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Biomedical subjects

A M Vernava

Publications and source records attributed to A M Vernava.

72 records · Page 4Linked to original sources
PubMed1994

Gastrointestinal disease in patients receiving salvage chemotherapy or bone marrow transplantation.

Thirty-three patients receiving either salvage chemotherapy or bone marrow transplantation with potential surgical illness related to gastrointestinal symptoms were identified. Sixty-nine percent of patients received salvage chemotherapy for either hematological (61%) or visceral malignancies (39%). Twenty-one percent of patients had a previous bone marrow transplant. Twenty-two (66%) had an absolute neutrophil count less than 10(3)/mm3. Ulcerative foregut disease (51%) and perianal disease (21%) were the most common disease entities identified. Esophagogastroduodenoscopy (79%) and anorectal examination under anesthesia (21%) provided the greatest diagnostic yield. The mean hospitalization was 21 days. Surgery was performed in 21% of patients, but was seldom required for abdominal pain or intestinal bleeding. Perianal disease was often chronic and required multiple operative procedures. Overall, a 27% mortality was found. Gastrointestinal disease in patients receiving salvage chemotherapy or bone marrow transplantation is usually manifested by bleeding and localized to the proximal gut, or related to perianal disease.

Antineoplastic Agents↗
PubMed1994

The role of intrarectal ultrasound (IRUS) in staging of rectal cancer and detection of extrarectal pathology.

Intrarectal Ultrasound (IRUS) is rapidly becoming an effective tool in the staging of rectal cancer. Twenty-nine consecutive patients with adenocarcinoma of the rectum underwent both CT scanning and IRUS in the preoperative assessment of rectal cancer in an effort to correlate IRUS staging with surgical pathology, correlate tumor staging comparing IRUS with CT scan, and determine incidence of extrarectal pathology by IRUS. Patients were reviewed as to IRUS stage, results of CT scan, TNM stage of extirpated tumor, incidence of genitourinary pathology, and sonographic result of preoperative radiotherapy (RT). The mean age of all patients was 69 years; there were 25 males and four females. Twenty-four patients underwent proctectomy with either low pelvic anastomosis or end stoma; five underwent local surgical therapy. Thirteen patients received preoperative RT. CT scan correlated poorly with IRUS staging of tumors penetrating the muscularis propria. IRUS overstaged 40 per cent, understaged 5 per cent, and correctly staged 55 per cent of patients when compared with pathological specimens. Eleven of the 25 males (44 per cent) had abnormal prostates by IRUS. Five (20%) had further urologic intervention, resulting in two prostatic cancers found. Our data suggests that CT scan staging correlated poorly with IRUS staging. CT poorly determines depth of rectal tumor wall invasion. IRUS correlated well with pathology and understaged 5 per cent of patients before surgery. Genitourinary abnormalities were detected in a significant number of patients. IRUS is an effective modality for preoperative staging of rectal cancer.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenocarcinoma↗
PubMed1993

Pudendal neuropathy and the importance of EMG evaluation of fecal incontinence.

A prospective study was undertaken to evaluate pudendal neuropathy in fecal incontinence. Fifty-two patients (38 women and 14 men) with fecal incontinence underwent manometric and electromyographic evaluation (measurement of pudendal nerve terminal motor latency [PNTML] and sphincter muscle mapping). The average age of all patients was 54 +/- 17 years. Fifty-two percent (27/52) were found to have a pudendal neuropathy (PNTML > 2.1 milliseconds). Seventeen of these 27 patients (63 percent) had a bilateral pudendal neuropathy. Patients with a pudendal neuropathy were older than those without a neuropathy (63.7 years vs. 51.9 years; P = 0.01). Women were significantly more likely than men to have a pudendal neuropathy (P = 0.03). Nine patients had an anatomic sphincter defect identified, and six of these (67 percent) had a neuropathy; 4/6 (67 percent) had a bilateral pudendal neuropathy. In the 43 patients who did not have an anatomic sphincter defect, there was no difference in resting pressure (69 mmHg vs. 60 mmHg; P = 0.4) or maximum voluntary contraction (95 mmHg vs. 86 mmHg; P = 0.5) when patients without a neuropathy were compared with those with a neuropathy. Patients with a pudendal neuropathy had a shorter sphincter length than those without a neuropathy (3.0 cm vs. 3.9 cm; P = 0.01). Bilateral pudendal neuropathy tended to occur more frequently in women (P = 0.08) and was not associated with poorer resting pressure, maximum voluntary contraction, or shorter sphincter length. We conclude that pudendal neuropathy is a common cause of fecal incontinence, particularly in older women, and frequently occurs in association with a sphincter defect. Manometric evaluation alone is not helpful in identifying the neuropathic patient. PNTMLs should be routinely measured in the evaluation of fecal incontinence.

Adult↗
PubMed1993

Advanced colorectal neoplasia in the high-risk elderly patient: is surgical resection justified?

A review of the perioperative morbidity and mortality and long-term survival in elderly and high-risk patients with colorectal neoplasia was undertaken. Elderly high-risk patients with localized disease were compared with those with advanced disease. Over a five-year period, 82 high-risk (at least one major organ system disease), or elderly (age > or = 70 years) patients underwent an operation for colorectal neoplasia. Overall, 43 of 82 (52 percent) had advanced disease (obstruction, perforation, hemorrhage, or metastatic disease), while 39 of 82 (48 percent) had localized disease. The mean age of all patients was 78.2 years. Preoperative comorbid diseases included: coronary atherosclerosis, 59 (72 percent); previous myocardial infarction, 17 (21 percent); previous arrhythmia, 10 (12 percent); emphysema, 32 (39 percent); renal failure, 6 (7 percent); and cirrhosis, 3 (4 percent). At the time of surgery, 26 patients (32 percent) had metastatic disease. Six patients (7 percent) died in the perioperative period. The presence of advanced neoplasia did not significantly affect 30-day mortality. There was no difference in major morbidity between patients operated on for localized and for advanced disease. The mean actuarial 18-month survival was less for patients with advanced disease (P < 0.05). Sixty-eight patients (83 percent) are alive at a follow-up of 17.7 +/- 29 months postoperatively. The morbidity and mortality associated with resection of colorectal neoplasia in high-risk elderly patients are acceptable even in the presence of advanced disease. In select patients, resection offers the best palliation and may improve the quality of remaining life.

Aged↗
PubMed1993

Colonoscopy in patients with benign anorectal disease.

A prospective study was performed to determine the incidence of colorectal neoplasia and inflammatory bowel disease in patients with benign anorectal disease. Over a three-year period, 102 consecutive patients who presented with hemorrhoids, fissure, fistula-in-ano, anorectal abscess, and anal condylomata and who did not have gastrointestinal symptoms underwent colonoscopy. The mean age of all patients was 53.5 years; males out-numbered females 1.6:1. No patient was found to have inflammatory bowel disease. Ten of 102 (9.8 percent) were found to have a neoplastic lesion (nine adenomas and one adenocarcinoma). Patients found to have a neoplastic lesion tended to be older (61 years vs. 52.7 years; P = 0.06). Neoplasia was found in 4 of 21 (19 percent) with a family history of colorectal cancer and in 6 of 81 (7.4 percent) without a family history (P = 0.24). Patients presenting with outlet-type bleeding were not found to have a higher detection of neoplasia. The specific type of anorectal disease present was not associated with an increased risk for colorectal neoplasia. Our study suggests that benign anorectal disease and colorectal neoplasia may coexist. Anorectal disease is not predictive of neoplasia. The decision to perform colonoscopy should be based on age, gastrointestinal symptoms, and other risk factors.

Adult↗
PubMed1993

Prokinetic agents for lower gastrointestinal motility disorders.

Prokinetic agents are currently being investigated as potential therapies for motility disorders of the lower gastrointestinal tract. Cholinergic agonists such as bethanechol are known to improve postoperative ileus but are limited because of side effects. Dopamine antagonists such as domperidone appear to have maximal prokinetic effect in the proximal gastrointestinal tract and are effective for such conditions as gastroparesis and gastroesophageal reflux, but they appear to have little physiologic effect in the colon or in colonic motility disorders. Naloxone, an opioid antagonist, appears to hold promise in patients with irritable bowel syndrome, small intestinal pseudo-obstruction, and constipation. Erythromycin exerts its prokinetic effect by acting as a motilin agonist; it has been used in the treatment of diabetic gastroparesis and appears to improve symptoms of colonic pseudo-obstruction and postoperative ileus. Metoclopramide, a combined cholinergic agonist and dopamine antagonist, is currently used exclusively for proximal motility dysfunction. Cisapride appears to hold the most promise for patients with colonic motility disorders. In patients with postoperative ileus, cisapride is associated with an increased return of bowel function compared with placebo. In patients with chronic constipation, cisapride increases stool frequency and decreases laxative abuse in both adults and children. Hopefully, as an understanding of gastrointestinal motility increases, effective prokinetic agents will be developed that will improve symptoms of patients with large bowel motility disorders and may also help to predict those patients who benefit from surgical management for constipation.

Gastrointestinal Motility↗
PubMed1992

Primary adenosquamous and squamous cell carcinoma of the colon and rectum.

Three new cases of squamous cell and adenosquamous carcinoma of the rectum are reported, bringing the total number of cases in the English medical literature to 72. Each of the three patients presented with painless hematochezia. Therapy was by surgical resection followed by chemoradiation therapy in two patients. The incidence, presentation, diagnostic criteria and methods, tumor location, natural history, theory of etiology and management of this unusual tumor are discussed.

Adenocarcinoma↗
PubMed1992

Clinical implications of jejunoileal diverticular disease.

Congenital and acquired diverticula of the jejunum and ileum in the adult are unusual and occur in approximately 1 percent to 2 percent of the population. They are pulsion diverticula thought to be the result of intestinal dyskinesia. These lesions can produce a significant diagnostic and therapeutic dilemma. They are multiple in the jejunum and solitary distally and are characteristically found in 60- or 70-year-old males. The diagnosis may be confirmed with contrast studies of the small intestine, arteriography, or nuclear scan. Consider these disorders in patients with 1) unexplained gastrointestinal bleeding, 2) unexplained intestinal obstruction, 3) an unexpected cause of acute abdomen, 4) chronic abdominal pain, 5) anemia, or 6) malabsorption. Medical therapy is helpful in controlling diarrhea and anemia, while surgical therapy is reserved for hemorrhage, obstruction, perforation, or failure of medical management. Asymptomatic diverticula discovered on routine contrast studies need not be resected. At surgery, incidental diverticula should be removed when evidence of dilated, hypertrophied loops of small bowel with large diverticula is found. Intraoperative air distention will aid in diagnosis. Resection and primary anastomosis is the preferred treatment for non-Meckelian diverticula. Diverticulectomy is reserved for a Meckel's diverticulum without evidence of ulceration. An incidental Meckel's diverticulum should be removed in the presence of mesodiverticular bands or ectopic tissue. Removal of a Meckel's diverticulum is not advised in the patient with Crohn's disease but may be performed in the patient undergoing restorative proctocolectomy for ulcerative colitis.

Algorithms↗
PubMed1992

Flow cytometric analysis of DNA content in colorectal carcinoma.

Over the past decade, flow cytometric DNA analysis has been employed by a number of investigators in an attempt to further define patient prognosis beyond classic pathologic staging. The results of these studies taken independently have been confusing; however, their cumulative effect suggests that flow cytometry is a useful prognostic indicator and can be used to further delineate prognosis within a specific pathologic stage. DNA nondiploid tumors are more likely to recur than diploid tumors, and patients with DNA nondiploid tumors have a poorer five-year survival than patients with DNA diploid tumors. There appears to be a weak relationship between advanced pathologic stage and DNA aneuploid tumors, although there is no clear and consistent relationship between tumor ploidy and histology. Therefore, all patients with colorectal tumors should undergo DNA ploidy analysis. Patients with DNA nondiploid tumors should be treated for biologically more aggressive disease independent of other prognostic variables. Ploidy status should be employed as a variable by which to randomize patients to both primary treatment schemes and adjuvant therapies in clinical trials.

Colorectal Neoplasms↗
PubMed1992

A prospective evaluation of distal margins in carcinoma of the rectum.

The controversy regarding the ideal distal margin after a "curative" anterior resection is currently unresolved. To clarify this issue, a prospective study was undertaken. Two hundred and forty-three patients who underwent "curative" anterior resection were included in this study. Patients were divided into 1 centimeter groups based upon the length of the distal margin (from 0.0 to 8.0 centimeters), and recurrence, local and distant, and survival were analyzed. There was no significant difference in local or distant recurrence or survival when each centimeter interval was studied to 1 centimeter. Patients with a distal margin of less than 0.8 centimeter (group 1) had more frequent anastomotic recurrences (30 percent) when compared with patients (group 2) with a distal margin greater than 0.8 centimeter (10.5 percent; p = 0.01). Both groups were well matched for age, gender, tumor size, length of proximal margin, number of positive lymph nodes, histologic factors, grade of differentiation, Dukes' classification, type of operation, preoperative and postoperative radiotherapy, follow-up evaluation and surgeon. Both groups had a similar pelvic area recurrence (5.0 versus 8.7 percent, p = NS) and distance recurrence rates (10.0 versus 14.2 percent, p = NS). The five year survival rate was adversely affected by a distal margin of less than 0.8 centimeter (49.3 percent in group 1 and 67.5 percent in group 2; p = 0.01). The data suggest that a distal margin of 1 centimeter in the pathologic specimen is adequate distal clearance for most carcinomas of the rectum.

Adenocarcinoma↗
PubMed1991

Preservation of urine voiding and sexual function after rectal cancer surgery.

In order to decrease the urinary and sexual morbidity which follows radical pelvic lymphadenectomy for rectal cancer, we began selective preservation of the pelvic autonomic nerves. Between 1985 and 1987, 134 patients with rectal cancer underwent a curative resection (52 abdominoperineal resections, 82 sphincter-saving resections) with extended pelvic lymphadenectomy and selective pelvic autonomic nerve preservation (PANP). PANP was classified into five degrees depending on the extent of pelvic dissection. First-degree PANP indicates complete preservation of the nerves; second-degree PANP indicates destruction of the hypogastric plexus: third-degree PANP indicates partial preservation of the pelvic autonomic plexus; fourth-degree PANP indicates bilateral or unilateral preservation of only the fourth pelvic parasympathetic nerve; and fifth-degree PANP indicates complete destruction of the pelvic autonomic nerves. Most patients with first-degree PANP were able to spontaneously void 7-10 days following the operation. However, 78 percent (28/36) of patients with fifth-degree PANP had not regained bladder sensation by the third postoperative week and were discharged with an indwelling catheter; 58 percent (21/36) had not regained bladder sensation by the 60th postoperative day. The cystometric data indicate a progressive decline in bladder sensation and function with increasingly extensive pelvic dissection. However, preservation of only the fourth parasympathetic nerve (fourth-degree PANP) resulted in partial sparing of bladder sensation and voiding function. Evaluation of sexual function in males under 60 years of age revealed that only 31 percent (12/39) recovered erectile function and only 19 percent (6/39) recovered normal ejaculatory function in the first postoperative year. Most of these patients had complete preservation of their pelvic autonomic plexus (i.e., first-degree PANP). Four patients with partial PANP have recovered erectile function. Complete PANP is the best way to prevent urinary and sexual morbidity after rectal resection. The opposing goals of maximizing the chance for cure and minimizing morbidity must be individualized and balanced in each patient. Our data demonstrate that it is now possible to perform radical pelvic lymphadenectomy in the majority of patients with advanced rectal cancer with a minimum of voiding dysfunction. Preservation of sexual function in males is more difficult and depends on complete PANP and, as such, should be restricted to the group of patients with Dukes' A and B carcinomas.

Adult↗
PubMed1991

Colonoscopic appendectomy: report of a case.

A persistent appendix occurred after inversion appendectomy. Colonoscopic removal was straightforward and would appear to be the treatment of choice in this unusual circumstance.

Adult↗
PubMed1989

Restorative resection: coloanal anastomosis for benign and malignant disease.

Sixteen patients underwent anterior resection and coloanal anastomosis between October 1984 and September 1987. Indications included adenocarcinoma of the low rectum in 9, villous tumor in 2, carcinoid tumor in 1, radiation proctitis in 1, adult onset Hirschprung's disease in 1, rectourethral fistula in 1, and megarectum in 1. There was no in-hospital mortality and no anastomotic dehiscence. The Kirwan classification was used to evaluate functional results. Ninety-three percent of patients expressed satisfaction with their surgical results. Eighty-seven percent of patients are normally continent. A single patient is grossly incontinent. Eight of nine patients with carcinoma were resected for cure. A single patient has died of an unrelated disorder and the remaining seven are free of disease at an average follow-up of 24 months. The authors conclude that coloanal anastomosis is a safe procedure accompanied by minimal morbidity, or risk of local recurrence. Excellent, or at least acceptable, continence can be anticipated in the majority of carefully selected patients. The coloanal anastomosis should be strongly considered in any patient with a low-lying rectal lesion in whom body habitus precludes the possibility of conventional low anterior resection.

Adolescent↗
PubMed1987

Lethal hyperparathyroid crisis: hazards of phosphate administration.

Two patients with hypercalcemia crisis and parathyroid adenoma died as a result of pulmonary insufficiency. The administration of phosphate is believed to have contributed to the deaths, since the pulmonary problems appeared when the blood [Ca] X [PO4] product rose and extensive metastatic calcification was present in the pulmonary alveolar lining. The use of phosphates as calcium-lowering agents in hypercalcemia is discouraged, because phosphate appears to lower calcium levels only by intravascular precipitation.

Adenoma↗
PubMed1981

Anemia in children and adolescents with hypothyroidism.

In a review of 17 adolescents and children (excluding newborns) with definite clinical signs, symptoms, and laboratory findings of hypothyroidism, 11 patients (65%) had anemia. The mean corpuscular volume (MCV) of the red blood cells was either macrocytic or normocytic. The hemoglobin did not correlate with the serum thyroxine level. Anemia occurred only in those patients with heights below the third percentile, but there was no similar correlation with weights. Of the 10 patients who had radiographs for bone age, all showed severe delay (47 to 103 months) and had heights below the third percentile. Nine of these patients were anemic, but the severity of the anemia did not correlate with the delay in bone age. Neither microcytic anemia nor pernicious anemia, noted in many adult hypothyroid patients, was found in the children and adolescents with hypothyroidism studied here. The "uncomplicated" anemia secondary to hypothyroidism responded to thyroid replacement therapy alone. Anemia can be the most prominent feature of hypothyroidism. In patients with mild to moderate anemia of unknown origin, especially those with fall-off in linear growth and increased MCV, hypothyroidism should be considered in the differential diagnosis of the anemia.

Adolescent↗
PubMedDate not supplied

Pneumopericardium and subcutaneous emphysema of the neck. An unusual manifestation of colonoscopic perforation.

Subcutaneous neck emphysema has been reported infrequently following colonoscopic perforation and only a single case of pneumopericardium has been previously reported. The successful management of these patients in the literature has largely been non-operative. We report a case of colonoscopic perforation which presented with subcutaneous neck emphysema, pneumopericardium, and pneumoperitoneum that required operative intervention.

Adult↗
PubMedDate not supplied

Adjuvant therapy for colorectal cancer.

The search for effective adjuvant therapy for colorectal cancer has been long and, until recently, largely unrewarding. Surgery alone is inadequate therapy in as many as 50% of patients. But recent studies demonstrate significant improvement in disease-free survival and overall survival for patients with advanced colon and rectal cancer who receive adjuvant therapy. Postoperative chemotherapy with fluorouracil and levamisole is the standard of care for patients with stage III colon cancer, and postoperative high-dose pelvic radiation combined with fluorouracil is the standard regimen for patients with stage II and III rectal cancer.

Adenocarcinoma↗