肛门电刺激治疗大便失禁的随机、对照试验

PURPOSE: Anal electric stimulation has been described as effective for fecal incontinence in several case series, but no study has addressed possible mechanism of benefit. We wished to examine whether anal electric stimulation, using an anal probe electrode, used on a daily basis at home for eight weeks, in the Absence of any adjunctive exercises or advice, would improve symptoms of fecal incontinence and anal sphincter pressures when compared with “ sham” electric stimulation. METHODS: Ninety patients (9 males, 81 females), with median age of 55 (range, 30- 77) years were randomized, 47 to active anal stimulation at 35 Hz and 43 to “ sham" stimulation at 1 Hz. Outcome measures included a one-week bowel diary, symptom questionnaire, manometry, and patients evaluation of outcome. RESULTS: Seventy patients completed the study. On an intention-to-treat analysis, there was no difference between the two groups on any of the outcome measures after eight weeks. Of those who completed stimulation, 44 (63 percent) felt the stimulation had improved their continence. Those with intact anal sphincters were not likely to rate their change more positively than those with sphincter disruption (P = 0.71). Median patient rating of bowel control increased from 3 of 10 before stimulation to 5 of 10 after stimulation (P = 0.001). CONCLUSIONS: Eight weeks of anal electric stimulation was rated by patients as having improved their bowel control to a modest extent. There was no statistically significant difference detected between the groups, suggesting that 1 Hz was as effective as 35 Hz. This raises the possibility that the main effect is not sphincter contraction but sensitization of the patient to the anal area,or simply the effect of intervening per se. Home electric stimulation is a relatively cheap and generally well-tolerated therapy in the conservative treatment of fecal incontinence.

夏威夷美籍日本人与日本本土人群结肠直肠癌的特征和存活率比较

PURPOSE: This study was designed to investigate whether characteristics, prognostic risk factors, and survival of colorectal cancer of Japanese-Americans in Hawaii are different from those of native Japanese in Japan. METHODS: A retrospective review of patients with colorectal cancer surgically resected in single institutions in Hawaii and Japan from 1996 to 2002. RESULTS: A total of 410 Japanese-American patients (218 males; median age, 73 years) and 621 native Japanese patients (382 males; median age, 65 years) were included. There were significant differences in age (P < 0.001), age distribution (P < 0.001), gender (P= 0.008), preoperative carcinoembryonic antigen (P < 0.001), and anatomic site distribution (P < 0.001). The tumor characteristics of Japanese- American patients were close to the general American population compared with the Surveillance, Epidemiology, and End Results data. There were no differences in tumor size, histologic grade, each of T, N, M status and TNM stage between the two groups. The overall five-year survival rates (Japanese-Americans, 75.5 percent; native Japanese, 76.2 percent; P = 0.55) and survival rates in each of four stratified stages were similar. Risk factors associated with survival were not different, except for carcinoembryonic antigen (P = 0.036). CONCLUSIONS: In patients with colorectal cancer in Japanese-Americans in Hawaii, some of tumor characteristics have changed from those of native Japanese in Japan. However, there are no remarkable differences in prognostic factors and survival between the two groups. The present study suggests that certain changes of colorectal cancer characteristics that were seen in Japanese-American may occur in native Japanese in Japan in the near future, although the survival-outcome of colorectal cancer may remain the same.

症状轻微的男性腹股沟疝患者接受密切观察与行腹股沟疝修复术的比较研究:一项随机临床试验

Context: Many men with inguinal hernia have minimal symptoms. Whether deferring surgical repair is a safe and acceptable option has not been assessed. Objective: To compare pain and the physical component score (PCS) of the Short Form-36 Version 2 survey at 2 years in men with minimally symptomatic inguinal hernias treated with watchful waiting or surgical repair. Design, Setting, and Participants: Randomized trial conducted January 1, 1999, through December 31, 2004, at 5 North American centers and enrolling 720 men (364 watchful waiting, 356 surgical repair) followed up for 2 to 4.5 years. Interventions: Watchful-waiting patients were followed up at 6 months and annually and watched for hernia symptoms; repair patients received standard open tensionfree repair and were followed up at 3 and 6 months and annually. Main Outcome Measures: Pain and discomfort interfering with usual activities at 2 years and change in PCS from baseline to 2 years. Secondary outcomes were complications, patient-reported pain, functional status, activity levels, and satisfaction with care. Results: Primary intention-to-treat outcomes were similar at 2 years for watchful waiting vs surgical repair: pain limiting activities (5.1%vs 2.2%, respectively; P=.52); PCS (improvement over baseline, 0.29 points vs 0.13 points; P=.79). Twenty-three percent of patients assigned to watchful waiting crossed over to receive surgical repair (increase in hernia-related pain was the most common reason offered); 17%assigned to receive repair crossed over to watchful waiting. Self-reported pain in watchful-waiting patients crossing over improved after repair. Occurrence of postoperative hernia-related complications was similar in patients who received repair as assigned and in watchful-waiting patients who crossed over. One watchful-waiting patient (0.3%) experienced acute hernia incarceration without strangulation within 2 years; a second had acute incarceration with bowel obstruction at 4 years, with a frequency of 1.8/1000 patient-years inclusive of patients followed up for as long as 4.5 years. Conclusions: Watchful waiting is an acceptable option for men with minimally symptomatic inguinal hernias. Delaying surgical repair until symptoms increase is safe because acute hernia incarcerations occur rarely.

胰管胸膜瘘:2例病例报道及文献综述

Pancreaticopleural fistulas are a rare complication of pancreatitis. We report two cases from our institution and review 37 cases of pancreaticopleural fistulas identified in the literature. Endoscopic retrograde cholangiopancreatography was more sensitive compared to computed tomography in demonstrating pancreaticopleural fistulas (79%versus 43%, respectively). Medical therapy with total parenteral nutrition, octreotide, and/or chest tube placement was successful in resolving the pancreaticopleural fistula in up to 33%of cases. None of the patients who underwent pancreatic duct stent and/or nasopancreatic drain placement required surgical intervention. Endoscopic retrograde cholangiopancreatography is the initial test of choice when the diagnosis of pancreaticopleural fistula is suspected. Early endoscopic intervention with pancreatic duct stent placement is recommended given its high success rate in fistula closure. Medical therapies are useful adjuncts to endoscopic therapy, but rarely result in pancreaticopleural fistula closure alone. Surgical interventions should only be considered after failure of endoscopic and medical therapies.

急性胰腺炎患者肺功能检测的临床意义

The aim of the present study was to investigate changes in pulmonary function tests (PFTs) in patients with acute pancreatitis (AP), to compare them with those changes in healthy controls, and to analyze the relationship between these parameters and computed tomography severity index (CTSI) and Ranson’s criteria scores as markers of disease severity. This study included 40 patients with AP without a diagnosis of any pulmonary disease and 40 sex-and age-matched healthy controls. All participants were evaluated with simple PFTs and single-breath carbon monoxide (CO) diffusion tests. Patients with AP were also evaluated according to their CTSI and Ranson’s criteria scores as markers of disease severity. The forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), FEV1/FVC, and peak expiratory flow, which determine lung capacity, were similar in the two groups. The forced expiratory volume during the middle half of the FVC (FEF25-75%), CO diffusing capacity (DLCO), and ratio of DLCO to alveolar ventilation (DLCO/VA), which determines alveolar membrane permeability, revealed a statistically significant decline in pulmonary gas exchange in patients with AP (P < 0.05). Correlation analysis showed that there is a significant negative relationship between CTSI and Ranson’s criteria scores with FEF25-75%, DLCO, and DLCO/V A (P < 0.05). We suggest that AP may cause impaired alveolar gas exchange without manifest pulmonary diseases. The effect of AP on FEF 25-75%, DLCO, and DLCO/VA appears to be dependent not only on the disease, but also on its severity. FEF25-75%, DLCO, and DLCO/VA may give additional prognostic information in patients with AP in the initial evaluation.

腹腔镜下结肠直肠外科术式转变的后果

INTRODUCTION: Laparoscopic procedures converted to open approaches have been associated with higher complication rates than laparoscopic and open cholecystectomy and appendectomy. Laparoscopic colorectal resections have relatively high conversion rates compared with other laparoscopic procedures. This study was designed to evaluate outcomes of conversions compared with laparoscopic and open colorectal resections. METHODS: We reviewed 498 consecutive colorectal resections performed between 1995 and 2002. Procedures were divided into laparoscopic colorectal resections, open colorectal resections, or conversions. Demographics, underlying disease, type of procedure performed, and operative outcomes were compared between groups. RESULTS: Of the 238 laparoscopic procedures performed, 182 were completed laparoscopically and 56 (23 percent) required conversion; 260 were performed open. Conversions were associated with greater blood loss (200 (range, 50- 750) vs. 100 (range, 30- 900) ml), longer time to first bowel movement (82 (range, 40- 504) vs. 72 (range, 12- 420) hr), and longer length of stay (6 (range, 2- 67) vs. 5 (range, 2- 62) days) than the laparoscopic colorectal resections group. There was no difference in operative time, transfusion requirements, intraoperative and postoperative complications, or mortality between conversions and laparoscopic colorectal resections. Conversions resulted in fewer patients requiring transfusions (4 vs. 14 percent), shorter time to first bowel movement (82 (range, 40- 504) vs. 93 (range, 24- 240) hr), and shorter length of stay (6 (range, 2- 67) vs. 7 (range, - 180) days) than in the open colorectal resections group. There were no differences in complications or mortality between the conversion group and the open colorectal resections group. CONCLUSIONS: Laparoscopic colorectal resections has a relatively high conversion rate; however, the converted cases have outcomes similar to open colorectal resections. In fact, the converted group required fewer blood transfusions than the open group. Experience and good judgment are fundamental for timely conversion of a laparoscopic procedure to open to decrease complication rates. Despite a high conversion rate, surgeons should consider laparoscopic colorectal resections, because even when necessary, conversion does not result in poorer outcomes than laparoscopic colorectal resections or open colorectal resections.

腺苷脱氨酶、超氧化物歧化酶和过氧化氢酶活性与幽门螺杆菌的关系

Our purpose was to investigate associations between adenosine deaminase (ADA), superoxide dismutase (SOD), and catalase (CAT) activities and H. pylori. Ninety-nine patients were studied. Eight antral mucosal biopsies were taken for biochemical assessment of ADA, CAT, and SOD activity and histological assessment. H. pylori density was evaluated according to the updated Sydney system. Patients were divided into three groups according to Sydney classification. ADA activity was found to be higher in patients having H. pylori in the present study. Also, ADA activity was higher in patients with a severe density of H. pylori. SOD level was found to be significantly higher with increased H. pylori density in our study (P < 0.05). In addition, SOD activity was higher in H. Pylori-positive than H. pylori-negative patients. We did not find CAT activity in some antral tissue specimens. The significantly high levels of ADA activity in patients with H. pylori infectionmay reflect the regulator role of ADA in acid secretion. The higher ADA level with increased H. pylori density and H. pylori positivity indicate the probable malign lymphoid process of the stomach. But these findings must be confirmed with larger studies that include different gastric lesions.

胃食管静脉曲张患者伴有失弛缓症:尚有疑问的治疗方案

The coexistence of achalasia and gastroesophageal varices has been reported sporadically in the English medical literature. We report the case of a 60-year-old Hispanic woman with cryptogenic cirrhosis who was referred for a liver transplant evaluation and subsequently developed progressive dysphagia to both solids and liquids as well as substernal chest pain and weight loss. Endoscopy revealed the presence of grade I esophageal varices and large fundic varices, as well as retained liquid and solid food in the distal esophagus. Radiographic and manometric studies were consistent with achalasia. After botulinum toxin (Botox) injections were no longer effective a transjugular intrahepatic portosystemic shunt was performed for portal decompression before proceeding with pneumatic dilation. Optimal treatment of these 2 conditions, when they occur simultaneously, is problematic. We discuss this patient’s management and our approach to this infrequent combination of diseases.

腹壁瘘口生活质量量表

PURPOSE: Few studies have evaluated the impact of a stoma on patient quality of life because of a lack of specific validated measures. This study documents the development and initial application of a Stoma Quality of Life Scale. METHODS: Content experts generated initial questions. Patient focus groups were conducted to ensure that the questions addressed all stoma-related issues considered important by patients. Responses from pilot groups allowed refinement to produce the final measure, the Stoma Quality of Life Scale, a 21- item questionnaire. Three scales are featured: Work/Social Function (6 items), Sexuality/Body Image (5 items), and Stoma Function (6 items). In addition, one item (scored separately) measures financial impact, one measures skin irritation, and two measure overall satisfaction. This questionnaire was administered to 100 consecutive ostomy patients, and readministered three weeks later. Reliability was assessed by using coefficient alpha for internal consistency and intraclass correlation coefficient for test-retest reproducibility. To test validity in extreme groups, scores were compared for patients with improved quality of life vs. those whose stoma worsened their quality of life. To evaluate convergent validity, we analyzed correlation of instrument scales with the SF-12. RESULTS: The Stoma Quality of Life scales demonstrated adequate test-retest reproducibility (intraclass correlation coefficient >0.8) and acceptable internal consistency (coefficient alpha approximately 0.8). The scales were capable of discriminating between patients with better and worse quality of life after stoma formation (P < 0.02 for all scales). The Stoma Quality of Life scales significantly correlated (range, 0.12- 0.75) with the Physical and Mental Health Composite Scale Scores of the SF- 12. CONCLUSIONS: The Stoma Quality of Life Scale demonstrates reasonable psychometric properties for measuring quality of life in patients with stomas. Further studies are needed to refine the instrument.

影响抗生素成功治疗腹腔脓肿的因素和经皮穿刺引流的必要性

PURPOSE: There is no definite consensus on the management of intra-abdominal Abscesses in adults. This retrospective study evaluated the use of antibiotic therapy and percutaneous image-guided drainage in adult patients with intra-abdominal Abscesses. METHODS: A retrospective chart review of 114 patients with intra-abdominal Abscesses was conducted. Data collected included patient demographics, presenting symptoms, radiographic interpretation, vital signs, antibiotic coverage, laboratory values, and details of the hospital course. Bivariate statistical tests were performed using the Wilcoxon rank-sum test, chi-squared test, or Fisher s exact test, where appropriate. RESULTS: Sixty-seven of 114 patients (59 percent) had intra-abdominal Abscesses resulting from appendicitis, diverticulitis in 30 patients (26 percent), postoperative in 13 patients (11 percent), and undetermined in 4 patients (4 percent). Three patients (3 percent; 95 percent confidence interval, 1- 8 percent) failed conservative management and underwent urgent operation. Sixty-one (54 percent; 95 percent confidence interval, 44- 63 percent) patients improved with intravenous antibiotic therapy alone. Fifty patients (44 percent; 95 percent confidence interval, 35- 54 percent) underwent image-guided percutaneous drainage after 48 to 72 hours of antibiotic therapy. Patients who improved on antibiotics alone had average Abscess diameter of 4 cm, whereas patients who underwent percutaneous drainage had average diameter of 6.5 cm (P < 0.0001). Maximal temperature at time of admission was 100.8° F for antibiotic group and 101.2° F for percutaneous drainage group (P = 0.0067). CONCLUSIONS: The majority of the patients with intra-abdominal Abscesses improved with antibiotic therapy alone. Those patients with an Abscess diameter >6.5 cm and temperature at admission >101.2° F have higher likelihood of failing conservative therapy with antibiotics alone and requiring percutaneous drainage.

Ⅳ期结肠直肠癌进行姑息性腹腔镜切除术

PURPOSE: Issues surrounding the safety and efficacy of palliative laparoscopic resections for patients with Stage IV colorectal cancer have not been explicitly examined in the literature. This article describes our experience with laparoscopic procedures for patients with Stage IV colorectal cancer and compares thir perioperative outcomes to a contemporaneous group of patients with clinically curable (Stages I- III) disease. METHODS: A prospective database of laparoscopic resections for colorectal cancer performed between 1991 and 2002 was reviewed. Data regarding patient demographics, perioperative morbidity and mortality, operative times, conversion rates, and length of stay were extracted. Statistical analysis included chi-squared and Student s t-tests as required and P ≤ 0.05 was considered significant. RESULTS: A total of 375 cases were identified, of these 49 (13 percent) underwent laparoscopic palliative resections while 326 (87 percent) patients had resections for cure. When comparing palliative to curative procedures, there were no differences in intraoperative (4 percent vs. 9 percent) or postoperative complications (14 percent vs. 12 percent), perioperative mortality (8 percent vs. 4 percent), or length of hospital stay. Patients with Stage IV disease had larger tumors (5.4 ± 2.3 cm vs. 4.6 ± 2.6 cm, P = 0.04) which contributed to an increased rate of conversion (22 percent vs. 11 percent, P = 0.05) with most conversions secondary to tumor fixation or bulk (64 percent) preventing determination of resectability. CONCLUSIONS: A palliative laparoscopic resection is a safe and feasible option and presents acceptable morbidity and mortality in patients with Stage IV colorectal cancer. Importantly, in this difficult group of patients, our results compare favorably with those from previously published series of open procedu res.