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PubMed1999

Approach to the patient.

A systematic approach to the patient with anorectal complaints allows for an accurate and efficient diagnosis of the underlying problem. The process can be divided into the interview, the examination, treatment, and conveyance of information. Throughout this process, the patient must be reassured and made as comfortable as possible. A successful interaction with the patient leads to a diagnosis and a treatment plan that is acceptable to both the physician and the patient.

Anus Diseases↗
PubMed1989

Congenital hypertrophy of the retinal pigment epithelium in familial adenomatous polyposis.

One hundred fifty-three members of 56 kindreds with familial adenomatous polyposis (FAP) underwent funduscopic examination for congenital hypertrophy of the retinal pigment epithelium (CHRPE). All patients underwent wide-angle fundus photography to document lesions, proctosigmoidoscopy to document polyps, and examination for extracolonic manifestations. Ninety-seven patients were diagnosed as having FAP and 56 patients were offspring of FAP patients and thus at 50% risk of inheriting the disease. In two thirds of the kindreds, CHRPE could be used as a congenital phenotypic marker to predict the presence or development of polyps. In these kindreds, all patients with diagnosed FAP and 39% of the patients at risk had at least four CHRPE lesions. In one third of the kindreds, CHRPE could not be used as a predictive congenital marker, and in these kindreds all patients had zero to three total lesions of CHRPE. The presence of CHRPE did not correlate with any other extracolonic manifestations. In kindreds without any other extracolonic manifestations, CHRPE can still be present and can be used as a predictive congenital phenotypic marker.

Adenomatous Polyposis Coli↗
PubMedDate not supplied

[EUS results of malignant rectal giant condyloma acuminatum (Buschke-Loewenstein tumor)].

Giant condyloma acuminatum is a large, exophytic, cauliflower-like lesion that usually affects the anogenital region. Localisation in the rectum is uncommon and has a high rate of malignant transformation but does not lead to develop distant metastases. For the time, we report the endosonographic appearance of a malignant intrarectal giant condyloma acuminatum.

Aged↗
PubMed1995

Cancer of the rectum--palliative endoscopic treatment.

Three methods of palliative endoscopic treatment of malignant strictures of the rectum are presented: laser therapy and its combination with the implantation of either plastic prostheses, or self-expanding metal stents. The aim of all procedures is to avoid a colostomy at least in older patients with shorter life expectancy and incurable tumours. The additional application of a stent maintains the luminal patency and prevents the repetition of laser therapy. Since 1988 we have treated 60 patients with these techniques. First, two to six sessions of laser therapy were necessary for recanalization of the stenosis. In the time following this the patients returned two to eight times for regular laser therapy before they died from the carcinoma. In spite of laser therapy one patient developed an obstruction and another suffered from an iatrogenic perforation of the rectal cancer. In both cases a stoma was fashioned. To avoid repetitive laser sessions we successfully inserted a plastic endoprosthesis in seven cases. In another two cases the implantation failed because of perforation and the patients had to undergo surgery. For the next 10 cases we have used flexible self-expanding metal stents. Serious complications or signs of re-obstruction were not observed until the patients' death. The survival time ranged from 2 to 25 months.

Aged↗
PubMed1997

Endocavitary Ir-192 radiation and laser treatment for palliation of obstructive rectal cancer.

Endoscopic laser therapy (ELT) either alone or combined with endocavitary Ir-192 radiation is performed for advanced, inoperable rectal cancer and when patients are ineligible for surgery due to severe concomitant medical illness. During the period from January 1984 to January 1997 we treated 81 patients (51 males, 30 females). Sixty-seven patients had ELT only using a ND-Yag Laser system. Twenty-five patients (average age: 80.5 years) were ineligible for surgery (Group I). Forty-two patients (74.1 years) had an advanced locally inoperable tumour (Group II). Fourteen patients (76.5 years) underwent a combined therapeutic regime with endocavitary Ir-192 afterloading following ELT (Group III). Adequate desobliteration was achieved in 100% (groups I and III) and 97% (group II) of the patients. The average interval to aftertreatment was 8.4 weeks in group I and 9.4 weeks in group II, compared to 11.5 weeks in group III. Serious complications (perianal abscess, rectovaginal fistula) occurred in 3.7%, minor complications (laser-induced bleedings, unclear fever) in 12.3%. All laser-induced bleedings could be dealt with using laser therapy. The frequency of treatment was governed by tumour mass and the patient's survival. The results suggest that additional endocavitary radiation significantly prolongs the maintenance of normal bowel function compared with laser therapy alone.

Aged↗
PubMed1998

Sphincter preservation in rectal cancer. Surgical considerations for local excision.

The principles involved in selecting patients for local excision of rectal cancers, as well as the various techniques and principles for local resection, are detailed in this article. The assessment of the current role of this technique awaits further maturation of data from phase II clinical trials. The addition of chemotherapy and radiation therapy may allow treatment of more advanced rectal cancers by these techniques.

Abdomen↗
PubMedDate not supplied

Laparoscopic-assisted vs. open colectomy for colorectal cancer: influence on neoplastic cell mobilization.

Laparoscopic surgery for treatment of colorectal cancer has been suggested to enhance tumor dissemination. Recently, molecular techniques have been developed to detect micrometastatic disease in patients with solid tumors, with a higher accuracy than cytologic or immunohistochemical approaches. This study was undertaken to investigate the potential harmful effects of laparoscopic-assisted colectomy on neoplastic cell mobilization in patients with resectable colorectal cancer. Fifty patients with nonmetastatic colorectal cancer were randomly assigned to laparoscopic-assisted (LAC, n = 26) or open (OC, n = 24) colectomy. Peripheral venous blood samples were obtained preoperatively, immediately after tumor removal, and 24 hours later. In 10 patients from each treatment group, portal blood and peritoneal fluid samples were also obtained before and after resection. Neoplastic cells were detected by means of reverse transcriptase-polymerase chain reaction targeted to carcinoembryonic antigen (CEA) transcription. CEA mRNA was detected in peripheral venous blood samples from 35 of 50 colorectal cancer patients preoperatively. Among those 15 baseline-negative patients, four experienced conversion 24 hours after tumor resection (2 [33%] of 6 in the LAC group vs. 2 [22%] of 9 in the OC group; NS). At that time point, clearance of CEA mRNA expression was observed in 14 of the 35 baseline-positive patients (9 [45%] of 20 in the LAC group vs. 5 [33%] of 15 in the OC group; NS). In addition, only one patient in the LAC group with baseline-negative CEA mRNA expression experienced portal blood conversion after tumor removal, although his peripheral blood level remained negative. Finally, baseline peritoneal fluid CEA mRNA expression was never detected, but one patient in each group became positive postoperatively. These results confirm that preoperative and perioperative mobilization of neoplastic cells is a frequent occurrence in patients with colorectal cancer, but the surgical approach (LAC vs. OC) does not seem to be a determining factor.

Adult↗
PubMedDate not supplied

Endoscopic transanal resection provides palliation equivalent to transabdominal resection in patients with metastatic rectal cancer.

Patients with metastatic rectal cancer precluding curative low anterior resection (LAR) or abdominoperineal resection (APR) can require palliation for impending obstruction. LAR or APR is frequently not optimal because of the associated operative morbidity. Lesser procedures such as diverting colostomy require patients to live with a permanent stoma. Endoscopic transanal resection (ETAR) has been used for excision of rectal lesions. To determine whether ETAR provides palliation equivalent to LAR or APR, we reviewed the outcomes of 49 patients with rectal adenocarcinoma and unresectable liver metastases who required palliative intervention between January 1989 and July 1996. Of these 49 patients, 24 underwent ETAR; the intraluminal tumor was resected using the urologic resectoscope to achieve a hemostatic, patent lumen. The outcomes of these patients were compared to those of the other 25 patients who had palliative LAR, APR, or a Hartmann procedure during the same period. The median distance of the tumors from the anal verge was similar (5 cm; range 1 to 15 cm). ETAR patients had a higher percentage of poorly differentiated tumors (35% vs. 6%, P = 0.034) and higher preoperative alkaline phosphatase values (478 +/- 75 mg/dl vs. 231 +/- 24 mg/dl; P < 0.015), suggesting more aggressive disease and greater hepatic tumor burden, respectively. Despite these differences, overall survival and time spent outside the hospital were similar in the two groups. The median number of debulking procedures required in the 24 ETAR patients was two (range 1 to 17). Resections in the 25 LAR/APR patients included LAR in 20, APR in two, and Hartmann procedures in three. There was a trend toward more stomas in the LAR/APR group (28% vs. 17%). More important, morbidity was significantly higher in the LAR/APR patients (24% vs. 4%; P = 0.049). In conclusion, ETAR is a safe alternative for the palliation of incurable rectal tumors. Compared to transabdominal resection, ETAR provides equivalent palliation as measured by survival and proportion of the patient's life spent outside the hospital, with a lower stoma rate and significantly less morbidity. Therefore, in select patients with metastatic rectal cancer, ETAR is an important palliative option.

Adenocarcinoma↗
PubMed2005

Transanal endoscopic microsurgical repair of iatrogenic recto-urethral fistula.

BACKGROUND: Recto-urethral fistula formation following radical prostatectomy is an uncommon but potentially devastating event. Traditional surgery for such fistulae is technically demanding, jeopardizes continence and usually necessitates a diverting colostomy. We present the case of an iatrogenic fistula treated by a transanal endoscopic microsurgical approach, without recourse to a stoma. METHOD: A 71-year-old man had recently undergone a radical prostatectomy, complicated by significant intra-operative haemorrhage. He subsequently developed a recto-urethral fistula, confirmed clinically and endoscopically. Due to his bleeding diathesis, he was considered for, and underwent, a transanal endoscopic microsurgical (TEMS) repair. CONCLUSION: TEMS is a safe and reliable minimally-invasive surgical technique for the treatment of this difficult condition.

Aged↗
PubMed2003

[Rational assessment and therapy of diarrhea].

Patient history, physical examination and basic laboratory tests often allow the clinician to suspect one of the numerous aetiologies of diarrhea and consequently establish a rapid diagnosis. Otherwise, the workup of diarrhea, especially when chronic, may represent a challenge. In this brief tutorial article a practical algorithm is proposed to guide the clinician through the initial diagnostic steps as well as therapeutic trials.

Acute Disease↗
PubMed2003

[New modalities and concepts in the treatment of hemorrhoids].

The surgical treatment of haemorrhoids has significantly changed by introducing new techniques in the last years. Nowadays, low grade haemorrhoids, grade II and III, are easily and painfree treatable by a minimal invasive, Doppler transducer guided ligation of the haemorrhoidal arteries. In cases of circular protruding haemorrhoids, grade III and IV; the stapled mucosectomy described by Longo is also a new effective treatment. Both procedures can be performed for an outpatient or with short hospital stay and allows patients to return to work earlier compared to conventional techniques. Additionally, due to the new techniques the treatment of haemorrhoids is less painful and has increased patients' satisfaction. Therefore, the traditional haemorrhoidectomy, the Milligan-Morgan or the Ferguson procedure, has become less common and is only performed in a few special indications.

Female↗
PubMed2001

Transanal excision for T1 and T2 rectal cancer--efficacy of local resection vs. adjuvant therapy. Extended abstract.

The principal goal in the management of any patient with rectal cancer is to provide the optimum chance for cure while maintaining their quality of life. Treatment options over the past century have reflected our ability to provide safe surgical care and, more recently, a greater understanding of tumor biology. Prior to the introduction of the abdominoperineal resection (APR) that was reported in the Lancet in 1908 by Sir Ernest Miles, perineal excision was the accepted approach for nearly all rectal cancer. Unfortunately, inconsistent surgical outcomes and high local recurrence even in Miles personal experience promoted alternative treatment. The acceptance of APR and subsequently low anterior resection reduced recurrence and improved long-term survival but often with the cost of decreased quality of life. A recent review by McCall et al. report disease specific recurrence at 8.5 percent, 16.3 percent and 28.6 percent for cancer stages I, II and III respectively with an overall reported recurrence rates following APR ranging from 10 to 29 percent. Reported five-year survival rates range 78 to 100 percent for stage I, 45 to 73 percent for stage II and 22 to 66 percent for stage III. The wide variations in recurrence and survival rates likely reflect differences in tumor size, proximity to the anal canal, depth of penetration in the rectal wall and unfavorable histologic characteristics. An additional confounding variable in the management of rectal cancer has been the use of adjuvant therapy do in part to the timing and dose/fractionation differences utilized. Given the variation in outcomes with APR and ongoing concerns regarding morbidity and quality of life issues associated with radical resection, many centers have revisited local therapy as a means of managing select patients with distal rectal cancers. These therapies include transanal and transcoccygeal excision as well as endocavitary radiation and even fulguration. It is the belief of many surgeons that our ability to more accurately stage patients preoperatively and add adjuvant therapy when indicated will improve our success with local excision.

Chemotherapy, Adjuvant↗
PubMed2003

Two siblings with total colonic aganglionosis extended to the ileum. Treatment with a modified Duhamel-Martin procedure.

UNLABELLED: Total colonic aganglionosis (TCA) extended to the ileum is seen quite rare among infants with Hirschsprung's disease. Type and timing of definitive surgery in these patients are controversial. This report was presented to discuss the management of two siblings with TCA. Case 1: A two-day-day-old girl was operated for partial intestinal obstruction. During laparotomy, serial frozen biopsies proved TCA extended to the terminal ileum and a loop ileostomy was performed. At five months of age, a modified Duhamel-Martin procedure without protective ileostomy was performed. An endo-GIA stapler was transanally used for colo-ileal anastomosis. She is doing well for the last five years. Case 2: A one-day-old boy admitted to the hospital with similar findings to his sister. Frozen biopsies during first laparotomy proved that majority of ileum and entire colon was aganglionic and a proximal ileostomy was performed. At 10 months of age, he underwent a similar Duhamel-Martin operation. He is in a good condition for the last four years. CONCLUSION: In infants, our modification on Duhamel-Martin procedure, which is based on the use of an endo-GIA stapler transanally for colo-ileal anastomosis without protective ileostomy, may be utilized as an alternative method in the definitive treatment of patients with TCA.

Anastomosis, Surgical↗
PubMed1997

Efficacy and tolerance of mesalazine suppositories vs. hydrocortisone foam in proctitis.

BACKGROUND: Topical treatments with steroids or mesalazine are the most effective treatments for idiopathic proctitis. AIM: To compare the efficacy and tolerance of mesalazine suppositories vs. hydrocortisone acetate foam in the treatment of acute proctitis. PATIENTS AND METHODS: 242 patients with active idiopathic proctitis were randomized to receive once daily either one Pentasa suppository (mesalazine 1 g) or 100 mg hydrocortisone (Colofoam) for 14-21 days (until remission). Disease activity and tolerance of the treatments were assessed using a daily questionnaire, by physician assessment, and endoscopy score. RESULTS: Both treatments induced a significant reduction in disease activity. Mesalazine suppositories were significantly more effective than hydrocortisone on rectal blood loss (P = 0.002) and mucus (P = 0.02) parameters, and on the degree of the decrease in endoscopy score (P = 0.02). No significant difference was observed between treatments concerning histology or tolerance. CONCLUSION: Mesalazine suppositories were as well-tolerated as hydrocortisone foam, but were more effective for some parameters of disease activity.

Acute Disease↗