美国与中国两组结直肠克罗恩病患者临床表现及病情严重程度比较

Objective To evaluate the differences in clinicopathological characteristics and severity between American and Chinese patients with colorectal Crohn disease (CD). Methods 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. Results 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). Conclusions 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.     

Accuracy of computed tomography in nodal staging of colon cancer patients

AIM: To predict node-positive disease in colon cancer using computed tomography(CT).METHODS: American Joint Committee on Cancer stage Ⅰ-Ⅲ colon cancer patients who underwent curavtiveintent colectomy between 2007-2010 were identified at a single comprehensive cancer center. All patients had preoperative CT scans with original radiology reports from referring institutions. CT images underwent blinded secondary review by a surgeon and a dedicated abdominal radiologist at our institution to identify pericolonic lymph nodes(LNs). Comparison of outside CT reports to our independent imaging review was performed in order to highlight differences in detection in actual clinical practice. CT reviews were compared with final pathology. Results of the outside radiologist review, secondary radiologist review, and surgeon review were compared with the final pathologic exam to determine sensitivity, specificity, positive and negative predictive values, false positive and negative rates, and accuracy of each review. Exclusion criteria included evidenceof metastatic disease on CT, rectal or appendiceal involvement, or absence of accompanying imaging from referring institutions.RESULTS: From 2007 to 2010, 64 stageⅠ-Ⅲ colon cancer patients met the eligibility criteria of our study. The mean age of the cohort was 68 years, and 26(41%) patients were male and 38(59%) patients were female. On final pathology, 26 of 64(40.6%) patients had nodepositive(LN+) disease and 38 of 64(59.4%) patients had node-negative(LN-) disease. Outside radiologic review demonstrated sensitivity of 54%(14 of 26 patients) and specificity of 66%(25 of 38 patients) in predicting LN+ disease, whereas secondary radiologist review demonstrated 88%(23 of 26) sensitivity and 58%(22 of 38) specificity. On surgeon review, sensitivity was 69%(18 of 26) with 66% specificity(25 of 38). Secondary radiology review demonstrated the highest accuracy(70%) and the lowest false negative rate(12%), compared to the surgeon review at 67% accuracy and 31% false negative rate and the outside radiology review at 61% accuracy and 46% false negative rate.CONCLUSION: CT LN staging of colon cancer has moderate accuracy, with administration of NCT based on CT potentially resulting in overtreatment. Active search for LN+ may improve sensitivity at the cost of specificity.     

磁共振成像在深部肛周脓肿诊断中的应用

Objective To evaluate magnetic resonance imaging (MRI) in the diagnosis of deep anorectal abscess. Methods Twenty-one patients who were suspected of having deep anorectal abscess were admitted to the Affiliated Hospital of Nanjing University of Chinese Medicine from January 2006 to December 2007, and their clinical data were retrospectively analyzed. Phased-array coil MRI was applied to all patients before the operation. We compared the efficacy of MRI and rectal digital examination in the classification of deep anorectal abscess and the diagnosis rate of internal opening according to the postoperative results. All data were analyzed using the chi-square test. Results Nineteen patients were diagnosed with deep anorectal abscess, one patient had presacral cyst combined with infection and one patient had perianal mucinous adenocarcinoma. A total of 25 lesions were identified, including 14 ischiorectal abscesses, five pelvirectal abscesses, and six high intersphincteric abscesses. Thirteen patients had single space abscesses and six had multiple space abscesses. There were no significant differences in the diagnosis rate between MRI (12/19) and rectal digital examination for internal opening (13/19) (χ2 =0. 116, P>0.05). The accuracy rate was significantly different between MRI (25/25) and rectal digital examination (16/25) in the classification of deep anorectal abscess (χ2 = 10.970, P <0.05). Operative exploration revealed that there were 13 patients with single space abscesses and six with multiple space abscesses. The accuracy rate was significantly different between MRI (19/19) and the rectal digital examination (13/19) for detecting multiple space abscesses (χ2 =7. 125, P <0. 05). Conclusions MRI with a phased-array coil can accurately detect the extent of deep anorectal abscess and its relationship with anorectal sphincters. MRI examination is helpful in excluding potential lesions in the anorectal region.     

结直肠肿瘤根治术后腹腔乳糜漏的诊治

Objective To investigate the treatment of chyle leak following radical resection for colorectal cancer.Methods The incidence of chyle leak was compared between the different surgical approaches (open vs.laparoscopic) as well as different tumor locations (right,left colon or rectum) in 1259 patients undergoing radical resection for colorectal cancer.Results Overall incidence of chyle leak was 3.6% (46/1259) after surgery.Forty-five patients were successfully managed by conservative treatment and one patient required re-operation.No patients died.The incidence of chyle leak was not significantly different between the open (3.2%,18/570) and laparoscopic (4.1%,28/689) groups (P＞0.05).However,right colectomy was associated with a significantly higher rate of chyle leak (9.6%,16/167) as compared to left colectomy (2.6%,7/268) and anterior resection(2.8%,23/824)(P＜0.05).Conclusions Conservative treatment is effective in early stage of chyle leak after radical resection for colorectal cancer.Right colectomy is associated with higher risk for chyle leak.     

磁共振成像在深部肛周脓肿诊断中的应用

Objective To evaluate magnetic resonance imaging (MRI) in the diagnosis of deep anorectal abscess. Methods Twenty-one patients who were suspected of having deep anorectal abscess were admitted to the Affiliated Hospital of Nanjing University of Chinese Medicine from January 2006 to December 2007, and their clinical data were retrospectively analyzed. Phased-array coil MRI was applied to all patients before the operation. We compared the efficacy of MRI and rectal digital examination in the classification of deep anorectal abscess and the diagnosis rate of internal opening according to the postoperative results. All data were analyzed using the chi-square test. Results Nineteen patients were diagnosed with deep anorectal abscess, one patient had presacral cyst combined with infection and one patient had perianal mucinous adenocarcinoma. A total of 25 lesions were identified, including 14 ischiorectal abscesses, five pelvirectal abscesses, and six high intersphincteric abscesses. Thirteen patients had single space abscesses and six had multiple space abscesses. There were no significant differences in the diagnosis rate between MRI (12/19) and rectal digital examination for internal opening (13/19) (χ2 =0. 116, P>0.05). The accuracy rate was significantly different between MRI (25/25) and rectal digital examination (16/25) in the classification of deep anorectal abscess (χ2 = 10.970, P <0.05). Operative exploration revealed that there were 13 patients with single space abscesses and six with multiple space abscesses. The accuracy rate was significantly different between MRI (19/19) and the rectal digital examination (13/19) for detecting multiple space abscesses (χ2 =7. 125, P <0. 05). Conclusions MRI with a phased-array coil can accurately detect the extent of deep anorectal abscess and its relationship with anorectal sphincters. MRI examination is helpful in excluding potential lesions in the anorectal region.     

Fulminant Clostridium difficile infection: An association with prior appendectomy?

AIM: To examine if fulminant Clostridium difficile infections(CDI) resulting in colectomy was associated with a prior appendectomy and whether any association affected the severity of the disease.METHODS: A retrospective chart review was performed on patients who underwent colectomy for CDI between 2001 and 2011.The appendectomy rate was calculated based on the absence of an appendix on the surgical pathology report.This was compared to an established lifetime risk of appendectomy in the general population.A chart review was performed for mortality and traditional markers of CDI disease severity.Fisher’s exact test was used to calculate the likelihood of association between prior appendectomy,mortality,and clinical markers of severity of infection.RESULTS: Fifty-five specimens were identified with pseudomembranous colitis consistent with CDI.All patients had a clinical history consistent with CDI and 45 of 55(81.8%) specimens also had microbiological confirmation of CDI.Appendectomy was observed in 24 of 55 specimens(0.436,99%CI: 0.280-0.606).This was compared to the lifetime incidence of appendectomy of 17.6%.The rate of appendectomy in our sample was significantly higher than would be expected in the general population(43.6% vs 17.6%,P < 0.01).Disease severity did not differ based on presence or absence of an appendix and no association was detected between prior appendectomy and mortality(OR = 0.588,95%CI: 0.174-1.970).CONCLUSION: The rate of appendectomy in the patients whose CDI led to colectomy,was significantly higher than the calculated lifetime risk,suggesting an association of appendectomy and severe CDI resulting in colectomy.Larger prospective studies are needed to assess any potential causal relationships affecting fulminant CDI.     

Comparison between open and laparoscopic reversal of Hartmann’s procedure for diverticulitis

AIM: To compare the open and laparoscopic Hartmann’s reversal in patients first treated for complicated diverticulitis.METHODS: Forty-six consecutive patients with diverticular disease were included in this retrospective,singlecenter study of a prospectively maintained colorectal surgery database.All patients underwent conventional Hartmann’s procedures for acute complicated diverticulitis.Other indications for Hartmann’s procedures were excluded.Patients underwent open(OHR) or laparoscopic Hartmann’s reversal(LHR) between 2000 and 2010,and received the same pre-and post-operative protocols of cares.Operative variables,length of stay,short-(at 1 mo) and long-term(at 1 and 3 years) postoperative complications,and surgery-related costs were compared between groups.RESULTS: The OHR group consisted of 18 patients(13 males,mean age ± SD,61.4 ± 12.8 years),and the LHR group comprised 28 patients(16 males,mean age 54.9 ± 14.4 years).The mean operative time and the estimated blood loss were higher in the OHR group(235.8 ± 43.6 min vs 171.1 ± 27.4 min;and 301.1 ± 54.6 mL vs 225 ± 38.6 mL respectively,P = 0.001).Bowel function returned in an average of 4.3 ± 1.7 d in the OHR group,and 3 ± 1.3 d in the LHR group(P = 0.01).The length of hospital stay was significantly longer in the OHR group(11.2 ± 5.3 d vs 6.7 ± 1.9 d,P < 0.001).The 1 mo complication rate was 33.3% in the OHR(6 wound infections) and 3.6% in the LHR group(1 hemorrhage)(P = 0.004).At 12 mo,the complication rate remained significantly higher in the OHR group(27.8% vs 10.7%,P = 0.03).The anastomotic leak and mortality rates were nil.At 3 years,no patient required re-intervention for surgical complications.The OHR procedure had significantly higher costs(+56%) compared to the LHR procedure,when combining the surgery-related costs and the length of hospital stay.CONCLUSION: LHR appears to be a safe and feasible procedure that is associated with reduced hospitality stays,complication rates,and costs compared to OHR.     

Laparoscopic approach in complicated diverticular disease

AIM: To analyze the results of laparoscopic colectomy in complicated diverticular disease.METHODS: This was a retrospective cohort study conducted at an academic teaching hospital. Data were collected from a database established earlier, which comprise of all patients who underwent laparoscopic colectomy for diverticular disease between 2000 and 2013. The series was divided into two groups that were compared: Patients with complicated disease(abscess, perforation, fistula, or stenosis)(G1) and patients undergoing surgery for recurrent diverticulitis(G2). Recurrent diverticulitis was defined as two or more episodes of diverticulitis regardless of patient age. Data regarding patient demographics, comorbidities, prior abdominal operations, history of acute diverticulitis, classification of acute diverticulitis at index admission and intra and postoperative variables were extracted. Univariate analysis was performed in both groups.RESULTS: Two hundred and sixty patients were included: 28%(72 patients) belonged to G1 and 72%(188 patients) to G2. The mean age was 57(27-89) years. The average number of episodes of diverticulitis before surgery was 2.1(r 0-10); 43 patients had no previous inflammatory pathology. There were significant differences between the two groups with respect to conversion rate and hospital stay(G1 18% vs G2 3.2%, P = 0.001; G1: 4.7 d vs G2 3.3 d, P < 0.001). The anastomotic dehiscence rate was 2.3%, with no statistical difference between the groups(G1 2.7% vs G2 2.1%, P = 0.5). There were no differences in demographic data(body mass index, American Society of Anesthesiology and previous abdominal surgery), operative time and intraoperative and postoperative complications between the groups. The mortality rate was 0.38%(1 patient), represented by a death secondary to septic shock in G2.CONCLUSION: The results support that the laparoscopic approach in any kind of complicated diverticular disease can be performed with low morbidity and acceptable conversion rates when compared with patients undergoing laparoscopic surgery for recurrent diverticulitis.     

Comparative study of oncologic outcomes after multivisceral resection for stage ⅡC colorectal cancer between inflammatory and malignant adhesion

Objective To evaluate the differences in oncologic outcomes between inflammatory adhesion and malignant adhesion in patients with stage Ⅱ C colorectal cancer after multivisceral resection(MVR). Methods A retrospective review was undertaken of 287 patients who underwent MVR for stage Ⅱ C CRC, 120 patients for stage Ⅱ B, and 140 patients for Ⅲ A. Patients were divided into two groups: inflammatory adhesion(IA) and malignant invasion(MI). Results There were 153 patients with colon cancer and 135 patients with rectal cancer in the stage Ⅱ C group. The overall survival was significantly lower in the MI group at 5 years (38.5% vs. 59.4%, P＜0.05). Stage ⅡC patients with IA had similar survival rate to the patients with stage Ⅱ B CRC. Compared to the MA group,patients with stage Ⅲ A CRC showed significant differences in 5 years overall survival rate. Univariate analysis showed that differentiation, adhesion pattern, and complication were significant prognostic factors for patients with colon cancer, while pathological characteristics, adhesion pattern, and differentiation were significant for rectal cancer. Conclusions MI is an adverse prognostic factor for patients with stage Ⅱ C CRC. T4 should be further classified according to the adhesion pattern.     

Prevalence of obesity and diabetes in patients with schizophrenia

AIM To compare the prevalence of diabetes in patients with schizophrenia treated at a community mental health center with controls in the same metropolitan area and to examine the effect of antipsychotic exposure on diabetes prevalence in schizophrenia patients. METHODS The study was a comprehensive chart review of psychiatric notes of patients with schizophrenia and schizoaffective disorder treated at a psychosis program in a community mental health center. Data collected included psychiatric diagnoses, diabetes mellitus diagnosis, medications, allergies, primary care status, height, weight, body mass index(BMI), substance use and mental status exam. Local population data was downloaded from the Centers for Disease Control Behavioral Risk Factor Surveillance System. Statistical methods used were χ~2 test, Student's t test, general linear model procedure and binary logistic regression analysis.RESULTS The study sample included 326 patients with schizophrenia and 1899 subjects in the population control group. Demographic data showed control group was on average 7.6 years older(P = 0.000), more Caucasians(78.7% vs 38.3%, P = 0.000), and lower percentage of males(40.7% vs 58.3%, P = 0.000). Patients with schizophrenia had a higher average BMI than the subjects in the population control(32.11, SD = 7.72 vs 27.62, SD = 5.93, P = 0.000).Patients with schizophrenia had a significantly higher percentage of obesity(58.5% vs 27%, P = 0.000) than the population group. The patients with schizophrenia also had a much higher rate of diabetes compared to population control(23.9% vs 12.2%, P = 0.000). After controlling for age sex, and race, having schizophrenia was still associated with increased risk for both obesity(OR = 3.25, P = 0.000) and diabetes(OR = 2.42, P = 0.000). The increased risk for diabetes remained even after controlling for obesity(OR = 1.82, P = 0.001). There was no difference in the distribution of antipsychotic dosage, second generation antipsychotic use or multiple antipsychotic use within different BMI categories or with diabetes status in the schizophrenia group. CONCLUSION This study demonstrates the high prevalence of obesity and diabetes in schizophrenia patients and indicates that antipsychotics may not be the only contributor to this risk.     

Perioperative and long-term morbidity and mortality after above-knee and below-knee amputations in diabetics and nondiabetics

We performed a retrospective review of a vascular surgery quality assurance database to evaluate the perioperative and long-term morbidity and mortality of above-knee amputations (AKA, n = 234) and below-knee amputations (BKA, n = 720) and to examine the effect of diabetes mellitus (DM) (181 of AKA and 606 of BKA patients). All patients in the database who had AKA or BKA from 1990 to May 2001 were included in the study. Perioperative 30-day cardiac morbidity and mortality and 3-yr and 10-yr mortality after AKA or BKA were assessed. The effect of DM on 30-day cardiac outcome was assessed by multivariate logistic regression and the effect on long-term survival was assessed by Cox regression analysis. The perioperative cardiac event rate (cardiac death or nonfatal myocardial infarction) was at least 6.8% after AKA and at most 3.6% after BKA. Median survival was significantly less after AKA (20 mo) than BKA (52 mo) (P < 0.001). DM was not a significant predictor of perioperative 30-day mortality (odds ratio, 0.76 [0.39-1.49]; P = 0.43) or 3-yr survival (Hazard ratio, 1.03 [0.86-1.24]; P = 0.72) but predicted 10-yr mortality (Hazard ratio, 1.34 [1.04-1.73]; P = 0.026). Significant predictors of the 30-day perioperative mortality were the site of amputation (odds ratio, 4.35 [2.56-7.14]; P < 0.001) and history of renal insufficiency (odds ratio, 2.15 [1.13-4.08]; P = 0.019). AKA should be triaged as a high-risk surgery while BKA is an intermediate-risk surgery. Long-term survival after AKA or BKA is poor, regardless of the presence of DM.     

Postoperative nausea and vomiting and opioid-induced nausea and vomiting: guidelines for prevention and treatment

Postoperative nausea and vomiting (PONV) causes patient discomfort, lowers patient satisfaction, and increases care requirements. Opioid-induced nausea and vomiting (OINV) may also occur if opioids are used to treat postoperative pain. These guidelines aim to provide recommendations for the prevention and treatment of both problems. A working group was established in accordance with the charter of the Sociedad Espa?ola de Anestesiología y Reanimación. The group undertook the critical appraisal of articles relevant to the management of PONV and OINV in adults and children early and late in the perioperative period. Discussions led to recommendations, summarized as follows: 1) Risk for PONV should be assessed in all patients undergoing surgery; 2 easy-to-use scales are useful for risk assessment: the Apfel scale for adults and the Eberhart scale for children. 2) Measures to reduce baseline risk should be used for adults at moderate or high risk and all children. 3) Pharmacologic prophylaxis with 1 drug is useful for patients at low risk (Apfel or Eberhart 1) who are to receive general anesthesia; patients with higher levels of risk should receive prophylaxis with 2 or more drugs and baseline risk should be reduced (multimodal approach). 4) Dexamethasone, droperidol, and ondansetron (or other setrons) have similar levels of efficacy; drug choice should be made based on individual patient factors. 5) The drug prescribed for treating PONV should preferably be different from the one used for prophylaxis; ondansetron is the most effective drug for treating PONV. 6) Risk for PONV should be assessed before discharge after outpatient surgery or on the ward for hospitalized patients; there is no evidence that late preventive strategies are effective. 7) The drug of choice for preventing OINV is droperidol.     

Body composition assessment and methodology in nonathletic and athletic adolescent and adult males and females

The purpose of this review is to outline methodology for assessing body composition utilizing anthropometric and densitometric techniques. The objective of body composition assessment is to measure body fat and lean body mass. The quantity of these components varies due to growth, physical activity, dietary regimens, and aging. Anthropometric techniques incorporate selected skinfolds, circumferences, skeletal widths, or other variables to estimate body composition within k2.0-4.0%. These techniques are adequate for field testing of groups or individuals, but are population specific. Densitometry measures body volume irrespective of physique, sex, or age. This laboratory technique estimates body composition within 1.0-2.0%, is more difficult to administer, but is not population specific. Some limitation exists with any present technique due to biological variability and incomplete research of reference body composition in children, females, and the aged. J Orthop Sports Phys Ther 1984;5(6):336-347.