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PubMed1997

[Treatment of recto-urethral fistulas in Crohn's disease].

We report the thirteenth case of a rectourethral fistula in Crohn's disease. The patient, a 37 year-old-white male, had a 20 year history of intestinal Crohn's disease and had undergone numerous bowel resections. His symptoms were fecaluria, urorrhea and passing of urine from an orifice just outside the base of the scrotum. He had urinary infection and severe ileocolitis. He underwent a diagnostic evaluation that revealed a fistula comprising the membranous urethra, the rectum, the perineum and the scrotum. We performed medical therapy with metronidazole (20 mg/kg/day/12 months). We present in this article a review of the literature on the management of rectourethral fistulas in Crohn's disease. Surgeons have successfully used several approaches in the repair of this disorder, but no single procedure had proved to be best or even universally applicable. We emphasize, as the literature suggests, that management must be individualized. Medical therapy with metronidazole has an important role in a patient with rectourethral fistula and concomitant proctitis, ileocolitis, urinary sepsis and multiple previous surgeries.

Adult↗
PubMed1998

[Surgical options in ulcerative colitis].

Surgery is needed in every second patient with pancolitis. Historically four surgical options have been developed: conventional ileostomy, ileorectostomy, continent ileostomy (Kock's pouch) and ileo-anal pouch. However, in emergent or unclear situations subtotal colectomy, ileostomy and preservation of the rectum is the most suitable operation. After recovery and in elective indications proctectomy and proctocolectomy establish the general surgical standard. Today, in most cases ileo-pouch-anal anastomosis is performed instead of creation of an ileostomy. Both lowered frequency of defecation and acceptable continence contribute to a better quality of life. However, functional disturbances are not uncommon and result in most cases from complications of the demanding technique. Definitive cure of the colitis is in interference with the risk of pouchitis in about 30%. The cumulative probability to loose the pouch may rise to 15-20% in the long-term course. Thus, ileorectostomy may be considered as a first step of surgical treatment, since pelvic nerve damage is excluded, function is much better and persistent proctitis can be treated topically. The attractively is that ileo-anal pouch can be performed later on, when decreasing function and increasing risk of malignant change will eventually require proctectomy. A Kock-pouch is seldom considered, especially in patients with ileostomy wishing sure fecal control. But the continent reservoir becomes more and more interesting again since it can be reconstructed from a failed ileo-anal pouch without loss of bowel. Conventional ileostomy should be reserved for patients not suitable for reconstructive methods or those who consider pough operations risk. However, it is the safest procedure with absolute cure of disease. The optimal choice of method considers medical and surgical aspects as well as patients conception and desire.

Colectomy↗
PubMed1998

'One-stop' rectal bleeding clinics without routine flexible sigmoidoscopy are unsafe.

Over 90% of patients referred to surgeons for investigation of rectal bleeding have haemorrhoids, fissure-in-ano or proctitis. Full investigation of these patients to exclude colonic neoplasia or inflammatory bowel disease imposes a considerable load on a hospital's resources as well as exposing the patient to significant inconvenience and morbidity. A 'one-stop' outpatient clinic was established, with selective use of flexible sigmoidoscopy, based on the judgement and clinical findings of a single experienced surgeon. Over a 4 month period, 344 patients were assessed, and 326 were identified as not needing flexible sigmoidoscopy. At 3 and 6 monthly follow-up, 22 presented with persistent rectal bleeding and three previously unidentified cancers were found on performance of flexible sigmoidoscopy. If a 'one-stop' policy is to be used in the management of rectal bleeding, routine flexible sigmoidoscopy is essential for all patients.

Adult↗
PubMed1998

High dose combination radiotherapy for the treatment of localized prostate cancer.

PURPOSE: We evaluate the efficacy of high dose combination radiotherapy for the treatment of localized prostate cancer. MATERIALS AND METHODS: A total of 212 patients with localized prostate cancer (T1-T3) were treated with transperineal radioactive seed implantation followed by 45 Gy. external beam radiation therapy. Patients with Gleason scores of 2-5 were treated with 125iodine at a minimum peripheral dose of 120 Gy., while 103palladium at a minimum peripheral dose of 90 Gy. was used for those with Gleason scores of 7-10. Patients with Gleason 6 diploid tumors were treated with 125iodine and those with aneuploid tumors were treated with 103palladium. Biochemical failure was defined as inability to achieve a prostate specific antigen nadir value of 0.5 ng./ml. or less. No patient was treated with androgen deprivation therapy. RESULTS: The 212 patients have a minimum of 24 months of followup (mean 33 months). Prostate specific antigen 0.5 ng./ml. or less was reached by 72% of the patients (152 of 212) and positive biopsies were detected in 13.9% (20 of 144). Using life table survivorship analysis the probability of initial biochemical success at 5 years was 91% (95% confidence interval, 83 to 97). The probability of subsequent failure following an initial success was 11% (95% confidence interval, 6 to 20) at 24 months. The complications of combination therapy included proctitis in 21.4% (47 of 212 men), impotence in 38% (38 of 100), urinary retention in 1.5%, incontinence in 2.8%, rectoprostate fistula in 2.4%, rectal wall breakdown in 0.5% and urethral stricture in 0.5%. Six patients (2.8%) required colostomy and urinary diversion. CONCLUSIONS: Short-term responses to high dose combination radiotherapy for localized prostate cancer are promising. The morbidity is acceptable. Further long-term followup is warranted to assess this treatment.

Aged↗
PubMed1998

[Interstitial high dosage irradiation of prostate carcinoma].

Between 1986 and 1995 a hundred and seventy-four patients with prostate cancer staged for T1b-T3c N0 M0 were treated with a combined tele- and HDR brachytherapy regimen. The distribution of stage and grading was as follows: T1b two patients, T2a-2c 113 patients T3a-3c 59 patients, and G1 27 patients, G2 87 patients, G3 60 patients respectively. The total dose administered for the subclinical disease (small pervis) was 50 Gy by teletherapy and 30 Gy via two fractions of 15 Gy HDR brachytherapy integrated in the percutaneous regime. Total treatment time 6 weeks. After a median follow-up of 50 months (8-103) the stage related systemic and local progression amounts for stage T3 15.25% and for stage T1-2 20.43%, respectively. The distribution of systemic and local progression related to histological grading is: for Grade G3 23.3% and for Grade G1-2 6.14%. Ten patients died tumor related and 18 others of intercurrent diseases. The overall survival amounts 84%, the cancer specific survival 94% and the disease free survival 88% respectively. The late radiation morbidity scored by the RTOG/EORTC score in relation to proctitis was: 12 Patients Grade I, 10 patients Grade II, and 5 cases (one of five with abdominal anus) Grade III, respectively. In terms of radiogenic cystitis 13 patients developed Grade I side effects, 5 Grade II, and 3 Grade III, respectively. One osteoporotic patient developed a radionecrosis of both bones.

Adult↗
PubMed1998

[Intraoperative radiotherapy combined with external beam radiation for prostate cancer without metastasis].

Between 1989 and 1996, 35 patients with prostate cancer without metastasis received intraoperative radiotherapy combined with external beam radiation. 10 of 16 stage B patients and all of 19 stage C patients received additional endocrine therapy for the initial treatment. The radiation therapy included 25-30 Gy of intraoperative radiotherapy for prostate and 30 Gy of external beam radiotherapy for small pelvic region. One patient of stage C was dead for cancer and 4 patient were dead for other causes during 15-99 (mean: 41.6) months follow up period. The overall actuarial survival at 5 years by Kaplan-Meier method were 92.3% for stage B and 87.2% for stage C. Although cystitis, proctitis and anal bleeding were observed as the adverse effects of radiotherapy, both acute and chronic symptoms were not critical. In conclusion, intraoperative radiotherapy combined with external beam radiotherapy was revealed as an effective treatment for prostate cancer without metastasis.

Aged↗
PubMed1998

The treatment of late radiation effects with hyperbaric oxygenation (HBO).

BACKGROUND: Late radiation injuries may impose a negative influence on the quality of life in the affected patients. In several entities, standardized treatment protocols are lacking. Hyperbaric oxygenation (HBO) has been shown to have beneficial effects in the treatment of late radiation sequelae. MATERIAL AND METHODS: The basic principles of HBO are reviewed as well as clinical issues. Current study protocols are presented. RESULTS: During HBO-therapy the patient breathes pure oxygen at pressures above 100 kPa. The oxygen solubility within the fluid phase of the blood is largely increased. Biological effects include an increased oxygen diffusibility, improved collagen synthesis and neoangiogenesis as well as an enhancement of antimicrobial defenses. By decreasing the capillary filtration pressure a reduction of edema becomes possible. HBO has been shown to prevent complications following surgery in irradiated tissues. Its efficacy as an adjunct in the treatment of osteonecroses in radiation patients could be demonstrated. In addition, the loss of osseointegrated implants in the maxillofacial bones of these patients could be significantly reduced. Further indications include soft tissue necroses, hemorrhagic cystitis and proctitis in tumor patients that have been treated by radiotherapy as part of a multimodality approach. CONCLUSIONS: HBO in the treatment of late radiation effects is still subject of investigation, but remarkable results have been reported. Optimized treatment protocols need to be determined in various entities. The rate of side effects is acceptable low.

Humans↗
PubMedDate not supplied

A preliminary report: frequency of A-T heterozygotes among prostate cancer patients with severe late responses to radiation therapy.

PURPOSE: To investigate whether a significant proportion of prostate cancer patients who have late sequelae after high-dose external-beam conformal radiation therapy are radio-sensitive because they are carriers of ataxia-telangiectasia, that is, are heterozygous for mutations in the ATM gene. PATIENTS AND METHODS: A group of prostate cancer patients were selected who experienced severe late sequelae, specifically proctitis or cystitis, after high-dose external-beam conformal radiation therapy, together with a control group of patients treated in the same way but who did not have severe late effects. Blood samples were taken from these patients, genomic DNA extracted, and mutations sought in the ATM gene. RESULTS: Of 17 late-effect patients in whom most or all of the ATM gene has been examined, significant mutations (17.6%) were identified in three. No significant mutations were found in the control group. The incidence of ataxia- telangiectasia heterozygotes in the United States population is 1% to 2%. DISCUSSION: These preliminary data suggest that a disproportionate number, but by no means all, of prostate cancer radiotherapy patients who experience severe late effects are ataxia-telangiectasia heterozygotes. If this conclusion is confirmed, these individuals could be identified prospectively and, with dose de-escalation, spared a great deal of discomfort and suffering. As a corollary, if most of the small late-effects population were prospectively identifiable, the dose to the remaining population could potentially be escalated. Present methods of identifying mutations in a large gene, such as ATM, are cumbersome and expensive, but the technology is evolving rapidly, so that rapid screening of the ATM gene is imminent.

Ataxia Telangiectasia↗
PubMedDate not supplied

Incidence of inflammatory bowel disease in the area of Liège: a 3 years prospective study (1993-1996).

UNLABELLED: A first prospective epidemiological study of IBD was conducted in the area of Liège. The duration of the study was short taking into account the small size of the population (1 million inhabitants). Therefore we carried out a 3 years prospective study. METHOD: Private and public gastroenterologists completed a questionnaire for each new case they diagnosed between 01.06.1993 and 31.05.1996. RESULTS: During that period 270 IBD patients were identified: 137 (51%) had Crohn's disease (CD), 111 (41%) had ulcerative colitis (UC) including 32 proctitis (29% of UC) and 22 (8%) had unclassified colitis. The mean annual incidence per 10(5) was 4.5 for CD and 3.6 for UC. The female/male ratio was 1,6 for CD and 0,5 for UC. The median age at the time of diagnosis was 30 years for CD and 39 years for UC. The mean time between the onset of symptoms and the diagnosis was 6,5 months for CD and only 4,8 months for UC. Family history of IBD was found in 15% of patients with CD and in 7% of UC. CONCLUSIONS: These data show a high incidence of IBD in the area of Liege. These results confirm those reported during the first year of the prospective study which were similar to those observed in North-western France. Contrary to the other countries of Northern Europe, the incidence of UC is lower than the one of CD. Belgium appears to be a privileged country to undertake a national register and to study epidemiological aspects of IBD.

Adult↗