全大肠切除直肠肌鞘内回肠造袋肛门吻合术治疗家族性腺瘤性息肉病

家族性腺癌性息肉病（ＦＡＰ）为一种常染色体显性遗传病，如不手术治疗终将发生癌变。现已公认本病的最佳术式为全大肠切除，直肠粘膜剥除，回肠造袋肛门吻合术。作者近９年内施行此手术１１例。患者年龄为１９～６５岁。５例在３０岁以内。平均随访１～９年，效果满意。除２例切口感染外无其它并发症。每日大便４～６次，能恢复工作。手术时５例已有恶变，其中１例有单个肝转移灶同时行局部切除。手术要点为：肌鞘宜短，充分止血并放置引流，无张力吻合，保护性回肠造口。作者认为除直肠内仅少数息肉，患者能坚持随访者外，均宜采用本术式。     

急诊左半结肠一期切除吻合术25例治疗体会

目的探讨急诊左半结肠切除一期肠吻合的可行性。方法腹腔探查完后，用布带结扎横结肠，游离肠系膜后，于预切除肠段的上端切开作肠外减压，挤压排空粪便，切除病变肠管，端端吻合，术后作肛管扩张，停留肛管引流，胃肠减压。结果全部病人预期痊愈出院，无发生吻合口漏和腹腔污染。结论该法有利于吻合口的愈合，增加左半结肠一期切除吻合的安全性，减少第2次手术痛苦，可推荐为左半结肠急诊切除一期吻合的良好方法。     

Inflammatory bowel disease-related colorectal cancer: Past,present and future perspectives

Inflammatory bowel disease-related colorectal cancer (IBD-CRC) is one of the most serious complications of IBD contributing to significant mortality in this cohort of patients. IBD is often associated with diet and lifestyle-related gut microbial dysbiosis, the interaction of genetic and environmental factors, leading to chronic gut inflammation. According to the “common ground hypothesis”, microbial dysbiosis and intestinal barrier impairment are at the core of the chronic inflammatory process associated with IBD-CRC. Among the many underlying factors known to increase the risk of IBD-CRC, perhaps the most important factor is chronic persistent inflammation. The persistent inflammation in the colon results in increased proliferation of cells necessary for repair but this also increases the risk of dysplastic changes due to chromosomal and microsatellite instability. Multiple pathways have been identified, regulated by many positive and negative factors involved in the development of cancer, which in this case follows the ‘inflammation-dysplasia-carcinoma’ sequence. Strategies to lower this risk are extremely important to reduce morbidity and mortality due to IBD-CRC, among which colonoscopic surveillance is the most widely accepted and implemented modality, forming part of many national and international guidelines. However, the effectiveness of surveillance in IBD has been a topic of much debate in recent years for multiple reasons — cost-benefit to health systems, resource requirements, and also because of studies showing conflicting long-term data. Our review provides a comprehensive overview of past, present, and future perspectives of IBD-CRC. We explore and analyse evidence from studies over decades and current best practices followed globally. In the future directions section, we cover emerging novel endoscopic techniques and artificial intelligence that could play an important role in managing the risk of IBD-CRC.     

Abdominal ventral rectopexy with colectomy for obstructed defecation syndrome: An alternative option for selected patients

BACKGROUNDAbdominal ventral rectopexy (AVR) with colectomy is controversial in the treatment of obstructed defecation syndrome (ODS). Literature data on this technique for ODS are very limited.AIMTo evaluate the safety and efficacy of AVR with colectomy for selected patients with ODS.METHODSConsecutive patients who underwent AVR with colectomy for ODS were identified prospectively from 2016 to 2017 in our department. Patient demographics, perioperative surgical results, and postoperative follow-up outcomes were collected and analyzed. Long-term follow-up was evaluated with standardized questionnaires. The severity of symptoms was assessed by the objective Wexner Constipation Score (WCS) and ODS Score. The quality of life was assessed by the Patients Assessment of Constipation Quality of Life score. Functional outcome was compared pre- and post-operatively for each patient. The primary outcomes were determined by the improvement in symptoms and quality of life. Secondary outcome measures were operating time, postoperative length of stay, morbidity and mortality, improvement of pelvic floor structure, and patient satisfaction.RESULTSFour patients underwent robotic-assisted surgery, and two patients underwent a laparoscopic-assisted procedure. The mean operating time for the robotic approach was 243 min (range 160–300 min), and the mean operating time for the laparoscopic approach was 230 min (range 220-240 min). The mean postoperative length of stay was 8.2 d (range 6-12 d). There was no conversion to open procedure and no postoperative mortality. No urinary retention, wound infection, prolonged ileus, pelvic infection and anastomosis leakage occurred. Six patients were followed up for 36 mo. The WCS, ODS, and Patients Assessment of Constipation Quality of Life score improved significantly postoperatively (P < 0.05). The WCS and ODS scores showed the best remission and stabilization at 6 to 12 mo after surgery. There was no recurrence or novel constipation after surgery. None of the patients used laxative medication.CONCLUSIONRobotic and laparoscopic-assisted ventral rectopexy with colectomy is a safe and effective procedure for selected patients with ODS. However, comprehensive preoperative evaluation and careful patient selection are essential.     

梗阻性左半结肠癌I期切除吻合术的探讨

目的探讨急性梗阻性左半结肠癌I期切除、吻合的可行性。方法采用术中肠管切开减压，近远端肠管顺行灌洗，I期肿瘤切除、吻合。结果15例患者除1例吻合口瘘经引流冲洗后治愈，余病例全部I期愈合。结论左半结肠癌引起肠梗阻，严格掌握手术适应证，合理围手术期处理，术中肠管减压、灌洗及术后扩肛，I期切除吻合术是安全可取的。     

Use of infliximab in the prevention and delay of colectomy in severe steroid dependant and refractory ulcerative colitis

AIM： To determine if infliximab can prevent or delay surgery in refractory ulcerative colitis （UC）. METHODS： UC patients who failed to have their disease controlled with conventional therapies and were to undergo colectomy if infliximab failed to induce a clinical improvement were reviewed. Patients were primarily treated with a single 5 mg/kg infliximab dose. The Colitis Activity Index （CAI） was used to determine response and remission. Data of 8 wk response and colectomy rates at 6 mo and 12 mo were collected. RESULTS： Fifteen patients were included, 7 with UC unresponsive or intolerant to Ⅳ hydrocortisone, and 8 with active disease despite oral steroids （all but one with therapeutic dosage and duration of immunomodulation）. All the Ⅳ hydrocortisone-resistant/intolerant patients had been on azathioprine/6-MP 〈 8 wk. At 8 wk, infliximab induced a response in 86.7% （13/15） with 40% in remission （6/15）. Within 6 mo of treatment 26.7% （4/15） had undergone colectomy and surgery was avoided in 46.6% （7/15） at 12 mo. The colectomy rate at 12 mo in those on immunomodulatory therapy 〈 8 wk at time of infliximab was 12.5% （1/8） compared with 100% （7/7） in patients who were on long-term maintenance immunomodulators （P 〈 0.02）. CONCLUSION： Infliximab prevented colectomy due to active disease in immunomodulatory-na？ve, refractory UC patients comparable to the use of Cyclosporine. In patients, however, on effective dosage and duration of immunomodulation at time of infliximab therapy colectomy was not avoided.     

Surgery for Crohn Colitis Over a Twenty-Eight-Year Period: Fewer Stomas and the Replacement of Total Colectomy by Segmental Resection

Background: This study describes how surgery for Crohn colitis developed between 1970 and 1997, towards the end of which period limited resection and medical maintenance treatment was introduced. Methods: A cohort of 211 patients with Crohn colitis (115 population-based), of which 84 had a primary colonic resection (42 population-based), was investigated regarding indication for surgery, the time from diagnosis to operation, type of primary colonic resection, risk for permanent stoma and medication over four 7-year periods. Results: Comparison of the periods 1970-90 and 1991-97 revealed that active disease as an indication for surgery decreased from 64% to 25% ( P < 0.01) while stricture as an indication increased from 9% to 50% ( P < 0.001). Median time from diagnosis to operation increased from 3.5 to 11.5 years ( P < 0.01). Proctocolectomy or colectomy fell from 68.8% to 10% of the primary resections, whereas segmental resection increased from 31.2% to 90%. At the end of the first 7-year period, 26% had medical maintenance treatment, steroids or azathioprine taken by 7%. Corresponding figures for the last period were 70% and 49%. Patients diagnosed during the last two time-periods had less risk for surgery ( P = 0.017), permanent stoma ( P < 0.01) and total colectomy ( P < 0.01). Findings were similar in the population-based cohort. Conclusions: Current management of Crohn colitis implies a longer period between diagnosis and surgery, a reduced risk for surgery and permanent stoma, and the replacement of total colectomy by segmental resection.     

Sham feed or sham? A meta-analysis of randomized clinical trials assessing the effect of gum chewing on gut function after elective colorectal surgery

Purpose  Enhanced recovery programs aim to expedite gut function after elective colorectal surgery. Early oral feeding simulates gut function but is not always feasible. Gum chewing, a form of sham feed, is an alternative. We assessed current evidence for gum chewing and gut function. Study design  All randomized controlled trials (RCTs) between 1990 and 2008 comparing gum chewing with controls/placebo were analyzed irrespective of language, blinding, or publication bias. The Jadad scale was used to assess study quality. Endpoints were time to flatus/feces, postoperative complications, and hospital stay. Random and fixed models were employed to aggregate study endpoints and assess heterogeneity. Results  Six RCTs containing 256 patients were included. Significant heterogeneity was identified and random effects model was employed. Heterogeneity may be explained through variations in delivery of surgical care. Significant reductions in the time to flatus and time to feces were identified but no significant difference in hospital or in-hospital postoperative complications were found. Conclusions  Gum chewing significantly reduced time to flatus and feces; however, hospital stay and postoperative complications were not reduced. Significant study heterogeneity means that these results should be interpreted with caution. Presentation to European Society of Coloproctology Annual Scientific Meeting Malta September 2007 Presentation to West of Scotland Surgical Association Annual Scientific Meeting October 2007     

Prevalence, detection rate and outcome of cytomegalovirus infection in ulcerative colitis patients requiring colonic resection

OBJECTIVE: To determine the prevalence of cytomegalovirus infection in patients with steroid-refractory ulcerative colitis who required colonic resection, and to assess its possible association with the use of immunosuppressive and steroid treatment and outcome after colectomy. PATIENTS AND METHODS: The study included surgical specimens and related pre-operative endoscopic biopsy specimens of 77 consecutive ulcerative colitis patients (34 females) who underwent colectomy because of intractable steroid-refractory ulcerative colitis (55 patients), toxic megacolon (6 patients), dysplasia or cancer (7 patients) or loss of function of the colon (9 patients). Clinical features and current and past treatments were analysed. Haematoxylin and eosin and specific immunohistochemical staining for cytomegalovirus were used to detect inclusion bodies in all specimens. RESULTS: Cytomegalovirus infection was found in 15 of 55 steroid-refractory ulcerative colitis patients (27.3%) and in 2 of 22 non-refractory patients (9.1%) (p=0.123). Only six patients had positive staining for cytomegalovirus in pre-operative endoscopic biopsy specimens. Detection of cytomegalovirus inclusion in biopsy specimens was not related to the number of biopsies or to time that had elapsed since colonoscopy and index surgery. Cytomegalovirus-positive patients were more likely to be on systemic corticosteroids (p=0.03). In contrast, current use and duration of immunosuppressive treatment, number of steroid cycles since diagnosis and in the last year, as well as chronic use of steroid in the last year were not significantly related to cytomegalovirus infection. Cytomegalovirus-positive patients did not receive antiviral therapy following proctocolectomy but did not show endoscopic or histological cytomegalovirus reactivation in the ileo-anal pouch and in the remaining bowel. CONCLUSIONS: Cytomegalovirus infection is frequently found in surgical specimens of patients with steroid-refractory ulcerative colitis and is more likely in patients on corticosteroid treatment. Cytomegalovirus infection is frequently unrecognised in pre-operative biopsy specimens, thus raising concerns about the accuracy of the available diagnostic tools. Unrecognised and untreated cytomegalovirus infection does not affect the outcome of ulcerative colitis patients following proctocolectomy.     

Outcome of Discharge Within 24 to 72 Hours After Laparoscopic Colorectal Surgery

Purpose Although laparoscopic colorectal surgery may permit early recovery and discharge from hospital, short lengths of stay are not routinely achieved. This is partly because accelerated recovery programs with early discharge are associated with high readmission and complication rates, especially after open colorectal surgery. Methods This study was designed to examine safety and outcomes after laparoscopic colectomy in cases discharged within 72 hours of surgery. A total of 118 consecutive patients (mean age 60 years) underwent elective laparoscopic colectomy by a single surgeon. An accelerated recovery program included an overnight intravenous patient- controlled analgesia pump, diet and oral analgesia on postoperative Day 1, and standardized discharge criteria. Results Mean body mass index was 28.5 (range, 20–45), and mean operative time was 142 minutes with no mortality. Median stay was 3 days, and 20 percent had a complication within 30 days. Eighty-two patients (70 percent) were discharged within 72 hours of surgery (10 Day 1; 46 Day 2; 26 Day 3). Patients were grouped and analyzed by day of discharge. Discharge on Days 1 to 2 was associated with significantly lower complication rates than seen for the overall group. Although patients discharged on Days 1 to 2 had the lowest readmission rate, this did not reach statistical significance. Conclusions Readmission and complication rates are low in patients discharged on Days 1, 2, or 3 after laparoscopic colectomy when using standardized postoperative care protocols and standardized discharge criteria. Dr. Delaney received a research grant and is a consultant to U.S. Surgical, Ethicon and Adolar. Read at the meeting of the America Society of Colon and Rectal Surgeons, June 2 to 6, St. Louis, Missouri. Reprints are not available.