Capsule endoscopy: a note of caution.
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Adult↗
Biomedical subjects
David W Larson
Publications and source records attributed to David W Larson.
Long-term functional and quality of life outcomes after coloanal anastomosis for distal rectal cancer.
PURPOSE: This study was designed to evaluate the long-term functional and quality-of-life outcomes of patients after coloanal anastomosis for distal rectal cancer. METHODS: A total of 192 patients underwent coloanal anastomosis between 1982 and 2001 at two tertiary referral institutions. Standardized and validated questionnaires to assess functional and quality-of-life outcomes were mailed to 151 patients, of which 121 patients responded (median follow-up, 65 months). RESULTS: Patients receiving pelvic radiotherapy had more bowel function problems than patients who did not receive pelvic radiotherapy. No significant differences in relevant functional and quality-of-life outcomes were seen among patients who received preoperative or postoperative pelvic radiotherapy. Patients requiring permanent diversion as a result of complications of the surgery had decreased quality of life. CONCLUSIONS: Coloanal anastomosis for distal rectal cancer has favorable long-term outcomes. Pelvic radiotherapy has an adverse effect on subsequent bowel function (whether given preoperatively or postoperatively) in patients who maintain intestinal continuity. Loss of intestinal continuity after a coloanal anastomosis is associated with diminished quality of life.
Adenocarcinoma↗
Safety, feasibility, and short-term outcomes of laparoscopic ileal-pouch-anal anastomosis: a single institutional case-matched experience.
OBJECTIVE: To compare safety and short-term outcomes of 100 laparoscopic ileal pouch-anal anastomosis (IPAA) versus 200 conventional open IPAA patients. SUMMARY BACKGROUND DATA: Outcomes of laparoscopic IPAA (LAP-IPAA) have been incompletely characterized. Previous reports are characterized by small numbers of patients and rarely include case-matched or randomized trial methodology. This report describes 100 LAP-IPAA patients case matched to 200 open IPAA patients. METHODS: Between 1998 and 2004, 100 consecutive LAP-IPAA patients (75 laparoscopic assisted, 25 hand assisted) were identified and case matched to 200 open IPAA control patients by age, operation, gender, date of operation, and body mass index. Operative and postoperative outcomes at 90 days were compared. RESULTS: A total of 300 patients (180 female) with a median age of 32 years (range, 17-66 years), and a median body mass index of 23 kg/m (range, 16-34 kg/m) underwent IPAA (100 LAP-IPAA, 200 open IPAA). Diagnosis (chronic ulcerative colitis 97%, familial adenomatous polyposis 3%) and previous operative history were equivalent between groups. One intraoperative complication occurred in each group. Overall, the laparoscopic conversion rate was 6%. Median operative time was longer for the LAP-IPAA group (333 minutes versus 230 minutes, P < 0.0001). LAP-IPAA patients had shorter median time to regular diet (3 versus 5 days), time to ileostomy output (2 versus 3 days), length of stay (4 versus 7 days), and decreased IV narcotic use (all P < 0.05. Postoperative morbidity was equivalent (LAP-IPAA = 33%, open IPAA = 37%), mortality was nil, and readmission rates were equal (LAP-IPAA = 21%, open IPAA = 22%). Reoperation was required in 3% of LAP-IPAA and 6.5% of open IPAA patients (P < 0.2) during the first 3 months. CONCLUSION: LAP-IPAA is equivalent to open IPAA in terms of safety and feasibility. In addition, LAP-IPAA provides significant improvements in short-term recovery outcomes.
Adenomatous Polyposis Coli↗
Ileal pouch-anal anastomosis: does age at the time of surgery affect outcome?
HYPOTHESIS: Functional outcome and quality of life in older patients (>55 years) undergoing ileal pouch-anal anastomosis (IPAA) for ulcerative colitis or familial adenomatous polyposis have been incompletely studied. Our aim was to update our understanding on how the age of the patient at the time of surgery influences functional outcome and quality of life after IPAA. METHODS: From January 1, 1981, to December 31, 2000, two thousand two patients who underwent IPAA were studied. Patients were grouped by age at operation: 45 years or younger (n = 1688), between 46 and 55 years (n = 249), and older than 55 years (n = 65). Mean age was 33.5 years. Postoperative complications, function, and quality of life were assessed with a questionnaire administered annually. RESULTS: Follow-up for patients older than 55 years was a mean +/- SD of 8.1 +/- 4.8 years. Overall, follow-up was a mean of 10.1 +/- 5.7 years. The pouch failure rate for patients older than 55 years was 1.6% at 10 years. No statistically significant difference in pouch failure between age groups was observed. Overall, frequent daytime and nighttime incontinence, respectively, occurred in 5.6% and 13.3% of the patients at 10 years. Incontinence was more common in older patients (P = .002 at 3 years). Quality of life as assessed by social activities, work, travel, sexual activity, family relationships, and sports and recreation was not significantly different among age groups. Most patients felt that their condition had improved or that they had no restrictions after IPAA. CONCLUSIONS: Postoperative complications after surgery seem to be unrelated to age at the time of surgery. Although incontinence may occur more frequently in older patients, IPAA does not adversely affect quality of life in patients older than 55 years.
Adenomatous Polyposis Coli↗
Immediate radical resection after local excision of rectal cancer: an oncologic compromise?
PURPOSE: Local excision for early-staged rectal cancers is controversial. Preoperative understaging is not uncommon and radical resection after local resection may be needed for a curative treatment. The aim of this study was to determine the frequency and outcome of radical resection (within 30 days) after local excision for rectal adenocarcinoma. METHODS: All locally excised rectal cancers (curative intent) that required radical surgery within 30 days were reviewed (1980-2000). T2-3N0-1 stage cancers were each matched to three primary radical surgery controls for stage, age (+/- 5 years), gender, date (+/- 1 years), and type (abdominoperineal resection or low anterior resection) of operation. T1N0-1 cancers were compared with stage-matched rectal cancers treated by either primary radical surgery (n = 78) or local excision alone (n = 77). RESULTS: Fifty-two locally excised rectal adenocarcinomas (29 transanal and 23 polypectomies) were followed by radical surgery (24 abdominoperineal resection and 28 low anterior resection) within 7 (range, 1-29) days. Radical surgery was performed because of a cancerous polyp (n = 42), positive margins (5), lymphovascular invasion (3), and T3-staged cancer (2). Twelve of 52 cancers (23 percent) were found to have nodal involvement and 15 of 52 (29 percent) showed residual cancer in the resected specimen. The T2-3N0-1 stage controls were well matched. No significant difference in tumor location, size, adjuvant therapy, or length of follow-up was noted. Local and distant recurrence occurred in 2 of 4 T2-3N1 tumors and in 2 of 11 T2-3N0 cancers and were comparable to the matched controls, as was survival, with the exception of shorter survival in T3N1 cases, but numbers were too small for a definitive conclusion. Length of follow-up was not different. For T1 cancers, the controls were also comparable regarding patient and tumor demographics and adjuvant therapy. Nodal involvement was 21 percent in T1 study cases and 15 percent in T1 primary radical-surgery controls, with a trend toward location in the lower third of the rectum in both groups (58 percent and 50 percent, respectively). Local recurrence rates were 3 percent in the study group, 5 percent for patients undergoing primary radical surgery, and 8 percent for local excision alone. Distant metastasis (11 percent, 12 percent, and 13 percent, respectively) and overall five-year survival were also not significantly different (78 percent, 89 percent, and 73 percent, respectively). CONCLUSIONS: Nodal involvement in attempted locally excised rectal cancers is not uncommon. Local excision of rectal tumors followed by radical surgery within 30 days in cancer patients does not compromise outcome compared with primary radical surgery. Even after radical surgery for superficial T1 rectal cancers, recurrence rates are not insignificant. Future improvements in preoperative staging may be helpful in selecting tumors for local excision only.
Adenocarcinoma↗
Laparoscopic-assisted vs. open ileal pouch-anal anastomosis: functional outcome in a case-matched series.
PURPOSE: Functional outcomes in laparoscopic-assisted ileal pouch-anal anastomosis have been incompletely studied. More than one-year follow-up has rarely been reported in these patients. This study was designed to assess operative, functional, and quality of life outcomes in patients with ulcerative colitis or familial adenomatous polyposis a minimum of one year after. METHODS: Thirty-three laparoscopic-assisted ileal pouch-anal anastomosis and 33 open ileal pouch-anal anastomosis patients, with a median of 13 months and minimum of 12 months follow-up, were identified from a prospective, laparoscopic database. Functional outcome was prospectively assessed by using a standardized survey. These cohorts were matched by individual patient for year of surgery, age, gender, body mass index, and indication. RESULTS: Median age was 27 years (open) and 28 years (laparoscopic). There were 27 females and 6 males in each group. All operations occurred between 1999 and 2001. Median body mass index was 22.3 (open) and 21.7 (laparoscopic) groups. There were no significant differences in diagnosis, use of diversion, and anastomotic technique. Postoperative morbidity occurred in 6 percent of the laparoscopic cases and 12 percent of the open cases. Functional outcome after a minimum of one year revealed equivalent median day and median nocturnal number of stools of six to seven and one to two respectively. Consistency of stool, medication usage, and continence were no different between groups. Daytime and nocturnal incontinence was similar. Quality of life in regard to social, home life, family, travel, sports, recreation, and sex life were equivalent. CONCLUSIONS: The function and quality of life outcomes for patients undergoing laparoscopic-assisted ileal pouch-anal anastomosis seem to be equivalent to our open experience. Laparoscopic-assisted ileal pouch-anal anastomosis offers selected patients a safe, feasible, and durable alternative.
Adenomatous Polyposis Coli↗
Rectal complications after modern radiation for prostate cancer: a colorectal surgical challenge.
The operative management of rectal complications after radiation for prostate cancer has been incompletely studied. Our aim was to determine a logical surgical approach to these severe rectal complications. From an institutional database, we identified 5719 patients who were evaluated between 1990 and 2003 with a history of prostate cancer that was treated with radiation. Fourteen patients were identified from this group who underwent operative intervention for complications stemming from radiation. Charts were retrospectively reviewed for demographics, prostate cancer treatment, rectal symptoms, diagnostic techniques, operative interventions, and outcome. Ten patients (71%) had documented rectourethral fistulas. An additional four patients (29%) had either transfusion-dependent rectal bleeding or intractable fecal incontinence. Using a surgical algorithm, we proceeded with fecal diversion alone (20%), urinary and fecal diversion alone (50%), and primary repair with or without a tissue flap and fecal diversion (29%) in the 14 affected patients. Symptomatic improvement and resolution of these three complications occurred in 12 (85%) of patients. However, only 2 (15%) were able to retain their intestinal continuity to achieve this outcome. The introduction of a step-wise approach to this problem has resulted in symptomatic resolution in the majority of patients. However, this is achieved at the cost of permanent fecal and sometimes urinary diversion.
Aged↗
Urinary fistulas following external radiation or permanent brachytherapy for the treatment of prostate cancer.
PURPOSE: Prostate cancer (PCa) radiotherapy (RT), including brachytherapy, may lead to significant morbidity, including urinary fistulas. If conservative measures fail, urinary and/or fecal diversion is often required. In this study we examined a series of patients with fistulas that developed after pelvic radiation therapy and explored potential predisposing factors and treatment recommendations for refractory fistulas. MATERIALS AND METHODS: Patients were identified who received radiation therapy for PCa between 1977 and 2002, and subsequently had a fistula to the urinary tract. Patients were excluded who had diverticulitis, inflammatory bowel disease, a history of recent radical retropubic prostatectomy (possible iatrogenic etiology) or cancer in the excised fistula. Data were extracted from patient charts, mailed questionnaires and outside records. RESULTS: A total of 51 patients were identified with a history of radiation for PCa who subsequently had a urinary fistula. Of 20 patients meeting inclusion criteria 30% received external beam RT alone, 30% received brachytherapy and 40% received combined external beam RT/brachytherapy. Most fistulas (80%) were from the rectum to the urinary tract with an average diameter of 3.2 cm. Of patients with rectal fistulas 81% had a history of rectal stricture, urethral stricture, rectal biopsy, rectal argon beam therapy or transurethral prostate resection after radiation. All patients with rectourethral fistulas who achieved symptomatic resolution required urinary and fecal diversion. CONCLUSIONS: Conservative treatment is generally ineffective in the management of large urinary fistulas. Surgical intervention offers symptomatic relief and improved quality of life in most patients.
Aged↗
Current concepts and controversies in surgery for IBD.
Surgery improves the quality of life in patients with Crohn's disease (CD) and cures patients with chronic ulcerative colitis (CUC). There are several surgical controversies primarily involving techniques and long-term outcomes. Some debates are long standing; whether to perform a double-stapled ileal pouch-anal anastomosis (IPAA) or a mucosectomy and hand-sewn anastomosis, and whether to divert or not to divert in patients with CUC undergoing an IPAA. Other issues are more recent, such as the effects of age, pregnancy, pouch salvage, and laparoscopic IPAA. In patients with Crohn's disease the anastomosis technique, the management of perianal disease, and the role of laparoscopic surgery are topics of debate. This review shows the current concepts and controversies in the surgical management of patients with CUC or CD.
Adult↗
Spigelian hernias: repair and outcome for 81 patients.
Spigelian hernia is a rare partial abdominal wall defect. The frequent lack of physical findings along with vague associated abdominal complaints makes the diagnosis elusive. A retrospective review of Mayo Clinic patients was performed to find all patients who had undergone surgical repair of a Spigelian hernia from 1976 to 1997. Patients were scrutinized for presentation, work-up, therapy, and outcome. The goal of this study was to obtain long-term outcome. The study was set in a tertiary referral center. There were 76 patients in whom 81 Spigelian hernias were repaired. Symptoms most commonly included an intermittent mass (n = 29), pain (n = 20), pain with a mass (n = 22), and bowel obstruction (n = 5). Five patients were asymptomatic. Preoperative imaging was performed in 21 patients and correctly diagnosed the hernia in 15. Spigelian hernias were repaired by primary suture closure (n = 75), mesh (n = 5), and laparoscopic (n = 1) techniques. Eight patients (10%) required emergent operations. Thirteen hernias (17%) were found to be incarcerated at the time of the operation. Overall mean follow-up for the 76 patients was 8 years, with three hernia recurrences identified. Spigelian hernia is rare and requires a high index of suspicion given the lack of consistent symptoms and signs. An astute physician may couple a proper history and physical examination with preoperative imaging to secure the diagnosis. Mesh and laparoscopic repairs are viable alternatives to the durable results of standard primary closure. Given the high rate of incarceration/strangulation, the diagnosis of Spigelian hernia is an indication for surgical repair.
Adolescent↗
Laparoscopic colectomy for cancer.
Laparoscopic segmental colectomy has been widely accepted as a surgical procedure for benign colonic disease. With improving technology and surgeon experience, more complex procedures have been performed. However, a minimal invasive approach may not be justified for all colonic diseases. The use of laparoscopic surgery for colonic cancer, for example, has been controversial and the results of our national and international trials are yet unknown. We anticipate, given the positive findings of multiple small randomized and nonrandomized trials, that laparoscopic colectomy for cancer may soon prove to be appropriate in this setting. Our aim in this paper is to explore the indications, contraindications, and techniques regarding laparoscopic surgery that we have used in the treatment of colon cancer for patients enrolled in the national trial.
Colectomy↗
Transmural atrial insulating lesions using epicardially applied radiofrequency energy coupled with saline irrigation.
The Maze procedure has been demonstrated to eliminate atrial fibrillation (AF) refractory to medical management. The procedure, however, is technically difficult and requires prolonged cardiopulmonary bypass (CPB). We investigated the use of epicardially applied radiofrequency (RF) energy delivered using a saline-irrigated probe to functionally reproduce the linear lesions of the surgical Maze procedure. The goals of this study were to safely produce transmural atrial insulation lines without CPB and to investigate whether they could retain their electrical insulation properties and structural integrity over an acute time period. Baseline pacing thresholds were measured on the atria of six swine. Then, circular insulating lesions (n = 11) were created around each pacing site using a saline-irrigated RF probe and specifically designed radiofrequency generator. Pacing thresholds were repeated at the same atrial sites, and in adjacent areas, immediately following lesion creation and at 7 days. At sacrifice the areas of interest were removed for histopathology. Pacing thresholds increased from 0.9 +/- 0.09 V to 9.59 +/- 0.87 V immediately following lesion formation (p <.05) and remained supraphysiologic at 4.05 +/- 0.36 V after 7 days (p <.05). Thresholds from outside the lesions were unchanged from baseline. There was no evidence of perforation and histologic analysis demonstrated transmural necrosis with advancing granulation tissue. Our data suggest that epicardially applied RF energy coupled with saline irrigation can produce transmural electrical insulation lines for up to 7 days. However, the decreasing trend in thresholds toward baseline suggests further investigation is needed to verify insulation line continuity over a chronic time period. These lines were created safely and efficiently without CPB, and may be applicable to a minimally invasive Maze procedure.
Animals↗