高频线阵及经直肠腔内超声对肛瘘及肛周脓肿的诊断价值

目的探讨利用超声高频线阵探头经肛周和腔内探头经直肠检查肛瘘及肛周脓肿的诊断价值。方法使用ATL超9及Philip HD11XE型彩色多普勒超声诊断仪的5-10MHz高频线阵探头经肛周结合5-9MHz腔内探头,经直肠对43例肛瘘患者进行检查。其中26例进行了手术治疗,检查结果与手术结果进行对比。结果对43例肛瘘患者外口（位置、距肛门距离、数目）、走行（曲直、方向、长度）、内口（是否可见,内口距肛门口的距离）、主管和支管（数目、与括约肌、肛提肌的关系以及走行的方向）、肛周脓肿（有无、范围、位置、数目）等进行详细观测和描述。按照检查结果依据肛瘘诊断标准,超声诊断低位单纯型22例、低位复杂型8例、高位单纯型5例、高位复杂型8例。对26例手术患者诊断主管的敏感度92.3%,漏诊率7.7%;诊断支管的敏感度91.7%,漏诊率8.3%,特异度100%。结论超声诊断能为肛瘘和肛周脓肿提供详细的影像学资料,具有较高的临床应用价值。     

Short-term outcomes of laparoscopic total mesorectal excision compared to open surgery

AIM:To investigate the short-term outcome of laparoscopic total mesorectal excision(TME) in patients with mid and low rectal cancers.METHODS:A consecutive series of 138 patients with middle and low rectal cancer were randomly assigned to either the laparoscopic TME(LTME) group or the open TME(OTME) group between September 2008 and July 2011 at the Department of Colorectal Cancer of Shanghai Cancer Center,Fudan University and pathological data,as well as surgical technique were reviewed retrospectively.Short-term clinical and oncological outcome were compared in these two groups.Patients were followed in the outpatient clinic 2 wk after the surgery and then every 3 mo in the first year if no adjuvant chemoradiation was indicated.Statistical analysis was performed using SPSS 13.0 software.RESULTS:Sixty-seven patients were treated with LTME and 71 patients were treated with OTME(sex ratio 1.3:1vs 1.29:1,age 58.4 ± 13.6 years vs 59.6 ± 9.4 years,respectively).The resection was considered curative in all cases.The sphincter-preserving rate was 65.7%(44/67) vs 60.6%(43/71),P = 0.046;mean blood loss was 86.9 ± 37.6 mL vs 119.1 ± 32.7 mL,P = 0.018;postoperative analgesia was 2.1 ± 0.6 d vs 3.9 ± 1.8 d,P = 0.008;duration of urinary drainage was 4.7 ± 1.8 d vs 6.9 ± 3.4 d,P = 0.016,respectively.The conversion rate was 2.99%.The complication rate,circumferential margin involvement,distal margins and lymph node yield were similar for both procedures.No port site recurrence,anastomotic recurrence or mortality was observed during a median follow-up period of 21 mo(range:9-56 mo).CONCLUSION:Laparoscopic TME is safe and feasible,with an oncological adequacy comparable to the open approach.Further studies with more patients and longer follow-up are needed to confirm the present results.     

Comparison between the ICRU rectal point and modern volumetric parameters in brachytherapy for locally advanced cervical cancer

PurposeThe implementation of image-guided brachytherapy in cervical cancer raises the problem of adapting the experience acquired with 2D brachytherapy to this technique. The GEC-ESTRO (Groupe européen de curiethérapie – European Society for Radiotherapy and Oncology) has recommended reporting the dose delivered to the rectum in the maximally exposed 2 cm³ volume, but so far, the recommended dose constraints still rely on 2D data. The aim of this study was to evaluate the relationship between the doses evaluated at the ICRU rectal point and modern dosimetric parameters.Material and methodsFor each patient, dosimetric parameters were generated prospectively at the time of dosimetry and were reported. For analysis, they were converted in 2 Gy equivalent doses using an α/β ratio of 3 with a half-time of repair of 1.5 hours.ResultsThe dosimetric data from 229 consecutive patients treated for locally advanced cervical cancer was analyzed. The mean dose calculated at ICRU point (DICRU) was 55.75 Gy ± 4.15, while it was 59.27 Gy ± 6.16 in the maximally exposed 2 cm³ of the rectum (P = 0.0003). The D2 cm³ was higher than the DICRU in 78% of the cases. The mean difference between D2 cm³ and DICRU was 3.53 Gy ± 4.91. This difference represented 5.41% ± 7.40 of the total dose delivered to the rectum (EBRT and BT), and 15.49% ± 24.30 of the dose delivered when considering brachytherapy alone. The two parameters were significantly correlated (P = 0.000001), and related by the equation: D2 cm³ = 0.902 × DICRU + 0.984. The r² coefficient was 0.369.ConclusionIn this large cohort of patients, the DICRU significantly underestimates the D2 cm³. This difference probably results from the optimization process itself, which consists in increasing dwell times above the ICRU point in the cervix. Considering these findings, caution must be taken while implementing image-guided brachytherapy and dose escalation.     

Usefulness of a state-legislated,comparative database to evaluate quality in colorectal surgery

PURPOSE: Colorectal surgery, a high-volume procedure, has been targeted for performance improvement to reduce length of stay. Specific postoperative quality indicators and readmission rates should be analyzed concomitantly to assure that adverse events are not associated with earlier discharge. METHODS: From July 1, 1990, to June 30, 1997, 1,218 consecutive patients who underwent transabdominal colorectal surgery were analyzed for length of stay, mortality, morbidity, and discharge disposition. Each patient was assigned an Admission Severity Group rating 0 to 4 using a hospital-based state-legislated software system (Atlas) to validate comparative performance internally and externally. Readmission data within 120 days of discharge were available for the last 678 consecutive patients from July 1, 1993, to June 30, 1997, using Lastword (computerized medical records). RESULTS: The annual frequencies of the 1,218 procedures were 173, 183, 175, 146, 167, 189, and 185, respectively, from July 1990 through June 1997. Severity distribution was 32 for Admission Severity Group 0, 517 for Admission Severity Group 1, 540 for Admission Severity Group 2, 128 for Admission Severity Group 3, and 1 for Admission Severity Group 4, with no annual difference (P=0.012). There was a significant reduction in total length of stay of 3.1 (12.9–9.8) days during the seven years (P=0.001). The overall operative mortality rate was 1.4 percent, and the morbidity was 2.6 percent, with no annual differences (P=0.655 andP=0.033, respectively). The disposition to home did not change (P=0.21). Of the 678 patients followed up for readmission, 100 (14.7 percent) were readmitted within 120 days, with no annual difference (P=0.302). CONCLUSION: Mortality, morbidity, disposition, and readmission rates were not affected by a decreased length of stay after colorectal surgery.Presented at the Research Forum at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio, Texas, May 2 to 7, 1998.     

Fever Evaluations after Colorectal Surgery: Identification of Risk Factors that Increase Yield and Decrease Cost

Purpose This study was designed to evaluate the yield and cost of fever evaluations in average-risk inpatients after elective colorectal surgery. Methods A 12-month, retrospective study was performed on patients who developed a postoperative fever ≥ 38°C after elective colorectal surgery. A positive fever evaluation was defined as a blood culture, urine culture, chest x-ray, or abdominal CT result that led to a change in patient management. Logistic regression, Fisher’s exact test, and chi-squared test were used; odds ratios were calculated. Results Of 133 patients, 26 percent had a positive evaluation. Blood culture, urine culture, chest x-ray, and CT were positive in 3, 8, 7, and 46 percent, respectively. Risk factors for a positive fever evaluation were temperature ≥ 38.5°C, fever evaluation after postoperative Day 6, and a clinical manifestation of systemic inflammatory response syndrome other than fever (all, P < 0.01). The cost per positive fever evaluation for the entire group, patients with 2 risk factors, or patients with 3 risk factors was $5,600, $4,200, and $2,140, respectively. Conclusions The current approach to fever evaluation after elective colorectal surgery is low yield and costly. High fever, late postoperative fever, and systemic inflammatory response syndrome are risk factors for a positive fever evaluation after colorectal surgery. Read at meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 7, 2007.     

Melanoma of the rectum： A rare entity

A 41-year-old man presented with a 6-mo history of changed defecation and rectal bleeding. A 3-cm polypoid tumor of the lower rectum was found at rectosigmoidoscopy, which proved to be a leiomyosarcoma upon biopsy. Dissemination studies did not show any metastases. He was underwent to an abdomino-perineal resection （APR）. Histopathology of the specimen showed a melanoma （S-100 stain positive）. Two years after the resection, metastases in the abdomen and right lung were found. He died one and half years later. Primary anorectal melanoma is a rare and very aggressive disorder. According to current data, one should always perform a S-100 stain when anorectal sarcoma is suspected. A positive S-100 stain suggests the tumour to be most likely a melanoma. Subsequently, thorough dissemination studies need to be performed. Depending on the outcome of the dissemination studies, a surgical resection has to be performed. Nowadays, a sphincter-saving local excision combined with adjuvant loco-regional radiotherapy should be preferred in case of small tumors. The same loco-regional control is achieved with less ＂loss of function＂ compared to non-sphincter saving surgery. Only in the case of large and obstructing tumors an abdomino-perineal resection is the treatment of choice.     

Incidence and natural history of dysplasia of the anal transitional zone after ileal pouch-anal anastomosis

PURPOSE: Preservation of the anal transitional zone during ileal pouch-anal anastomosis is still controversial because of the risk of dysplasia and the theoretical risk of associated cancer. Without long-term follow-up data, the natural history and optimal treatment of anal transitional zone dysplasia are unknown. The aim of this study was to determine the long-term risk of dysplasia in the anal transitional zone and to evaluate the outcome of a conservative management policy for anal transitional zone dysplasia. METHODS: Two hundred ten patients undergoing anal transitional zone-sparing ileal pouch-anal anastomosis for ulcerative or indeterminate colitis between 1987 and 1992 and who were studied with serial anal transitional zone biopsies for at least five years postoperatively were included. Median follow up was 77 (range, 60–124) months. RESULTS: Anal transitional zone dysplasia developed in seven patients 4 to 51 (median, 11) months postoperatively. There was no association with gender, age, preoperative disease duration or extent of colitis, but the risk of anal transitional zone dysplasia was significantly increased in patients with prior cancer or dysplasia in the colon or rectum. Dysplasia was high grade in one and low grade in six. Two patients each with low-grade dysplasia detected on three separate occasions underwent mucosectomy 29 and 38 months after detection of low-grade dysplasia, but no cancer was found. The five other patients with dysplasia on one or two occasions were treated expectantly and were apparently dysplasia-free for a median of 72 (range, 48–100) months. CONCLUSIONS: Anal transitional zone dysplasia after ileal pouch-anal anastomosis is infrequent, is most common in the first two to three years postoperatively and may apparently disappear on repeated biopsy. Anal transitional zone preservation did not lead to the development of cancer in the anal transitional zone after five to ten years of follow-up. Long-term surveillance is recommended to monitor dysplasia. If repeat biopsy confirms persistent dysplasia, anal transitional zone excision with neoileal pouch-anal anastomosis is recommended.Presented at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio, Texas, May 2 to 7, 1998.     

内镜黏膜下剥离术治疗直肠病变

目的探讨内镜黏膜下剥离术治疗直肠病变的应用价值。方法对肠镜发现的较大直肠腺瘤和黏膜下肿瘤应用头端弯曲的针形切开刀进行内镜黏膜下剥离术（ESD）治疗：（1）黏膜下注射生理盐水抬高病变，使病变与肌层相分离；（2）预切开病变周围黏膜；（3）剥离病变下方黏膜下层结缔组织，完整切除病变。结果12例低位直肠病变，大小0．6～4．5cm（平均2．8cm），均成功完成ESD治疗。术后11例病理确诊基底和切缘未见病变累及；1例腺癌累及黏膜下层病例接受外科根治手术，手术标本病理未见肿瘤残留。ESD手术时间（自黏膜下注射至完整剥离病变）30～120min（平均52min）。术中出血量平均约75ml，均经电凝、氩离子凝固术和止血夹成功止血，未出现需再次肠镜下治疗的出血。2例剥离深至肌层，出现皮下气肿和少量膈下游离气体，保守治疗好转。9例1个月后肠镜复查，创面基本愈合。结论ESD是治疗消化道病变的新方法，不仅能切除较大的病变，还能提供完整的病理学诊断资料。以往需要外科手术的消化道早期癌和部分黏膜下肿瘤，通过ESD可以达到同样的治疗效果。     

Rectal compliance in females with obstructed defecation

PURPOSE: This study was designed to investigate whether rectal compliance is altered in females with obstructed defecation. METHODS: Eighty female patients with obstructed defecation and 60 control subjects were studied. Rectal compliance was measured with an infinitely compliant polyethylene bag. This bag was inserted in the rectum and inflated with air to selected pressure plateaus (range, 0–60 mmHg; cumulative steps of 2 mmHg with a duration of ten seconds) using a computer-controlled electromechanical barostat system. Volume changes at the levels of distending pressures were recorded. The distending pressures, needed to evoke first sensation of content in the rectum, earliest urge to defecate, and the maximum tolerable volume were noted. RESULTS: In all cases, the compliance curve had a characteristic triphasic (S-shaped) form. The mean compliance curve obtained from the patients was identical to that of the controls. However, the course of the compliance curve fell above the normal range (mean + 2 SD) in 14 patients. In ten (71 percent) of these patients, a large rectocele was seen at evacuation proctography. Such a rectocele was observed in only five patients (7.6 percent) with a normal compliance curve (P<0.001). Eighty percent of the controls experienced earliest urge to defecate during the second phase of the curve. In 75 percent of the patients, this occurred in the third phase. The mean pressure threshold for first sensation, earliest urge to defecate, and maximum tolerable volume were significantly higher in patients compared with control subjects. Ten of the patients experienced no sensation at all in the pressure range between 0 and 60 mmHg. CONCLUSION: In females with obstructed defection, the compliance of the rectal wall is normal.