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Biomedical subjects

A F Engel

Publications and source records attributed to A F Engel.

At least 19 recordsLinked to original sources
PubMed2006

Preoperative radiation therapy for locally advanced rectal cancer: a comparison between two different time intervals to surgery.

BACKGROUND: Although it is now considered a standard treatment to irradiate an advanced mid or low rectal tumor before surgical total mesorectal excision (TME), the optimal time interval between radiation therapy and surgery remains controversial. MATERIALS AND METHODS: Between 1995 and 2005, patients undergoing preoperative radiation therapy and TME for locally advanced mid and low rectal tumors treated in the VU Medical Center or the Zaans Medical Center were entered into this study. All patients received identical radiation treatment in the VU Medical Center and were subsequently operated on within 2 weeks in the Zaans Medical Center (SI group) and after 6-8 weeks in the VU Medical Center (LI group). Preoperative tumor staging, operative data, postoperative complications, pathology results, and follow-up were compared. RESULTS: The SI group (N=57) underwent surgery after a median delay of 4 days and the LI group (N=51) after 45 days. Operative data and short-term morbidity were comparable for both groups. However, significantly higher numbers of complete remissions (12 vs 0%), tumor downstaging (55 vs 26%), and less lymph-node metastases (22 vs 44%) were found in the LI group. No significant differences were found regarding local control or long-term survival after a median follow-up of 34 months. CONCLUSION: Several advantages, such as complete remissions and downstaging in the LI group, do not appear to have expression in a better survival or less local recurrences after a median follow-up of 34 months. Although larger (randomized) studies will be needed for definite conclusions, this may indicate that patients can be operated on within 2 weeks after radiation therapy.

Aged↗
PubMed2006

Reversal of Hartmann's procedure after surgery for complications of diverticular disease of the sigmoid colon is safe and possible in most patients.

BACKGROUND: Although evidence is growing that most patients who need an operation for diverticular disease of the sigmoid colon can be treated by a single-stage procedure, a two-stage procedure will still be necessary in some patients because of significant sepsis or technical difficulties. The outcomes of 65 patients who underwent secondary restoration after a Hartmann procedure for complicated diverticulitis were studied and the factors leading to complications and mortality were identified. PATIENTS AND METHODS: Of 91 patients, in a consecutive 12-year period, whose primary operation was a Hartmann procedure, 72 survived longer than 3 months after discharge. Sixty-five underwent an attempted reversal of the Hartmann procedure. The POSSUM scores were calculated in all patients as well as the morbidity and mortality rates. RESULTS: In 63 (96.9%) patients the bowel continuity could be restored with a morbidity of 38.5% and a mortality of 3.1%. The POSSUM and p-POSSUM scores adequately predicted the mortality in this series. CONCLUSION: This series shows that when surgical treatment for complicated diverticular disease of the sigmoid colon is necessary, the Hartmann procedure is still a valid indication. In a high percentage of patients the Hartmann procedure could be restored with a low mortality.

Adult↗
PubMed2006

Electrical stimulation and pelvic floor muscle training with biofeedback in patients with fecal incontinence: a cohort study of 281 patients.

PURPOSE: Pelvic floor rehabilitation is an appealing treatment for patients with fecal incontinence but reported results vary. This study was designed to assess the outcome of pelvic floor rehabilitation in a large series of consecutive patients with fecal incontinence caused by different etiologies. METHODS: A total of 281 patients (252 females) were included. Data about medical history, anal manometry, rectal capacity measurement, and endoanal sonography were collected. Subgroups of patients were defined by anal sphincter complex integrity, and nature and possible underlying causes of fecal incontinence. Subsequently patients were referred for pelvic floor rehabilitation, comprising nine sessions of electric stimulation and pelvic floor muscle training with biofeedback. Pelvic floor rehabilitation outcome was documented with Vaizey score, anal manometry, and rectal capacity measurement findings. RESULTS: Vaizey score improved from baseline in 143 of 239 patients (60 percent), remained unchanged in 56 patients (23 percent), and deteriorated in 40 patients (17 percent). Mean Vaizey score reduced with 3.2 points (P < 0.001). A Vaizey score reduction of >or= 50 percent was observed in 32 patients (13 percent). Mean squeeze pressure (+5.1 mmHg; P = 0.04) and maximal tolerated volume (+11 ml; P = 0.01) improved from baseline. Resting pressure (P = 0.22), sensory threshold (P = 0.52), and urge sensation (P = 0.06) remained unchanged. Subgroup analyses did not show substantial differences in effects of pelvic floor rehabilitation between subgroups. CONCLUSIONS: Pelvic floor rehabilitation leads overall to a modest improvement in severity of fecal incontinence, squeeze pressure, and maximal tolerated volume. Only in a few patients, a substantial improvement of the baseline Vaizey score was observed. Further studies are needed to identify patients who most likely will benefit from pelvic floor rehabilitation.

Biofeedback, Psychology↗
PubMed2006

Sentinel node staging in colon carcinoma: value of sentinel lymph node biopsy with radiocolloid and blue staining.

BACKGROUND: Nodal staging accuracy is important in the prognosis and selection of patients for chemotherapy. This prospective study aims to assess the feasibility and accuracy of the sentinel lymph node procedure (SNP) using radiocolloid and blue dye in colon carcinoma. METHODS: In 56 patients, lymphatic mapping was accomplished by means of intraoperatively injecting patent blue and nanocoll subserosally around the tumour. Sentinel nodes (SNs) were harvested ex-vivo. Nodes were stained with H&E. If lymph nodes were interpreted as negative for metastatic tumour, serial sectioning and immunohistochemical staining were performed. RESULTS: At least one SN was detected in 49 of 53 patients (92.5%). Three patients were excluded because of preoperatively detected metastases. Overall, 121 SN were harvested with a mean of 2.2 SN/patients. Eighteen patients had tumour positive nodes. In four patients, pathological nodes were palpable during operation and were excluded. The SN was histologically negative in 2 of 14 patients with positive nodes (false-negative rate 14.3%). In 5 of 14 patients with positive nodes, the SN was the exclusive site of regional nodal metastasis. Four patients were upstaged by immunohistochemical staining (28.6%). The negative predictive value was 93.9% and the overall accuracy 95.6%. Scintigraphy was done in 17 patients. In three patients the SN was detected only by this modality. DISCUSSION: The SN biopsy with the combined technique proved a feasible technique with a steep learning curve. It can change the initial staging from stage II to stage III colon carcinoma. Scintigraphy can improve the success rate of the technique.

Adult↗
PubMed2006

Mortality after acute surgery for complications of diverticular disease of the sigmoid colon is almost exclusively due to patient related factors.

OBJECTIVE: Auditing the outcome of surgery for complicated diverticulitis of the sigmoid colon is difficult. A comparison of studies is hardly possible because risk factors both in terms of the severity of diverticulitis and patient-related risk factors are neither well described nor standardized. The purpose of this study was to define morbidity and mortality of primary surgery for acute complications of diverticular disease of the sigmoid colon and to identify the relation between risk factors and morbidity and mortality. METHODS: In a prospective computerized morbidity and mortality registration from 1990 to 2002, 114 patients, who underwent surgery on an acute or urgent base for acute complications of diverticular disease of the sigmoid colon, were identified. In all patients the POSSUM score was calculated. To audit mortality rates a POSSUM based scoring system was introduced. RESULTS: Mortality was 16.7%, and morbidity 71.1%. Higher morbidity rates were significantly related to a higher POSSUM physiological score (P = 0.012) and to older age (P < 0.001). Higher mortality rates also were significantly related to a higher POSSUM physiological score (P < 0.001) and older age (P = 0.003). Patients who died had significantly more sepsis (P < 0.001), multiple organ failure (P = 0.027), cardiac (P < 0.001) and pulmonary (P = 0.013) complications. Gender, operation indication and type of neither surgery nor surgeon had a significant relation with morbidity or mortality. CONCLUSION: Surgery for acute complications of diverticular disease of the sigmoid colon carries a high morbidity rate and a substantial mortality rate. The majority of deceased patients had severe comorbidity. Post-operative mortality and morbidity are to a large extent driven by patient related factors. Elevated physiological severity scores and a lack of peri-operative management failures express this in the majority of deceased patients.

Aged↗
PubMed2006

Outcome of elective primary surgery for diverticular disease of the sigmoid colon: a risk analysis based on the POSSUM scoring system.

BACKGROUND: The outcome of surgery for diverticular disease of the sigmoid colon remains largely unclear. A comparison of studies is hardly possible because risk factors for diverticular disease severity and patient-related risk factors are lacking. The purpose of this study was to define morbidity and mortality of primary surgery for nonacute complications of diverticular disease of the sigmoid colon and to identify the risk factors that predict a higher morbidity and mortality. METHODS: Patients who underwent elective surgery for complications of diverticular disease of the sigmoid colon (n = 149) were identified in a prospective computerized morbidity and mortality registration. In all patients, the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) was calculated, as were the morbidity and mortality rates. Factors predicting postoperative morbidity and mortality were identified. To audit mortality figures, a POSSUM based scoring system is introduced. RESULTS: The mortality rate was 4.7% and morbidity rate was 53.7%. Significantly higher morbidity rates were correlated with a higher physiological POSSUM score (P = 0.010). Non-survivors were older (P = 0.029) and also had a higher physiological POSSUM score (P < 0.001) and operation severity POSSUM score (P < 0.001). CONCLUSION: The morbidity and mortality rates of surgery for nonacute complications of diverticular disease of the sigmoid colon are considerable. To a large extent, mortality and morbidity are driven by patient- and disease-related factors, as expressed by elevated physiological severity and operative severity scores and failures of peri-operative management in most deceased patients.

Aged↗
PubMed2005

Operative mortality after colorectal resection in the Netherlands.

BACKGROUND: The aim of this study was to quantify factors related to operative mortality after colorectal resection in the Netherlands. METHODS: Multilevel logistic regression modelling was used. Institutional effects were calculated with and without adjustment for specific patient (age, sex, urgency of operation) and hospital (number of procedures, type of hospital) characteristics. All adult Dutch patients who underwent primary colorectal resection between 1994 and 1999 were included, except those who had (sub)total colectomy or local rectal resection. RESULTS: A total of 67 594 patients underwent colorectal resection. The in-hospital mortality rate was 7.0 per cent (elective 3.9 per cent, acute 14.3 per cent). Acute operation (odds ratio 3.89) and age (odds ratios 2.63, 5.23 and 10.13 for patients aged 50-69, 70-79 and 80 or more years respectively compared with those aged less than 50 years) had the strongest effects, followed by male sex (odds ratio 1.48) and type of hospital. There was no difference in operative mortality rate between low-, medium- and high-volume hospitals. CONCLUSION: In the Netherlands, advanced age and acute operation are by far the most important factors related to operative mortality after colorectal resection. Male sex and type of hospital have only a modest effect, and there is no discernible effect of hospital volume.

Adult↗
PubMed2004

Volar scaphotrapezial dislocation.

We present a case of volar luxation of the scaphotrapezial bone, in which radiographs suggested luxation of the scaphoid, but unclear relations to the other carpal bones. Computer tomographic reconstruction showed an isolated scaphotrapezial luxation. This was treated by closed reduction and a plaster cast, after which the patient regained normal function of her wrist.

Adolescent↗
PubMed2003

Nationwide decline in annual numbers of abdomino-perineal resections: effect of a successful national trial?

OBJECTIVE: Large national trials may influence surgical practice. In this study the relation between the successful national randomized trial on the management of rectal cancer (the Dutch TME trial) and national ratio of abdomino-perineal resection to low anterior resection and anastomosis was analysed. PATIENTS AND METHODS: In the study period, 1994-99, 15978 patients underwent either abdomino-perineal resection (n = 2575) or low anterior resection and anastomosis (n = 13403). The Dutch TME trial started in 1996 and a total of 1530 patients were included by 83 hospitals and 82.1% of these patients were treated from 1997 to 1999. Teaching sessions, tutor assisted surgery and quality control formed an integral and important part of the TME trial. RESULTS: Ratio of abdomino-perineal resection vs. low anterior resection was compared between period I (1994-96) and period II (1997-99). The ratio decreased from 0.19 to 0.13 between period I and II (95% CI, -0.08 to -0.04, P < 0.001). In hospital mortality rate did not change between period I and II (3.5 vs. 3.7, 95% CI, -0.08 to 0.03, P=0.385). CONCLUSION: Significant changes in surgical attitude may accompany successful national randomized trials in which investigated surgical procedures are specified, taught, and controlled. The APR ratio declined by 32% in the Netherlands during and following the Dutch TME trial, without a rise in hospital mortality rate for rectal resections.

Clinical Trials as Topic↗
PubMed2002

Fissurectomy and isosorbide dinitrate for chronic fissure in ano not responding to conservative treatment.

BACKGROUND: Although lateral sphincterotomy heals chronic fissure in ano in over 90 per cent of cases it is a surgical technique with inherent complications. To avoid such complications, chronic fissure in ano was treated by fissurectomy in this study. To enhance postoperative tissue perfusion allowing stable wound healing, fissurectomy was combined with temporary chemical sphincterotomy by a nitric oxide donor cream. METHODS: Seventeen consecutive patients (ten women) with chronic fissure in ano not responding to conservative management underwent diathermy fissurectomy. After operation patients used a 1 per cent isosorbide dinitrate cream. Postoperative follow-up continued until wounds had healed, at which time anal endosonography was performed. A telephone inquiry into fissure recurrence and continence status was made. RESULTS: Seventeen patients underwent fissurectomy, without postoperative complications. All wounds had healed within 10 weeks. No fissure recurrence was seen after a median follow-up of 29 months. Histopathology showed non-specific scar tissue without signs of internal anal sphincter fibrosis. Postoperative endosonography showed no evidence of new internal sphincter defects. CONCLUSION: In the treatment of chronic anal fissure not responding to chemical sphincterotomy with nitric oxide donors, fissurectomy in combination with isosorbide dinitrate cream may be a sphincter-sparing surgical technique.

Adult↗
PubMed2000

[Same-day diathermic hemorrhoidectomy in 48 patients; few complications and tolerable pain].

OBJECT: To measure pain characteristics and to ascertain patient satisfaction and level of complications after day-care haemorrhoidectomy. DESIGN: Prospective. METHOD: Diathermic haemorrhoidectomy was performed in daytime care in 40 successive patients in hospital De Heel, Zaandam in 1997-1998. The operation was part of a package of measures, such as extensive counseling, preoperative bulking agents, surgery performed by colorectal surgeon, dedicated anaesthesiological techniques, adequate pain medication, and frequent outpatient clinic visits. RESULTS: The 40 patients were 21 men and 19 women with a mean age of 43 years (range: 27-67). One male patient was admitted for 24 hours because of urinary retention and 1 female patient developed a wound infection. No other serious complications were seen. During the first 5 postoperative bowel movements 75% of the total pain score was obtained. Postdefaecatory pain lasted on average 81 min on day 1 to 8 min on day 7. Time away from work was on average 6.4 days (range: 0-12). In between clinic visits 5 patients consulted their general practitioners. After 6 weeks 95% of the patients would again have consented to day-care haemorrhoidectomy. CONCLUSION: Diathermic haemorrhoidectomy has a low complication rate and tolerable pain and can be performed in day care.

Adult↗
PubMed2000

Long-term results of overlapping anterior anal-sphincter repair for obstetric trauma.

BACKGROUND: Anterior structural damage to the anal sphincter occurs in up to a third of women at first vaginal delivery, and of these a third have new bowel symptoms. The standard treatment for such structural damage is anterior overlapping anal-sphincter repair. We aimed to assess the long-term results of this operation. METHODS: We assessed the long-term results in 55 consecutive patients who had had repair a minimum of 5 years (median 77 months [range 60-96]) previously. Questionnaire and telephone interview assessed current bowel function and continence, restriction in activities related to bowel control, and overall satisfaction with the results of surgery. 42 of these patients had been continent of solid and liquid stool at a median of 15 months after the repair. FINDINGS: We were able to contact 47 (86%) of the 55 patients. One of these patients had required a proctectomy and end ileostomy for Crohn's disease. Of the remaining 46 patients, 27 reported improved bowel control without the need for further surgery, and 23 rated their symptom improvement as 50% or greater. Seven patients had undergone further surgery for incontinence and one patient had not had a covering stoma closed. Thus, the long-term functional outcome of the sphincter repair alone could be assessed in 38 patients. Of these patients, none was fully continent to both stool and flatus; only four were totally continent to solid and liquid stool; six had no faecal urgency; and eight had no passive soiling. Of the 38 patients, 20 still wore a pad for incontinence and 25 reported lifestyle restriction. 14 reported the onset of a new evacuation disorder after sphincter repair. 23 of the 46 patients contacted had a successful long-term outcome (defined as no further surgery and urge faecal incontinence monthly or less). INTERPRETATION: The results of overlapping sphincter repair for obstetric anal-sphincter damage seem to deteriorate with time. Preoperative counselling should emphasise that although most patients will improve after the procedure, continence is rarely perfect, many have residual symptoms, and some may develop new evacuation disorders.

Adult↗
PubMed1997

Sphincteroplasty for incontinence after surgery for idiopathic fistula in ano.

Between 1990 and 1992, external sphincter repair was performed in 20 patients rendered faecally incontinent after earlier fistula surgery. All were improved, 13 (65%) achieving Grade 1 or 2 continence. Postoperative ultrasound was useful in explaining the sub-optimal outcome of 3 patients who still had defects. Clinical outcome in female patients was better than in male patients. Clinical outcome was not related to the results of preoperative manometry, the site of external sphincter damage, the use of a stoma, or the occurrence of wound complications. External sphincter repair for faecal incontinence after fistula surgery achieves good results in the majority of patients.

Adult↗
PubMed1996

Pathology of the rectal wall in solitary rectal ulcer syndrome and complete rectal prolapse.

BACKGROUND: The aetiology and pathology of rectal prolapse and solitary rectal ulcer are poorly understood. AIMS: To examine the full thickness rectal wall in these two conditions. METHODS: The pathological abnormalities in the surgically resected rectal wall were studied from nine patients with solitary rectal ulcer syndrome, 11 complete rectal prolapse, and nine cancer controls. Routine haematoxylin and eosin and Van Gieson staining for collagen were performed. RESULTS: The rectal wall from solitary rectal ulcer syndrome specimens was thickened compared with complete rectal prolapse and controls. The major difference was in the muscularis propria (2.2 v 1.1 v 1.2 mm, medians, p < 0.005) and particularly the inner circular muscular layer, and to a lesser extent the submucosal and outer longitudinal muscular layers. Some solitary rectal ulcer syndrome specimens showed unique features such as decussation of the two muscular layers (four of nine), nodular induration of inner circular layer (four of nine) and grouping of outer longitudinal layer into bundles (three of nine); these were not seen in complete rectal prolapse or control specimens. CONCLUSIONS: These features, which resemble the features of high pressure sphincter tissue, may be of aetiological importance, and suggest a different pathogenesis for these two disorders. Excess collagen was seen in both disorders, was more severe in solitary rectal ulcer syndrome specimens, and probably reflects a response to repeated trauma.

Adult↗
PubMed1995

Relationship of symptoms in faecal incontinence to specific sphincter abnormalities.

We aimed to determine if the type of clinical presentation in patients with faecal incontinence correlated with the underlying sphincter pathology. One hundred fifty one consecutive patients (129 female) with faecal incontinence were classified as having either passive (faecal incontinence without the patient's knowledge) or urge incontinence (incontinence occurring with the patient's awareness, against their will because of lack of voluntary control), and were investigated by routine anorectal physiological testing and anal endosonography. Sixty six patients had passive incontinence (PI) only, 42 patients had urge incontinence (UI) only, 38 patients had combined passive and urge incontinence, and 5 patients had soiling after defaecation only. Patients with PI alone (n = 66) were significantly older than those with UI alone (PI vs UI, 60 vs 42 yr, p < 0.001), had a lower maximum resting anal pressure (51 vs 64 cm H2O, means, p = 0.02) and had a significantly (p < 0.001) greater prevalence of internal anal sphincter (IAS) defects. Patients with UI alone (n = 42) had a significantly lower maximum voluntary contraction pressure (PI v UI, 72 v 42 cm H2O, p < 0.001), and a significantly (p < 0.001) greater prevalence of external anal sphincter (EAS) defects. The clinical classification of faecal incontinence into passive and urge incontinence relates to specific patterns of abnormality of the internal and external anal sphincters.

Adolescent↗
PubMed1995

Unwanted anal penetration as a physical cause of faecal incontinence.

OBJECTIVE: To investigate sexual abuse as a cause of faecal incontinence. PATIENTS: Seven patients (two men and five women) with a history of sexual abuse, including anal penetration, and faecal incontinence. METHODS: Anorectal physiological techniques and anal endosonography were used for patient assessment. RESULTS: All seven patients had evidence of internal sphincter disruption and three had additional external anal sphincter dysfunction. CONCLUSION: Unwanted anal penetration can cause permanent structural anal sphincter damage.

Adolescent↗