PubMed Health⌕ Search

Biomedical subjects

B D George

Publications and source records attributed to B D George.

At least 19 recordsLinked to original sources
PubMed2006

Long-term follow-up of strictureplasty for Crohn's disease.

BACKGROUND: Strictureplasty is an effective means of alleviating obstructive Crohn's disease while conserving bowel length. The aim of this study was to establish long-term outcomes of strictureplasty. METHODS: Between 1978 and 2003, 479 strictureplasties were performed in 100 patients during 159 operations. Information on Crohn's disease, medical therapy, laboratory indices, surgical details, complication rates and outcomes was recorded. The primary endpoint was abdominal reoperation. RESULTS: Mean follow-up was 85.1 (range 0.2-240.9) months. The overall morbidity rate was 22.6 per cent, with septic complications in 11.3 per cent, obstruction in 4.4 per cent and gastrointestinal haemorrhage in 3.8 per cent. The 30-day mortality rate was 0.6 per cent and the procedure-related series mortality rate 3.0 per cent. Perioperative parenteral nutrition was the only marker for morbidity (P < 0.001). Reoperation rates were 52 per cent at a mean of 40.2 (range 0.2-205.8) months after a first, 56 per cent at 26.1 (range 3.5-63.5) months after a second, 86 per cent at 27.4 (range 1.4-74.5) months after a third, and 62.5 per cent at 25.9 (range 7.3-70.5) months following a fourth strictureplasty procedure. The major risk factor for reoperation was young age (P < 0.001). CONCLUSION: Long-term follow-up has confirmed the safety of strictureplasty in Crohn's disease. Morbidity is appreciable, although the surgical mortality rate is low. Reoperation rates are comparable following first and repeat strictureplasty procedures.

Adolescent↗
PubMed2006

Randomized clinical trial of botulinum toxin plus glyceryl trinitrate vs. botulinum toxin alone for medically resistant chronic anal fissure: overall poor healing rates.

PURPOSE: This study was designed to assess whether addition of glyceryl trinitrate to botulinum toxin improves the healing rate of glyceryl trinitrate-resistant fissures over that achieved with botulinum toxin alone. METHODS: Patients were randomized between botulinum toxin plus glyceryl trinitrate (Group A) and botulinum toxin plus placebo paste (Group B). Patients were seen at baseline, four and eight weeks, and six months. The primary end point was fissure healing at eight weeks. Secondary end points were symptomatic relief, need for surgery, side effects, and reduction in maximum resting and squeeze pressures. RESULTS: Thirty patients were randomized. Two-thirds of patients had maximum anal resting pressures below or within the normal range at entry to the study. Healing rates in both treatment groups were disappointing. There was a nonsignificant trend to better outcomes in Group A compared with Group B in terms of fissure healing (47 vs. 27 percent), symptomatic improvement (87 vs. 67 percent), and resort to surgery (27 vs. 47 percent). CONCLUSIONS: There is some evidence to suggest that combining glyceryl trinitrate with botulinum toxin is superior to the use of botulinum toxin alone for glyceryl trinitrate-resistant anal fissure. The poor healing rate may reflect the fact that many of the patients did not have significant anal spasm at trial entry.

Adult↗
PubMed2004

Preoperative chemoradiotherapy and total mesorectal excision surgery for locally advanced rectal cancer: correlation with rectal cancer regression grade.

PURPOSE: Preoperative long-course chemoradiotherapy is recommended for rectal carcinoma when there is concern that surgery alone may not be curative. Downstaging of the tumor can be measured as rectal cancer regression grade (1-3) and may be of importance when estimating the prognosis. The aim of this study was to look at the long-term results of tumor regression in patients receiving long-course chemotherapy before surgical resection of rectal cancer. METHODS: We reviewed those patients who received preoperative chemoradiotherapy followed by surgical resection for carcinoma of the mid rectum or distal rectum found to be stage T3/4 between January 1995 and November 1999. Patients received 45 to 50 Gy irradiation in 2-Gy fractions and an infusion of 5-fluorouracil. Surgical specimens were assessed for rectal cancer regression grade. Patients were followed up routinely with clinical examination, computed tomography, and colonoscopy. RESULTS: Sixty-five patients with a mean age 65 (range, 32-83) years underwent chemoradiotherapy before surgical resection. Thirty patients (46 percent) were classified as rectal cancer regression Grade 1, with 9 patients (14 percent) having complete sterilization of the tumor. Fifty-three patients (82 percent) underwent a curative resection. Overall survival, with a median follow-up of 39 (range, 24-83) months, was 67 percent and was associated with tumor downstaging. The local recurrence rate was 5.8 percent in those patients who underwent a curative resection and was significantly lower with rectal cancer regression Grade 1 tumors (P = 0.03). Eight of nine patients (89 percent) whose tumor had been sterilized were alive and well with no recurrence of tumor at a median follow-up of 41 (range, 24-70) months. CONCLUSIONS: Preoperative chemoradiotherapy resulted in significant regression of tumor. Overall survival was high and was associated with downstaging of tumor. The local recurrence rate was significantly lower with rectal cancer regression Grade 1 tumors and was not seen in patients with sterilized tumors.

Adenocarcinoma↗
PubMed2002

Quantification of histologic regression of rectal cancer after irradiation: a proposal for a modified staging system.

PURPOSE: Long-course preoperative radiotherapy has been recommended for rectal carcinoma when there is concern about the ability to perform a curative resection, for example, in larger tethered tumors or those sited anteriorly or near the anal sphincter. "Downstaging" of the tumor may occur, and this is of importance when estimating the prognosis and selecting postoperative therapy for patients. We studied the effects of preoperative chemoradiotherapy on the pathology of rectal cancer, and we propose a simplified measurement of tumor regression, the Rectal Cancer Regression Grade. METHODS: We have reviewed those patients who received preoperative chemoradiotherapy followed by surgical resection for carcinomas of the mid or distal third of the rectum found to be Stage T3/4 on transrectal ultrasound or CT between January 1995 and December 1998. Patients received 45 to 50 Gy irradiation and an infusion of 5-fluorouracil. The surgical specimens were examined by one pathologist, and the Rectal Cancer Regression Grade was quantified. RESULTS: Forty-two patients, mean age 60 (range, 42-86) years, underwent chemoradiotherapy before surgery for rectal carcinoma. There were 28 anterior resections (67 percent; 9 with a colonic pouch), 12 abdominoperineal resections (27 percent), and 2 Hartmann's procedures (5 percent). Comparison of preoperative and pathologic staging revealed that the depth of invasion was downstaged in 17 patients (38 percent), and the status of involved lymph nodes was downstaged in 13 (50 percent) of 26 patients. Tumor regression was more than 50 percent (Rectal Cancer Regression Grades 1 and 2) in 36 patients (86 percent), with 7 patients (17 percent) having complete regression with absence of residual cancer cells. CONCLUSION: Significant tumor regression was seen in 86 percent of cases after chemoradiotherapy, with 19 patients showing a "good" responsiveness. We propose a modified pathologic staging system for irradiated rectal cancer, the Rectal Cancer Regression Grade, which includes a measurement of tumor regression. The utility of the proposed Rectal Cancer Regression Grade must be tested against long-term outcomes before its value in predicting prognosis and survival can be determined.

Adult↗
PubMed2002

Histopathology of stapled haemorrhoidectomy specimens: a cautionary note.

OBJECTIVE: Stapled haemorrhoidectomy is a new technique with encouraging early results. The aim of this study was to examine the tissue removed during stapled haemorrhoidectomy, in particular to check on the presence or absence of transitional or squamous anal canal mucosa and internal anal sphincter muscle. METHODS: Twenty-six consecutive patients undergoing stapled haemorrhoidectomy were studied. Resected tissue was examined histologically according to a standardized histological protocol. RESULTS: All 26 specimens contained columnar mucosa. Twelve specimens also contained anal transitional and stratified squamous epithelium. Two specimens contained columnar and transitional mucosa. Twenty-two of 26 specimens contained smooth muscle as well as mucosa (median maximum diameter 7.5 mm, range 2-20 mm). In 11 specimens this was circular muscle only; in 11 circular and longitudinal smooth muscle were present. In 10 specimens smooth muscle was seen to be lying beneath stratified squamous or transitional epithelium, suggesting that it was from the internal anal sphincter. CONCLUSIONS: Stapled haemorrhoidectomy results in resection of stratified squamous mucosa or part of the internal anal sphincter in a significant proportion of patients. Surgeons should be aware that this technique may result in damage to the internal anal sphincter.

Journal Article↗
PubMed2001

Impotence after mesorectal and close rectal dissection for inflammatory bowel disease.

PURPOSE: Close rectal dissection is a surgical technique used by some surgeons in inflammatory bowel disease. It is performed within the mesorectum, close to the rectal muscle wall, with the aim of minimizing damage to the pelvic sexual nerves. Other surgeons dissect in the more anatomical mesorectal plane. Our aim was to determine whether close rectal dissection is more protective of the pelvic sexual nerves than mesorectal dissection. METHOD: Patients undergoing surgery for inflammatory bowel disease were entered prospectively into a database. Male patients were mailed a standardized, validated, urologic impotence questionnaire: the International Index of Erectile Function. RESULTS: There was an 81 percent response rate. Six of 156 assessable patients were totally impotent (3.8 percent). They were all in the 50-year-old to 70-year-old age group, with no impotence in patients younger than 50 years old. Twenty-one patients complained of minor diminution of erectile function (13.5 percent), where sexual activity was still possible. There was no statistical difference in the rate of complete (2.2 percent vs. 4.5 percent, P = 0.67) or partial (13.5 percent vs. 13.3 percent, P = 0.99) impotence between close rectal and mesorectal dissection (Fisher's exact test). There were no ejaculatory difficulties. The time elapsed since surgery ranged from 2.7 months to 192.7 months, with a median of 74.5 months. CONCLUSION: Rectal excision for inflammatory bowel disease can be conducted with low rates of impotence. Minor degrees of erectile dysfunction may be more common than currently recognized. We could not demonstrate that close rectal dissection significantly protects the patient from impotence compared with operating in the anatomical mesorectal plane. Age appears to be the most important risk factor for postoperative impotence.

Adolescent↗
PubMed2001

Connective tissue changes in ileal Crohn's disease: relationship to disease phenotype and ulcer-associated cell lineage.

PURPOSE: Abnormalities of enteric collagen and smooth-muscle cell content have been documented in Crohn's disease. We studied the relationships among connective tissue changes, disease "type," and other disease features using immunohistochemistry and image analysis. METHODS: Twenty consecutive ileal resections for Crohn's disease and ten normal terminal ileal specimens were evaluated using conventional histopathologic examination. Monoclonal antibodies to smooth-muscle actin and Type III collagen fibers were used to determine the percentage area of the submucosa occupied by these constituents using image analysis. RESULTS: There were no significant differences in smooth-muscle content among stenosed, perforated, and ulcerated specimens. There was a significantly increased submucosal Type III collagen content in stenosed vs. other types. The only factor that correlated with smooth-muscle cell content was the amount of ulcer-associated cell lineage present. CONCLUSIONS: Increased deposition of Type III collagen fibers rather than smooth-muscle proliferation is associated with a stenotic phenotype. Loss of Type III collagen fibers may play a role in the development of perforating complications. We have found no evidence that smooth-muscle cells are the source of Type III collagen fiber production although there is evidence that ulcer-associated cell lineage may be related to the stimulus leading to submucosal neomuscularization.

Cell Division↗
PubMed2001

Lessons from laparoscopic surgery-a fresh look at post-operative management after major colorectal procedures.

OBJECTIVE: Laparoscopy holds promise of exciting advances in colorectal surgery, yet the data we require to draw appropriate evidence-based conclusions on its apparent advantages are sadly lacking. In the meantime, our focus on improved recovery after major colorectal resections has changed the way we manage patients after open surgery. METHODS: A literature review was undertaken to collect published data on laparoscopic colorectal surgery. In addition, data on newer developments in open colorectal surgery were collected. RESULTS: Although there are many published data in laparoscopic colorectal surgery, very few are randomized and controlled. It is clear that, at least in the short to medium term, oncological outcomes are comparable to open surgery. There are data suggesting advantages, including less immune suppression, faster recovery with earlier feeding, less ileus, shorter length of stay and earlier return to normal activity. CONCLUSION: Unfortunately, due to study design the data are largely not comparable with open surgery data, and open surgery itself has changed to some extent recently. We must encourage recruitment of patients into current ongoing randomized controlled trials of laparoscopic and open surgery and await the results.

Journal Article↗
PubMed2000

Percutaneous endoscopic gastrostomy at the time of tumour resection in advanced oral cancer.

The role of percutaneous endoscopic gastrostomy (PEG) in patients undergoing resection of head and neck malignancy is well established. The procedure may be performed pre- or post-operatively with intravenous sedation or alternatively under general anaesthesia at the time of tumour resection. There are concerns as to the safety of PEG, particularly when performed under intravenous sedation. Elderly patients with poor general health and those with airway compromise may be at significant risk. We believe that patients with advanced oral malignancy often fall into such groups and, therefore, we routinely perform PEG at the time of resection. The aim of this study was to determine the potential risk factors for PEG insertion in patients with advanced oral malignancy and present our experience with insertion at the time of resection. A retrospective study was undertaken of the risk factors for PEG insertion in 72 consecutive patients with stage IV oral cancer treated between April 1993 and March 2000. Age, sex, tumour site, past medical history, American Society of Anaesthesiologists (ASA) and laryngoscopy grade, as an assessment of potential airway compromise, were recorded. There were 72 patients, 40 males and 32 females, with a mean age of 63 years (27-90). Eighteen patients (25%) scored 3 or 4 on the ASA scores of physical status. Laryngoscopy grades were recorded in 65 patients; of these, 18 (25%) had reduced visualisation of the larynx and in two patients not even the epiglottis could be seen. It is concluded that patients with advanced oral cancer have significant risk factors for PEG placement. However, PEG can be safely performed at the time of ablative surgery and has the advantage of avoiding an additional operative event for the patient.

Adult↗
PubMed2000

Role of a defunctioning stoma in the management of large bowel Crohn's disease.

BACKGROUND: The faecal stream plays a significant role in the pathogenesis of Crohn's disease. This retrospective study aimed to assess the effect of faecal diversion on the natural history of refractory Crohn's colitis (RCC) and severe perianal disease (PAD). METHODS: All patients undergoing a defunctioning stoma without resection for RCC or PAD between 1970 and 1997 were studied. Indications for surgery, acute clinical response, subsequent outcome and stoma rates were recorded. RESULTS: Some 73 patients underwent a defunctioning stoma (55 RCC and 18 PAD). Acute remission was achieved in 63 patients (48 RCC, 15 PAD). Twenty-nine patients had subsequent closure of the defunctioning stoma (25 of 48 acute responders with RCC and four of 15 acute responders with PAD). Eleven patients with RCC and two with PAD achieved good long-term function without disease relapse (median follow-up 36 months). Overall 52 patients have undergone proctocolectomy or remain with a defunctioning stoma (37 with RCC and 15 with PAD). CONCLUSION: Faecal diversion is associated with acute clinical remission in the majority of patients with RCC and PAD, but sustained benefit occurs less often. For selected patients, diversionary surgery alone offers a realistic alternative to major bowel resection.

Adult↗
PubMed1999

Anal ultrasound predicts the response to nonoperative treatment of fecal incontinence in men.

OBJECTIVE: To assess the etiology, treatment, and utility of anal ultrasound in men with fecal incontinence and to review the outcomes of conservative (nonoperative) treatment. SUMMARY BACKGROUND DATA: The etiology of fecal incontinence in women is almost exclusively from obstetric or iatrogenic surgical injuries resulting in damage to the anal sphincters and/or pudendal nerves. Corresponding data on men with fecal incontinence are sparse. METHODS: Between January 1995 and January 1998, 37 men with fecal incontinence were evaluated in the John Radcliffe Hospital anorectal ultrasound unit. Their clinical histories, anal ultrasound results, anorectal physiology studies, and responses to conservative therapy were reviewed. RESULTS: Median age was 57 years. Major incontinence was present in 27% of the patients. Anal ultrasound localized anal sphincter damage in nine patients, and the characteristics of these nine patients with sphincter damage were then compared with the remaining 28 without sphincter damage. Prior anal surgery was more common in patients with sphincter damage. Hemorrhoids were more common in patients without sphincter damage. Anorectal physiology studies revealed significantly lower mean maximum resting and squeeze pressures in patients with sphincter damage, confirming poor sphincter function. With 92% follow-up, patients without sphincter damage were more likely to improve with nonoperative therapy. CONCLUSIONS: Anal ultrasound is extremely useful in the evaluation of fecal incontinence in men. Unlike women, the majority of men do not have a sphincter defect by anal ultrasound, and conservative management is usually successful in these patients. In contrast, in men with anal sphincter damage, almost all of these defects resulted from previous anal surgery. Conservative management rarely is successful in these cases, and surgical repair of the anal sphincter may be indicated. Therefore, because the presence or absence of sphincter damage on anal ultrasound usually predicts the response to nonoperative treatment, anal ultrasound should be used to guide the initial management of men with fecal incontinence.

Adult↗
PubMed1998

Protocol violation in deep vein thrombosis prophylaxis.

This study aimed to determine how closely deep vein thrombosis (DVT) prophylactic policies are adhered to in routine general surgical practice, to identify reasons for policy violations and to assess the effects of policy modification. Eight adult patients, sixty of whom had undergone an operation, under the care of six general surgeons, each with their own written DVT protocol, were studied on one weekday. Thirty patients (50%) did not receive DVT prophylaxis according to the policy of the relevant consultant. Most violations occurred for unacceptable reasons, mainly starting low-dose subcutaneous heparin or using thromboembolic stockings postoperatively. However, 43% of protocol violations occurred for acceptable clinical reasons. Following the initial study, a uniform departmental DVT prophylaxis policy was introduced. Nursing and medical staff were thoroughly appraised of the new policy. In a repeat study of 75 patients 1 year later, there were 15 protocol violations among 58 patients who had undergone an operation (27%). However, there were no violations for acceptable reasons. The number of unacceptable protocol violations in the two studies was similar (24/60 and 17/56). The number of patients at moderate or high DVT risk who received no preoperative prophylaxis was the same in both studies (8/48 in both audits). DVT protocol violations are common in routine general surgical practice. Policy modification and unification results in fewer violations, but made little impact on the level of thromboprophylactic care.

Adolescent↗
PubMed1997

The consent form signature: a useful clinical sign?

The quality of a patient's consent form signature was assessed in 42 adult patients undergoing emergency major abdominal surgery. Patients with a poor quality or absent consent form signature had a significantly higher mortality and higher APACHE II scores than those with a satisfactory consent form signature.

APACHE↗
PubMed1996

The electrically stimulated gracilis neosphincter incorporated as part of total anorectal reconstruction after abdominoperineal excision of the rectum.

OBJECTIVE: The authors investigated the feasibility and effectiveness of combining electrically stimulated gracilis neoanal (ESGN) sphincter and a coloperineal anastomosis in selected patients after abdominoperineal excision of the rectum (APER). SUMMARY BACKGROUND DATA: The ESGN is effective in the treatment of idiopathic fecal incontinence. METHODS: Between March 1989 and September 1993, 12 patients (9 men, 3 women) with a median age of 59.25 years (range, 45-70) underwent the procedure. The underlying disease was adenocarcinoma in 10, anal malignant melanoma in 1, and a sweat gland tumor in the other. In all patients, a sphincter saving resection was contraindicated. The procedure was performed in stages. Stage 1 involved a conventional APER with the formation of a perineal stoma. Eleven patients underwent a vascular delay procedure. All patients were defunctioned. In stage 2, the gracilis was mobilized, transposed around the anal canal, and the electrodes and hardware needed for electrical stimulation were implanted. Once muscle conversion was complete, the defunctioning stoma was closed. RESULTS: Eight patients were closed successfully. In seven of the eight patients, complete physiologic measurements were taken. Median basal and maximum neosphincter pressures were 30 and 122 cm H2O, respectively, at the start of electrical stimulation and 22.5 and 76.2 cm H2O, respectively, after 1 year. Median functioning neosphincter pressure was 36 cm H2O at 1 year. All of the patients whose stomas were closed experienced episodes of incontinence to solid stool and wore pads for persistent fecal soiling. They all reported difficulty in evacuation. Despite imperfect continence, no patient wished to go back to life with a stoma. CONCLUSIONS: The incorporation of ESGN as part of total anorectal reconstruction is technically feasible. The majority of patients are satisfied with their function and pleased to avoid a permanent stoma.

Aged↗
PubMed1993

Physiological and histochemical adaptation of the electrically stimulated gracilis muscle to neoanal sphincter function.

The physiological and histochemical characteristics of the gracilis muscle were studied in 19 patients undergoing electrically stimulated gracilis neosphincter construction. Indications for surgery were faecal incontinence (n = 11) and reconstruction following sphincter excision or congenital absence (n = 8). Transposition of the gracilis muscle around the anal canal followed by chronic low-frequency electrical stimulation was associated with a shift in the frequency-response curve and a prolongation of the time-course of individual muscle twitches suggestive of transformation to a slow-twitch fatigue-resistant type. Temporary cessation of electrical stimulation resulted in a reversal of the frequency-response changes. Muscle biopsies taken before and a median of 80 (range 49-137) days after transposition and low-frequency electrical stimulation indicated a significant increase in the proportion of type 1 fibres and a significant decrease in their diameter. These results show that the human gracilis muscle is capable of physiological and histochemical adaptation to long-term neosphincter function.

Adaptation, Physiological↗
PubMed1993

Transcranial revascularisation in childhood and adolescence.

Fifteen patients under the age of 20 years underwent transcranial revascularisation surgery: 13 presented with acute strokes or recurrent transient neurological events, one with progressive dementia and one with recurrent syncope. Five underwent unilateral and seven bilateral anastomosis of the superficial temporal artery to a branch of the middle cerebral artery (STA-MCA bypass). One patient aged 22 months underwent bilateral encephaloduroarterisynangiosis (EDAS). Three patients deteriorated postoperatively: one died from a probable cardiac cause, one had subarachnoid haemorrhage and the patient who underwent EDAS suffered further permanent ischaemic damage. No further permanent ischaemic events occurred following STA-MCA bypass (median follow-up 41 months). Transient ischaemic events persisted postoperatively in four cases, but with reduced severity. The results suggest that STA-MCA bypass may be effective in protecting young patients from further permanent ischaemic events in the treated vascular territory.

Adolescent↗