RESUMO
PURPOSE: While hemorrhoidal disease is common, its etiology remains unclear. It has been postulated that disturbances in collagen lead to reduced connective tissue stability, and in turn to the development of hemorrhoidal disease. We aimed to compare the quality and quantity of collagen in patients with hemorrhoidal disease versus normal controls. METHODS: Specimens from 57 patients with grade III or IV internal hemorrhoids undergoing hemorrhoidectomy between 2006 and 2011 were evaluated. Samples from 20 human cadavers without hemorrhoidal disease served as controls. Quality of collagen was analyzed by collagen I/III ratio, and quantity of collagen was determined by collagen/protein ratio. The study group was subdivided into gender and age subgroups. RESULTS: The male:female ratios in the study and control groups were 30:27 and 10:10, respectively. Median age was significantly less in the study group [46.9 years (range 20-69)] compared to the control group [76 years (range 46-90)] with P < 0.05. Tissues from patients in the study group had significantly lower collagen I/III ratio as compared to the control group (4.4 ± 1.1 vs. 5.5 ± 0.6; P < 0.0001). Nevertheless, despite a trend toward lower collagen/protein ratio in the study group, it did not reach statistical significance (57 ± 42.4 vs. 73 ± 32.5 g/mg; P = 0.167). There was no difference in collagen I/III or collagen/protein ratios among different age groups and genders. CONCLUSIONS: Hemorrhoidal tissues from patients with hemorrhoidal disease appear to have reduced mechanical stability as compared to normal controls.
Assuntos
Colágeno Tipo III/análise , Colágeno Tipo I/análise , Tecido Conjuntivo/patologia , Hemorroidas/etiologia , Proteínas/análise , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Cadáver , Estudos de Casos e Controles , Feminino , Hemorroidectomia , Humanos , Masculino , Pessoa de Meia-Idade , Fatores Sexuais , Adulto JovemRESUMO
BACKGROUND: Previous laboratory studies have shown that angiotensin II is produced locally in the rat internal anal sphincter causing potent contraction. The aim of this first human study was to evaluate the safety and manometric effects of topical application of captopril (an ACE inhibitor) on the resting anal pressure in healthy adult volunteers. METHODS: Ten volunteers, mean age 32.5 years (range, 19-48 years), underwent anorectal manometric evaluation of the mean anal resting pressure (MRAP) and the length of the high-pressure zone (HPZ) before 20 and 60 min after topical application of captopril (0.28 %) cream. Cardiovascular variables (systolic blood pressure, diastolic blood pressure and pulse) were measured before and for up to 1 h after cream application. Side effects were recorded. Adverse events and patient comfort after the cream application were evaluated within a 24-h period by completing a questionnaire. RESULTS: There was no significant change overall in MRAP following captopril administration, although in half the patients, there were reductions in MRAP after treatment. Half the patients had a reduction in the mean resting HPZ length; however, there was no overall difference between pre- and post-treatment values. There was no effect on basic cardiovascular parameters and no correlation between manometric and cardiovascular variables. CONCLUSIONS: Topical application of captopril cream may result in a reduction in MRAP in volunteers without anorectal disease. Its use is associated with minimal side effects. It may be a new potential therapeutic option in the treatment of anal fissure. Further studies are required to determine the optimal concentration, dose and frequency of application.
Assuntos
Canal Anal/efeitos dos fármacos , Canal Anal/fisiologia , Inibidores da Enzima Conversora de Angiotensina/administração & dosagem , Captopril/administração & dosagem , Administração Tópica , Adulto , Feminino , Voluntários Saudáveis , Humanos , Masculino , Manometria , Projetos Piloto , Pressão , Adulto JovemRESUMO
AIM: According to National Kidney Foundation guidelines, early stages of chronic kidney disease (CKD) can be detected through the estimated glomerular filtration rate (eGFR). We assessed complications following colorectal surgery (CRS) in patients with CKD Stages 3 and 4, as defined by the eGFR. METHOD: Patients with CKD were identified within our database. Patients with an eGFR of 15-59 ml/min (CKD Stages 3 and 4) formed the CKD group and were compared with American Society of Anesthesiology (ASA) score-matched controls with an eGFR of ≥ 60 ml/min. Assessments included demographics, comorbidity, ASA score, operative details and 30-day postoperative outcome. RESULTS: Seventy patients in the CKD group were matched with 70 controls. ASA scores and length of stay did not differ significantly between the groups. CKD patients were older (mean age 76.5 years vs 71.1 years; P < 0.001) and had a lower mean body mass index (24.3 vs 28.2; P < 0.001) compared with controls. Compared with the CKD group, the mean operation time was longer in the control group (181.5 min vs 151.6 min; P = 0.02) and the estimated blood loss was greater (232 ml vs 165 ml; P = 0.004). Postoperative infection was more common in the CKD group (60%vs 40%; P = 0.01). There were no significant differences in reoperation rates, 30-day readmissions or the incidence of acute renal failure (ARF). CONCLUSION: Patients with CKD Stages 3 and 4 had a higher incidence of postoperative infections than matched controls after colorectal surgery. ARF developed in 18.6% of patients. Preoperative optimization should include adequate hydration and assessment of potentially nephrotoxic substances for bowel preparation, preoperative antibiotics and pain control.
Assuntos
Doenças do Colo/cirurgia , Infecções/etiologia , Complicações Pós-Operatórias/etiologia , Doenças Retais/cirurgia , Insuficiência Renal Crônica/complicações , Idoso , Análise de Variância , Perda Sanguínea Cirúrgica , Estudos de Casos e Controles , Doenças do Colo/complicações , Feminino , Taxa de Filtração Glomerular , Humanos , Tempo de Internação , Masculino , Duração da Cirurgia , Doenças Retais/complicações , Insuficiência Renal Crônica/fisiopatologia , Estatísticas não ParamétricasRESUMO
AIM: The sensation that the rectum remains or is functioning after abdominoperineal excision (APE) is called phantom rectum (PR). Its postoperative and long-term morbidity are not well documented. Informed consent may not include the risk and consequences of this condition. We assessed the incidence and morbidity of PR after APE and compared those with vs those without vertical rectus abdominis myocutaneous flaps. METHOD: Patients who underwent APE between 1 January 2004 and 31 December 2008 were identified. Preoperative radiation and operative reconstruction by vertical rectus abdominis myocutaneous (VRAM) flaps were noted. Patients were interviewed by telephone to assess the presence and timing of PR symptoms and their effect on quality of life. RESULTS: Thirty-six of 80 patients who underwent APE were available for follow-up. Twenty-three (64%) described PR symptoms including urgency to evacuate [22 (61%)], sensation of faeces in the rectum [19 (52%)] and sensation of passing flatus [17 (48%)]. Eleven (47%) who had VRAM vs 25 who did not, reported having symptoms of PR at < 3 months after APE. Patients described their symptoms as 'unchanged over time' [20 (56%)], 'gradually decreasing and ultimately disappearing' [13 (35%)] or 'worsening' [3 (9%)]. Preoperative radiation and laparoscopic approach were not associated with PR symptoms. Significantly more patients having a VRAM flap reported early PR symptoms [7/11 (64%) vs 4/25 (16%)] (P = 0.008). CONCLUSION: PR sensations were experienced by 23 (64%) patients who underwent APE for rectal cancer. VRAM reconstruction was associated with early PR presentation. The possibility of PR should be discussed preoperatively in patients undergoing APE for anorectal neoplasm.
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Retalho Miocutâneo/efeitos adversos , Complicações Pós-Operatórias/etiologia , Neoplasias Retais/cirurgia , Reto , Transtornos de Sensação/etiologia , Feminino , Humanos , Masculino , Períneo/cirurgia , Qualidade de Vida , Reto/cirurgia , Reto do Abdome/transplante , Fatores de TempoRESUMO
AIM: To assess the feasibility and outcomes of reoperative laparoscopic-assisted surgery for recurrent Crohn's disease compared with index laparoscopic resections. METHOD: A retrospective analysis of a prospectively maintained database was performed from 2001 to 2008 on patients who had primary laparoscopy (group I) or reoperative laparoscopy for Crohn's disease (group II). Data collection included demographic and surgical data, and postoperative outcomes. RESULTS: One hundred and thirty patients were included in this study, distributed as follows: group I, 80 patients with a mean age of 35 years; and group II, 50 patients with a mean age of 42 years. Preoperative American Society of Anesthesiologists score and body mass index were similar in both groups. Patients in group II had a longer period of disease (15.5 vs 8.9 years in groups I and II, respectively; P = 0.0002). Immunosuppressive therapy had been utilized in 66 (82.5%) and in 42 (84%) patients in groups I and II, respectively. Ileocolic resection was the most commonly performed procedure in both groups (82%), followed by subtotal colectomy. Conversion rates were 18.7 and 32% in groups I and II, respectively (P = 0.09). The mean operative time (182 vs 201 min) and mean blood loss (161 vs 202 ml) were not significantly different (P > 0.05); however, the overall incisional length was significantly longer in group II (6.7 vs 11.4 cm, P = 0.045). A stoma was created in 17 and 16% of patients in groups I and II, respectively. Overall, early postoperative complications were not statistically significantly different between the two groups (P > 0.05); anastomotic leak occurred in four (5%) and one (2%) patients (P = 0.65), and abdominal abscess in three (3.75%) and four (8%) patients (P = 0.56), in groups I and II, respectively. Reoperative rates were 10 and 6% (P = 0.53), and mean hospital stay was similar in groups I and II respectively (6.7 vs 7.5 days, respectively; P = 0.3266). There was no mortality. CONCLUSION: The results of laparoscopic-assisted resection for recurrent Crohn's disease are similar to those for primary resection.
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Colo/cirurgia , Doença de Crohn/cirurgia , Íleo/cirurgia , Laparoscopia/efeitos adversos , Reoperação/efeitos adversos , Estomas Cirúrgicos , Abscesso Abdominal/etiologia , Adulto , Fístula Anastomótica/etiologia , Colectomia , Doença de Crohn/complicações , Humanos , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade , Recidiva , Reoperação/métodos , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
AIM: The aim of this study was to review the recent results of ileal pouch-anal anastomosis (IPAA) in elderly patients compared with younger patients. METHOD: Retrospective evaluation was carried out based on a prospective Institutional Review Board approved database of patients who underwent IPAA from 2001 to 2008. Patients aged ≥ 65 years were matched with a group of patients aged < 65 years by gender, date of procedure, diagnosis and type of procedure performed. Preoperative and intra-operative data and early postoperative complications were obtained. RESULTS: Thirty-three patients (22 women), 32 with mucosal ulcerative colitis, were included in each group. The elderly group had a mean age of 68.7 years, body mass index of 27 kg/m², duration of disease of 17.4 years, high American Society of Anesthesiologists (ASA) score and high incidence of comorbid conditions (87.9% had one or more). Dysplasia and carcinoma were the indication for the surgery in more than 50% of patients, followed by refractory disease (24.4%). The matched younger group had a mean age of 36.9 years, body mass index of 25.4 kg/m², shorter duration of disease (8.1 years; P = 0.001), lower ASA score (P = 0.0001) and lower comorbidity (42.4%; P = 0.0002). Operative data were similar for both groups. The elderly group had a higher rate of rehospitalization for dehydration (P = 0.02). Other medical complications (30 vs 27%) and surgical postoperative complications (33 vs 24%) were similar for both groups. The long-term function and complications were comparable for the groups. CONCLUSION: Elderly patients who underwent IPAA had more comorbid conditions than younger patients. Except for rehospitalization for dehydration, medical and surgical postoperative complications were not different in the two groups.
Assuntos
Canal Anal/cirurgia , Colite Ulcerativa/cirurgia , Bolsas Cólicas , Adulto , Fatores Etários , Idoso , Anastomose Cirúrgica , Comorbidade , Desidratação/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente , Complicações Pós-Operatórias , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: Overlapping external anal sphincter repair is the preferred procedure for incontinent patients with functional yet anatomically disrupted anterior external anal sphincter. When incomplete disruption, thinning or technically difficult mobilization of the external anal sphincter occurs, imbrication without division may be the more feasible surgical option. The aim of the study was to assess retrospectively the indications for external anal sphincter imbrication in patients who underwent either overlapping external anal sphincter repair or external anal sphincter imbrication, and to compare the success rates. METHOD: Patients who had external anal sphincter repair and follow up of at least 3 months were studied. Fecal incontinence was measured using the validated Wexner fecal Incontinence Scoring system (0 = perfect continence, 20 = complete incontinence); postoperative scores 0-10 were interpreted as successful, and scores of 11-20 as failures. RESULTS: A total of 131 females who had anal sphincter repair between 1988 and 2000 were analysed. One hundred and twenty-one patients had overlapping external anal sphincter repair (group I), and 10 had external anal sphincter imbrication (group II). Indications for external anal sphincter imbrication were attenuation of the external anal sphincter without overt defect (n = 5), partial disruption of external anal sphincter with muscle fibres bridging the scar (n = 2), thick bulk of scar between the muscle edges (n = 2), and wide lateral retraction of the muscle edges (n = 1). There were no statistically significant differences between the groups relative to preoperative incontinence score (16.5 vs 16.5, P = 0.99), pudendal nerve terminal motor latency assessment (left 9.6%vs 0.0%, P = 0.19; right 13.4%vs 11.1%, P = 0.84), and extent of electromyography pathology (61%vs 47%, P = 0.30). The patients in group I were younger than those in group II (mean age 50.8 years vs. 61.7 years, respectively; P = 0.052) and the length of follow-up was significantly longer (32.3 months vs 14.3 months, respectively; P < 0.0001). Both procedures had similar success rates (59.5%vs 60%; P = 0.98). CONCLUSION: Imbrication of the external anal sphincter may yield similar results as overlapping external anal sphincter repair in patients with incomplete external anal sphincter disruptions, external anal sphincter attenuation, and in patients presenting with wide lateral retraction of the muscle edges.
Assuntos
Canal Anal/lesões , Canal Anal/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Incontinência Fecal/cirurgia , Adulto , Idoso , Canal Anal/inervação , Distribuição de Qui-Quadrado , Estudos de Coortes , Eletromiografia , Incontinência Fecal/diagnóstico , Feminino , Seguimentos , Humanos , Plexo Lombossacral/fisiopatologia , Manometria , Pessoa de Meia-Idade , Seleção de Pacientes , Probabilidade , Recuperação de Função Fisiológica , Valores de Referência , Estudos Retrospectivos , Medição de Risco , Sensibilidade e Especificidade , Índice de Gravidade de Doença , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVE: Data concerning faecal incontinence (FI) in men are lacking. The aim of this study was to evaluate the historical aetiology and contrast aetiologies in younger and older men suffering from FI. METHOD: After institutional review board approval, a retrospective chart review was undertaken of all patients with FI seen between 1999 and 2005. The data of male patients was further analysed to assess the impact of age and historical aetiology on FI. RESULTS: A total of 404 males were included, 203 patients were <70 years of age (group A) and 201 patients were >or=70 years of age (group B). The most common prior diagnosis in group A was perianal sepsis in 23 (11.3%) patients and symptomatic haemorrhoids in 20 (9.9%) patients; in group B it was prostate cancer in 57 (28.4%) patients, symptomatic haemorrhoids in 31 (15.4%) patients and neurological diseases in 18 (9%) patients. The most common prior procedure in group A was restorative proctectomy/proctocolectomy in 32 (15.8%) patients, fistulotomy or haemorrhoidectomy in 21 (10.3%) and 19 (9.4%) patients respectively. In group B, radiation therapy for prostate cancer was utilized in 48 (23.9%) patients and haemorrhoidectomy in 29 (14.4%) patients. Comparing group A and group B relative to diagnosis - perianal sepsis, perineal trauma, congenital disorders, HIV infection and anal cancer were more common in group A, whereas prostate cancer, neurological diseases and colon cancer were significantly more common in group B. CONCLUSION: Prostate cancer, symptomatic haemorrhoids, perianal sepsis, rectal cancer and a history of restorative rectal resection were common associations with FI in men. The aetiologies for FI in men vary with age.
Assuntos
Incontinência Fecal/etiologia , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Distribuição de Qui-Quadrado , Criança , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de DoençaRESUMO
BACKGROUND: The steadily increasing age of the population mandates that potential benefits of new techniques and technologies be considered for older patients. AIM: To analyze the short-term outcomes of laparoscopic (LAP) colorectal surgery in elderly compared to younger patients, and to patients who underwent laparotomy (OP). METHODS: A retrospective analysis of patients who underwent elective sigmoid colectomies for diverticular disease or ileo-colic resections for benign disorders; patients with stomas were excluded. There were two groups: age < 65 years (A) and age >or= 65 years (B). Parameters included demographics, body mass index (BMI), length of operation (LO), incision length (LI), length of hospitalization (LOS), morbidity and mortality. RESULTS: 641 patients (M/F - 292/349) were included between July 1991 and June 2006; 407 in group A and 234 in group B. There were significantly more LAP procedures in group A (244/407 - 60%) than in group B (106/234 - 45%) - p = 0.0003. Conversion rates were similar: 61/244 (25%) in group A, and 25/106 (24%) in group B (p = 0.78). There was no difference in LO between the groups in any type of operation. LOS was shorter in patients in group A who underwent OP: 7.1 (3-17) days versus 8.7 (4-22) days in group B (p <0.0001), and LAP: 5.3 (2-19) days versus 6.4 (2-34) days in group B (p = 0.01). In both groups LOS in the LAP group was significantly shorter than in OP group. There were no significant differences in major complications or mortality between the two groups; however, the complication rates in the OP groups were significantly higher than in LAP and CON combined (p = 0.003). CONCLUSIONS: Elderly patients who undergo LAP have a significantly shorter LOS and fewer complications compared to elderly patients who undergo OP. Laparoscopy should be considered in all patients in whom ileo-colic or sigmoid resection is planned regardless of age.
Assuntos
Colectomia/métodos , Doenças do Colo/cirurgia , Laparoscopia , Doenças Retais/cirurgia , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND: Numerous studies have demonstrated the feasibility of laparoscopy in the management of acute adhesive small-bowel obstruction (AASBO). However, comparative data with laparotomy are lacking. The aim of this study was to compare laparoscopy and laparotomy for the treatment of AASBO in terms of patient outcome and cost-effectiveness. METHODS: A retrospective chart review of all patients who underwent surgery for AASBO from 1999 to 2005 was conducted. Data recorded included operative and postoperative course, among others. Operative and total hospital charges were estimated from the Patient Accounting System. RESULTS: Thirty-one patients who underwent laparoscopy were matched to a similar group of patients who underwent laparotomy. In the laparoscopy group, four patients (13%) had a laparoscopy-assisted procedure and ten patients (32%) were converted. The laparoscopy group was subdivided into laparoscopy, laparoscopy-assisted, converted, and assisted-converted subgroups. In the majority of the patients, AASBO was secondary to a single band. Overall morbidity was significantly higher in the laparotomy group (p = 0.007). Morbidity rates were statistically significant between the laparoscopy and assisted-converted subgroups (p = 0.0001) but not between the laparotomy group and assisted-converted subgroup (p = 0.19). Median hospital stay and median time to first bowel movement were significantly shorter in the laparoscopy group. Charge data were available for only the last three years of the study. Operative charges and total hospital charges were similar between the laparoscopy and the laparotomy groups (p = 0.14 and p = 0.10, respectively). There was a significant difference in total hospital charges between the laparoscopy subgroup and laparotomy group (p = 0.03). CONCLUSIONS: Laparoscopy for AASBO is associated with reduced hospital stay, early recovery, and decreased morbidity. Laparoscopy-assisted and converted surgeries do not differ significantly from laparotomy in regard to patient outcome. Operative and total hospital charges are similar for both laparoscopy and laparotomy.
Assuntos
Obstrução Intestinal/cirurgia , Intestino Delgado/cirurgia , Laparoscopia , Laparotomia , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise Custo-Benefício , Feminino , Custos de Cuidados de Saúde , Humanos , Laparoscopia/economia , Laparotomia/economia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Obesity is a relative contraindication to performing restorative proctocolectomy. The aim of this study was to assess the morbidity and functional results after restorative proctocolectomy in obese patients as compared to a matched cohort of non-obese patients. METHODS: 334 patients who had restorative proctocolectomy were reviewed; obesity was defined as a body mass index (BMI) greater than or equal to 30 kg/m2. 31 obese patients were matched to 31 non-obese patients for age, gender, steroid use, and diagnosis. Operative time, length of hospitalization, and both perioperative (< 6 weeks) and long-term morbidity (> 6 weeks), especially sepsis, were evaluated. RESULTS: The BMI was significantly higher in the obese group (33.7 vs 23.2) (p < 0.0001), and no difference was found between the obese and non-obese groups relative to the matched parameters of age, gender, steroid use and diagnosis. There was no difference in the rate of mucosectomy performed between the obese and non-obese patients (9.6% vs 3.2%, p = NS). 16% of the obese patients underwent one stage restorative proctocolectomies as compared to 10% in the non-obese group. Operative time was longer in the obese group (229 min vs 196 min; p = 0.02), but overall hospital length of stay was similar (9.7 days vs 7.7 days; p = 0.13). Perioperative morbidity was higher in obese patients (32% vs 9.6%, p = 0.058). However, there was no statistical significance in long-term morbidity (23% vs 32%, p = 0.57) at a mean follow-up of 51 months in the obese group and 53 months in the non-obese group. Obese patients had more stomal complications (10 vs 0%) and incisional hernias (13 vs 3%) (p = NS). Overall the pelvic sepsis-rate was significantly higher in the obese group (16 vs 0%; p < 0.05). 60% of the obese patients who developed pelvic sepsis had pouch-anal anastomosis performed without proximal fecal diversion. Mean bowel movements/24 hours, pad use, nocturnal evacuation, accidents/24 hours and incontinence scores were not statistically significant between the groups. CONCLUSION: Obese patients have a higher rate of pelvic sepsis and peri-operative morbidity when compared to a matched non-obese cohort of patients; however, the functional outcome of restorative proctocolectomy in obese patients is not significantly different than in non-obese patients.
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Polipose Adenomatosa do Colo/epidemiologia , Colite Ulcerativa/epidemiologia , Obesidade/epidemiologia , Proctocolectomia Restauradora , Polipose Adenomatosa do Colo/cirurgia , Adolescente , Adulto , Idoso , Criança , Colite Ulcerativa/cirurgia , Comorbidade , Contraindicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Proctocolectomia Restauradora/efeitos adversos , Estudos RetrospectivosRESUMO
BACKGROUND: The importance of the overlapping scar in an anterior sphincteroplasty is often emphasized. The aim of this study was to identify the tissue type used in overlapping sphincter repair based upon ultrasound images, and to correlate these results with the immediate clinical outcome. METHODS: Data were collected prospectively on all patients with faecal incontinence who underwent anterior overlapping sphincteroplasty between June 1998 and May 1999. Continence was assessed by a standardized incontinence score ranging from 0 to 20. Pre-operative ultrasound images were compared to intraoperative ultrasound findings for each patient. In each case the surgeon performed an overlap of what was grossly felt to represent scar after which a single blinded observer performed intraoperative ultrasound. The degree of overlap was measured and classified as hyperechoic over hyperechoic (muscle over muscle; Type 1), hyperechoic over or under hypoechoic (muscle over or under scar; Type 2), hypoechoic over hypoechoic (scar over scar; Type 3). The patient follow-up included incontinence score that was obtained by telephone interview; suboptimal outcome was considered as an incontinence score >/= 6. Statistical analysis was performed using the Mann-Whitney test and Wilcoxon matched-pairs test. RESULTS: Fourteen female patients with a mean age of 51.6 (range 28-79) years were evaluated. The mean pre-operative incontinence score was 17.1 (range 7-20) and 13 of the 14 (93%) patients had an incontinence score >/= 15. All pre-operative ultrasound images were hypoechoic which correlated with the surgeon's intraoperative findings of scar. The operative appearance included two Type 1, four Type 2, and eight Type 3 images. Larger pre-operative ultrasound image defects were statistically significantly related to intraoperative Type 3 ultrasound images. At a mean follow up of 7.5 (range 2-16) months the mean postoperative incontinence score was 4.5 (range 0-12). In patients with Type 1 and Type 2 images, the mean postoperative score was 8.6 (range 4-12) whereas in patients with Type 3 it was 1.3 (range 0-5) (P < 0.003); 7 of the 8 patients in Type 3 (87.5%) had an incontinence score = 2. CONCLUSION: These preliminary results show a significant immediate benefit to the overlap of scar over scar, however, such overlapping may not always be achieved despite the surgeon's intent. Furthermore, larger pre-operative defects may predispose to more extensive anterior scarring and thus a better chance of achieving this desired overlap.
RESUMO
After total mesorectal excision for rectal cancer was introduced in 1982, local recurrence rates decreased to 5%. These results were found to be reproducible; therefore, the technique became standard for the treatment of rectal cancer. Laparoscopic surgery for curable colorectal malignancy is still considered investigational. Indeed, the United States National Cancer Institute (NCI) trial excludes rectal carcinoma. The application of laparoscopy to rectal carcinoma must compete with total mesorectal excision, which has obtained favorable results in the last decade. In this review, we assess the adequacy of laparoscopic total mesorectal excision, describe the techniques (both anterior resection and abdominoperineal resection), and discuss their potential advantages.
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Carcinoma/cirurgia , Laparoscopia/métodos , Neoplasias Retais/cirurgia , Abdome/cirurgia , Carcinoma/prevenção & controle , Humanos , Recidiva Local de Neoplasia/prevenção & controle , Períneo/cirurgia , Neoplasias Retais/prevenção & controleRESUMO
BACKGROUND: In this study, we set out to examine the current attitudes among surgeons toward laparoscopic colorectal surgery (LCS). METHODS: A total of 3628 questionnaires were sent to all North American members of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and the American Society of Colon and Rectal Surgeons (ASCRS); 40% of the members of each society responded (B15 respondents). RESULTS: Currently, 85% of the respondents perform laparoscopic surgery; LCS was performed by 48% of the respondents in 21% of their patients. Although 35% of the members of SAGES have increased the number of laparoscopic colorectal operations they perform in the last 3 years, only 26% of ASCRS members did so. Our findings showed that 74% of the surgeons who perform LCS do so for diverticular disease, 68% for colonic polyps, 61% for villous adenoma, and 36% for ileal Crohn's disease. However, only 15% operate for the cure of carcinoma of any stage (16% of SAGES members and 11% of ASCRS members), whereas 8.5% and 7% operate for the cure of all upper and lower rectal carcinomas, respectively. Thirty-six percent of the surgeons who perform LCS for cancer have done between one and 10 curative resections, 8% have done 11-20 procedures, and 14% have done >20 procedures. There were 80 cases of port site recurrence reported by 4.4% of surgeons. Although 56% of the respondents would themselves undergo laparoscopic colorectal surgery for a rectal villous adenoma, only 9% would do so for a distal-third rectal carcinoma (12% of SAGES and 5% of ASCRS respondents). CONCLUSIONS: The overall percentage of respondents performing LCS has decreased over the last 3 years; moreover, surgeons are more hesitant to perform laparoscopic surgery for the cure of colonic cancer. Due to the overall low response rate, the fact that 4.4% of those surgeons who did respond have seen port site recurrences does not allow any conclusions to be drawn about the prevalence of this problem.
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Atitude do Pessoal de Saúde , Doenças do Colo/cirurgia , Cirurgia Colorretal/estatística & dados numéricos , Laparoscopia/estatística & dados numéricos , Doenças Retais/cirurgia , Adenoma/cirurgia , Carcinoma/cirurgia , Colectomia/estatística & dados numéricos , Doenças do Colo/diagnóstico , Pólipos do Colo/cirurgia , Coleta de Dados , Humanos , Estadiamento de Neoplasias , América do Norte/epidemiologia , Vigilância da População , Doenças Retais/diagnóstico , Sociedades Médicas/estatística & dados numéricos , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Common laparoscopic colorectal procedures in patients with Crohn's disease include ileocolic resection and subtotal colectomy. The aim of this study was to compare and contrast the results of these two procedures. METHODS: Patients who underwent one of these procedures between June 1992 and January 1999 were identified and included in the study. Statistical analysis was performed using the Mann-Whitney test, Student's t-test, or Fisher's exact test. RESULTS: In all 109 patients (63 women and 46 men) with an average age of 36.7 years (range, 15-74) underwent ileocolic resection (ICR), while 21 patients (16 women and five men) with an average age of 36.5 years (range, 18-77) underwent subtotal colectomy (STC) (p = NS). There were 14 intraoperative complications, eight (7%) in the ICR group and six (29%) in the STC group (p = 0.01). Total operative time was 167 min (range, 90-285) in the ICR group and 231 min (range, 140-340) in the STC group (p < 0.01). Despite this difference in operating time, the hospital stays were very similar at 8.8 days (range, 3-27) and 8.8 days (range, 3-14) (p = NS). In 19 (17%) of the ICR patients and five (24%) of the STC patients, their procedure was converted to a laparotomy (p = NS). In the ICR group, 20 of the patients (18%) had surgery-related postoperative complications, including five anastomotic leaks. In the STC group, six of the patients (29%) had surgery-related complications, including two anastomotic leaks (p = NS). CONCLUSION: Although STC is a far more extensive procedure than ICR, the overall postoperative complication rate is not significantly different between the two groups; however, we found that there were more intraoperative complications associated with STC.
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Doença de Crohn/cirurgia , Laparoscopia/métodos , Adolescente , Adulto , Idoso , Colectomia/métodos , Colo/cirurgia , Estudos de Viabilidade , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Íleo/cirurgia , Complicações Intraoperatórias/epidemiologia , Laparoscopia/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Fatores de Tempo , Resultado do TratamentoRESUMO
In recent years, the use of transanal stenting of malignant colonic strictures for the palliation of obstructive symptoms has increased. Due to the rectosigmoid angle, stenting sigmoid tumors is more troublesome than rectal lesions, but the difficulty may be overcome by using a two-team approach. The radiologist assists the endoscopist with the use of fluoroscopy to ensure proper positioning of both the colonoscope and the stent. The most common complication is stent migration, but stent obstruction and colonic perforation may also occur. We treated a woman suffering from metastatic gastric cancer with peritoneal metastases by creating a 12-cm stricture in the sigmoid colon. Two adjoining Wallstents were required to bridge the obstruction. Following migration of the proximal stent, a third stent was introduced to bridge the previous two stents with satisfactory outcome.
Assuntos
Colo Sigmoide/cirurgia , Migração de Corpo Estranho/cirurgia , Obstrução Intestinal/cirurgia , Reto/cirurgia , Neoplasias do Colo Sigmoide/cirurgia , Stents/efeitos adversos , Colo Sigmoide/diagnóstico por imagem , Colo Sigmoide/patologia , Colonoscopia , Feminino , Fluoroscopia , Migração de Corpo Estranho/diagnóstico por imagem , Migração de Corpo Estranho/etiologia , Gastrectomia , Humanos , Obstrução Intestinal/diagnóstico por imagem , Obstrução Intestinal/patologia , Pessoa de Meia-Idade , Neoplasias Peritoneais/secundário , Neoplasias Peritoneais/cirurgia , Reto/diagnóstico por imagem , Reto/patologia , Reoperação , Neoplasias do Colo Sigmoide/secundário , Neoplasias Gástricas/patologia , Neoplasias Gástricas/cirurgiaRESUMO
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.
Assuntos
Hemorroidas/cirurgia , Animais , Mucosa Intestinal/patologia , Modelos Animais , Prolapso Retal , Recidiva , Reoperação , SuínosRESUMO
BACKGROUND: The localization of focal colonic pathologies is problematical in laparoscopic surgery because it is difficult to palpate the colon. The aim of this study was to evaluate the use of intraoperative lower endoscopy in laparoscopic segmental colectomy. METHODS: We did a retrospective review of the charts of patients who had undergone laparoscopic segmental colectomy. Patients in whom intraoperative lower endoscopy had been used were compared to a group of 250 patients who had colectomy by laparotomy. The patients were matched by type of surgery and operating surgeon. RESULTS: Between 1991 and 2000, 233 patients underwent laparoscopic segmental colectomy at our clinic. Lower endoscopy was employed in 57 of them (24%), as compared to 42 patients (17%) in the laparotomy matched group ( p = 0.042). The diseased segment was successfully identified in all of the patients in whom the main indication for endoscopy was localization (65% of cases). Endoscopy was judged to have changed the surgical management in 66% of the 57 cases in whom it was employed, and especially in 88% of the 37 patients for whom the main indication had been localization. There were no endoscopy-related complications. CONCLUSION: Intraoperative lower endoscopy is a useful and safe tool for the localization of pathologies and the assessment of the intracorporeal anastomosis in laparoscopic segmental colectomy.
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Colectomia/métodos , Colonoscopia/métodos , Idoso , Anastomose Cirúrgica/métodos , Cirurgia Colorretal/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , SigmoidoscopiaRESUMO
BACKGROUND: The aim of this study was to assess the outcome of laparoscopic colorectal surgery in obese patients and compare it to that of a nonobese group of patients who underwent similar procedures. METHODS: All 162 consecutive patients who underwent an elective laparoscopic or laparoscopic-assisted segmental colorectal resection between August 1991 and December 1997 were evaluated. Body mass index (BMI; kg/m2) was used as an objective index to indicate massive obesity. The parameters analyzed included BMI, age, gender, comorbid conditions, diagnosis, procedure, American Society of Anesthesiologists classification score, operative time, estimated blood loss, transfusion requirements, intraoperative complications, conversion to laparotomy, postoperative complications, length of hospitalization, and mortality. RESULTS: Thirty-one patients (19.1%) were obese (23 males and 8 females). Conversion rates were significantly increased in the obese group (39 vs 13.5%, p = 0.01), with an overall conversion rate of 18%. The postoperative complication rate in the obese group was 78% versus 24% in the nonobese group (p <0.01). Specifically, rates of ileus and wound infections were significantly higher in the obese group [32.3 vs. 7.6% (p <0.01) and 12.9 vs 3.1%. (p = 0.03), respectively]. Furthermore, hospital stay in the obese group was longer (9.5 days) than in the nonobese group (6.9 days, p = 0.02). CONCLUSION: Laparoscopic colorectal segmental resections are feasible in obese patients. However, increased rates of conversion to laparotomy should be anticipated and the risk of postoperative complications is significantly increased, prolonging the length of hospitalization when compared to that of nonobese patients.
Assuntos
Cirurgia Colorretal/métodos , Laparoscopia/métodos , Obesidade/complicações , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Contraindicações , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Humanos , Complicações Intraoperatórias/etiologia , Masculino , Pessoa de Meia-Idade , Fatores de RiscoRESUMO
BACKGROUND: The benefits of laparoscopic colectomy (LC) vs open colectomy (OC) for the treatment of benign disease have not yet been clearly demonstrated with regard to long-term consequences and health-related quality of life (HRQL). The aim of this study was to compare LC and OC in terms of outcome and HRQL and to determine whether a generic nonspecific instrument for HRQL assessment is valid in postoperative follow-up. METHODS: Forty-nine patients who underwent LC for elective right hemicolectomy (RH) or sigmoid resection (SR) for benign polyps or uncomplicated diverticular disease between 1992 and 2000 were evaluated and compared to 50 controls treated by OC in the same period. All patients were evaluated by postal questionnaire to determine recurrence rates and surgery-related complications. HRQL was assessed by the SF-36 Physical and Mental Component Summary Score (PCS, MCS) and by the SF-36 Health Survey, which measures eight different health-quality domains, including physical and social functioning (PF, SF), general health perception (GH), physical and emotional role limitations (RP, RE), body pain (BP), vitality (VT), and mental health (MH). RESULTS: The LC and OC patients were similar in age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, and diagnosis. There were significant differences between the two groups in resection type (26 RH:23 SR in LC vs 16 RH:34 SR in OC, p = 0.03) and length of follow-up (median, 39 and 53.5 months, respectively, p = 0.04), but neither parameter was predictive of the main SF-36 scores (PCS and MCS). There were no differences between the groups in recurrence rates (8% in LC vs 11% in OC) or surgery-related complications, including incisional hernias (16.3% in LC vs 17% in OC) and small bowel obstructions (2% in LC vs 10.4% in OC). None of the eight SF-36 Health Survey domains or the PCS or MCS scores showed significant differences between LC and OC patients in HRQL. However, occurrence of hernia after surgery was predictive of lower SF-36 scores, specifically in PF (p = 0.047), GH (p = 0.045), SF (p = 0.047), MH (p = 0.041), and MCS (p = 0.037). In addition, small bowel obstruction was significantly associated with lower scores in BP (p = 0.008), GH (p = 0.008), SF (p = 0.013), RE (p = 0.026), MH (p = 0.003), and MCS (p = 0.003). CONCLUSION: LC was not different from OC for selected indications that measure long-term outcome and HRQL. SF-36 appears to be an appropriate instrument to measure postoperative HRQL, showing responsiveness to changes in objective outcome measures.