Evaluating the efficacy of treatments for haemorrhoids: time for a standardized definition of recurrence?
Evaluating the efficacy of treatments for haemorrhoids: time for a standardized definition of recurrence?
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评估痔疮治疗的疗效：是时候对复发进行标准化定义了？
DOI：
10.1111/codi.12364
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发表时间：
2013
影响因子：
3.4
通讯作者：
S. Brown
中科院分区：
文献类型：
--
作者：
J. Tiernan;D. Hind;S. Brown
用于肿瘤适应症（19%）。这可能会影响住院时间，以及尿路感染和术后脓肿形成，这些在结肠惰性患者中更常见。在这项研究中，作者没有提供有关患者术后 30 天结果的数据。结肠惯性的定义因中心而异，从使用不透射线标记物识别的结肠传输延迟到使用结肠测压法评估的特征性结肠运动障碍。在Reshef等人的研究中，尚不完全清楚使用哪种定义来诊断结肠惰性[1]。无论如何，结肠切除术与回直肠吻合术仅适用于医学上难治性便秘的患者。文献综述表明，该手术与大约 20-25% 的慢传输型便秘患者复发性小肠梗阻有关。事实上，在结肠动力障碍患者中，结肠动力改变也可能影响胃肠道 (GI) 的其他部分 [2]。因此，与食管和肛门直肠测压或转运研究相比，小肠测压是检测肠肌病和/或神经病患者上消化道普遍损伤的最明智的技术（术中透壁活检除外）[3]。在我们中心，16 名顽固性便秘患者在 24 小时结肠测压记录中符合严重结肠运动功能障碍的标准（24 小时内或对比沙可啶刺激没有反应的自发高振幅传播收缩，顺行传播运动活动减少，结肠运动活动没有餐后反应）[4]，接受了 24 小时小肠测压。四人（25%）表现出小肠蠕动的严重改变。这一观察结果与其他文献一致，表明大约 25% 被诊断为结肠惰性的患者也存在上消化道运动或传输障碍 [2]。这可以解释为什么20-25%接受结肠切除加回直肠吻合术的患者在随访中表现出复发性小肠梗阻。事实上，已有研究表明，术前胃肠道运动或转运，甚至尿动力学受损，与复发性小肠梗阻的发生有关[5]。因此，现在人们普遍认为，除结肠外其他胃肠道段有运动/传输障碍的患者在结肠切除术后的预后比孤立的结肠运动/传输障碍的患者要差[2]。因此，了解 Reshef 等人的研究将会很有趣。 [1] 术后长时间肠梗阻的患者术前是否接受其他胃肠道运动/传输测量。我们认为，在此类严重且经过选择的患者中，至少应考虑进行小肠测压，以识别术后肠梗阻或复发性小肠梗阻高风险的患者。
dure for neoplastic indication (19%). This is likely to have impacted on the length of stay, as well as the urinary tract infection and postoperative abscess formation that were found to be more frequent in patients with colonic inertia. In this study, the authors did not provide data regarding the patients’ outcome 30 days after surgery. The definition of colonic inertia varies between centres, from delayed colonic transit identified using radio-opaque markers to characterized colonic motility disturbance assessed using colonic manometry. In the study of Reshef et al., it is not completely clear which definition was used for the diagnosis of colonic inertia [1]. In any case, colectomy with ileorectal anastomosis should be considered only in patients with medically refractory constipation. Review of the literature shows that this procedure is associated with recurrent small bowel obstruction in approximately 20–25% of patients with slow transit constipation. In fact, it has been shown in patients with colonic motility impairment that motility alteration may also affect other parts of the gastrointestinal (GI) tract [2]. As such, small bowel manometry, compared with oesophageal and anorectal manometry or transit studies, is the most sensible technique (with the exception of per-operative transmural biopsies) to detect generalized impairment of the upper GI tract in patients with enteric myopathy and/or neuropathy [3]. In our centre, 16 patients with refractory constipation fulfilling the criteria of severe colonic motor dysfunction on 24-h colonic manometry recording (absence of spontaneous high amplitude propagated contractions over 24 h or in response to bisacodyl stimulation, reduced anterograde propagating motor activity, absence of postprandial response in colonic motor activity) [4] underwent 24-h small bowel manometry. Four (25%) displayed severe alteration of small bowel motility. This observation is concordant with the rest of the literature, which shows that approximately 25% of patients diagnosed with colonic inertia also have impairment of upper GI motility or transit [2]. This may explain why 20–25% of patients undergoing colectomy with ileorectal anastomosis display recurrent small bowel obstruction in the follow-up. In fact, it has been shown that preoperative impairment of GI motility or transit, or even urodynamics, was associated with the occurrence of recurrent small bowel obstruction [5]. Therefore it is now accepted that patients with motility/transit impairment of other GI segments than the colon have a poorer outcome after colectomy than patients with isolated disturbance of colonic motility/transit [2]. Therefore, it would be interesting to know in the study of Reshef et al. [1] whether patients with prolonged postoperative ileus underwent other GI motility/transit measurements before surgery or not. In our view manometry of the small bowel should at least be considered in such severe and selected patients to identify patients with a high risk of postoperative ileus or recurrent small bowel obstruction.