Gluteus maximus flap transplantation for anrectal dysfunction after anorectal malformation operation

目的 评价臀大肌瓣转移肛提肌加强术治疗肛门直肠畸形术后排便功能障碍的恢复情况.方法 选择28例先天性肛门闭锁术后排便功能障碍的患儿,年龄4～14岁,男19例,女9例,单纯肛提肌功能不良的18例,肛提肌和肛门外括约肌功能均不良的10例,全部行臀大肌瓣转移肛提肌加强术,术前均行盆底肌MRI、钡灌肠及臀大肌肌电图检查,手术前后均行结肠传输试验、肛门直肠测压和排便功能评分.术后对患儿进行6～48个月的随访,平均24个月.结果 28例手术患儿中26例获得随访,术前臀大肌肌电图均显示臀大肌功能良好,钡灌肠显示直肠无扩张,结肠传输试验表现为出口梗阻,盆底肌MRI见28例患儿肛提肌发育薄弱或不对称,排便功能评分结果示28例患儿均差.肛管静息压手术前后分别为(16.77±4.25) mmHg和(18.67±4.48)mmHg、肛管最大收缩压在手术前后分别为(61.05±14.37) mmHg和(72.12±16.76)mmHg,差异均无统计学意义(P＞0.05),术后单纯肛提肌功能不良的排便功能评分达优6例,良10例,肛提肌和肛门外括约肌功能均不良的排便功能评分优0例,良2例,差8例.优良率占69.23％.结论 对于肛提肌功能不全所导致的排便功能障碍,行臀大肌瓣转移肛提肌加强术可改善排便功能,部分括约肌功能不良的患儿术后可能失禁不能改善或者加重,需要进一步的手术或训练治疗.     

Annual hospital volume and colorectal cancer survival in a population-based nationwide cohort study in Finland

PurposeTo examine the annual hospital volume of surgery in relation to survival in colorectal cancer. Previous studies on hospital volume and survival following colorectal cancer surgery are conflicting.MethodsAll 49 032 patients who underwent resection for colorectal cancer in 1987–2016 in Finland were included, with complete follow-up until December 31, 2019. Primary outcome was 5-year mortality. Cox regression provided hazard ratios (HR) with 95% confidence intervals (CI) for quartiles of annual hospital volume for colorectal surgery, adjusted for calendar period, age, sex, comorbidity, stage, tumor location and oncological therapy. Additionally, colon and rectal cancer surgery were assessed separately. Sensitivity analysis of patients with confirmed curative intent was conducted.ResultsCompared to highest quartile (≥108 resections annually), lowest hospital volume (≤37 resections annually) was associated with slightly increased 5-year all-cause mortality (adjusted HR 1.07, 95% CI 1.02–1.12). A pre-planned subgroup-analysis suggested a slightly improved 5-year survival in high-volume institutions for rectal cancer, but not colon cancer surgery. Sensitivity analysis including only those operated with confirmed curative intent suggested no differences between hospital volume groups in colorectal, colon or rectal cancer for 5-year all-cause mortality.ConclusionHigher hospital volume is associated with slightly improved all-cause 5-year mortality in colorectal cancer surgery, but this effect may be limited to rectal cancer surgery only. Volume-outcome relationship in rectal cancer surgery should be investigated further using large datasets. These results do not support centralization of colon cancer surgery based on hospital volume only.     

经内镜黏膜下剥离术治疗直肠神经内分泌肿瘤的疗效及安全性CSCD

目的探讨经内镜黏膜下剥离术(ESD)治疗直肠神经内分泌肿瘤(RNET)的疗效,并评估其安全性。方法回顾性分析2011年1月—2017年12月在江苏省人民医院行直肠ESD治疗、经病理及免疫组织化学确诊为RNET的80例患者(91处病变)的临床资料,并对患者进行随访。结果所有病变均为完整切除病灶。有症状的患者术后3天~2月症状均有不同程度缓解,无严重术后并发症,标本切缘阳性率20.88%(19/91),切缘可疑阳性率35.16%(32/91)。切除标本最大长径20 mm。单因素分析中,肿瘤长径≥10 mm、肿瘤处于G2级与切缘可疑阳性及阳性相关(P<0.05)。肿瘤处于G2级为切缘可疑阳性及阳性的独立危险因素。仅有1例患者术前证实为RNET。中位随访时间34月,复发率4.40%(4/91)。结论ESD在治疗直径<20 mm的G1级和G2级的RNET患者中具有良好疗效。对于ESD术后显示切缘阳性及可疑阳性的RNET患者,可密切随访暂不实施其他治疗。     

灌肠灵治疗慢性结、直肠炎68例临床观察

目的 :观察灌肠灵治疗慢性结、直肠炎的临床疗效。方法 :对 136例符合慢性结、直肠炎诊断标准的患者 ,随机分为灌肠灵治疗组与对照组各 6 8例。两组治疗均为保留灌肠 ,每日 1次 ,10d为 1疗程 ,共 2疗程。结果 :治疗组优于对照组 ,总有效率为 91.1%与 72 .1% ,P <0 .0 5。结论 :灌肠灵治疗慢性结、直肠炎是目前疗效较好的一种理想方法     

Outlet constipation syndrome caused by elongation of the rectosigmoide as a frequent etiology for pelveo-abdominal pain and intestinal troubles in women with endometriosis

The aim of the study was to isolate from the clinical history and examination, symptoms, or combination of symptoms highly suspicious for intestinal infiltration in endometriosis patients. In a prospective study, preoperative anamnesis on defecation problems and pain symptoms was correlated with the vaginal examination and the laparoscopic findings in 2,000 consecutive patients with suspicion of intestinal endometriosis; 65.7% of the patients reported a typical symptomatology combining left-sided pelvic pain irradiating systematically to the back and occasionally to the left leg, with dyschesia, abdominal bloating, and/or sensation of a doubt masse in the left lower or middle abdomen, sometimes rectorrhagia and an improvement in the pain after defecation. In the absence of a palpable endometriotic nodule of the rectovaginal space, the combination of this symptoms correlated in 93.7% of the patients with an outlet constipation syndrome due to a significant elongation with kinking of the rectosigmoide. In the patients with a palpable endometriotic nodule of the posterior fornix (n = 712), the combination of an apareunia with the apparition of constipation for 2–3 days at the beginning of the period bleeding followed by a diarrhea until the end of the period shows a positive predictive value for deep intestinal infiltration of 95%. In all endometriosis patients undergoing a laparoscopy for pain and intestinal disorders, the elongation of the rectosigmoide must be perceived and recognized as a potential cause for an outlet constipation syndrome which can be cured easily by a left-sided sigmoidopexy. In patients with a macroscopic endometriotic nodule of the posterior fornix, the presence of an apareunia and the apparition of constipation at the beginning of the menstruation followed 2–3 days later by a diarrhea are strong arguments for an invasive intestinal endometriosis, and those patients must be primarily referred to a tertiary referral center. No financial support was received for this study.     

Design,Organization and Management of a Controlled Population Screening Study for Detection of Colorectal Neoplasia: Attendance Rates in the NORCCAP Study (Norwegian Colorectal Cancer Prevention)

Background: In the past three decades, the incidence of colorectal cancer (CRC) in Norway has doubled, surpassing all other Nordic countries for both men and women to become the most frequently diagnosed cancer. A small-scale, randomized study on flexible sigmoidoscopy (FS) screening in Telemark, Norway, has shown a reduction in accumulated CRC incidence after 13 years. The aim of our study was to evaluate the effect on CRC mortality and morbidity by screen detection of CRC and removal of precursor lesions (polypectomy), and to test out the management and organization mimicking a countrywide screening service. A total of 13,823 men and women (1:1), age 55-64 years, were drawn randomly from the population registries in Oslo (urban) and the county of Telemark (mixed urban and rural) and invited to have a screening examination. The rest of the relevant age cohorts constituted the control groups. In the screening group, 535 individuals were excluded according to exclusion criteria, rendering 13,288 individuals eligible for screening examination. Methods: A once only screening model was used. In the screening group, individuals were randomized to have a once only FS or a combination of FS and faecal occult blood test (FOBT). Results: The overall attendance rate was 8,849 out of 13,288 (67%); 73% in Telemark and 60% in Oslo. Attendance for FS only was 68% and 65% for combined FS&FOBT. Conclusions: The present FS/FS&FOBT screening study obtained a high acceptance rate for both screening modalities. The attendance rate was stable throughout the trial, suggesting an acceptable model for management of future countrywide screening.     

Non-steroidal anti-inflammatory drugs in colorectal surgery: A risk factor for anastomotic complications?

In a recent article, Gorissen et al report on 795 patients with primary colorectal anastomosis operated on during the period 2008-2010 for different colorectal conditions at two centres. The leakage rate was significantly higher among patients who were administered non-steroidal anti-inflammatory drugs (NSAIDs) in the perioperative course. A dose-response relationship could also be traced, where longer NSAID use yielded a higher risk of anastomotic breakdown. However, as this study is observational in design, confounding by indication may be present and there is also a risk of residual confounding from unmeasured covariates. Moreover, the question whether different affinity for the cyclooxygenase enzyme is important in different NSAIDs seems to be largely unanswered. The results, conclusions and clinical relevance of the aforementioned study, including the possible effects of different types of NSAIDs, are discussed. While acknowledging that this study represents the best attempt so far in establishing the causal relationship between perioperative NSAID use and anastomotic leakage, the need for further research in this important area is underlined.     

Complications following formalin installation in the treatment of radiation induced proctitis

Formalin installation has been safely and effectively used to treat refractory bleeding caused by radiation proctitis. This study evaluated the results of such treatment in terms of outcome and complications. All four patients who underwent formalin irrigation for transfusion-dependent radiation proctitis over a 15-month period were evaluated retrospectively. The procedure was performed under sedation in the operating room, with patients in the prone jack-knife position. A solution of 4% formalin was introduced in aliquots of 50 ml kept in contact with the mucosa for 30 s and then cleared away using saline irrigation; five to six aliquots were used in each session. In a fifth patient formalin-soaked gauze pads were applied directly to the injured mucosa. At a mean follow-up of 18 months (range 6–26) two patients had repeat episodes of bleeding, one underwent successful repeat irrigation, and the other refused further treatment. One patient suffered from severe anococcygeal pain and worsening of incontinence after the procedure. The pain was treated with lidocaine ointment and sitz baths with partial success. Another patient developed severe formalin-induced colitis 5 days after the procedure, which required intravenous antibiotics and hydration. Formalin installation may be effective in controlling refractory bleeding due to radiation induced proctitis. The procedure, however, is not risk free and may induce major complications such as acute colitis. Accepted: 16 February 2000     

肛管直肠恶性黑色素瘤13例病理分析

目的 探讨肛管直肠恶性黑色素瘤(AMM)的临床病理学特征和鉴别诊断.方法 收集13例肛管直肠AMM,进行免疫组织化学染色,结合有关文献进行临床病理学分析.结果 13例肛管直肠AMM多为中老年人,平均年龄55.8岁,镜下肿瘤结构复杂,细胞形态多样,瘤细胞常呈巢状,弥散片状或梁状分布.多数瘤组织中含有黑色素,少数无色素.免疫组织化学显示瘤细胞染色S-100、HMB45阳性.结论 肛管直肠AMM恶性程度高,预后差,HMB45和5-100是其敏感性的标记物.     

导致直肠癌误诊误治原因分析

目的探讨直肠癌在临床诊治中出现的误诊误治的原因及其如何提高直肠癌的早期诊断和其在体检中正确的检查方法。方法回顾分析2002年7月～2005年11月共收治误诊误治直肠癌患者37例的临床资料。结果3例单发直肠腺瘤恶变局部黏膜下切除;25例直肠癌经手术治愈或缓解;9例直肠癌行姑息手术。结论重视直肠指诊是避免直肠癌误诊不可或缺的重要手段,是直肠肛管疾病的首选检查方法。同时,应加强医生业务水平、提高医生职业道德素养。