PURPOSE: This study was designed to examine the effect of neoadjuvant chemoradiation on pelvic sepsis after mesorectal excision for rectal cancer. METHODS: A retrospective chart review was conducted for all patients w...PURPOSE: This study was designed to examine the effect of neoadjuvant chemoradiation on pelvic sepsis after mesorectal excision for rectal cancer. METHODS: A retrospective chart review was conducted for all patients who underwent curative mesorectal excision for rectal cancer during an eight-year period. Demographic, preoperative, perioperative data were collected. Pelvic sepsis was defined as clinical or radiographically demonstrable leak or a pelvic abscess. Neoadjuvant chemoradiation included 5,040 Gy in conjunction with three cycles of 5-fluorouracil-based chemotherapy, followed by a one-month waiting period. RESULTS: From January 1994 to December 2002, 246 patients (151 males; mean age 68 (range, 36-97) years) underwent curative resection for rectal cancer. Procedures included 186 anterior resections, 52 abdominoperineal resections, and 8 Hartmann’s. Of 60 patients (24.4 percent) who had neoadjuvant chemoradiation, 9 (15 percent) developed pelvic sepsis (3 leaks, 6 abscesses) compared with 9 of 186 (4.8 percent) after primary surgery (6 leaks, 3 abscesses; P < 0.01). Ninety-three patients had an anastomosis ≤6 cm from the anal verge. Of these, 9 patients (9.7 percent) developed pelvic sepsis (5 leaks, 4 abscesses): 5 of 28 (17.9 percent) after neoadjuvant chemoradiation vs. 4 of 65 (6.2 percent) after primary surgery (P = 0.22). Only 6 of 93 patients (6.5 percent) with an anastomosis ≥7 cm developed pelvic sepsis (5 leaks and 1 abscess), of whom 1 had preoperative radiation. Pelvic abscess developed in 3 of 24 patients after neoadjuvant chemotherapy and abdominoperineal resection. After primary abdominoperineal resection, none of the remaining 28 patients developed pelvic sepsis. A multivariable logistic regression model was constructed to determine predictors of sepsis. Neoadjuvant chemotherapy was the only variable that was predictive (odds ratio, 3.4; 95 percent confidence interval, 1.3-9). CONCLUSIONS: The addition of neoadjuvant chemoradiation to mesorectal excision significantly increased the rate of pelvic sepsis. This was particularly true for anastomoses in the lower third of the rectum. Fecal diversion should be considered in these patients.展开更多
PURPOSE: This study was designed to determine the outcome of patients with Crohn’ s disease and indeterminate colitis who have an ileal pouch- anal anastomosis. METHODS: Between 1982 and 2001, 1,270 patients underwen...PURPOSE: This study was designed to determine the outcome of patients with Crohn’ s disease and indeterminate colitis who have an ileal pouch- anal anastomosis. METHODS: Between 1982 and 2001, 1,270 patients underwent a restorative proctocolectomy at the Mount Sinai Hospital: 1,135 had ulcerative colitis, 36 had Crohn’ s disease, 21 had indeterminate colitis, and 78 had another diagnosis. Perioperative data were collected prospectively. Functional outcomes were assessed with a 35- question survey mailed to all patients with a functioning pouch of at least six months duration. RESULTS: Pouch complications were significantly more common in patients with Crohn’ s disease (64 percent) and indeterminate colitis (43 percent) compared with patients with ulcerative colitis (22 percent) (P < 0.05). Similarly, 56 percent of patients with Crohn’ s disease had their pouch excised or defunctioned, compared with 10 percent of patients with indeterminate colitis and 6 percent with ulcerative colitis (P < 0.01). In the subgroup of patients with a diagnosis of Crohn’ s disease, multivariate analysis revealed that the pathologist’ s initial designation of ulcerative colitis (based on the colectomy specimen) and an increasing number of pathologic, clinical, and endoscopic features of Crohn’ s disease were independently associated with pouch failure. The functional results in patients with Crohn’ s disease with a successful pouch were not significantly different from those with indeterminate colitis or ulcerative colitis. CONCLUSIONS: Although complication rates may be higher in patients with indeterminate colitis compared with ulcerative colitis, the overall pouch failure rate is similar. On the other hand, more than one- half of patients with Crohn’ s disease will require pouch excision or diversion. Our data suggest that it is difficult to identify patients with Crohn’ s disease who are likely to have a successful outcome after restorative proctocolectomy. Thus, Crohn’ s disease should remain a relative contraindication to restorative proctocolectomy, whereas ileal pouch- anal anastomosis is an acceptable alternative for patients with indeterminate colitis.展开更多
文摘PURPOSE: This study was designed to examine the effect of neoadjuvant chemoradiation on pelvic sepsis after mesorectal excision for rectal cancer. METHODS: A retrospective chart review was conducted for all patients who underwent curative mesorectal excision for rectal cancer during an eight-year period. Demographic, preoperative, perioperative data were collected. Pelvic sepsis was defined as clinical or radiographically demonstrable leak or a pelvic abscess. Neoadjuvant chemoradiation included 5,040 Gy in conjunction with three cycles of 5-fluorouracil-based chemotherapy, followed by a one-month waiting period. RESULTS: From January 1994 to December 2002, 246 patients (151 males; mean age 68 (range, 36-97) years) underwent curative resection for rectal cancer. Procedures included 186 anterior resections, 52 abdominoperineal resections, and 8 Hartmann’s. Of 60 patients (24.4 percent) who had neoadjuvant chemoradiation, 9 (15 percent) developed pelvic sepsis (3 leaks, 6 abscesses) compared with 9 of 186 (4.8 percent) after primary surgery (6 leaks, 3 abscesses; P < 0.01). Ninety-three patients had an anastomosis ≤6 cm from the anal verge. Of these, 9 patients (9.7 percent) developed pelvic sepsis (5 leaks, 4 abscesses): 5 of 28 (17.9 percent) after neoadjuvant chemoradiation vs. 4 of 65 (6.2 percent) after primary surgery (P = 0.22). Only 6 of 93 patients (6.5 percent) with an anastomosis ≥7 cm developed pelvic sepsis (5 leaks and 1 abscess), of whom 1 had preoperative radiation. Pelvic abscess developed in 3 of 24 patients after neoadjuvant chemotherapy and abdominoperineal resection. After primary abdominoperineal resection, none of the remaining 28 patients developed pelvic sepsis. A multivariable logistic regression model was constructed to determine predictors of sepsis. Neoadjuvant chemotherapy was the only variable that was predictive (odds ratio, 3.4; 95 percent confidence interval, 1.3-9). CONCLUSIONS: The addition of neoadjuvant chemoradiation to mesorectal excision significantly increased the rate of pelvic sepsis. This was particularly true for anastomoses in the lower third of the rectum. Fecal diversion should be considered in these patients.
文摘PURPOSE: This study was designed to determine the outcome of patients with Crohn’ s disease and indeterminate colitis who have an ileal pouch- anal anastomosis. METHODS: Between 1982 and 2001, 1,270 patients underwent a restorative proctocolectomy at the Mount Sinai Hospital: 1,135 had ulcerative colitis, 36 had Crohn’ s disease, 21 had indeterminate colitis, and 78 had another diagnosis. Perioperative data were collected prospectively. Functional outcomes were assessed with a 35- question survey mailed to all patients with a functioning pouch of at least six months duration. RESULTS: Pouch complications were significantly more common in patients with Crohn’ s disease (64 percent) and indeterminate colitis (43 percent) compared with patients with ulcerative colitis (22 percent) (P < 0.05). Similarly, 56 percent of patients with Crohn’ s disease had their pouch excised or defunctioned, compared with 10 percent of patients with indeterminate colitis and 6 percent with ulcerative colitis (P < 0.01). In the subgroup of patients with a diagnosis of Crohn’ s disease, multivariate analysis revealed that the pathologist’ s initial designation of ulcerative colitis (based on the colectomy specimen) and an increasing number of pathologic, clinical, and endoscopic features of Crohn’ s disease were independently associated with pouch failure. The functional results in patients with Crohn’ s disease with a successful pouch were not significantly different from those with indeterminate colitis or ulcerative colitis. CONCLUSIONS: Although complication rates may be higher in patients with indeterminate colitis compared with ulcerative colitis, the overall pouch failure rate is similar. On the other hand, more than one- half of patients with Crohn’ s disease will require pouch excision or diversion. Our data suggest that it is difficult to identify patients with Crohn’ s disease who are likely to have a successful outcome after restorative proctocolectomy. Thus, Crohn’ s disease should remain a relative contraindication to restorative proctocolectomy, whereas ileal pouch- anal anastomosis is an acceptable alternative for patients with indeterminate colitis.
