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1.
Int J Colorectal Dis ; 31(10): 1729-37, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27631643

RESUMO

PURPOSE: Extralevator abdominoperineal excision (ELAPE) was introduced to improve outcomes for low-lying locally advanced rectal cancers (LARC) not amenable to sphincter preserving procedures. This study investigates prospectively outcomes of patients operated on with ELAPE compared with a similar cohort of patients operated on with conventional APE. METHODS: After the exclusion of patients without neoadjuvant therapy, in-hospital mortality, and incomplete metastatectomy, we identified 72 consecutive patients who had undergone either conventional APE (n = 36) or ELAPE (n = 36) for LARC ≤6 cm from the anal verge. The primary outcome measure was local recurrence at 5 years, and secondary outcome measures were cause-specific and overall survival. RESULTS: Median distance from the anal verge was significantly lower in the ELAPE group (2 vs. 4 cm, p = 0.029). Inadvertent bowel perforation could be completely avoided in the ELAPE group, but amounted to 16.7 % in the conventional APE group (p = 0.025). Cumulative local recurrence rate at 5 years was 18.2 % in the APE group compared to 5.9 % in the ELAPE group (p = 0.153). Local recurrence without distant metastases occurred in 15.5 % in the APE group but was not observed in the ELAPE group (p = 0.039). We did not detect significant differences in cause-specific nor in overall survival. CONCLUSION: ELAPE results in lower local recurrence rates as compared with conventional APE. We conclude that the extralevator approach should be the procedure of choice for advanced low rectal cancer not amenable to sphincter preserving procedures.


Assuntos
Abdome/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Períneo/cirurgia , Neoplasias Retais/cirurgia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Resultado do Tratamento
3.
Int J Colorectal Dis ; 30(6): 797-806, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25922143

RESUMO

PURPOSE: This study aimed to investigate the outcome for stage II and III rectal cancer patients compared to stage II and III colonic cancer patients with regard to 5-year cause-specific survival (CSS), overall survival, and local and combined recurrence rates over time. METHODS: This prospective cohort study identified 3,355 consecutive patients with adenocarcinoma of the colon or rectum and treated in our colorectal unit between 1981 and 2011, for investigation. The study was restricted to International Union Against Cancer (UICC) stages II and III. Postoperative mortality and histological incomplete resection were excluded, which left 995 patients with colonic cancer and 726 patients with rectal cancer for further analysis. RESULTS: Five-year CSS rates improved for colonic cancer from 65.0% for patients treated between 1981 and 1986 to 88.1% for patients treated between 2007 and 2011. For rectal cancer patients, the respective 5-year CSS rates improved from 53.4% in the first observation period to 89.8% in the second one. The local recurrence rate for rectal cancer dropped from 34.2% in the years 1981-1986 to 2.1% in the years 2007-2011. In the last decade of observation, prognosis for rectal cancer was equal to that for colon cancer (CSS 88.6 vs. 86.7%, p = 0.409). CONCLUSION: Survival of patients with colon and rectal cancer has continued to improve over the last three decades. After major changes in treatment strategy including introduction of total mesorectal excision and neoadjuvant (radio)chemotherapy, prognosis for stage II and III rectal cancer is at least as good as for stage II and III colonic cancer.


Assuntos
Adenocarcinoma/mortalidade , Adenocarcinoma/cirurgia , Neoplasias do Colo/mortalidade , Neoplasias do Colo/cirurgia , Neoplasias Retais/mortalidade , Neoplasias Retais/cirurgia , Adenocarcinoma/patologia , Idoso , Neoplasias do Colo/patologia , Humanos , Terapia Neoadjuvante , Recidiva Local de Neoplasia , Estadiamento de Neoplasias , Estudos Prospectivos , Neoplasias Retais/patologia , Taxa de Sobrevida , Resultado do Tratamento
4.
Dis Colon Rectum ; 55(7): 750-5, 2012 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-22706126

RESUMO

BACKGROUND: Total fistulectomy with simple closure of the internal opening has been used for the management of complex anal fistulas. This approach involves complete removal of the fistula tract and closure of the internal opening with sutures. OBJECTIVE: This study aimed to report long-term outcomes in patients with complex cryptoglandular fistulas who undergo this procedure. DESIGN: This is a retrospective review of a prospectively collected consecutive series. SETTINGS: This study was conducted at a community-based hospital with a specialized colorectal unit. PATIENTS: : Patients included in this study had cryptoglandular fistulas and underwent total fistulectomy with simple closure of the internal opening between 1997 and 2007. MAIN OUTCOME MEASURES: The main outcome measures were success rate and postoperative continence (Cleveland Clinic Florida Fecal Incontinence Scale). Treatment was considered successful if the external opening was closed and no drainage was present at the last follow-up. RESULTS: Success was achieved in 187 (74%) patients with a median follow-up time of 70 (range, 14-141) months. Patients with posterior transsphincteric or suprasphincteric fistulas had a higher success rate than those with other types of fistulas (82% vs 67%;p = 0.014), and patients for whom the procedure failed were significantly younger than those for whom the procedure was a success (mean, 45 vs 50 years; p = 0.010). Of 160 patients with success who had no previous surgery, 89 (56%) had normal continence postoperatively (CCF-FI score = 0). LIMITATIONS: The limitations of this study include its retrospective nature, the potential for selection bias, and the lack of preoperative continence scores. CONCLUSIONS: Total fistulectomy with simple closure of the internal opening is effective for the long-term closure of complex cryptoglandular fistulas.However, this procedure may affect continence despite its sphincter-sparing quality. Nonetheless, the high success rate in patients with posterior transsphincteric or suprasphincteric fistulas renders this procedure a reasonable option in this subgroup of patients with complex fistulas.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/métodos , Fístula Retal/cirurgia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Incontinência Fecal/epidemiologia , Incontinência Fecal/etiologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Retrospectivos , Técnicas de Sutura , Resultado do Tratamento , Adulto Jovem
5.
Langenbecks Arch Surg ; 397(5): 771-8, 2012 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-22350643

RESUMO

PURPOSE: Stapled transanal rectal resection (STARR) has recently been recommended for patients with obstructed defecation caused by rectocele and rectal wall intussusception. Our study investigates the long-term results and predictive factors for outcome. METHODS: Between November 2002 and February 2007, 80 patients (69 females) were operated on using the STARR procedure and included in the following study. Symptoms were defined according to the ROME II criteria. Preoperative assessment included clinical examination, colonoscopy, video defecography, and dynamic MRI. Preoperatively and during follow-up visits, we evaluated the Cleveland Constipation Score (CCS) to rate the severity of outlet obstruction and the Wexner Incontinence Score to rate anal incontinence. Patients were asked to judge the outcome of the operation as improved or poor/dissatisfied. We performed a univariate analysis for 11 patient- and disease-related factors to detect an association with outcome. RESULTS: The median follow-up was 39 months (range 20-78). Major postoperative complications (one staple line insufficiency, one urosepsis, one prolonged urinary dysfunction with indwelling catheter) were found in 3.8%. The result after STARR procedure was a success in the long-term follow-up in 62 patients (77.5%), although the improvement did not persist in 15 patients (18.7%). The mean value of the CCS decreased significantly from 9.3 before surgery to 4.6 after 2 years and increased again slightly to 6.5 after 4-6 years. The Median Wexner Incontinence Score was 3.3 at baseline, but rose significantly to 6.0. However, a third of patients who reported deteriorated continence developed the symptoms 1-4 years after surgery. Of the factors investigated for the prediction of outcome, we could only identify the number of pelvic floor changes in defecography or dynamic MRI as being associated with the success of the operation. CONCLUSION: Our study indicates that STARR is a safe procedure. A significant improvement of symptoms is to be expected, but this improvement may deteriorate with time. Patients' satisfaction is also associated with the occurrence of urge to defecate or incontinence. It remains difficult to predict outcome.


Assuntos
Constipação Intestinal/complicações , Obstrução Intestinal/cirurgia , Proctoscopia/métodos , Reto/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Distribuição de Qui-Quadrado , Estudos de Coortes , Constipação Intestinal/diagnóstico , Defecação/fisiologia , Defecografia , Incontinência Fecal/etiologia , Incontinência Fecal/fisiopatologia , Feminino , Seguimentos , Humanos , Obstrução Intestinal/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Recuperação de Função Fisiológica , Reto/diagnóstico por imagem , Estudos Retrospectivos , Índice de Gravidade de Doença , Técnicas de Sutura , Suturas , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
6.
Dis Colon Rectum ; 54(4): 401-11, 2011 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-21383559

RESUMO

BACKGROUND: Neoadjuvant treatment in the multimodal therapy concept of rectal carcinoma has considerable effects on prognosis appraisal. OBJECTIVE: This study aimed to evaluate the tumor response specified as an improvement by at least one stage defined in terms of the International Union Against Cancer stages as a prognostic factor. DESIGN: This investigation was designed as a prospective cohort study. SETTING: This study was performed at a community-based hospital with a specialized colorectal unit. PATIENTS: One hundred seventy-four patients with locally advanced rectal carcinoma, treated in the Dresden-Friedrichstadt hospital from 1997 to 2009, who received long-term preoperative chemoradiotherapy and underwent curative resection, were included in this study. MAIN OUTCOME MEASURES: The main outcome measures were cause-specific and disease-free survival with respect to T and N category, International Union Against Cancer stage, venous and lymphatic invasions, grading, CEA level, complete pathologic response, tumor regression grading, International Union Against Cancer stage shift, T, N, and CEA shift, types of neoadjuvant therapy, adjuvant therapy, interval between completion of neoadjuvant chemoradiotherapy and surgery, and number of extracted lymph nodes in resected specimens. Univariate and multivariate analyses were performed. RESULTS: Median follow-up was 45 months. One hundred twenty-one patients (69.5%) showed a response to the treatment, whereas 53 (30.5%) did not. Five-year cause-specific and disease-free survival for responders (n = 121) vs nonresponders (n = 53) were 92.6% and 73.7% vs 84.9% and 47.9%. In the univariate analysis, ypN category, venous and lymphatic invasion, tumor regression grading, International Union Against Cancer stage shift, and T and N shift were significantly predictive for cause-specific and disease-free survival. Furthermore, ypUICC stage, ypT category, grading, and complete pathologic response had an impact on disease-free survival. In the multivariate analysis, only the International Union Against Cancer stage shift kept its independent explanatory power for cause-specific P = .012, HR 3.10 (95% CI 1.28-7.51) and disease-free survival P < .001, HR 3.85 (95% CI 1.98-7.51). LIMITATIONS: The determination of International Union Against Cancer stage shift depends on the pretreatment staging modalities. CONCLUSION: Our investigation demonstrates that the response of tumor to neoadjuvant therapy is an independent prognostic factor in patients with rectal carcinoma.


Assuntos
Adenocarcinoma/terapia , Terapia Neoadjuvante , Neoplasias Retais/terapia , Adenocarcinoma/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Prognóstico , Estudos Prospectivos , Neoplasias Retais/patologia , Taxa de Sobrevida
7.
Int J Colorectal Dis ; 26(7): 919-25, 2011 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-21350936

RESUMO

BACKGROUND: Extra-levator abdominoperineal excision (ELAPE) has been introduced to avoid oncologic problems encountered with conventional abdominoperineal excision (APE) such as high rates of inadvertent bowel perforation and of positive circumferential resection margin. We compare our short-term results of this new approach with a historic patient cohort. PATIENTS AND METHODS: From 1997 until 2010, we performed 46 consecutive conventional APE and 28 ELAPE after neoadjuvant therapy with a macroscopically complete resection in the true pelvis. Patient data was prospectively collected in our colorectal tumor database. Patient and tumor characteristics were compared as were the rates of inadvertent bowel perforation, of circumferential margin involvement, and of wound abscesses. RESULTS: The rates of inadvertent bowel perforation, of circumferential margin involvement, and of wound abscesses were 15.2% vs. 0 (p = 0.04), 4.9% vs. 0 (p = 0.511), and 17.4% vs. 10.7% (p = 0.518), respectively, in the conventional APE vs. ELAPE group. CONCLUSION: With a significant reduction of the bowel perforation rate and a reduction of circumferential margin involvement and wound abscess formation, ELAPE improves important surrogate parameters for local recurrence rate and survival.


Assuntos
Abdome/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Períneo/cirurgia , Neoplasias Retais/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Perfuração Intestinal/complicações , Perfuração Intestinal/patologia , Perfuração Intestinal/cirurgia , Masculino , Pessoa de Meia-Idade , Neoplasias Retais/patologia , Fatores de Tempo , Resultado do Tratamento
8.
Int J Colorectal Dis ; 25(9): 1093-102, 2010 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-20549219

RESUMO

PURPOSE: In 2007, the German Working Group "Workflow Rectal Cancer II" published 19 quality indicators with 36 quality goals for the treatment of rectal cancer. We investigate whether these parameters are practicable in a specialized coloproctologic unit. PATIENTS AND METHODS: We included 578 consecutive patients with rectal cancer who were treated in our institution from January 2000 to December 2008. Patient data were collected in a prospective database. Follow-up was conducted in a colorectal tumor clinic. Data were analyzed for the defined reference groups, and the results were compared with the quality goals. RESULTS: Median follow-up was 54.4 (range 1-116) months. We achieved 19 of the 36 defined quality goals. Among these were important parameters such as the rate of postoperative mortality (0.9%), the rate of intraoperative local tumor perforation (2.2% for anterior resection and 8.5% for abdominoperineal excision), the 5-year local recurrence rate (5.9% stages I-III), and the 5-year overall survival rates for stages yII and II (79.9%), and stages yIII and III (60.7%) for patients with microscopically negative resection margins. CONCLUSION: Most of the defined quality goals can be achieved in a specialized coloproctologic unit. The debate on quality goals has the potential to enable further improvement in the care of rectal cancer patients.


Assuntos
Metas , Indicadores de Qualidade em Assistência à Saúde , Neoplasias Retais/terapia , Humanos , Terapia Neoadjuvante , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Prognóstico , Neoplasias Retais/patologia , Análise de Sobrevida
9.
Dis Colon Rectum ; 52(7): 1264-71, 2009 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-19571703

RESUMO

PURPOSE: Relative survival estimates are widely used by cancer registries. They provide survival rates adjusted for causes of death other than cancer. They have rarely been used in clinical settings. When compared with cause-specific survival rates or competing risks analysis, their applicability is hardly known. This study compares these three outcome measures on the basis of a well-documented clinical database of patients with colorectal cancer. METHODS: We selected a consecutive series of 1,791 histopathologically completely resected colorectal cancer patients without neoadjuvant therapy from a prospective database from 1981 through 2006. Median follow-up was 4.7 (range, 0-23) years with only 3.1% patients lost. Cause-specific and relative survival are reported as failure rates as is the cumulative incidence in the presence of competing risks. RESULTS: The analysis comprised 1,081 patients with colon cancer and 710 patients with rectal cancer. Stage distribution was as follows: Stage I, 480 patients; Stage II, 785 patients; Stage III, 472 patients; and Stage IV, 54 patients. The "cause-specific" failure rate, the "relative" failure rate, and the cumulative incidence in the presence of competing risks at five years (95% CI) for all patients were 21.1 (range, 19.0-23.4) %, 22.5 (range, 19.6-25.2) %, and 19.0 (range, 17.0-20.9) %, respectively. CONCLUSION: Because we could demonstrate almost identical failure rates, we consider relative survival to be a powerful tool in clinical settings in which a comprehensive follow-up is not possible. It is especially useful as a reference parameter for clinical audit.


Assuntos
Carcinoma/mortalidade , Neoplasias Colorretais/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma/patologia , Carcinoma/terapia , Causas de Morte , Estudos de Coortes , Neoplasias Colorretais/patologia , Neoplasias Colorretais/terapia , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Estudos Retrospectivos , Medição de Risco , Análise de Sobrevida , Taxa de Sobrevida , Falha de Tratamento
10.
J Gastrointest Surg ; 12(7): 1246-50, 2008 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-18340498

RESUMO

BACKGROUND: The time schedule for chemotherapy and primary tumor resection in patients with rectal carcinoma (RC) and unresectable synchronous metastases (USM) is not well defined. We evaluated whether response to chemotherapy is an appropriate criterion for deciding to perform surgery. METHODS: We treated 22 patients with RC and USM who received chemotherapy and were regularly evaluated. After documentation of a partial remission (PR) or stable disease (SD), patients were offered resection of the primary tumor. Results were compared with those of a historical control group of 42 patients who underwent immediate surgery. RESULTS: Seven patients had a PR, four showed SD, and 11 progressed under chemotherapy. Seven patients underwent resection of the primary tumor (no perioperative mortality). The median survival for all 22 patients was 20.2 months. Patients with primary tumor resection survived 27.2 months, whereas patients without resection survived only 12.4 months (p = 0.017). The median survival in the control group was 13.5 months (perioperative mortality, 9.5%). CONCLUSION: Chemotherapy and response-dependent resection of the primary tumor results in the same survival time as that attained with immediate surgery. Patients who face a poor prognosis due to progressive disease are thereby spared the risks of major rectal surgery.


Assuntos
Antineoplásicos/uso terapêutico , Carcinoma de Células Renais/cirurgia , Procedimentos Cirúrgicos Eletivos/métodos , Neoplasias Renais/cirurgia , Nefrectomia/métodos , Cuidados Pré-Operatórios/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Renais/tratamento farmacológico , Carcinoma de Células Renais/secundário , Feminino , Seguimentos , Humanos , Neoplasias Renais/tratamento farmacológico , Neoplasias Renais/patologia , Masculino , Pessoa de Meia-Idade , Metástase Neoplásica , Cuidados Paliativos/métodos , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Resultado do Tratamento
11.
J Clin Oncol ; 25(1): 110-7, 2007 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-17194912

RESUMO

PURPOSE: To evaluate the activity and safety of preoperative radiotherapy (RT) and concurrent capecitabine and oxaliplatin (XELOX-RT) plus four cycles of adjuvant XELOX in patients with rectal cancer. PATIENTS AND METHODS: One hundred ten patients with T3/T4 or N+ rectal cancer were entered onto the trial in 11 investigator sites and received preoperative RT (50.4 Gy in 28 fractions). Capecitabine was administered concurrently at 1,650 mg/m2 on days 1 to 14 and 22 to 35, and oxaliplatin was administered at 50 mg/m2 on days 1, 8, 22, and 29. Surgery was scheduled 4 to 6 weeks after completion of XELOX-RT. Four cycles of adjuvant XELOX (capecitabine 1,000 mg/m2 bid on days 1 to 14; oxaliplatin 130 mg/m2 on day 1) were administered. The main end points were activity as assessed by the pathologic complete response (pCR) rate and the feasibility of postoperative XELOX chemotherapy. RESULTS: After XELOX-RT, 103 of 104 eligible patients underwent surgery; pCR was achieved in 17 patients (16%), one patient had ypT0N1 disease, and 53 patients showed tumor regression of more than 50% of the tumor mass. R0 resections were achieved in 95% of patients, and sphincter preservation was accomplished in 77%. Full-dose preoperative XELOX-RT was administered in 96%. Grade 3 or 4 diarrhea occurred in 12% of patients. Postoperative complication occurred in 43% of patients. Sixty percent of patients received all four cycles of adjuvant XELOX, with sensory neuropathy (18%) and diarrhea (12%) being the main grade 3 or 4 toxicities. CONCLUSION: Preoperative XELOX-RT plus four cycles of adjuvant XELOX is an active and feasible treatment. This regimen is proposed for phase III evaluation comparing standard fluorouracil-based treatment with XELOX- based multimodality treatment.


Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Terapia Combinada/métodos , Desoxicitidina/análogos & derivados , Fluoruracila/análogos & derivados , Compostos Organoplatínicos/administração & dosagem , Compostos Organoplatínicos/uso terapêutico , Neoplasias Retais/tratamento farmacológico , Neoplasias Retais/radioterapia , Adulto , Idoso , Capecitabina , Quimioterapia Adjuvante , Desoxicitidina/administração & dosagem , Desoxicitidina/uso terapêutico , Feminino , Fluoruracila/administração & dosagem , Fluoruracila/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Oxaliplatina , Neoplasias Retais/cirurgia , Indução de Remissão , Resultado do Tratamento
12.
J Surg Oncol ; 93(5): 350-4, 2006 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-16550556

RESUMO

BACKGROUND AND OBJECTIVES: Resection combined with standard lymphadenectomy is generally recommended for T2N0 rectal cancer. In order to evaluate the outcome of this specific tumor category, our own data were reviewed. METHODS: To evaluate the results of patients with curative resected T2N0 rectal carcinoma, we reviewed data of 164 consecutive patients with adenocarcinoma of the rectum between 1981 and 2003 in our department. In addition, patient characteristics were stratified according to the position of the rectal tumor with respect to the anal verge. RESULTS: One hundred ten patients (67.1%) underwent anterior resection and 54 patients (32.9%) received abdominoperineal amputation. The follow-up revealed 6 local recurrences (3.7%); in 10 patients (10.0%), metastases were discovered. Regarding the tumor localization nearly no local recurrence or distant metastases were observed in the middle or the upper rectum. However, in the lower rectum the actuarial 5-year recurrence rate was 16.2%. CONCLUSIONS: Although T2N0 rectal carcinomas are considered as low risk tumors, we found a considerable local recurrence rate of 3.7%. The question arises whether this result can be improved by adjuvant treatment modalities without being compromised by the toxicity of an adjuvant treatment.


Assuntos
Adenocarcinoma/cirurgia , Neoplasias Retais/cirurgia , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Adenocarcinoma/terapia , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Quimioterapia Adjuvante , Feminino , Seguimentos , Alemanha/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/epidemiologia , Radioterapia Adjuvante , Neoplasias Retais/mortalidade , Neoplasias Retais/patologia , Neoplasias Retais/terapia , Taxa de Sobrevida
13.
J Surg Oncol ; 89(4): 211-7, 2005 Mar 15.
Artigo em Inglês | MEDLINE | ID: mdl-15726622

RESUMO

BACKGROUND: The prognostic impact of primary tumor resection in patients presenting with unresectable synchronous metastases from colorectal carcinoma (CRC) is not well established. In the present study, we analyzed fifteen factors to define the value of primary tumor resection with regard to prognosis. PATIENTS AND METHODS: We identified 186 consecutive patients with proven stage IV CRC from the year 1995 to 2001. Variables were tested for their relationship to survival in univariate analyses with the Kaplan-Meier method and the log rank test. Factors that showed a significant impact were included in a Cox proportional hazards model. The tests were repeated for 107 patients who had no symptoms from their primary tumor. RESULTS: Overall there were six independent variables with a relationship to survival: performance status, ASA-class, CEA level, metastatic load, extent of primary tumor, and chemotherapy. In the asymptomatic patients we investigated 13 factors, 3 of which proved to be independent predictors of survival: performance status, CEA level, and chemotherapy. Resection of primary tumor was only predictive of survival if in-hospital mortality was excluded. CONCLUSION: Resection of the tumor, if possible, is doubtless the best option for stage IV CRC patients with severe symptoms caused by their primary tumor. In asymptomatic patients, chemotherapy is preferable to surgery.


Assuntos
Neoplasias do Colo/mortalidade , Cuidados Paliativos , Neoplasias Retais/mortalidade , Idoso , Neoplasias do Colo/patologia , Neoplasias do Colo/cirurgia , Feminino , Humanos , Masculino , Análise Multivariada , Metástase Neoplásica , Estadiamento de Neoplasias , Prognóstico , Modelos de Riscos Proporcionais , Neoplasias Retais/patologia , Neoplasias Retais/cirurgia , Análise de Sobrevida , Resultado do Tratamento
14.
Plast Reconstr Surg ; 114(7): 1754-60, 2004 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-15577345

RESUMO

Sublay prosthetic herniorrhaphy has become a widely accepted procedure for incisional hernias. To evaluate the effect of fascia closure on top of mesh repair on infection, and the recurrence rate, the authors reviewed their data regarding herniorrhaphy in the sublay technique. This study was a retrospective analysis of 175 consecutive patients who underwent hernia repair by implantation of prostheses by means of the Stoppa-Rives technique from December of 1994 to December of 2001. All 175 patients had the mesh implanted in the subfascial plane, 130 received a light-weight or heavy-weight polypropylene mesh (Vypro or Prolene) (74 percent), eight had a polyester mesh (Mersilene) (5 percent), and 37 had an expanded polytetrafluoroethylene patch (Gore-Tex) (21 percent). After sublay mesh positioning, the mesh could not be covered by the fascia in 50 cases; in 31 of these cases, a second mesh was placed into the fascial defect. To evaluate the influence of the fascia closing procedure on top of the sublay mesh, three groups were differentiated: initial fascia closure (n = 125), no fascia closure and concomitant mesh interposition (n = 31), and no fascia closure without mesh interposition (n = 19). After a mean follow-up of 20 months, 11 deep prosthetic infections (8 percent) and 15 hernia recurrences (9 percent) were observed. There was an increased risk of mesh infection when the fascia could not be closed, but there was no influence of fascia closure on hernia recurrence. When the fascia was left open, the placement of a second mesh inlay technique reduced mesh infection. The authors' data give evidence that closing the ventral fascia after mesh repair in the sublay position is beneficial. When the edges of the hernia defect could not be approximated, the suturing of a second mesh into the fascia defect was a useful tool for reducing the prosthetic infection rate; however, no significant influence on hernia recurrence was observed.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/métodos , Hérnia Abdominal/cirurgia , Telas Cirúrgicas , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Seguimentos , Hematoma/etiologia , Humanos , Polipropilenos , Recidiva , Telas Cirúrgicas/efeitos adversos , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/terapia
15.
BMC Surg ; 4: 6, 2004 May 21.
Artigo em Inglês | MEDLINE | ID: mdl-15153248

RESUMO

BACKGROUND: Within the last years, stapled rectal mucosectomy (SRM) has become a widely accepted procedure for second and third degree hemorrhoids. One of the delayed complications is a stenosis of the lower rectum. In order to evaluate the specific problem of rectal stenosis following SRM we reviewed our data with special respect to potential predictive factors or stenotic events. METHODS: A retrospective analysis of 419 consecutive patients, which underwent SRM from December 1998 to August 2003 was performed. Only patients with at least one follow-up check were evaluated, thus the analysis includes 289 patients with a mean follow-up of 281 days (+/-18 days). For statistic analysis the groups with and without stenosis were evaluated using the Chi-Square Test, using the Kaplan-Meier statistic the actuarial incidence for rectal stenosis was plotted. RESULTS: Rectal stenosis was observed in 9 patients (3.1%), eight of these stenoses were detected within the first 100 days after surgery; the median time to stenosis was 95 days. Only one patient had a rectal stenosis after more than one year. 8 of the 9 patients had no obstructive symptoms, however the remaining patients complained of obstructive defecation and underwent surgery for transanal strictureplasty with electrocautery. A statistical analysis revealed that patients with stenosis had significantly more often prior treatment for hemorrhoids (p < 0.01). According to the SRM only severe postoperative pain was significantly associated with stenoses (p < 0.01). Other factors, such as gender (p = 0.11), surgical technique (p = 0.25), revision (p = 0.79) or histological evidence of squamous skin (p = 0.69) showed no significance. CONCLUSION: Rectal stenosis is an uncommon event after SRM. Early stenosis will occur within the first three months after surgery. The majority of the stenoses are without clinical relevance. Only one of nine patients had to undergo surgery for a relevant stenosis. The predictive factor for stenosis in the patient-characteristics is previous interventions for hemorrhoids, severe postoperative pain might also predict rectal stenosis.


Assuntos
Hemorroidas/cirurgia , Obstrução Intestinal/etiologia , Doenças Retais/etiologia , Grampeamento Cirúrgico/efeitos adversos , Distribuição de Qui-Quadrado , Constrição Patológica/etiologia , Feminino , Humanos , Mucosa Intestinal/cirurgia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Retrospectivos , Fatores de Risco
16.
Dis Colon Rectum ; 47(2): 185-91, 2004 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-15043288

RESUMO

PURPOSE: The disappointing outcome of local fascial repair and stoma relocation in parastomal hernias has stimulated a variety of new techniques that use a prosthetic mesh for herniorrhaphy. Many of these procedures either carry the risk of mesh contamination or allow only a local repair. We established a method that allows both an aseptic operation and the management of concurrent incisional hernias. METHODS: In a retrospective study we evaluated all patients who had undergone operation for a paracolostomy hernia with an expanded polytetrafluoroethylene (PTFE) mesh in the intraperitoneal onlay position in our Department of General Surgery from 1994 until 2002. Twenty patients with large paracolostomy hernias and 10 additional ventral hernias, mostly large incisional or recurrent incisional hernias, were identified. We combined the Sugarbaker and the Rives-Stoppa techniques by covering the defects with an ePTFE mesh after laparotomy and fixing the mesh with traction sutures. RESULTS: Postoperatively, there was no incidence of mesh infection. After a mean follow-up of 3 1/2 years we found three recurrences of paracolostomy hernias and two recurrences of incisional hernias. Another two hernias emerged in the previously intact midline. All these hernias were small, without tendency to enlargement, and did not warrant reoperation. CONCLUSIONS: Patients with symptomatic paracolostomy hernias or a combination of abdominal wall defects should properly be managed surgically with an intraperitoneally placed mesh that covers all hernias. Our results, with a recurrence rate of only 15 percent for the parastomal site and 20 percent for combined defects, support this approach.


Assuntos
Colostomia/efeitos adversos , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Hérnia/etiologia , Herniorrafia , Complicações Pós-Operatórias , Telas Cirúrgicas , Idoso , Feminino , Humanos , Laparotomia , Masculino , Pessoa de Meia-Idade , Politetrafluoretileno , Recidiva , Estudos Retrospectivos , Técnicas de Sutura , Resultado do Tratamento
17.
J Urol ; 168(6): 2461-3, 2002 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-12441940

RESUMO

PURPOSE: A large hernia after flank incision for nephrectomy is a challenging problem in hernia surgery. In recent decades preperitoneal prosthetic herniorrhaphy became a widely accepted procedure for hernias of the abdominal wall. To evaluate the outcome of mesh hernia repair of the flank we reviewed our data on all patients who underwent preperitoneal mesh repair. MATERIALS AND METHODS: We identified 4 patients who underwent prosthesis repair after incisional hernia of the flank within the last 6 years. The primary reason for surgery was nephrectomy in 2 cases, pyeloplasty in 1 and complicated kidney cyst resection in 1. Mean followup time was 33 months. RESULTS: In a mean operative time +/- SD of 208 +/- 55 minutes the patients underwent incisional hernia repair with prosthesis implantation in the sublay position. In 3 patients an expanded polytetrafluoroethylene patch was used and in 1 polypropylene mesh was implanted. Mean prosthesis size was 25 x 38 cm. (950 +/- 300 cm. ). There were no postoperative complications. Patients were discharged from the hospital after a mean of 15 +/- 2 days. Followup revealed that none of the 4 patients with flank incision had recurrent hernia. Pain persisted in 3 patients after flank incision. However, no regular analgesic drug prescription was necessary. CONCLUSIONS: Mesh repair for incisional flank hernia provides reinforcement of the hernia. However, the flank remains paralyzed with a muscle bulge and some patients have persistent discomfort.


Assuntos
Hérnia Ventral/cirurgia , Nefrectomia/efeitos adversos , Telas Cirúrgicas , Idoso , Feminino , Dor no Flanco/etiologia , Hérnia Ventral/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Polipropilenos , Politetrafluoretileno , Complicações Pós-Operatórias , Estudos Prospectivos , Próteses e Implantes
18.
Anticancer Res ; 22(2B): 1225-30, 2002.
Artigo em Inglês | MEDLINE | ID: mdl-12168930

RESUMO

BACKGROUND: Increasing evidence suggests that COX-2 promotes carcinogenesis but it is controversial as to whether COX-2 expression is a prognostic factor for rectal carcinoma. MATERIALS AND METHODS: Data of 62 consecutive patients with rectal carcinoma in UICC-stages I-III, which were curatively resected between 1995 and 1996, were analyzed. The paraffin-embedded tumor samples were stained for COX-2 expression. A labeling index of stained cells was calculated and the median COX- 2 labeling index was used as the cut-offpoint for statistical analysis. RESULTS: The median labeling index was 0.58 (SD +/- 0.25). The Chi-square test revealed no correlation between COX-2 overexpression and the established prognostic factors. In the univariate analysis, COX-2 did not show significance according to the endpoints, local recurrence (p=0.41), disease-specific survival (p=0.28) or overall-survival (p=0.69). In contrast increased COX-2 level was a significant prognostic factor for pulmonary metastasis (p=0.04). DISCUSSION: COX-2 expression lacked significance as a prognostic factor for local control and survivaL However, there is evidence that COX-2 might be linked to an increased risk of hematogenous metastatic spread.


Assuntos
Isoenzimas/biossíntese , Recidiva Local de Neoplasia/enzimologia , Prostaglandina-Endoperóxido Sintases/biossíntese , Neoplasias Retais/enzimologia , Idoso , Ciclo-Oxigenase 2 , Feminino , Humanos , Imuno-Histoquímica , Mucosa Intestinal/enzimologia , Mucosa Intestinal/patologia , Masculino , Proteínas de Membrana , Análise Multivariada , Metástase Neoplásica , Estadiamento de Neoplasias , Neoplasias Retais/patologia , Taxa de Sobrevida
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