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  • 1
    Digitale Medien
    Digitale Medien
    Reconstructive Surgery for Pelvic Pouches (1998)
    Springer
    World journal of surgery 22 (1998), S. 342-346 
    Details
    ISSN: 1432-2323
    Quelle: Springer Online Journal Archives 1860-2000
    Thema: Medizin
    Notizen: Abstract. Restorative proctocolectomy with ileo–pouch–anal anastomosis has become the elective surgical procedure of choice for most of our patients with ulcerative colitis and for selected patients with familial adenomatous polyposis. This report reviews the results of the outcome of patients who have undergone a more radical reconstructive approach for salvage of the pelvic pouch where multiple local procedures have failed. A group of 24 patients were reviewed (19 females, 5 males). The indication for surgery was ulcerative colitis in 22 patients; 10 of the 24 patients were referred from other centers. The 24 patients underwent a mean of 2.9 local salvage procedures per patient. Of the 19 females within the group, 12 had an anastomotic vaginal fistula. The 24 patients were divided into two groups. The first group consisted of 14 patients whose initial pouch was used once again for revisionary surgery. Group 2 comprised 10 patients whose initial pouch was removed and a redo pouch was constructed. Of the 24 patients, only 2 have had their pouches removed. More than 75% of the patients have had a successful outcome using a reconstructive approach. Four patients still have an ileostomy; of these four, two are awaiting closure of their loop ileostomy. Of 18 patients who were evaluable, 13 were considered to have normal daytime continence, and 17 of 18 were sexually functional. Of the 18 evaluable patients, 15 were satisfied with the outcome. Radical reconstructive surgery can be performed where local procedures to effect pouch salvage have failed, and it should be considered as a first-line management where factors dictate that local procedures might fail. The commitment of the surgeon and the patient to achieving a successful outcome is essential. Severe pouch-specific complications can be managed successfully by surgeons who have a specific interest in pelvic pouch surgery and have considerable experience dealing with complications that arise.
    Materialart: Digitale Medien
    URL: http://dx.doi.org/10.1007/s002689900394
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  • 2
    Digitale Medien
    Digitale Medien
    Family history characteristics, tumor microsatellite instability and germline MSH2 and MLH1 mutations in hereditary colorectal cancer (1999)
    Springer
    Human genetics 〈Berlin〉 104 (1999), S. 167-176 
    Details
    ISSN: 1432-1203
    Quelle: Springer Online Journal Archives 1860-2000
    Thema: Biologie , Medizin
    Notizen: Abstract Recent characterization of the molecular genetic basis of hereditary nonpolyposis colorectal cancer provides an important opportunity for identification of individuals and their families with germline mutations in mismatch repair genes. Cancer family history criteria that accurately define hereditary colorectal cancer are necessary for cost-effective testing for germline mutations in mismatch repair genes. The present report describes the results of analysis of 33 colorectal cancer cases/families that satisfy our modified family history criteria (Mount Sinai criteria) for colorectal cancer. Fourteen of these families met the more stringent Amsterdam criteria. Germline MSH2 and MLH1 mutations were identified by the reverse transcription-polymerase chain reaction and the protein truncation test, and confirmed by sequencing. Microsatellite instability analysis was performed on available tumors from affected patients. MSH2 or MLH1 mutations were detected in 8 of 14 Amsterdam criteria families and in 5 of the remaining 19 cases/families that only satisfied the Mount Sinai criteria. Three of the latter families had features of the Muir-Torre syndrome. A high level of microsatellite instability (MSI-H) was detected in almost all (16/18) colorectal cancers from individuals with MSH2 and MLH1 mutations, and infrequently (1/21) in colorectal cancer specimens from cases without detectable mutations. Families with germline MSH2 and MLH1 mutations tended to have individuals affected at younger ages and with multiple tumors. The Amsterdam criteria are useful, but not sufficient, for detecting hereditary colorectal cancer families with germline MSH2 and MLH1 mutations, since a proportion of cases and families with mutations in mismatch repair genes will be missed. Further development of cancer family history criteria are needed, using unbiased prospectively collected cases, to define more accurately those who will benefit from MSH2 and MLH1 mutation analysis.
    Materialart: Digitale Medien
    URL: http://dx.doi.org/10.1007/s004390050931
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  • 3
    Digitale Medien
    Digitale Medien
    Treatment of rectovaginal fistulas that has failed previous repair attempts (1995)
    Springer
    Diseases of the colon & rectum 38 (1995), S. 921-925 
    Details
    ISSN: 1530-0358
    Schlagwort(e): Rectovaginal fistula ; Advancement flap ; Gracilis transfer ; Coloanal anastomosis ; Sphincteroplasty
    Quelle: Springer Online Journal Archives 1860-2000
    Thema: Medizin
    Notizen: Abstract PURPOSE: The purpose of this study was to assess results of treatment of rectovaginal fistulas (excluding pouch vaginal fistulas) that have failed previous attempts at repair. METHOD: A retrospective chart review of all patients presenting with nonhealing rectovaginal fistula was performed. RESULTS: Twenty eight patients with persistent fistulas were identified. In 18 patients the fistula was classified as simple, and in 10 the fistula was complex. Fourteen fistulas were secondary to obstetric injury, five were caused by Crohn's disease, and nine patients had miscellaneous etiologies for their fistulas. Of patients with persistent simple fistulas, 13 (72 percent) of the fistulas healed, 5 after advancement flaps, 5 following sphincteroplasty, and 3 after coloanal anastomoses. Of persistent complex fistulas, only four of ten (40 percent) healed, one following sphincteroplasty, one with coloanal anastomosis, and two after gracilis transposition. A total of 23 advancement flaps were done in 17 patients with five fistulas healing (29 percent). Sphincteroplasty and fistulectomy was successful in six of seven patients (86 percent). Coloanal anastomosis resulted in healing of four of six patients (67 percent) in whom it was attempted. Gracilis muscle transfer was successful in two of two patients (100 percent). CONCLUSION: Persistent rectovaginal fistula presents a difficult management problem. Choice of operation must be tailored to the underlying pathology and type of repair previously done. Advancement flap repair is generally not recommended for persistent complex fistulas or for simple fistulas that have failed a previous advancement flap repair.
    Materialart: Digitale Medien
    URL: http://dx.doi.org/10.1007/BF02049726
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  • 4
    Digitale Medien
    Digitale Medien
    Changing causes of mortality in patients with familial adenomatous polyposis (1996)
    Springer
    Diseases of the colon & rectum 39 (1996), S. 384-387 
    Details
    ISSN: 1530-0358
    Schlagwort(e): Familial adenomatous polyposis ; Colorectal carcinoma ; Desmoid tumors ; Periampullary tumors
    Quelle: Springer Online Journal Archives 1860-2000
    Thema: Medizin
    Notizen: Abstract Widespread use of prophylactic colectomy has resulted in a reduction in the incidence of colorectal cancer in familial adenomatous polyposis (FAP) patients. A retrospective chart review of families registered at the Steve Atanas Stavro Familial Gastrointestinal Cancer Registry in Toronto was performed to determine whether the decrease in the number of patients developing colorectal cancer implies that causes of mortality in FAP patients are shifting to that of extracolonic manifestations of FAP. Information was available on 140 deaths within 158 families and among 461 individuals with FAP. When stratified by decade, from the 1930s to the 1990s, the ratio of deaths caused by extracolonic manifestations of FAP compared with deaths caused by colorectal cancer was noted to have risen. Even though most deaths in FAP patients are still from colorectal cancer, it appears that screening policies and prophylactic colectomy have resulted in a reduction in the number of FAP patients who develop colorectal cancer. Thus, in recent decades, a greater percentage of deaths in FAP patients appears to be attributable to extracolonic manifestations of the disease.
    Materialart: Digitale Medien
    URL: http://dx.doi.org/10.1007/BF02054051
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  • 5
    Digitale Medien
    Digitale Medien
    Invited editorial (1998)
    Springer
    Diseases of the colon & rectum 41 (1998), S. 1355-1356 
    Details
    ISSN: 1530-0358
    Quelle: Springer Online Journal Archives 1860-2000
    Thema: Medizin
    Materialart: Digitale Medien
    URL: http://dx.doi.org/10.1007/BF02237047
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  • 6
    Digitale Medien
    Digitale Medien
    Negative genetic test result in familial adenomatous polyposis (1999)
    Springer
    Diseases of the colon & rectum 42 (1999), S. 307-310 
    Details
    ISSN: 1530-0358
    Schlagwort(e): Familial adenomatous polyposis ; Genetic testing ; Registries ; APC gene
    Quelle: Springer Online Journal Archives 1860-2000
    Thema: Medizin
    Notizen: Abstract PURPOSE: The goal of genetic testing is to define individual risk, which in turn may guide clinical management. METHODS: Thirty-two international familial adenomatous polyposis registries were surveyed regarding their approach to a specific clinical management question. There were 30 respondents. Respondents declared their clinical policy for an at-risk, first-degree relative who undergoes direct mutation analysis and does not have anAPC gene mutation known to be present in his or her family. RESULTS: Nineteen of 30 (63.3 percent) registries would discharge this negativeAPC mutation case from clinical screening. Eleven of 30 (37 percent) registries would maintain clinical screening. Reasons offered for maintaining surveillance included the need for additional confirmation of theAPC mutation in two affected relatives, the possibility of sampling error or two different mutations in an affected family, limited prospective data, and patient anxiety. CONCLUSIONS: The discrepancy in response to the survey suggests that some clinicians are as yet reluctant to accept fully that predictive genetic analysis is a definitive guide to clinical management in familial adenomatous polyposis. Nevertheless, we believe that use of a predictive gene test for familial adenomatous polyposis should alter management, decrease cost, and reduce psychological trauma for the tested individual. Although the benefit ofAPC analysis is accepted for the positive gene carrier, the challenge remains to reclassify the negative gene carriers who are no longer at risk for familial adenomatous polyposis.
    Materialart: Digitale Medien
    URL: http://dx.doi.org/10.1007/BF02236343
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  • 7
    Digitale Medien
    Digitale Medien
    Effect of intervention in inflammatory bowel disease on health-related quality of life: A critical review (1995)
    Springer
    Diseases of the colon & rectum 38 (1995), S. 1147-1161 
    Details
    ISSN: 1530-0358
    Schlagwort(e): Quality of life ; Ulcerative colitis ; Crohn's disease ; Inflammatory bowel disease ; Pelvic pouch ; Ileostomy
    Quelle: Springer Online Journal Archives 1860-2000
    Thema: Medizin
    Notizen: Abstract Health-related quality of life (HRQOL) is a quantitative measurement of subjective perception of health state, including emotional and social aspects. It can be reliably measured with several valid instruments. Previous reviews of the literature suggested inadequate attention to HRQOL in studies of interventions in inflammatory bowel disease. PURPOSE: This study was undertaken to assess the current status of the quality of measurement of HRQOL in studies of inflammatory bowel disease and to review the clinical conclusions warranted by the literature. METHOD: Medline was searched for articles relating to ulcerative colitis, Crohn's disease, or inflammatory bowel disease and quality of life since 1981. The articles found were reviewed for citations of further articles. The adequacy of HRQOL measure was assessed and graded, and the study design was categorized to assess the strength of the literature on the whole. RESULTS: A trend was found toward higher quality of HRQOL measurement in the period 1988 to 1994 compared with 1981 to 1987. Most of the improvement was because of increased use of standardized and multidomain but unvalidated and unpublished questionnaires for measurement. CONCLUSIONS: Confidence in the following clinical conclusions in studies of surgical interventions in inflammatory bowel disease is limited by study design: that pelvic pouch is not inferior to ileostomy, that specific domains of HRQOL are differentially affected by different surgical procedures, and (with less confidence) that surgery is helpful in Crohn's disease. Medical studies have demonstrated that high quality HRQOL measures can be integrated into randomized, prospective trials. Clinically equivalent treatments have shown differential effects on HRQOL: 9 mg daily of budesonide is superior to 15 mg, and hydrocortisone foam enemas are superior to prednisolone. Home parenteral nutrition has received modest support, limited again by study design. It is recommended that standard tests of HRQOL be used to increase comparability of studies and to increase the quality of this literature in general. In particular the Inflammatory Bowel Disease Questionnaire, Rating Form of Inflammatory Bowel Disease Concerns, and Direct Questioning of Objectives are recommended.
    Materialart: Digitale Medien
    URL: http://dx.doi.org/10.1007/BF02048330
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  • 8
    Digitale Medien
    Digitale Medien
    Using genetic information to make surgical decisions (1997)
    Springer
    Diseases of the colon & rectum 40 (1997), S. 240-243 
    Details
    ISSN: 1530-0358
    Schlagwort(e): Hereditary nonpolyposis colorectal carcinoma ; Microsatellite instability ; Genetic counseling ; Registries
    Quelle: Springer Online Journal Archives 1860-2000
    Thema: Medizin
    Notizen: Abstract PURPOSE: We report the case of a boy aged 13 years who was diagnosed with a Dukes B obstructing cancer of the sigmoid colon. At the time of diagnosis, he underwent a Hartmann's procedure with end colostomy. Because of his unusually young age, he was referred to the Familial GI Cancer Registry at Mount Sinai Hospital for genetic assessment. A detailed pedigree revealed no significant history other than lung cancer in his maternal grandfather. METHODS: We obtained his tumor specimen and performed molecular analysis of both normal colonic and tumor DNA. Specifically, we identified replication errors (RER) in the patient's tumor DNA when compared with normal colonic DNA. RER has been found in more than 90 percent of tumors from patients with Hereditary Nonpolyposis Colon Cancer (HNPCC) and is, thus, considered to be one of the hallmarks of this disease. Because HNPCC patients have a 40 percent risk of synchronous or metachronous tumors, the recommended surgery for HNPCC should be at least a subtotal colectomy with ileorectal anastomosis. RESULTS: Based on molecular results, we were able to recommend that the patient have a subtotal colectomy performed instead of merely colostomy closure, to reduce his lifetime risk of developing further colon tumors and to make surveillance of the remaining rectum relatively easy. In this patient, we subsequently identified a germline mutation of the mismatch repair gene hMSH2 that is implicated in HNPCC. The possibility of HNPCC should be considered in adolescents who are diagnosed with colorectal cancer, so appropriate surgical decisions can be made.
    Materialart: Digitale Medien
    URL: http://dx.doi.org/10.1007/BF02054995
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  • 9
    Digitale Medien
    Digitale Medien
    Risk factors for pelvic pouch failure (1997)
    Springer
    Diseases of the colon & rectum 40 (1997), S. 257-262 
    Details
    ISSN: 1530-0358
    Schlagwort(e): Heal pouch-anal anastomosis ; Ulcerative colitis ; Crohn's disease ; Familial adenomatous polyposis ; Complications
    Quelle: Springer Online Journal Archives 1860-2000
    Thema: Medizin
    Notizen: Abstract PURPOSE: This study was designed to identify factors associated with pelvic pouch failure. METHOD: A retrospective review of patients undergoing the pelvic pouch procedure with a minimum of 30 months follow-up was conducted. RESULTS: A total of 551 patients had pelvic pouch procedures from 1981 to 1992. Forty-nine patients (8.8 percent) have undergone pouch excision, and 9 (1.6 percent) have been defunctioned, for 58 (10.5 percent) patients with pouch failure. Cause of failure was leakage from the ileoanal anastomosis (IAA) in 21 (39 percent) patients, poor functional results in 13 (23 percent), pouchitis in 7 (12 percent), pouch leakage in 7 (12 percent), perianal disease in 7 (12 percent), and miscellaneous in 3 (5.2 percent). Nine of 22 patients (41 percent) had pouch failure during the first two years, with 2 of 147 patients (1 percent) having failure during the last two years of the study. The 58 patients whose pouches failed (Group 1) were compared with the 493 patients whose pouches did not fail (Group 2). Handsewn IAA (P 〈0.001), tension on the IAA (P 〈0.001), use of a defunctioning ileostomy (P 〈0.01), a diagnosis of Crohn's disease (P 〈0.001), and a leak from the pouch (P 〈0.001) or the IAA (P 〈0.001) were associated with pouch failure. Pouchitis was not a risk factor. CONCLUSION: The majority of pouch failures were caused by leaks at the IAA. Although the leak rate remained stable, leaks following a stapled anastomosis seemed to have a better prognosis than leaks following a handsewn anastomosis. Experience with the pouch procedure and the management of complications likely plays an important role in decreasing the risk of pouch failure.
    Materialart: Digitale Medien
    URL: http://dx.doi.org/10.1007/BF02050412
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  • 10
    Digitale Medien
    Digitale Medien
    Functional outcome of conversion of ileorectal anastomosis to ileal pouch-anal anastomosis in patients with familial adenomatous polyposis and ulcerative colitis (1999)
    Springer
    Diseases of the colon & rectum 42 (1999), S. 903-908 
    Details
    ISSN: 1530-0358
    Schlagwort(e): Ulcerative colitis ; Familial adenomatous polyposis ; Anastomosis
    Quelle: Springer Online Journal Archives 1860-2000
    Thema: Medizin
    Notizen: Abstract PURPOSE: The aim of this study was to review the functional outcome in 20 patients with familial adenomatous polyposis and ulcerative colitis who were converted from ileorectal anastomosis to ileal pouch-anal anastomosis. METHODS: From 1985 to 1997, 12 patients with familial adenomatous polyposis (5 males; mean age, 39.1 years) and 8 patients with ulcerative colitis (5 males; mean age, 36.7 years) underwent conversion from ileorectal anastomosis to ileal pouch-anal anastomosis. Clinical and operative data were analyzed retrospectively. Functional results were obtained by telephone interview in 16 patients (94 percent) after pouch construction. Four patients were not interviewed (2 were deceased, 1 was lost to follow-up, and 1 was not reachable). RESULTS: Indications for conversion were uncontrollable rectal polyps (10 patients) and colonic cancer found in the pathology specimen after ileorectal anastomosis in patients with familial adenomatous polyposis (2 patients), intractable proctitis (5 patients), colonic cancer found in the pathology specimen of patients with ulcerative colitis after ileorectal anastomosis (2 patients), and rectal dysplasia (1 patients). Mean follow-up time was 5 (range, 1–11) years. Ileal pouch-anal anastomosis was handsewn in 14 patients, and the remaining cases were double-stapled in 4 patients with ulcerative colitis. No intraoperative difficulties were reported in 13 cases; technical problems were related to adhesions (3 cases), difficult rectal dissection (2 cases), and stapler-related difficulties (2 cases). Postoperative complications after ileal pouch-anal anastomosis included small-bowel obstruction (4 patients) and ileal pouch-anal anastomosis leak (1 patient). Patients with ileorectal anastomosisvs. those with ileal pouch-anal anastomosis had a better functional outcome with regard to nighttime continence (14 (88 percent)vs. 6 (38 percent) patients) and average bowel movements (〈6/day; 12 (75 percent)vs. 4 (25 percent) patients). Complete daytime continence, 15 (94 percent)vs. 10 (62 percent) patients, was similar in the two groups. Physical and emotional well-being were similarly rated as very good to excellent. CONCLUSIONS: In patients with familial adenomatous polyposis and ulcerative colitis with ileorectal anastomosis, conversion to ileal pouch-anal anastomosis may be required. In view of the risk of rectal cancer or intractable proctitis, patients seem to accept the conversion in spite of poorer bowel function.
    Materialart: Digitale Medien
    URL: http://dx.doi.org/10.1007/BF02237099
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