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David J Schoetz

Publications and source records attributed to David J Schoetz.

12 recordsLinked to original sources
PubMed2006

Evolving practice patterns in colon and rectal surgery.

BACKGROUND: Minimum numbers of cases required for certification by the American Board of Colon and Rectal Surgery (ABCRS) have been determined from a prospective database of all applicants applying for examination since 1989. These data represent the longitudinal evolution of practice patterns in tertiary colorectal training programs. STUDY DESIGN: After obtaining permission from the ABCRS, access to the database was obtained and data from the 12-year period 1994 to 2005 were analyzed. RESULTS: The database contains the operative and endoscopic case numbers of 673 residents. The number of training programs increased from 28 to 39 (28%) and the number of residency positions from 50 to 66 (24%). Median numbers of anorectal patients per resident remained remarkably constant over the period of study. Both rigid sigmoidoscopy (67 to 44 per resident) and flexible sigmoidoscopy (135.5 to 39 per resident) decreased substantially; colonoscopy volume increased (209 to 264 per resident). Perineal procedures for rectal prolapse consistently comprise 50% to 60% of the total procedures for prolapse. Low anterior resection for rectal cancer outnumber abdominoperineal resections by a 3/1 ratio. Coloanal anastomoses have steadily increased. Laparoscopic approaches for all abdominal operations have increased substantially, with the greatest increase being in diverticular resections (6.5% to 44.7%). CONCLUSIONS: Prospective data collection by ABCRS has permitted calculation of minimum numbers of operative cases for training colorectal surgeons, with the advantage of a rolling average that reflects evolving practice patterns in teaching programs. Analysis of these data allows planning of needs-based educational programs and may ultimately be involved in designing the maintenance of certification process.

Anal Canal↗
PubMed2004

Benefits of hand-assisted laparoscopic restorative proctocolectomy: a comparative study.

PURPOSE: Hand-assisted laparoscopic colectomy is thought to facilitate colonic mobilization while maintaining the benefits of laparoscopic surgery. Although previous studies of hand-assisted colectomy have focused on segmental colonic resection, the use of hand-assisted laparoscopic restorative proctocolectomy has not been investigated. This study evaluated the effectiveness of hand-assisted laparoscopic approach compared with a conventional laparoscopic method in patients undergoing restorative proctocolectomy. METHODS: From a prospective database, a consecutive series of patients were identified undergoing conventional and hand-assisted laparoscopic restorative proctocolectomy and results were compared. Twenty-three patients, comprising 10 hand-assisted and 13 conventional laparoscopic patients, were identified. Patient characteristics, perioperative parameters, and outcomes were assessed. RESULTS: Both groups were well matched with no differences in age, gender, body mass index, operative indication, diagnosis, comorbidity, or steroid usage. There were no differences among incision size between the hand-assisted (8 (range, 8-20) cm) and conventional laparoscopic cases (8 (range, 5-10) cm). The median operative time was significantly shorter in the hand-assisted group (247 (range, 210-390) minutes) compared with the conventional laparoscopic group (300 (range, 240-400) minutes; P < 0.01). The length of stay was similar between groups (hand-assisted: 4 (range, 3-13) days vs. conventional: 6 (range, 4-17) days). Complications occurred in four hand-assisted patients (40 percent; 2 ileus, mechanical obstruction, and dehydration) and in four patients undergoing conventional laparoscopic method (31 percent; 2 anastomotic leak, ileus, and mechanical obstruction). CONCLUSIONS: Compared with conventional laparoscopic restorative proctocolectomy, the hand-assisted method resulted in a significant reduction in operative time without detriment to bowel function, length of stay, or patient outcome. The hand-assisted approach to restorative proctocolectomy is likely to replace conventional laparoscopic methods as the preferred laparoscopic approach for this technically challenging procedure.

Adolescent↗
PubMed2004

The fate of the ileal pouch in patients developing Crohn's disease.

PURPOSE: Recent studies have suggested that a subset of patients with Crohn's colitis may have a favorable outcome after ileal pouch-anal anastomosis and have advocated elective ileal pouch-anal anastomosis in selected patients with Crohn's disease. We have not offered ileal pouch-anal anastomosis to patients with known Crohn's disease, but because of the overlap in clinical presentation of ulcerative colitis and indeterminate colitis, some patients receiving an ileal pouch-anal anastomosis are subsequently found to have Crohn's disease. We review our experience with these patients to identify potential preoperative predictors of ultimate pouch failure. METHODS: Patients with a final diagnosis of Crohn's disease were identified from an ileal pouch-anal anastomosis registry. These patients are followed prospectively. Preoperative and postoperative clinical and pathologic characteristics were evaluated as predictors of outcome. Median (range) values are listed. RESULTS: Thirty-two (18 females) patients (4.1 percent) with a final diagnosis of Crohn's disease were identified from a registry of 790 ileal pouch-anal anastomosis patients (1980-2002). Patients underwent ileal pouch-anal anastomosis in two stages (11 patients) or three stages (21 patients). The preoperative diagnosis was ulcerative colitis in 24 patients and indeterminate colitis in 8 patients. Median follow-up was 153 (range, 13-231) months. The median time from ileal pouch-anal anastomosis to diagnosis of Crohn's disease was 19 (range, 0-188) months. Complications occurred in 93 percent, including perineal abscess/fistula (63 percent), pouchitis (50 percent), and anal stricture (38 percent). Pouch failure (excision or current diversion) occurred in nine patients (29 percent) at a median of 66 (range, 6-187) months. Two of these 9 patients had preoperative anal disease (not significant). Comparing patients with failed pouches (n = 9) to patients with functioning pouches (n = 23), post-ileal pouch-anal anastomosis perineal abscess (67 vs. 26 percent, P = 0.05) and pouch fistula (89 vs. 30 percent, P = 0.01) were more commonly associated with pouch failure. Preoperative clinical, endoscopic, and pathologic features were not predictive of pouch failure or patient outcome. For those with a functional pouch, 50 percent have been or are currently on medication to treat active Crohn's disease. This group had six bowel movements in 24 (range, 3-10) hours, with leakage in 60 percent and pad usage in 45 percent. CONCLUSIONS: Patients who undergo ileal pouch-anal anastomosis and are subsequently found to have Crohn's disease experience significant morbidity. Preoperative characteristics, including the presence of anal disease, were not predictive of subsequent pouch failure. We choose not to recommend the routine application of ileal pouch-anal anastomosis in any subset of patients with known Crohn's disease.

Adolescent↗
PubMed2003

Linear pressure profiles and symmetric findings in the stimulated gracilis muscle.

PURPOSE: This is the first report of linear pressure profiles and symmetric findings in preoperative and postoperative (after gracilis muscle retraining) patients. Length of the anal canal and symmetry have been well documented in the literature as significant parameters in the maintenance of anal incontinence. Significant improvement of these parameters should play a critical role in the functional outcome of the stimulated gracilis. METHODS: Six patients underwent preoperative and postoperative anorectal manometry using an eight-channel radial catheter. Pressures were collected at 8 Hz using an automated continuous pullout technique (1 mm/sec). Preoperative and posttraining resting and squeeze pressures, pressure volumes, anal canal length, and linear and cross-sectional images were compared. RESULTS: Resting pressures significantly improved from 13.7 mmHg to 26.8 mmHg (P < 0.02). The squeeze pressure significantly improved from 28.67 mmHg to 62.9 mmHg (P < 0.02). The pressure volume increased from 10,429 mmHg to 26,162 mmHg. Anal canal length increased from an abnormal length of 2.95 cm to normal length of 3.55 cm (P < 0.04). The percentage of sphincter asymmetry decreased from 28.6 percent to 23.5 percent (P < 0.01). The most striking observation was the impact the gracilis muscle had on correcting the geographic cross sections as it wrapped more than 360 degrees from the proximal to distal anal canal. Patients were significantly improved, with four of the six patients completely continent to solid stool. Two of the six patients had minor episodes of seepage. Preoperatively, all patients were grossly incontinent to solid stool. CONCLUSIONS: Significant improvement in resting pressure, pressure volume, anal canal length, and cross-sectional symmetry has led to a significant improvement in anal incontinence after dynamic myoplasty.

Anal Canal↗
PubMed2003

Is routine pouch surveillance for dysplasia indicated for ileoanal pouches?

PURPOSE: Isolated accounts of neoplastic pouch transformation suggest the need to perform routine ileoanal pouch surveillance with biopsy. These reports imply a model of dysplasia to cancer transformation of the pouch mucosa. More recent reports studying "high risk" ulcerative colitis patients concluded that the development of pouch dysplasia is indeed a rare event. This study was designed to evaluate our institutional incidence of dysplasia in ileoanal pouch during long-term follow-up. METHODS: A prospective database of all patients undergoing ileoanal pouch construction (n = 767) was queried for all patients undergoing pouch biopsy between 1983 and 2001. All patients with ulcerative colitis who underwent pouch biopsy were included. This excluded patients with Crohn's disease, indeterminate colitis, and familial adenomatous polyposis. Pathology reports were reviewed for histologic evidence of inflammation, atypia, metaplasia, dysplasia, or cancer. Patient age at biopsy, pouch age at time of biopsy, and pathology were analyzed. RESULTS: The ileoanal pouches of 160 patients were surveyed with biopsies a total of 222 times. The average length of follow-up from pouch construction to time of surveillance and biopsy was 8.4 +/- 4.6 years. There were 83 patients (52 percent) whose pouches were older than 10 years (mean, 12.7 +/- 2) at time of surveillance. With over 1,800 pouch-years of surveillance, only 1 patient had focal, low-grade dysplasia in the pouch. This patient demonstrated no evidence of dysplasia on further surveillance. CONCLUSION: Even with long-term follow-up of ileoanal pouch patients, there is little evidence to support routine biopsy of the ileal mucosa in ulcerative colitis patients.

Adenomatous Polyposis Coli↗
PubMed2003

Retrorectal cyst: a rare tumor frequently misdiagnosed.

BACKGROUND: The rarity of retrorectal cysts and their nonspecific clinical presentations often lead to misdiagnoses and inappropriate operations. In recent years, several such patients have been referred to our institutions for evaluation and treatment of misdiagnosed retrorectal cysts. A review of these patients is presented. STUDY DESIGN: Medical records of the colorectal surgery divisions at two institutions were reviewed. Patients found to have previously misdiagnosed retrorectal cysts were identified. Preliminary diagnoses, radiologic examinations, operative procedures, and final diagnoses were obtained. RESULTS: Seven patients with retrorectal cysts who had been misdiagnosed before referral were identified. These patients had been treated for fistulae in ano, pilonidal cysts, perianal abscesses; psychogenic, lower back, posttraumatic, or postpartum pain, and proctalgia fugax before the correct diagnosis was made. Patients underwent an average of 4.1 operative procedures. Physical examination in combination with CT scanning made the correct diagnosis in all patients. All patients underwent successful resection through a parasacrococcygeal approach, and six of seven did not require coccygectomy. The resected tumors included four hamartomas, two epidermoid cysts, and one enteric duplication cyst. CONCLUSIONS: Retrorectal cysts are a rare entity that can be difficult to diagnose without a high index of clinical suspicion. A history of multiple unsuccessful procedures should alert the clinician to the diagnosis of retrorectal cyst. Once suspected, the correct diagnosis can be made with physical examination and a CT scan before a definitive surgical procedure.

Abscess↗
PubMed2002

Detection of APC mutations in fecal DNA from patients with colorectal tumors.

BACKGROUND: Noninvasive methods for detecting colorectal tumors have the potential to reduce morbidity and mortality from this disease. The mutations in the adenomatous polyposis coli (APC) gene that initiate colorectal tumors theoretically provide an optimal marker for detecting colorectal tumors. The purpose of our study was to determine the feasibility of detecting APC mutations in fecal DNA with the use of newly developed methods. METHODS: We purified DNA from routinely collected stool samples and screened for APC mutations with the use of a novel approach called digital protein truncation. Many different mutations could potentially be identified in a sensitive and specific manner with this technique. RESULTS: Stool samples from 28 patients with nonmetastatic colorectal cancers, 18 patients with adenomas that were at least 1 cm in diameter, and 28 control patients without neoplastic disease were studied. APC mutations were identified in 26 of the 46 patients with neoplasia (57 percent; 95 percent confidence interval, 41 to 71 percent) and in none of the 28 control patients (0 percent; 95 percent confidence interval, 0 to 12 percent; P<0.001). In the patients with positive tests, mutant APC genes made up 0.4 to 14.1 percent of all APC genes in the stool. CONCLUSIONS: APC mutations can be detected in fecal DNA from patients with relatively early colorectal tumors. This feasibility study suggests a new approach for the early detection of colorectal neoplasms.

Adenoma↗
PubMed2002

Pudendal nerve terminal motor latency testing: assessing the educational learning curve: can we teach our own?

PURPOSE: Pudendal nerve terminal motor latency testing is useful as a diagnostic tool in fecal incontinence. It has also been used as a predictive factor in sphincteroplasty repairs. The technique is seldom taught and mastered in colorectal training programs. The purpose of this study was to assess a learning curve for teaching this procedure. METHODS: The student was a formally trained colorectal surgeon with no pudendal nerve terminal motor latency experience; the instructor has performed more than 3,000 pudendal nerve terminal motor latency studies. Fifty consecutive patients had manometry and pudendal nerve terminal motor latency testing. Both the student and instructor performed pudendal nerve terminal motor latency in a sequential fashion. Variables collected included pudendal nerve terminal motor latency, completion of test, time to complete test, and accuracy of the test. Variables were analyzed with paired t-test and chi-squared analysis. RESULTS: The study group included 41 female and 9 male patients. The average age of the patients was 53 years. Bowel complaints included constipation in 16 and incontinence in 34 patients. Data were analyzed in their entirety and at ten-patient intervals. The student tended to record longer latencies (P < 0.001). This led to false-positive rates of 23 and 21 percent, respectively, for left and right pudendal nerve terminal motor latency. On average, the time to complete the procedure was three times longer for the student than for the instructor (P < 0.001). At ten-patient intervals, the pudendal nerve terminal motor latency difference between the two groups disappeared at the 41-to-50-patient mark. CONCLUSION: Given the proper learning environment, pudendal nerve terminal motor latency testing can be mastered in a relatively short period. On the basis of this study, our estimation is 40 patients are required for a student to master this technique. The novice examiner can expect false-positive results early in the learning curve, and these should be validated accordingly.

Constipation↗
PubMed2002

The safety and efficacy of the artificial bowel sphincter for fecal incontinence: results from a multicenter cohort study.

PURPOSE: The aim of this trial was to evaluate the safety, efficacy, and impact on quality of life of the Acticon trade mark artificial bowel sphincter for fecal incontinence. METHODS: A multicenter, prospective, nonrandomized clinical trial was conducted under a common protocol. Patients were evaluated with anal physiology, endoanal ultrasonography, a fecal incontinence scoring system, fecal incontinence quality of life assessment, and overall health evaluation. Patients with a fecal incontinence score of 88 or greater (scale, 1-120) were considered candidates for the study. Implanted patients underwent identical reevaluation at 6 and 12 months postimplant. RESULTS: One hundred twelve of 115 patients (86 females) enrolled were implanted. Mean age was 49 (range, 18-81) years. A total of 384 device-related or potentially device-related adverse events were reported in 99 enrolled patients. Of these events, 246 required no intervention or only noninvasive intervention. Seventy-three revisional operations were required in 51 (46 percent) of the 112 implanted patients. Infection rate necessitating surgical revision was 25 percent. Forty-one patients (37 percent) have had their devices completely explanted, of which 7 have had successful reimplantations. In patients with a functioning neosphincter, improvement in quality of life and anal continence was documented. Mean matched fecal incontinence scores in 63 patients at 6 months follow-up was improved from 105 preimplant to 51 postimplant. In 55 patients at 12 months follow-up, mean matched fecal incontinence scores were 105 preimplant 48 postimplant. A successful outcome was achieved in 85 percent of patients with a functioning device. Intention to treat success rate was 53 percent. CONCLUSIONS: Although morbidity and the need for revisional surgery are high, the artificial bowel sphincter can improve anal incontinence and quality of life in patients with severe fecal incontinence.

Adult↗