Urinary Dysfunction in the Rectal Cancer Survivor

Improvements in diagnosis and treatment have resulted in significant improvement in survival rates for rectal cancer. This has led to increasing focus on post-treatment quality of life. One common sequela of treatment for rectal cancer is urinary dysfunction, defined as either difficulty voiding or incontinence. This consists of multiple clinical syndromes of distinct etiologies, most commonly dysfunction of the pelvic autonomic nerves or pelvic floor instability. This can vary in both duration and severity, with some patients experiencing transient and mild symptoms, while others experience prolonged functional impairment. A number of treatment options exist, including behavioral, pharmacologic, and surgical interventions. Because of the multifaceted nature of this process, optimal symptom relief requires careful evaluation of the severity and etiology of a patient’s complaints. Ultimately post-treatment urinary dysfunction can have a significant impact on quality of life, and it is important for clinicians to understand both the causes and management of this process.     

Complications and Quality of Life Following Urinary Diversion After Cystectomy

Objective:

The aim of this review is to outline specific surgical complications, metabolic consequences and quality of life (QOL) following urinary diversion in patients undergoing radical cystectomy.

Methods:

Based on a comprehensive literature search (MEDLINE) the published knowledge on urinary diversion was examined regarding the research question with an emphasis on contemporary cystectomy series.

Results:

Despite the fact, that urinary diversion is commonplace in these days and the existing literature is rather extensive, the vast majority of assumptions are based on low level evidence (retrospective, single-institutional case series with small sample sizes and short-term followup). There are few randomized trials in this field.Early and late surgical complications following radical cystectomy have decreased over the past three decades for both incontinent and continent diversion, but are still significant. While metabolic disturbances are common after continent forms of urinary diversion, the problems can be minimized in most cases. Most reports testify that QOL is high after cystectomy irrespective of type of urinary diversion although urinary and sexual problems are common.

Conclusion:

Careful patient selection, strict adherence to proper surgical technique and appropriate life-long follow-up are of paramount importance in the successful management of patients undergoing radical cystectomy for bladder cancer.     

老年结肠癌并急性肠梗阻的术后并发症的危险因素分析

目的 探讨老年结肠癌伴发急性肠梗阻术后并发症及其危险闪素.方法 回顾性分析2009年6月-2011年6月治疗的70例老年患者的临床资料.结果 患者术后有19例(27.1%)出现并发症,围手术期死亡8例(11.4%).单因素分析显示,美国麻醉医师协会(ASA)分级3～4级、APACHE-Ⅲ评分者＞14分、闭袢性结肠梗阻及合并肠穿孔或肠浆膜撕裂术后并发症发生率较高.结论 结肠癌致急性肠梗阻术后并发症发生率及围手术期死亡率较高;对于有高危因素的患者应谨慎选择恰当术式及术后加强监护.     

The Role of Urinary Diversion for Bladder Pain

Interstitial cystitis/bladder pain syndrome is a complex urologic disorder often managed in a non-operative fashion, but patients with severe symptoms occasionally require surgical intervention. Several approaches to reconstruction have been reported, including trigone-sparing cystectomy with enterocystoplasty, simple cystectomy with diversion, and diversion without cystectomy. While a trigone-sparing approach offers the potential for spontaneous voiding, it leaves bladder and urethral tissue that can cause pain postoperatively. Final choice of surgery is based upon surgeon and patient preference. In recent years, enhanced recovery after surgery (ERAS) protocols modeled after colorectal surgery have been utilized for radical cystectomy postoperative management with success. These approaches can be used for cystectomy for non-malignant cases as well.     

For Patients with Colorectal Cancer, the Long-Term Use of Statins Is Associated with Better Clinical Outcomes

Statins have been found to suppress tumor cell growth and to limit the ability of tumor cells to metastasize in studies involving cell lines and animals. To explore how the long-term use of statins influences the presentation and survival of patients with colorectal cancer (CRC), we conducted a retrospective case-control study of male patients with a new diagnosis of CRC who we categorized as: (1) Statin Users who used statins continuously ≥3 years prior to the diagnosis of CRC and (2) Statin Non-Users who did not use statins. Clinical factors were analyzed by simple Chi-square and multivariate regression analysis to identify independent predictors for advanced CRC. We identified 1,309 male patients with a new diagnosis of CRC (mean age 69 ± 1.1 (SE) years; 326 Statin Users, 983 Statin Non-Users). Compared to Statin Non-Users, Statin Users had a less advanced tumor stage (2.2 vs. 2.6; P < 0.01), a lower prevalence of metastases (OR = 0.7 [0.4–0.9, 95% CI]; P < 0.01), and a higher frequency of right-sided tumors (OR = 1.6 [1.3–2.1], 95%CI]; P < 0.01). Overall 5-year survival for Statin Users was 37% compared to 33% in Statin Non-Users (OR = 0.7 [0.6–0.9], 95%CI]; P = 0.03). In patients who present to the hospital with CRC, the long-term use of statins is associated with a less advanced tumor stage, a higher prevalence of right-sided tumors, a lower frequency of distant metastases, and a better survival rate.     

Septic Complications after Restorative Proctocolectomy do not Impair Functional Outcome: Long-Term Follow-Up from a Specialty Center

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.     

急性肺栓塞患者治疗及长期随访结果分析

目的急性肺栓塞(PE)是临床常见的心血管急症,危害极重。本研究通过对本院疑诊、确诊PE患者的资料进行回顾,以总结PE的治疗经验。方法检索本院1997年8月—2009年6月出院诊断为PE的病例,记录相关资料,并对出院患者进行电话随访。结果 83例患者确诊为PE,1例患者住院死亡,38例患者接受了随访,其中8例死亡,其他患者失访。38例患者接受溶栓联合抗凝治疗,1例死亡;46例单独接受抗凝治疗。已知临床结局的39例患者中,接受或无接受溶栓治疗组比较,病死率发生的相对危险度(RR)=1.04,95%CI(0.33,3.28);长期坚持服用与无坚持服用华法林组比较,患者病死率RR=1.56,95%CI(0.38,6.41),差异均无统计学意义。结论对确诊PE患者,溶栓联合抗凝和单纯抗凝治疗存在争议,长期服用华法林的依从性也较差。     

Management of End-Stage Radiation Cystitis in the Cancer Survivor

Millions of cancer survivors have received pelvic radiation, and a significant minority of them will have long-term lower urinary tract sequelae manifesting as hematuria, storage and emptying dysfunction, and fistulas. Hemorrhagic radiation cystitis is managed with intravesical agents in the acute setting, and systemic oral and hyperbaric oxygen therapy for long-term control. In certain cases, however, urinary diversion will be required. Similarly, most cases of lower urinary tract symptoms relating to poor storage and emptying can be managed conservatively. However, some will warrant urinary diversion. Radiation-related urinary fistulas have notoriously poor outcomes after attempts at repair, and early consideration to urinary diversion should be given in these cases. Continent as well as incontinent urinary diversion can be safely performed in patients with prior pelvic radiation, and limited contemporary data confirm significant quality-of-life improvements after urinary diversion in patients with end-stage radiation cystitis.     

Long-Term Follow-Up of TIPS Created with Expanded Poly-Tetrafluoroethylene Covered Stents

Background

Transjugular intrahepatic portosystemic shunts (TIPS) created with expanded poly-tetrafluoroethylene-covered stents have largely replaced bare metal stents. Short-term shunt patency is typically assessed with protocol Doppler ultrasound (US), while little information exists with regard to long-term patency.

Aim

We investigated the value of Doppler US in assessing TIPS patency as well as long-term clinical outcomes.

Methods

A retrospective analysis of 59 patients with covered stents used for TIPS between January 2001 and December 2011 was performed.

Results

Fifty-four patients had early (median 9 days) Doppler US follow-up. Seven of eight patients with an abnormal baseline US required stent revisions. None of the 46 patients with normal baseline Doppler US required revisions within the first 6 months; six of these patients subsequently had a portogram because of symptoms, but all TIPS were patent. Fifty-two patients survived for long-term (>6 months) follow-up, averaging 654 days and three Doppler US exams. Five of six patients with abnormal follow-up Doppler US required revisions, whereas none of the 46 patients with normal follow-up US had revisions. The recurrence of symptoms of portal hypertension and/or hepatic encephalopathy (HE) was low (4/52 patients). No significant predictors of long-term stenosis were identified. Post-TIPS HE was independent of pre-TIPS HE or Child-Pugh score.

Conclusions

Short-term patency and that at approximately 2 years after TIPS placement was 87 and 77 %, respectively. We conclude that Doppler US at least 1 week after TIPS is warranted, but repeated Doppler US follow-up is probably not necessary in the absence of clinical symptoms.     

Postoperative Complications Associated with Laparoscopy-assisted Colectomy

Abstract: The intraoperative and postoperative complications of laparoscopic colectomy were analyzed in a consecutive series of 69 cases in our experience. The final histological diagnosis of these patients was adenoma of the colon in eight, carcinoma of the colon and rectum in 59, leiomyoma of the colon in one and Crohn's disease in one. The TIMM staging of the carcinomas in our series was Tis in four, T1 in 20, T2 in 10 and T3 in 25 cases. Conversion to open surgery was necessary in four of the 69 cases. The reasons for conversion were bleeding in two, adhesion in one and malignant invasion to the bladder in one. Major postoperative complications occurred in the four cases in whom a reoperation was carried out. These included perforation of the colon, pancreatic fistula, ileus and bleeding. Among the 11 minor postoperative complications, wound infection was the most frequent and occurred in six cases. There were no operative or postoperative deaths. The postoperative observation period ranged from one month to 4¹/₂ years. There was only one case with a possible local recurrence who had a CEA level of 34 ng/ml. In this patient, no findings of port site recurrence were detected. We thus consider laparoscopic-assisted colectomy, when done by technically well experienced surgeons, to be an effective and curative procedure for the treatment of colorectal carcinoma. However, in view of our complication rate, both sufficient training and experience with the techniques required to perform a laparoscopic colectomy are important for the future development of this procedure.     

Hepatocellular Carcinoma in a Long-Term Survivor of Intrahepatic Biliary Duct Hypoplasia

We describe the development of hepatocellular carcinoma (HCC) in a 46-yr-old woman with intrahepatic biliary duct hypoplasia. Her underlying liver disease was quiescent for many years until a dramatic rise in serum bilirubin was seen. Orthotopic liver transplantation was performed, and a large tumor was found during surgery. A bile-producing HCC was identified, infiltrating about 50% of an otherwise noncirrhotic liver which had a paucity of intrahepatic ducts. The findings of HCC in this long-term survivor of intrahepatic biliary duct hypoplasia indicates HCC may occur in patients with long-standing disease.     

Current Concepts for Urinary Diversion in Women

Intestinal continent diversions in women, although widely used in males, have been the subject of recent refinements. Potential associated problems are related to the functional aspects of these diversions and the possibility of secondary urethral tumors.The present paper reviews the basic anatomical components of the urethral sphincter in women and discusses the indication and surgical techniques of this approach in women.Postoperative results may be improved by performing a nerve-sparing procedure and by using low-pressure reservoirs.     

Long-Term Clinical and Manometric Follow-Up of Patients with Nonspecific Esophageal Motor Disorders

In the manometric evaluation of patients complaining of chest pain, a nonspecific esophageal motor disorder is commonly identified. Yet, the clinical characteristics of these patients and stability of the manometric pattern with time have not been previously described. This study reports a 3.2-yr clinical and manometric follow-up of 23 patients with nonspecific esophageal motor disorder. These subjects were most commonly middle-aged women with long-standing, persistent, and debilitating clinical symptoms. Ninety-six percent (22/23) of our patients complained of chest pain; 65% (15/23) had dysphagia. In addition, 15 (65%) had evidence of reflux during ambulatory pH studies. Symptoms caused such concern that the patients frequently sought medical assistance to exclude serious diseases. Although the symptoms tended to persist, the motility patterns changed in some patients. Follow-up manometric studies were normal in 29%, and nonspecific esophageal motor disorder persisted in 57% of the patients. In three patients (14%), the pattern evolved into diffuse esophageal spasm. When symptoms were compared with these changes in follow-up manometric patterns, the correlation was poor. This observation suggests that additional mechanism(s) other than disturbed esophageal motility may be responsible for the symptoms seen in these individuals.