Comparison of clinical manifestation and severity between hospital-based American and Chinese patients with colorectal Crohn disease / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the differences in clinicopathological characteristics and severity between American and Chinese patients with colorectal Crohn disease(CD).</p><p><b>METHODS</b>Between March 1985 and September 2004, 68 patients with colorectal CD in Cleveland Clinic Florida (America) and 85 patients with colorectal CD in the 301 Hospital(China) were enrolled in the study. Data of two groups,including demographics, clinical characteristics, extraintestinal manifestations, presenting symptoms, location and pathological characteristics,were compared.</p><p><b>RESULTS</b>60.3% of American patients and 36.5% of Chinese patients were female(P=0.003). 11.8% of American patients and 1.2% of Chinese patients had a family history of CD(P=0.016). American patients had a significantly higher rate of extraintestinal disease (39.7% vs 20.0%), abscess(19.0% vs 0), and anorectal fistulas(51.5% vs 0). American patients had significantly more extensive disease than Chinese patients(pancolitis: 44.1% vs 4.7%, P<0.01). American patients had a significantly higher rate of disease involving the ascending colon, transverse colon, descending colon, sigmoid colon, anorectal area compared with Chinese patients(all P<0.05).</p><p><b>CONCLUSIONS</b>American patients with colorectal Crohn disease seem to have a female predominance, a higher rate of CD family history, to involve the distal intestinal tract more often, and have more severe clinical manifestation and pathological process, as compared with Chinese patients.</p>

Clinical Value of Prophylactic Ureteral Stent Indwelling During Laparoscopic Colorectal Surgery

One of the hazards of colorectal surgery is ureteric injury. The aim of this study was to evaluate the results of ureteric catheterization regarding its safety and operative time. One-hundred sixty two patients underwent laparoscopic segmental left or right colectomy. The mean time for placement of ureteric catheters was 11.4 min for the right hemicolectomy and 11.3 min for the left hemicolectomy group. The mean preparation times for right hemicolectomy and left hemicolectomy (group 1 vs. group 2) were 54.7 vs. 39.1 min (p=0.00001) and 61.4 vs. 47.6 min (p=0.006), respectively. There were no significant differences in the laparoscopic operative time in either the right or left hemicolectomy groups (134.2 vs. 145.5 min and 198.4 vs. 170.1 min, respectively). There was no morbidity directly related to the ureteric catheters and in fact the incidence of postoperative urinary tract infection was lower in group 1 (1.5%) than in group 2 (5.3%) (p<0.05). Although the use of ureteric catheters added a mean of 11.3 min to the surgical procedure, the overall anesthetic time for right hemicolectomy was no longer than that for left hemicolectomy. The morbidity rate was quite acceptable. Thus, ureteric catheters may be useful in selected cases of laparoscopic left and right colorectal resections.

Clinical Presentation and Surgical Outcome in Patients with Solitary Rectal Ulcer Syndrome

PURPOSE:Solitary rectal ulcer syndrome (SRUS) is a poorly understood clinical condition and its scheme of treatment has not been defined yet. The aim of this investigation was to review the clinical spectra and outcome of various surgical treatments in patients with SRUS, thus to define more rational approach to the management of this ambiguous condition. METHODS:The study population was composed of 49 patients, among whom 20 patients (18 females and 2 males; median age, 55) were diagnosed primarily as SRUS histopathologically (=primary SRUS). Reviewing all pathologic reports and slides from specimens resected surgically in patients with rectal prolapse, another 20 cases were diagnosed to be combined with SRUS. Other 9 patients included those who were diagnosed histologically as or to be combined with SRUS after the operation for an indication other than SRUS. The latter 29 cases (26 females and 3 males; median age, 72) were defined as secondary SRUS, and then differences in clinical features and outcome of surgical treatment between 2 groups were reviewed retrospectively. The median follow-up was 24 months (range, 5-49 months). RESULTS:Ulcerative morphology was predominant in primary SRUS (70 percent), whereas erythematous (45 percent) and polypoid (34 percent) in the secondary ones. This difference in morphologic distribution between two groups was significant statistically (P=0.0025). No statistical difference was observed for symptomatologic distributions between two groups. The most common problem associated with evacuation was rectal bleeding in both groups (85 percent and 76 percent, respectively). In primary SRUS, clinical and defecographic studies revealed a rectal prolapse in 5 patients (25 percent), intussusception in 11 patients (55 percent), sigmoidocele (2 degrees) in 4 (20 percent), and paradoxical puborectalis contraction (PPC) in 3 (15 percent) to be combined. Beside rectal prolapse in secondary group, other defecographic findings associated with possible evacuatory problem included sigmoidocele (2 degrees) in 5 (25 percent), rectocele and intussusception in 2 (10 percent), respectively. Clinical improvement after surgery was obtained in 14 of 19 procedures (74 percent) in 17 patients with primary SRUS and 23 of 29 (79 percent) in secondary SRUS, the difference of which was not significant. Though statistically not significant, transabdominal rectopexy was superior to local excision for symptomatic relief in primary SRUS without overt prolapse (86 percent vs. 33 percent). Neither of changes in the percentage of symptoms before and after the operation between two groups showed significance. Clinical and pathologic variables were compared between two treatment result groups of 'improvement' and 'no improvement' and manifestations as tenesmus and digitation correlated with a poorer outcome after surgery (P=0.0065 and 0.02, respectively). CONCLUSIONS:SRUS is rather a clinical condition associated with functional anorectal evacuatory disorders than an independent disorder. This study shows optimistic role of a surgical treatment against underlying functional disorders in the improvement of secondary SRUS. Proper surgical option, however, for treatment in variable clinical spectra of primary SRUS is still not established, which awaits a conclusion from extensive prospective randomized trials.

Is the Level of Anastomosis within the Anal Canal Pertinent to Physiologic and Functional Outcome in the Double-stapled Ileoanal Reservoir?

PURPOSE: The aims of this investigation were to access the relative ratio of epithelial types within the anal canal after a double-stapled ileoanal reservoir (DSIAR) and to review physiologic and functional differences based on this diversity in epithelial types. METHODS: According to types of the epithelium present at histologic sections of the distally excised tissue ring ("donut") after the stapling for restorative proctocolectomy with construction of a DSIAR, one hundred thirty-eight patients with ulcerative colitis were stratified into two groups: 40 patients (22 males and 18 females) were categorized to be of lower anastomosis (group I), where squamous, squamous mixed with columnar, or squamocuboidal component was reported to be present, and 98 patients (50 males and 48 females) to be of higher one (group II), which was evidenced by columnar epithelium at the "donut". Physiologic and functional parameters were appraised between 2 groups to define whether this difference in epithelial types is associated with a significant difference in postoperative anorectal functional outcome. RESULTS: None of preoperative parameters reflecting resting and squeeze pressures showed significant differences between 2 groups. Postoperative mean and maximal resting pressures (MRP and MxRP) were declined to 48.8 16.9 mmHg and 67.1 21.3 mmHg in group I, and 61.1 22.7 mmHg and 90.0 38.6 mmHg in group II, differences of which were significant (P=0.046 and 0.031, respectively). Neither postoperative mean nor maximal squeeze pressure was, however, statistically different between 2 groups. Mean length of the high pressure zone was decreased in both groups postoperatively, but there were no intergroup differences. Rectoanal inhibitory reflex decreased significantly from 97.4% to 50% in group I and from 86.5% to 53.9% in group II, respectively (P<0.0001 in both). However, there was no significant intergroup difference postoperatively. Maximal tolerance volume and compliance of the reservoir were significantly improved postoperatively in both groups; from 52.2 26.1 ml and 2.8 3.3 to 163.3 115.7 ml and 14.7 15.3 in group I (P=0.0001, and <.0001, respectively), and from 77.0 59.5 ml and 4.4 6.8 to 167.3 87.9 ml and 28.7 44.0 in group II (P<0.0001, both). But there was no intergroup difference in either parameters postoperatively. There were no significant differences between groups relative to functional outcome except the diurnal incontinence to solid stool (P<0.011). CONCLUSIONS: Although epithelial types were shown to be variable at the anal side of the anastomosis after a DSIAR, these differences were not associated with physiologic and functional differences. Therefore, if technically feasible, this procedure can be performed with safety without fear of significant functional derangement.

Role of Colonic Transit Study in Determining the Results of a Subtotal Colectomy for Colonic Inertia

PURPOSE: The results of a subtotal colectomy in colonic inertia, even those reported in the most recent literature, vary dramatically. The purpose of this study was to assess the effect of a colonic transit study on the results of a subtotal colectomy in colonic inertia. METHODS: Between 1992 and 1997, 30 patients underwent a subtotal colectomy with ileorectal anastomosis due to colonic inertia. Twenty-one of them underwent a colonic transit study only one time preoperatively, and 9 patients underwent such a study two times. The success rate was calculated using traditional definition with two sets of criteria. We modi fied the criteria of success by including new symptoms, such as abdominal, pelvic, or rectal pain, difficult evacuation, and loose stool or diarrhea. The success rate was recalculated using our more stringent cri teria, and compared between group 1 and group 2. RESULTS: By the traditional definition, the functional success rate was 100% for patients undergoing a colonic transit study two times preoperatively and 90% for patients undergoing only one study (p=0.34). By our more stringent criteria, the success rate was 100% for patients undergoing studies two times and 62% for those undergoing only one study (p=0.03). CONCLUSIONS: The success rate of a colectomy for colonic inertia was significantly higher for patients who underwent a repeat transit study than for those who underwent a single study. Patients who have two or more transit studies to confirm the diagnosis of inertia have a significantly higher probability of postoperative improvement of both bowel frequency and associated symptoms, such as pain and difficult evacuation. The mechanism for this discriminatory effect of repeated colonic transit studies requires elucidation by further study.

Study of Reproducibility of Colonic Transit Study in Patients with Chronic Constipation

BACKGROUND: There are few reports about the reproducibility of colonic transit studies. Major therapeutic decisions are rendered based upon a single colonic transit study. Therefore, the aim of this study was to access the reproducibility of colonic transit studies in patients with chronic constipation. METHODS: Fifty one (51) patients with chronic constipation underwent two separate colonic transit studies. All clinical conditions, methodologies, and patients' instructions were identical on both occasions. The gamma rate (linear correlation analysis) was taken between the first and the second colonic transit studies. The patients were subdivided into those tested within the same year and those whose tests occurred more than 12 months apart. These two groups were further divided according to the diagnosis of colonic inertia, paradoxical puborectalis contraction, and chronic idiopathic constipation. RESULTS: In 35 of the 51 patients (69%), the results were identical between the two studies; however, in 16 patients (31%), the results were disparate (gamma correlation coefficient=0.53; p<0.01). The correlation coefficient for tests repeated within one year was 0.38 (p<0.05) whereas for periods greater than one year it was 0.72 (p<0.01). The specific correlation coefficients for patients with colonic inertia, paradoxical puborectalis contraction, and chronic idiopathic constipation were 0.12, 0.21, and 0.60 (p<0.05), respectively. CONCLUSIONS: Colonic transit studies are reproducible in patients with chronic constipation, regardless of the duration between tests. The correlation coefficient is best for patients with idiopathic constipation and worst for patients with colonic inertia.

Anorectal Physiology in the Rectal Prolapse Patient

PURPOSE: The aim of our study was to evaluate the physiological spectrum of anorectal dysfunction among patients with full thickness circunferential rectal prolapse. MATERIAL AND METHODS: Between January 1988 and March 1995, 88 patients who visited department colorectal surgery, Cleveland Clinic Florida with rectal prolapse were studied. There were 8 males and 80 females, with a mean age 69 (range 28~101) years. Patients underwent a detailed history and the following anorectal physiology tests were performed: anal canal manometry, pudendal nerve terminal motor latency (PNTML) assessment, anal electromyography and cinedefecography.4 standard continence scoring system, based on the frequency and type of incontinence (0=full continence, 20=complete incontinence) was used. Patients with rectal prolapse (n=88) were divided into two subgroups: Group I=continent patients (n=33) and Group II= incontinent patients (n=55). RESULTS: There were statistically significant differences between each group when comparing mean resting pressures, anal pressures, anal canal length, rectal compliance, rectoanal inhibitory reflex, increased fiber density, the occurrence of premature evacuation (p0.05) between groups. CONCLUSION: Continence may be disturbed in patients with rectal prolapse; knowledge of impairment in continence may assist in surgical management.