Biomedical subjects

J Efron

Publications and source records attributed to J Efron.

At least 19 recordsLinked to original sources

PubMed2006

Strategies of follow-up for colorectal cancer: a survey of the American Society of Colon and Rectal Surgeons.

BACKGROUND: The postoperative surveillance of patients who have undergone curative treatment for colorectal cancer (CRC) is controversial. The aim of this study was to investigate the follow-up practice of colorectal surgeons in the United States. METHODS: A postal survey was sent to 1641 active members of the American Society of Colon and Rectal Surgeons practicing in the United States to assess the frequency of follow-up and the methods used in the surveillance of asymptomatic patients following curative surgery for CRC. RESULTS: Only 582 (36%) of the questionnaires that were sent were returned fully completed. Of these, 173 surgeons (30%) followed their patients according to guidelines. Ninety-four percent of surgeons during the first year and 81% during the second year saw their patients regularly every 3 or 6 months. The most widely used tests were colonoscopy and carcinoembryonic antigen (CEA) testing. There was wide discrepancy in the frequency of follow-up and techniques employed, with only about 50% of surgeons following recommended practice. CONCLUSIONS: Surveillance strategies mainly rely on clinical examination, CEA monitoring and colonoscopy. No clear consensus on surveillance programs for CRC patients exists.

Carcinoembryonic Antigen↗

PubMed2006

Do internal anal sphincter defects decrease the success rate of anal sphincter repair?

BACKGROUND: Anatomic anal sphincter defects can involve the internal anal sphincter (IAS), the external anal sphincter (EAS), or both muscles. Surgical repair of anteriorly located EAS defects consists of overlapping suture of the EAS or EAS imbrication; IAS imbrication can be added regardless of whether there is IAS injury. The aim of this study was to assess the functional outcome of anal sphincter repair in patients intraoperatively diagnosed with combined EAS/IAS defects compared to patients with isolated EAS defects. METHODS: The medical records of patients who underwent anal sphincter repair between 1988 and 2000 and had follow-up of at least 3 months were retrospectively assessed. Fecal incontinence was assessed using the Cleveland Clinic Florida incontinence score wherein 0 equals perfect continence and 20 is associated with complete incontinence. Postoperative scores of 0-10 were interpreted as success whereas scores of 11-20 indicated failure. RESULTS: A total of 131 women were included in this study, including 38 with combined EAS/IAS defects (Group I) and 93 with isolated EAS defects (Group II). Thirty-three patients (87%) in Group I had imbrication of a deficient IAS, compared to 83 patients (89%) in Group II. All patients had either overlapping EAS repair (n=121) or EAS imbrication (n=10). Mean follow-up was 30.9 months (range, 3-131 months). There were no statistically significant differences between the two groups relative to age (48.3 vs. 53.0 years; p=0.14), preoperative incontinence score (16.1 vs. 16.7; p=0.38), extent of pudendal nerve terminal motor latency pathology (left, 11.1% vs. 8%; p=0.58; right, 8.6% vs. 15.1%; p=0.84), extent of pathology at electromyography (54.8% vs. 60.1%; p=0.43), and length of follow-up (26.9 vs. 32.5 months; p=0.31). The success rates of sphincter repair were 68.4% for Group I versus 55.9% for Group II (p=NS). Both groups were well matched for incidence of IAS imbrication as well as age, follow-up interval, and physiologic parameters. The success rates of anal sphincter repair were not statistically significant between the two groups. CONCLUSION: A pre-existing IAS defect does not preclude successful sphincteroplasty as compared to repair of an isolated EAS defect. Thus, patients with combined anal sphincter defects should not be considered as poor candidates for sphincter repair.

Anal Canal↗

PubMed2006

Ileal pouch anal anastomosis for ulcerative colitis is feasible for septuagenarians.

OBJECTIVE: Proctocolectomy and ileal pouch anal anastomosis (IPAA) has become the standard surgery for patients with mucosal ulcerative colitis (MUC). Although there is no absolute age limitation, there are concerns as to its use in elderly patients due to the risks of potential complications and poor function. The aim of this study was to assess the complications and outcome of patients over the age of 70 years with MUC who underwent IPAA. Results in these patients were compared to the results in a group of patients aged less than 70 years who had IPAA. METHODS: After Institutional Review Board approval, a retrospective review of the medical records of patients with MUC who underwent IPAA was undertaken. These patients were divided into four age groups: <30 years of age, 30-49 years, 50-69 years, >or=70 years. RESULTS: From 1989 to 2001, 330 patients underwent IPAA for preoperative clinical and histopathological and postoperative histopathologically confirmed MUC; 17 were aged>or=70 years. The mean hospital stay was 5.8 (SEM 0.7) days in the patients aged<70 years and 6.0 (SEM 0.4) days in the patients aged>or=70 years (P=0.911). Postoperative complications occurred in 39% of patients>or=70 years and in 40% in the <70 years group (P=0.08). Pouch failure occurred in two (11.8%) patients>or=70 years and in 6 (1.9%)<70 (P=0.2). CONCLUSION: IPAA is a safe and feasible option in MUC patients over the age of 70 with functional results similar to results seen in younger patients.

Adult↗

PubMed2006

Timing of restorative proctectomy following subtotal colectomy in patients with inflammatory bowel disease.

BACKGROUND: There is no general consensus regarding the timing of restorative proctocolectomy (RPC) in patients who have undergone subtotal colectomy with end ileostomy (STC). The aim of this study was to determine the impact of timing of RPC in patients who have undergone subtotal colectomy and end ileostomy for inflammatory bowel disease (IBD). METHODS: A retrospective medical record review of patients who had undergone RPC after STC was undertaken. Patients were divided into 3 groups according to timing of the completion proctectomy: 7 months. RESULTS: From 1990 to 2000, 91 patients had undergone RPC after STC for IBD. There were no statistically significant differences among the three groups relative to mean age, gender, final diagnosis, duration of disease, body mass index, comorbidity, extraintestinal manifestations, use of immunuosuppressives, or operative time. The number of intra-operative complications were significantly higher in the <or= 3 month group compared to the other groups. There was no significant difference in the overall incidence of postoperative complications among the 3 groups. Postoperative fistulas were significantly more common after RPC in Groups 1 and 2 as compared to Group 3. CONCLUSION: Restorative proctocolectomy performed within 3 months after the initial subtotal colectomy was associated with a significant increase in the incidence of intra-operative complications. Although this increase was not statistically significant, there was a significantly higher incidence of fistula formation when RPC was undertaken at up to 7 months after the subtotal colectomy for IBD. Thus, if possible, early RPC after subtotal colectomy should be discouraged.

Adult↗

PubMed2005

Quality of life after colectomy for colonic inertia.

BACKGROUND: Total abdominal colectomy (TAC) with ileorectal anastomosis represents the procedure of choice in patients with colonic inertia and relieves constipation in the majority of patients. The aim of this study was to assess postoperative long-term health related quality of life in these patients in relation to their functional outcome. METHODS: A consecutive series of patients with isolated colonic inertia who underwent TAC between 1993 and 1999 was identified from a clinical database and investigated in a cohort outcome study. Functional variables including the weekly number of bowel movements (BM), abdominal pain, bloating and distension, fecal incontinence, and the use of medications for BM assistance were assessed preoperatively and postoperatively. Main outcome measure was health-related quality of life assessed at follow-up using the SF-36 Health Survey. RESULTS: A total of 17 women with a mean age of 47.8 years (SD=14.3 years) were assessed and were followed postoperatively for 58.3+/-27.3 months. Preoperatively, all patients were constipated with less than one bowel movement per week, used laxatives, and experienced abdominal pain, bloating and distension. Postoperatively, all patients had some relief of constipation symptoms, with 3.7+/-2.8 bowel movements/day; 41% complained of abdominal pain, 65% of bloating, 29% required BM assistance, and 47% had occasional incontinence to gas or liquid stool. The SF-36 scores were significantly lower than those of the general population (p<0.005). In univariate regression analysis, postoperative abdominal pain was predictive for lower scores in general health and vitality and the need for BM assistance for lower scores in physical role functioning, social functioning, and emotional role limitations. CONCLUSIONS: After TAC, quality of life is significantly reduced in patients with colonic inertia despite successful relief of symptoms of constipation. Postoperative pain and functional impairment are predictive of lower quality of life scores.

Adult↗

PubMed2004

Anal ultrasound and endosonographic measurement of perineal body thickness: a new evaluation for fecal incontinence in females.

BACKGROUND: Perineal body thickness (PBT) is measured by endoanal ultrasonography. The literature has shown that women with obstetric trauma to the anal sphincter have decreased PBT, and a measurement of 10 mm or less has been proposed as abnormal. Therefore, this study aimed to compare the proposed definitions of normal to pathologic findings in patients with fecal incontinence (FI) and to correlate PBT with anorectal physiologic findings. METHODS: All female patients who had endoanal ultrasonography and PBT measurement for evaluation of FI were assessed and divided into three groups on the basis of PBT: 10 mm or less, 10 to 12 mm, more than 12 mm. The degree of FI (0 = complete continence; 20 = complete incontinence) was correlated with PBT. RESULTS: For this study, 83 female patients with a mean age of 59.7 years (range, 30-88 years) had endoanal ultrasonography and PBT measurement. Sphincter defects were suggested by endoanal ultrasonography in 77% of the patients in the three groups as follows: 57 (97%) of 59 patients, 4 (36%) of 11 patients, and 3 (23%) of 13 patients. The mean external sphincter defect angle was 110 degrees (range, 45-170 degrees ), and the mean FI score was 13.8. For 89% of the patients there was a history of vaginal delivery. As reported, 35% had undergone one or more prior perineal surgeries, 27% had both, and 4% denied having had either. A significant correlation between sphincter defect and PBT (p < 0.001) was noted. External sphincter defect angles were negatively correlated with PBT (p = 0.001). CONCLUSION: A PBT of 10 mm or less is considered abnormal, whereas a PBT of 10 mm to 12 mm is associated with sphincter defect in one-third of patients with FI. Those with a PBT of 12 mm or more are unlikely to harbor a defect unless they previously have undergone reconstructive perineal surgery.

Adult↗

PubMed2004

Can the procedure for prolapsing hemorrhoids (PPH) be done twice? Results of a porcine model.

BACKGROUND: The procedure for prolapsing hemorrhoids (PPH) is a new surgical method for the treatment of symptomatic hemorrhoids. In cases of recurrent prolapse, the performance of a second PPH may result in a ring of mucosa and submucosa between the two circular staple lines. In this study, we used a porcine model to assess whether PPH can be safely performed twice. METHODS: Five adult pigs underwent two PPH procedures in one session, leaving a ring of approximately 1 cm of mucosa between the two staple lines. One month later, the pigs were examined under anesthesia. The anal canal was assessed using the following four methods: (a) clinical examination, (b) evaluation of mucosal blood perfusion at different levels of the anal canal via a laser Doppler flow detector, (c) measurement of concentrations of hydroxyproline and collagen to check for fibrosis, and (d) histopathological examination. RESULTS: At the completion of the study period, all five pigs showed no clinical evidence of anorectal dysfunction. On examination under anesthesia 1 month after surgery, there was no evidence of anal stenosis in any of the pigs. The mean mucosal blood flow between the two staple lines did not differ significantly from the flow measured proximally and distally (394 vs 363 and 339 flow units, respectively; p = NS). The collagen levels, based on hydroxyproline concentration, were 81 mcg/mg between the staple lines, compared to 82 and 79 proximally and distally, respectively ( p = NS). There was no significant difference in degree of fibrosis, as assessed histopathologically, between specimens taken from the ring between the staple lines and specimens taken from the area external to the staple lines. CONCLUSIONS: The results of this porcine model suggest that a second synchronous PPH is feasible. A controlled experience involving human subjects is required to determine the safety and usefulness of this technique in cases of metachronous application for recurrent or residual hemorrhoids.

Animals↗

PubMed2004

Perineal rectosigmoidectomy for rectal prolapse: role of levatorplasty.

BACKGROUND: The management of full thickness rectal prolapse remains controversial. Although abdominal approaches have a lower recurrence rate than do perineal operations, they are associated with a higher morbidity. The aim of this study was to compare the outcomes of perineal rectosigmoidectomy with and without levatorplasty. METHODS: Between 1989 and 1999, a total of 109 consecutive patients (10 men) underwent 120 perineal procedures. These patients were retrospectively evaluated in two groups on the basis of the type of surgery received: perineal rectosigmoidectomy (PRS) or perineal rectosigmoidectomy with levatorplasty (PRSL). Subsequent functional outcome and physiological parameters were assessed. RESULTS: The patients had a mean age of 75.7 years (range, 23.0-94.8 years) and they were followed for an overall mean (in both groups combined) of 28.0 months (range, 0.4-126.4 months) after surgery. Mean duration of surgery was 78.1 min (SD=25.9) and 97.6 min (SD=32.3) in PRS and PRSL, respectively ( p=0.002, unpaired t test). There was no significant difference between the two groups in terms of hospital stay, morbidity or mortality. Recurrence rates and mean time interval to recurrence were, respectively, 20.6% and 45.5 months in PRS compared to 7.7% and 13.3 months in PRSL ( p=0.049, chi-square test; p=0.001, unpaired t test). Both groups had significant improvements in postoperative incontinence score ( p<0.0001, Wilcoxon's matched-pairs signed-ranks test), however, there were no significant changes in anorectal manometric findings and pudendal nerve terminal motor latency assessment. CONCLUSIONS: Perineal rectosigmoidectomy with levatorplasty is associated with a lower recurrence rate and a longer time to recurrence than perineal rectosigmoidectomy alone. Levatorplasty should be offered to patients when a perineal approach for rectal prolapse is selected.

Adult↗

PubMed2004

The effect of diverticular disease on the colonic J pouch.

OBJECTIVE: The aim of this study was to assess the impact of the diverticular disease (DD) on function and on postoperative complications of the colonic J-pouch (CJP) with pouch-anal anastomosis. METHODS: Patients who underwent a CJP between December 1990 and August 2001, were retrospectively reviewed. The presence of DD in the CJP was assessed on pouchogram prior to ileostomy closure. A questionnaire designed to evaluate the degree of continence (total incontinence score (IS): 0 = worst, 20 = best) and pouch evacuation (total evacuation score (ES): 0 = worst, 28 = best) was used for comparison between patients with DD and those without DD (NDD). RESULTS: Sixty-six patients (47 males; 19 females) with a median age of 68 years (range 28-87 years) were included. The median follow-up period was 22 months (range 2-106 months). Twenty-four patients comprised the DD group and 42 were in the NDD group. The two groups were comparable for age, gender and time from ileostomy closure; all patients with postoperative chemoradiation therapy were in the NDD group. The total ES and IS total did not significantly differ between the two groups with a P-value of 0.11 and 0.09 respectively. Furthermore, there was no significant difference in the total incidence of pouch complications between the two groups (3 strictures, 1 leak, 1 fistula in the NDD group vs. 1 pelvic sepsis in the DD group; P = 0.4). CONCLUSIONS: The presence of DD in a CJP does not seem to impact pouch function or the postoperative complication rate.

Aged↗

PubMed2004

High compliance rates observed for follow up colonoscopy post polypectomy are achievable outside of clinical trials: efficacy of polypectomy is not reduced by low compliance for follow up.

INTRODUCTION: The National Polyp Study demonstrated that removal of adenomas with at least a three-year follow up reduced the incidence of colorectal cancer. However, compliance with follow up colonoscopy may affect the estimates of reduction in colorectal cancer incidence demonstrated by the National Polyp Study. While an 80% compliance rate for follow up colonoscopy was achieved during the National Polyp Study, the compliance rate for follow up colonoscopy is unknown in the general population. The aim of this study was to determine the compliance rate for follow up colonoscopy and factors which affect follow up. METHODS: A retrospective medical record review to identify patients who had adenomatous polyps excised in 1997 was undertaken. Patients who had inflammatory bowel disease, a prior history of colorectal cancer, familial adenomatous polyposis syndrome, colonic surgery; incomplete polypectomy or incomplete colonoscopy, and those patients who died before planned follow up, were excluded from analysis. Follow up was performed by telephone survey. RESULTS: Three hundred and thirty-three patients were identified (196 males; 147 females) with a mean age of 70 years. Three hundred and thirty-one (99%) of 333 had a documented recommendation for follow up of three years or less. Thirty-four percent (113 of 333) had previously undergone colonoscopy; 29% (98 of 333) had previously undergone polypectomy and 54% (180 of 333) were symptomatic at the time of the colonoscopy. Twenty-eight percent (40 of 141) had a family history of colorectal cancer. Pathology at polypectomy included a single polyp and polyps less than 10 mm in 68% and 88% of cases, respectively. Follow up was available in 211 of these cases, 179 (85%) of which had been compliant with follow up colonoscopy. In a univariate analysis, previous colonoscopy (P = 0.035), previous polyps (P = 0.043), asymptomatic status at time of colonoscopy (P = 0.021), polyp size (P = 0.008) and number of polyps (P = 0.010) were significantly associated with patients who were compliant with follow up colonoscopy. A multivariate logistics regression analysis revealed number of polyps (P = 0.036) and polyp size (P = 0.045) to be statistically significantly associated with compliance. CONCLUSION: Compliance with follow up colonoscopy after polypectomy is greater than 80%, regardless of age, education, family history, prior colonoscopy, or prior polypectomy. Risk reduction published in the National Polyp Study may likely reflect what can be achieved through the general use of colonoscopy for surveillance.

Adenomatous Polyps↗

PubMed2004

Is routine pouchogram prior to ileostomy closure in colonic J-pouch really necessary?

INTRODUCTION: Colonic J-pouch with coloanal anastomosis has gained popularity in the surgical treatment of middle and lower rectal pathologies. If a diverting ileostomy is performed, a pouchogram is frequently performed prior to ileostomy closure. The aim of this study was to assess the routine use of pouchogram prior to ileostomy closure in patients with colonic J pouch-anal anastomosis. METHODS: All patients who underwent a colonic J pouch-anal anastomosis between 1990 and 2000 were retrospectively reviewed. Patients with temporary loop ileostomy who had pouchogram prior to ileostomy closure were included. Pouchogram results were compared to the patient's post ileostomy closure clinical outcome. Sensitivity, specificity and predictive values of pouchogram were assessed. RESULTS: Eighty-four patients had a pouchogram prior to ileostomy closure. Radiological abnormalities were evident in 6 patients, including 4 strictures, 1 pouch-vaginal fistula and 1 leak. Of these findings, 4 were false positives (3 strictures and 1 leak) and two were true positives (1 stricture and 1 pouch-vaginal fistula). The actual rate of pouch complications was 9.5% (8 complications) including 3 anastomotic leaks, all with normal pouchogram, 3 strictures requiring dilatation under anaesthesia, only one detected by pouchogram, and 2 pouch-vaginal fistulas, only one diagnosed by pouchogram. The sensitivity and specificity of pouchogram, respectively, was 0 and 98% for anastomotic leak, 33 and 96% for stricture, and 50 and 100% for pouch-vaginal fistula. Overall, pouchogram changed the management in only 1 of 84 patients. CONCLUSION: Pouchogram has a low sensitivity in predicting complications following ileostomy closure in patients after colonic J-pouch anal anastomosis and rarely changes the management of these patients. The use of pouchogram prior to ileostomy closure may be unnecessary and should be reserved in cases of clinical suspicion of complications.

Adult↗

PubMed2003

Colonoscopy: why are general surgeons being excluded?

BACKGROUND: The role of surgeons as endoscopists has been extensively debated in the literature, with conflicting studies published regarding the safety and efficacy of surgeons performing colonoscopies. A multitude of medical federations and societies have set various standards for granting endoscopy privileges, many with a bias against general surgeons [1, 3]. We reviewed the colonoscopy experience at our institution to evaluate differences between gastroenterologists (GI) and general (GS) and colorectal surgeons (CRS) in procedure times and complication and cecal intubation rates. METHODS: Between January 2000 and July 2002, 5237 colonoscopies were performed at our institution. The data for procedure times, completion, and complication rates were collected in a prospective database. Complications were defined as perforation, bleeding, and postpolypectomy syndrome. Incomplete colonoscopies due to colitis, poor bowel preparation, or tumor obstruction were excluded. Chi-squared test was used to compare complication and cecal intubation rates between the three groups. Median procedure times were compared using the Kruskall-Wallis and Dunn's pairwise tests. A significant p-value was defined as <0.05. RESULTS: No differences in the complication rate was noted between the three groups: GI (0.12%), CRS (0.15%), and GS (0.11%) ( p = 0.99). There was a trend toward a lower incomplete colonoscopy rate in the GS group compared to CRS and GI: 0.32% vs 0.84% and 0.36%, respectively ( p = 0.07). The median colonoscopy times for GS (29 min), however, were shorter than for GI (34 min, p < 0.001) or CRS (31 min, p < 0.001). CONCLUSION: General surgeons perform colonoscopies expeditiously, with as low a morbidity rate and as high a completion rate as their gastroenterology or colorectal surgery colleagues. As the results of this study confirm, general surgeons should not be excluded from endoscopy suites.

Cecostomy↗

PubMed2003

Screening colonoscopy in the asymptomatic 50- to 59-year-old population.

BACKGROUND: In an effort to decrease the death rate from colorectal cancer, a multitude of medical societies and task forces recommend routine screening for colorectal cancer beginning at age 50. Yet, there is no consensus as to the best and most cost-effective screening method. Medicare now pays for screening colonoscopies for its average risk beneficiaries [3]. Many insurance companies, however, will not cover this test in younger patients. We therefore reviewed our institution's colonoscopy experience with asymptomatic 50- to 59-year-olds, with negative fecal occult blood tests and negative family histories. METHODS: Between January 1999 and January 2002, 4779 colonoscopies were performed at our institution. The charts for 619 persons 50-59 years of age were retrospectively reviewed, with 91 patients meeting the strict requirements of this study. We defined polyps with high-grade neoplasias as those with villous or tubulovillous components, and cancerous lesions included those with carcinoma in situ. The distal colon was defined as the rectum and sigmoid colon. RESULTS: There was a 58% incidence of neoplastic polyps in this younger asymptomatic population. More than 4% of our subjects had high-grade neoplasias or cancerous lesions. In the absence of any distal findings, flexible sigmoidoscopy would have missed up to 38% of these polyps. CONCLUSIONS: The findings generally support the recommendations by the American College of Gastroenterology for average-risk patients to preferentially undergo a screening colonoscopy at age 50 in lieu of other methods.

Adenocarcinoma↗

PubMed2001

The pathology and molecular biology of anal intraepithelial neoplasia: comparisons with cervical and vulvar intraepithelial carcinoma.

BACKGROUND: Anal intraepithelial neoplasia (AIN) is a well-described pathological precursor of invasive squamous cell carcinoma which has recently been detected with increasing frequency in immunocompromised patients, particularly those with seropositivity for human immunodeficiency virus (HIV). The epidemiology and natural history of this entity is somewhat unclear, since the overall prevalence in the HIV seronegative population is unknown. DISCUSSION: There is a clear etiological association between AIN and high-risk human papillomavirus (HPV) subtype infection although there is great variability in HPV DNA detection of cytological and histological material in these patients. It appears that there is an antigen-specific hyporesponsiveness by cytotoxic lymphocytes against HPV peptide sequences or recombinant proteins encoded by oncogenic HPV subtypes in these patients, which is dependent upon the stage of their HIV-associated disease. Although the molecular biology of AIN and cervical or vulvar intraepithelial neoplasia are comparable, in AIN there is less significance of tumor suppressor gene mutations, proto-oncogenic growth factor activation, and genomic instability. CONCLUSION: Current concepts in the epidemiology and etiology of AIN are discussed, as well as its immunological response in the HIV-positive population, drawing parallels where possible between other HPV-related preinvasive disorders, and concluding with a suggested management protocol

Anus Neoplasms↗

PubMed2001

Converted laparoscopic colorectal surgery.

BACKGROUND: Conversion rates following laparoscopic colorectal surgery vary widely between studies, and the outcome of converted patients remains controversial. METHODS: A comprehensive search of the English-language literature was updated until May 1999. RESULTS: Twenty-eight studies on 3232 patients were considered for analysis. The overall conversion rate was 15.38%. Seventy nine percent of the studies did not include a definition for conversion; in these studies, the conversion rate was significantly lower than in the series where a specific definition was considered (13.7% vs 18.9%, chi-square test, p < 0.001). Converted patients had a prolonged hospital stay (11.38 vs 7.41 days) and operative time (209 vs 189 min) in comparison with laparoscopically completed patients (95% confidence interval (CI), 1.70-4.00 and 35.90-37.10, respectively). The factors associated with an increased rate for conversion were left colectomy (Odds Ratio [OR] = 1.061), anterior resection of the rectum (OR = 1.088), diverticulitis (OR = 1.302), and cancer (OR = 2.944) (for each parameter, Wald chi-square value, p < 0.001). CONCLUSIONS: In nonrandomized studies, the rate of laparoscopically completed colorectal resections is close to 85%. Because converted patients have a distinct outcome, a clear definition of conversion is required to compare the results of randomized trials. Such trials should also consider a 20% rate of conversion when estimating the sample size for the desired power level. It is likely that converted patients will have a significant impact on the results of future clinical research in laparoscopic colorectal surgery.

Aged↗

PubMed2001

Quantitative short-term study of anal sphincter function after chemoradiation for rectal cancer.

HYPOTHESIS: Pelvic irradiation adversely affects anal sphincter function after proctectomy with coloanal anastomosis for low rectal and middle rectal (<10 cm from the anal verge) tumors. DESIGN: Case-control study. SETTING: Private, tertiary care referral center. PATIENTS: Patients treated for low rectal adenocarcinoma between January 1, 1994, and October 31, 1999. INTERVENTIONS: Anal manometric data were prospectively collected at the time of initial diagnosis and before ileostomy closure. MAIN OUTCOME MEASURES: Mean and maximum resting pressures (RPs) and squeeze pressures, threshold volume for sensation, and maximal tolerable volume. RESULTS: Twenty-three patients in the surgery group and 19 in the chemoradiotherapy group were considered for analysis; 15 patients had preoperative radiotherapy and 4 had postoperative radiotherapy. At the time of ileostomy closure, RPs were significantly lower in the chemoradiotherapy group than in the surgery group (32.7 +/- 17 vs 45.3 +/- 18 mm Hg; P =.03). Squeeze pressures were not significantly different between the surgery and chemoradiotherapy groups (108.7 +/- 56.7 vs 102.0 +/- 52.6 mm Hg; P =.69). The ratios of postresection to preresection RPs were also significantly lower in the chemoradiotherapy group (0.49 +/- 0.29) than in the surgery group (0.76 +/- 0.22) (P =.005). Eight to 12 weeks after proctectomy with coloanal anastomosis, a 24% decrease in RP was noted in the surgery group. The addition of adjuvant pelvic irradiation decreased RP by another 27%. CONCLUSION: Adequate shielding of the anal sphincter should be performed for low rectal cancers whenever a sphincter-preserving procedure is considered.

Adenocarcinoma↗

PubMed2001

Loss of heterozygosity and HIV infection in patients with anal squamous-cell carcinoma.

PURPOSE: This study was designed to determine whether loss of heterozygosity and/or microsatellite instability correlate with HIV infection and tumor recurrence after chemoradiation therapy in patients with squamous-cell carcinoma of the anus. BACKGROUND: The molecular mechanisms leading to the progression of HIV-related squamous-cell carcinoma of the anus are poorly understood. In particular, genetic alterations responsible for resistance to chemoradiation have important clinical and functional implications. METHODS: In a case-control study, we analyzed normal and tumor DNA samples of four patients with squamous-cell carcinoma of the anus who were successfully treated with chemoradiotherapy and four patients with radio-resistant squamous-cell carcinoma of the anus who required abdominoperineal resection for local recurrence. To determine the presence of microsatellite instability, we used the reference panel of five pairs of microsatellite primers recommended for colorectal cancer specimens. These include the microsatellite markers BAT25, BAT26, D5S346 (APC), D2S123 (hMSH2), and D17S250 (P53). In addition, we used microsatellite markers for loss of heterozygosity analyses that were tightly linked to tumor suppressor genes. These included D3S1611 (hMLH1), D17S513 (P53), D18S46 and 18qTA (DCC/SMAD4), D5S107 (APC), and CA5 (hMSH2). RESULTS: There were two HIV-positive and two HIV-negative patients in each group. Three HIV-positive patients (one in the chemoradiotherapy group and two in the nonchemoradiotherapy group) demonstrated loss of heterozygosity. In the chemoradiotherapy group, one HIV-positive patient demonstrated loss of heterozygosity at the hMLH1 locus. In the nonchemoradiotherapy group, two HIV-positive patients exhibited a total of four instances of loss of heterozygosity. One tumor had loss of heterozygosity at hMSH2 and DCC/SMAD4; another tumor demonstrated loss of heterozygosity at hMSH2 and APC. Microsatellite instability-low was found in two HIV-positive patients. No instances of loss of heterozygosity and microsatellite instability were detected in HIV-negative patients. CONCLUSION: Loss of heterozygosity and microsatellite instability, which reflect inactivation of tumor-suppressor genes and genomic instability, occur with increased frequency in HIV-associated squamous-cell carcinoma. These data demonstrate for the first time evidence of loss of heterozygosity at the APC and DCC/SMAD4 gene loci in anal carcinoma. Although the findings presented here need to be expanded in a larger study, the recurrent loss of heterozygosity at D2S123, which was demonstrated in HIV-positive patients with radio-resistant squamous-cell carcinoma of the anus, is notable.

Adult↗

PubMed2001

Effect of age on the functional outcome of total abdominal colectomy for colonic inertia.

OBJECTIVE: Colonic inertia (CI) usually presents in women in the third decade of life; however, elderly patients are at times diagnosed with the disease. Total abdominal colectomy (TAC) is considered the preferred surgical treatment for patients with well established CI refractory to conservative and medical management. Surgeons are reluctant to proceed with colectomy in aged patients because of anticipated high morbidity and poor functional outcome. MATERIALS AND METHODS: We retrospectively reviewed the outcome in 14 patients over the age of 65 years (range 65-80) (Group I) who underwent TAC for CI between 1988 and 1996. The functional and clinical outcome was compared with that of 41 patients under the age of 65 (range 21-61) (Group II) operated upon during the same time period. Functional outcome was assessed by postal and telephone questionnaires at least 12 months following surgery. RESULTS: There was no major postoperative morbidity in either group. Three (21%) patients in Group I developed small bowel obstruction postoperatively and, of them, 2 required surgical treatment. In Group II the rate of obstruction was 7% (3 patients), with one patient requiring surgery. One patient in Group I subsequently underwent completion proctectomy and creation of an end ileostomy due to continued panenteric hypomotility. Three patients in Group I died during follow-up from causes unrelated to surgery. The mean frequency of spontaneous bowel movements following surgery was 3.8 (range 1-10)/day in Group I and 2.9 (range 1-8)/day in Group II (P=NS). 'Excellent' outcome was reported by 7 patients (64%) in Group I and 39 patients (95%) in Group II (P=0.01). CONCLUSION: TAC can be performed in elderly patients with established CI with acceptable functional results and no increase in morbidity, resulting in lifestyle improvement. Complete physiological evaluation with increased emphasis on small bowel and gastric motility studies is required in this patient population.

Journal Article↗