative colon cancer through adjuvant therapy.
Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 7,
2006. 相似文献
10.
The Effect of Restorative Proctocolectomy on Sexual Function,Urinary Function,Fertility, Pregnancy and Delivery: A Systematic Review 总被引:3,自引:0,他引:3
Cornish JA Tan E Teare J Teoh TG Rai R Darzi AW Paraskevas P Clark SK Tekkis PP 《Diseases of the colon and rectum》2007,50(8):1128-1138
Purpose This study was designed to evaluate the effect of restorative proctocolectomy on sexual function, urinary function, fertility,
pregnancy, and delivery in patients with ulcerative colitis.
Methods A systematic literature search was performed of articles published between 1980 and 2005 on patients undergoing restorative
proctocolectomy for ulcerative colitis reporting data on the outcomes of interest. A random-effect, meta-analytical model
was used for pooled estimates and 95 percent confidence intervals.
Results A total of 22 studies, with 1,852 females, were included. Infertility rate was 12 percent before restorative proctocolectomy
and 26 percent after, among 945 patients in seven studies. The incidence of sexual dysfunction was 8 percent preoperatively
and 25 percent postoperatively (7 studies, n = 419). Two studies (n = 62) reported no urinary dysfunction in patients undergoing
restorative proctocolectomy. There was an increased incidence of cesarean section after restorative proctocolectomy. During
the third trimester of pregnancy, there was an increase in stool frequency by 1.15 stools per day compared with before pregnancy
frequency (n = 49 95 percent confidence interval, 0.28–2.03 P = 0.01 chi-squared statistic, 0.04 P = 0.84). No significant differences were seen in pouch function after vaginal delivery (n = 456; weighted mean difference,
0.23; 95 percent confidence interval, 0.43–0.88; P = 0.49; chi-squared statistic, 1.29; P = 0.26).
Conclusions The incidence of dyspareunia increases after restorative proctocolectomy. There was a decrease in fertility after restorative
proctocolectomy. Pregnancy after restorative proctocolectomy was not associated with an increase in complications. There was
an increase in stool frequency and pad usage during the third trimester. Vaginal delivery is safe after restorative proctocolectomy.
Pouch function after delivery returns to pregestational function within six months. 相似文献
11.
Purpose The extraperitoneal rectum is anatomically and biologically different from the intraperitoneal rectum, therefore, the surgical
outcomes may be different. This study was designed to assess operative outcomes of laparoscopic resection of extraperitoneal
(≤7 cm from the anal verge) vs. intraperitoneal rectal cancer.
Methods Prospective data were collected from 312 patients with rectal cancer who underwent laparoscopic resection. Patients were divided
into two groups: extraperitoneal (EP, n = 138) vs. intraperitoneal (IP, n = 174). Mean follow-up was 33 months.
Results Patients with pT3/pT4 accounted for 69.6 percent of EP and 74.1 percent of IP. Circumferential margin was positive in 8.7
percent of EP and 0.6 percent of IP (P = 0.0004). Anastomotic leakage developed in 9.7 percent of EP vs. 4.6 percent of IP (P = 0.1081, overall 6.4 percent). Local recurrence rate at three years was 7.6 percent in EP and 0.7 percent in IP (P = 0.0011, overall 4 percent). By multivariate analysis, extraperitoneal location was a risk factor for local recurrence.
Conclusions Laparoscopic resection of rectal cancer, regardless of EP or IP, provided acceptable operative outcomes. There was an increasing
tendency for positive circumferential margin, leakage, and local recurrence in EP vs. IP. A multicenter, prospective study is ongoing to identify the high-risk group for local recurrence who may really benefit
from neoadjuvant therapy in the era of laparoscopy.
Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 7, 2006. 相似文献
12.
Nakamura T Mitomi H Kanazawa H Ohkura Y Watanabe M 《Diseases of the colon and rectum》2008,51(5):568-572
Purpose High-risk patients with Stage II colon cancer may benefit from adjuvant chemotherapy, but they are difficult to identify.
We assessed the value of tumor budding, defined as small clusters of undifferentiated cancer cells at invasive margins, as
a predictor of outcomes in patients with Stage II colon cancer.
Methods We studied a total of 200 patients with Stage II colon cancer who underwent curative surgery. With hematoxylin and eosin-stained
specimens, the degree of tumor budding was classified as low-grade or high-grade. The survival rate of patients who had Stage
II disease with low-grade or high-grade tumor budding was compared with that of 226 patients who had Stage III colon cancer.
Results Univariate analysis revealed that serosal surface involvement (P = 0.04) and tumor budding (P < 0.001) were significantly related to survival. Cumulative five- and ten-year survival rates differed significantly between
patients with low-grade tumor budding (93.9 and 90.6 percent, respectively) and those with high-grade (73.9 and 67.8 percent,
respectively). Survival rates did not differ significantly between patients with Stage II disease who had high-grade tumor
budding and patients with Stage III disease. Cox’s regression analysis demonstrated that tumor budding (hazard ratio, 4.89;
P < 0.001) and serosal surface involvement (hazard ratio, 2.561; P = 0.023) were independent prognostic factors. Liver (P < 0.001) and peritoneal (P = 0.003) metastases were more frequent in the patients with high-grade tumor budding than in those with low-grade.
Conclusions Tumor budding is useful for prognosis and identifying patients with Stage II colon cancer who have a high risk of disease
recurrence after curative surgery. 相似文献
13.
Colak T Dag A Turkmenoglu O Polat A Comelekoglu U Bagdatoglu O Polat G Akca T Sucullu I Aydin S 《Diseases of the colon and rectum》2007,50(5):660-669
Purpose This study was designed to investigate the effect of octreotide on side effects of immediate usage of 5-fluorouracil after
colonic anastomosis.
Methods Forty male Wistar rats were randomly assigned into four groups and underwent standardized left colonic anastomosis. The rats
served as control or received intraperitoneal 5-fluorouracil (20 mg/kg daily), subcutaneous octreotide (20 μg/kg daily), or
both. Diarrhea and wound complications were noted during the experiment. The colonic anastomoses were assessed for healing
on postoperative Day 7 by determining the anastomotic bursting pressure, performing histologic examination, and measuring
the tissue hydroxyproline content, serum malondialdehyde, and nitric oxide levels. Intraperitoneal adhesions and anastomotic
leakage were also noted.
Results No statistical significant difference was found between the control and octreotide groups for each of the parameters measured.
Immediate 5-fluorouracil use resulted with higher adhesion score (P = 0.002), significant depression in anastomotic bursting pressure (P = 0.0001), histopathologic score (P = 0.0001), hydroxyproline content (P = 0.0001), and increasing nitric oxide (P = 0.0001) and malondialdehyde levels (P = 0.0001) compared with the control group. Diarrhea was seen in 80 percent of the 5-fluorouracil group but in neither the
control nor octreotide groups (P = 0.0001 for each comparison). However, all these parameters were ameliorated by use of concomitant octreotide and 5-fluorouracil
(P = 0.019, P = 0.023, P = 0.0001, P = 0.006, P = 0.0001, and P = 0.013, respectively). In addition, diarrhea was found to be prevented (P = 0.0001).
Conclusions The results of this study showed that concomitant octreotide use might prevent the side effects of 5-fluorouracil, such as
diarrhea, postoperative adhesion, and delaying the anastomotic healing parameters. In addition, it might reduce tissue damage
and inflammation. 相似文献
14.
Purpose Transanal endoscopic microsurgery, developed by Buess in the 1980s, has become increasingly popular in recent years. No large
studies have compared the effectiveness of transanal endoscopic microsurgery with traditional transanal excision.
Methods Between 1990 and 2005, 171 patients underwent traditional transanal excision (n = 89) or transanal endoscopic microsurgery
(n = 82) for rectal neoplasms. Medical records were reviewed to determine type of surgery, resection margins, specimen fragmentation,
complications, recurrence, lesion type, stage, and size.
Results The groups were similar with respect to age, sex, lesion type, stage, and size. Mean follow-up was 37 months. There was no
difference in the complication rate between the groups (transanal endoscopic microsurgery 15 percent vs. traditional transanal excision 17 percent, P = 0.69). Transanal endoscopic microsurgery was more likely to yield clear margins (90 vs. 71 percent, P = 0.001) and a nonfragmented specimen (94 vs. 65 percent, P < 0.001) compared with transanal excision. Recurrence was less frequent after transanal endoscopic microsurgery than after
traditional transanal excision (5 vs. 27 percent, P = 0.004).
Conclusions Transanal endoscopic microsurgery is the technique of choice for local excision of rectal neoplasms.
Dr. Cataldo is an instructor and an invited speaker for Richard Wolf Medical Instruments Company.
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
15.
Purpose Pilonidal sinus is a disease that does not have a standardized surgical treatment method. This study was designed to compare
the outcomes of Limberg fasciocutaneous transposition and V-Y fasciocutaneous advancement flaps in the treatment of patients
with pilonidal sinus.
Methods A total of 111 patients (98 males; 88.3 percent; mean age, 27.1 years) who received reconstruction after pilonidal sinus excision
in our clinics with Limberg flap (Group 1, n = 66, 59.5 percent) or V-Y flaps (Group 2, n = 45, 40.5 percent) between 1997
and 2004 were investigated retrospectively.
Results No significant difference was detected between Groups 1 and 2 in terms of gender, history of infection or abscess, mean duration
of operation, requirement for analgesics, wound-related complications, such as necrosis, seroma, and infection, and average
time off work. Mean follow-up periods were 45.4 vs. 48.8 months in Group 1 and Group 2, respectively (P = 0.337). On the other hand, rate of recurrence was significantly lower in Group 1 (n = 1, 1.5 percent) compared with Group
2 (n = 5, 11.1 percent; P = 0.039).
Conclusions We conclude that, if the defect is to be reconstructed with a flap in pilonidal sinus cases, reconstruction with Limberg flap
should be preferred over reconstruction with V-Y flap because of its lower rate of recurrence. 相似文献
16.
Ciobotaru B Leiman G St John T Hyman N Ramundo M Grace C 《Diseases of the colon and rectum》2007,50(7):1011-1016
Purpose This study was designed to determine the prevalence and risk factors for anal squamous intraepithelial lesions and human papillomavirus
infection in a rural population of HIV-infected males.
Methods A cross-sectional study was performed. Risk factors were collected. Anal Papanicolaou smear and human papillomavirus screening
for oncogenic types were performed.
Results Of 211 eligible male patients, 149 (70.6 percent) participated. HIV transmission risk was predominantly males who have sex
with males (82 percent). The mean duration of HIV infection was 9.9 years. Ninety (60 percent) males had abnormal anal cytology,
including atypical cells of unknown significance 40 (26 percent), low-grade squamous intraepithelial lesions 28 (19 percent),
and high-grade squamous intraepithelial lesions 22 (15 percent). Human papillomavirus was detected in 61 percent. Binary logistic
regression adjusted risks for abnormal anal cytology included: males who have sex with males (P < 0.001), human papillomavirus infection (P < 0.001), history of anogenital warts (P = 0.014), and the mean lowest CD4 count (abnormal cytology, 158 (standard deviation, 135), negative cytology, 208 (standard
deviation, 180; P = 0.017)). Twenty-two patients with high-grade squamous intraepithelial lesions underwent colorectal surgical examination
and anoscopy. Two (10 percent) were found to have invasive squamous-cell carcinoma and three (15 percent) others had mass
lesions with high-grade squamous intraepithelial lesions.
Conclusions Anal squamous intraepithelial lesions and oncogenic human papillomavirus are highly prevalent in males infected with HIV and
living in a rural setting.
Supported by Ryan White Care Act, Title III, # H76HA00203, 2003.
Read at the meeting of the Infectious Disease Society of America, Boston, Massachusetts, September 29, 2004 to October 3,
2004.
Reprints are not available. 相似文献
17.
Purpose The primary end point of this study was to determine the risk factors that predict chronic pouchitis in those patients having
ileal pouch-anal anastomosis.
Methods A total of 237 patients with ulcerative colitis and undergoing ileal pouch-anal anastomosis by one surgeon at Oregon Health
& Science University from 1993 to 2003 were evaluated. Data were gathered via retrospective chart reviews and by a questionnaire
administered by telephone in 2004. Patients were excluded if there was less than one-year follow-up documented in the chart
or they could not be contacted by telephone (n = 62), postoperative diagnosis of Crohn’s disease (n = 3), failed ileoanal
procedure (n = 1), and one-stage ileal pouch-anal anastomosis (n = 3), leaving 167 patients for evaluation. Patients were
defined as having chronic pouchitis (>3 episodes of pouchitis) or no pouchitis (≤ 3 episodes of pouchitis). Potential risk
factors included number of operations used to perform ileal pouch-anal anastomosis, fulminant ulcerative colitis with two-stage
operation, duration of diverting ileostomy after pouch formation, primary sclerosing cholangitis, other extraintestinal manifestations
of ulcerative colitis, preoperative liver function tests, duration of ulcerative colitis, and the occurrence of postoperative
complications. Initial univariate analysis was performed on all risk factors. Multivariate analysis was performed on all univariate
risk factors with P values < 0.2.
Results The prevalence of chronic pouchitis in our population was 46 percent. The following variables were identified during univariate
analysis and entered into a multivariate model: preoperative serum albumin (P = 0.07), PSC (P = 0.126), duration of diverting ileostomy (P = 0.111), fulminant ulcerative colitis with two-stage operation, (P = 0.051), the presence of postoperative complications (P = 0.031), and the type of postoperative complications (anastomotic complications, P = 0.013). Patients who did not undergo diverting ileostomy at the time of their ileal pouch-anal anastomosis trended toward
a lower likelihood of developing chronic pouchitis (P = 0.06). Multivariate analysis showed that patients with postoperative complications (53 percent, P = 0.042), specifically anastomotic complications, were more likely to develop chronic pouchitis (P = 0.005). Eight percent of patients had primary sclerosing cholangitis and 11 percent of patients had at least one extraintestinal
manifestation of ulcerative colitis. Patients with primary sclerosing cholangitis were not more likely to develop chronic
pouchitis (P = 0.168). Patients with extraintestinal manifestations also were not more likely to develop chronic pouchitis (P = 0.273).
Conclusions Chronic pouchitis is a frequent complication after ileal pouch-anal anastomosis. In this study patients with primary sclerosing
cholangitis or other extraintestinal manifestations of ulcerative colitis were not more likely to develop chronic pouchitis.
Patients with postoperative complications, specifically anastomotic complications after ileal pouch-anal anastomosis, were
more likely to develop chronic pouchitis and may benefit from early strategies to prevent pouchitis.
Poster presentation at the meeting of the American College of Gastroenterology, Honolulu, Hawaii, October 28 to November 2,
2005. 相似文献
18.
Purpose The natural history of sigmoid diverticulitis in terms of the virulence and management in young patients is an ongoing controversy.
This retrospective study was designed to assess the severity and early management of acute diverticulitis according to age.
Methods From 2000 to 2004, 284 patients were admitted for acute diverticulitis. Fifty-two patients (18 percent) were aged 50 years
or younger and were divided in two groups: aged 40 years or younger (Group 1, n = 20), and patients older than aged 40 years
(Group 2, n = 32). The diagnosis was confirmed by computed tomography in 49 patients (94 percent).
Results Radiologic findings showed that the rate of complicated lesions (i.e., diverticular perforation and/or abscess) was significantly higher for patients younger than aged 40 years than patients older,
respectively 72 and 35 percent (P = 0.02). The risk of requiring immediate surgical treatment was significantly more frequent in Group 1 than Group 2 (40 vs.13 percent; P = 0.04). There was a trend toward a higher risk of “major surgery” (i.e., Hartmann’s procedure) in Group 1 than Group 2 (15 vs. 0 percent; P = 0.05).
Conclusions Diverticulitis in patients younger than aged 40 years seems to have a particularly aggressive and fulminant course and requires
early surgical procedures for complications (associated abscess, colonic perforation) in 40 percent of cases. The use of “major
procedure” (i.e., stoma) is more frequent in these patients. 相似文献
19.
Introduction Perceptions of poor outcome may detract caregivers from offering standard therapies to patients over 80 years who have been
diagnosed with rectal cancer. We evaluate the effect of operative intervention on their survival.
Methods Demographics, tumor characteristics, treatment, and survival for patients over 80 years with rectal and rectosigmoid cancer
from 1993 to 2002 in the Surveillance, Epidemiology and End Results Program of the National Cancer Institute were examined.
Survival was determined by using the Kaplan-Meier method. Patients who underwent operation (Group A) were compared with those
who did not undergo surgery (Group B). Fisher's exact, chi-squared, analysis of variance, and log-rank tests were used as
appropriate, and P < 0.05 was considered statistically significant.
Results A total of 9,501 patients (19 percent) were aged older than 80 years. Mean age was 85 years, and median survival was 24 months.
Stage of disease was unknown for 2,915 patients. Median survival was 58, 53, 39, 27, and 5 months for Stages 0 (n=163), I
(n=1,878), II (n=1,796), III (n=1,536), and IV (n=1,213), respectively. A total of 6,900 patients (81 percent) underwent surgery.
Median survival for operated patients was significantly longer for all stages (36 vs. 5 months, P < 0.00001), Stage 0 (60 vs. 7 months, P < 0.01), Stage I (55 vs. 11 months, P < 0.0001), Stage II (41 vs. 13 months, P < 0.0001), Stage III (28 vs. 14 months, P < 0.05), and Stage IV (8 vs. 3 months, P < 0.0001). For patients with rectal cancer, local therapy also significantly improved median survival compared with nonoperated
patients (P < 0.0001).
Conclusions Operative intervention provides sustained benefit in terms of survival to patients aged >80 years with rectal cancer at all
stages who are assessed to be a good operative risk. Age older than 80 years should not detract surgeons from offering optimal
therapy to good-risk patients.
Reprints are not available. 相似文献
20.
Spinoglio G Summa M Priora F Quarati R Testa S 《Diseases of the colon and rectum》2008,51(11):1627-1632
Purpose Laparoscopic colorectal surgery is believed to be technically and oncologically feasible. However, some limitation of traditional
laparoscopic surgery may cause difficulties. Robotic-assisted surgery may overcome these pitfalls.
Methods From December 2005 to July 2007, 50 patients were selected for robotic-assisted colorectal resection mainly for cancer.
Results Of the 50 patients enrolled, 32 (64 percent) were men and 18 (36 percent) were women. Their mean age was 66.7 (range, 37–92)
years. The American Society of Anesthesiologists’ (ASA) class distribution was 13 (26 percent) ASA I, 24 (48 percent) ASA
II, 12 (24 percent) ASA III, and 1 (2 percent) ASA IV. Forty-four patients suffered from cancer and six patients from benign
disease. Amongst the cancer patients, 3 percent were at UICC (International Union Against Cancer) Stage 0, 36 percent at UICC
Stage I, 24 percent at Stage II, 28 percent at Stage III, and 9 percent at Stage IV. The global conversion rate was 4 percent.
The mean operative time was 338.8 minutes. It decreased as the experience increased (419 minutes in the first 20 cases vs. 346 minutes in the last 30 cases; P = 0.036). As a gross comparison, the results of a coeval standard laparoscopy group of patients were shown.
Conclusions Robotic laparoscopic colon surgery is feasible and safe. A longer operating time is needed. 相似文献