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Biomedical subjects

G S Duthie

Publications and source records attributed to G S Duthie.

At least 19 recordsLinked to original sources
PubMed2006

Endoscopic mucosal resection (EMR) in the management of large colo-rectal polyps.

BACKGROUND: Colonoscopic polypectomy plays a major role in preventing colo-rectal cancer. However, resection of sessile, broad-based pedunculated and flat lesions carries a high risk of perforation. Endoscopic Mucosal Resection (EMR) may significantly reduce this risk. We aim to assess the safety and efficacy of EMR in our unit. PATIENTS AND METHODS: A review of a prospective database over a 3-year period identified 87 patients who underwent endoscopic polypectomy for polyps in sizes from 10 to 50 mm, performed by two experienced endoscopists. A total of 33 EMRs were performed on 30 lesions in 24 of these patients. RESULTS: Median size of lesions was 20 mm. Most were located in the rectum and sigmoid. 22 lesions were resected en-bloc while 8 were resected piecemeal. Histologically these lesions were predominantly adenomatous polyps. An incidental focus of adenocarcinoma was found in 7 lesions. Histologically complete excision was achieved in 10 lesions. Although histological completeness of excision was not confirmed in 19 lesions, repeat colonoscopy confirmed successful excision. Only one lesion was incompletely excised requiring surgical resection. Bleeding occurred during 2 EMRs, both times successfully controlled by further injection of adrenaline locally. There was no case of bowel perforation. Further surveillance colonoscopy was performed according to established guidelines. Median follow-up period was 21 months. None of the patients diagnosed with adenocarcinoma showed any evidence of recurrence. CONCLUSION: Within our unit endoscopic mucosal resection appeared to be safe and effective procedure for resecting large colorectal polyps not suitable for conventional polypectomy. This data would support prompt referral of lesions fulfilling these criteria to specialist units offering this service to avoid unnecessary surgery.

Adenocarcinoma↗
PubMed2006

Investigation and treatment of faecal incontinence.

Faecal incontinence is a debilitating condition affecting people of all ages, and significantly impairs quality of life. Proper clinical assessment followed by conservative medical therapy leads to improvement in more than 50% of cases, including patients with severe symptoms. Patients with advanced incontinence or those resistant to initial treatment should be evaluated by anorectal physiology testing to establish the severity and type of incontinence. Several treatment options with promising results exist. Patients with gross sphincter defects should undergo surgical repair. Those who fail to respond to sphincteroplasty and those with no anatomical defects have the option of either sacral nerve stimulation or other advanced procedures. Stoma formation should be reserved for patients who do not respond to any of the above procedures.

Artificial Organs↗
PubMed2004

Sacral nerve stimulation for faecal incontinence in the UK.

BACKGROUND: Sacral nerve stimulation (SNS) is an effective therapy for faecal incontinence. Published studies derive largely from single centres and there is a need to determine the broader applicability of this procedure. METHODS: Prospective data were collected for all patients undergoing SNS in the UK. Records were reviewed to determine the outcome of treatment. RESULTS: In three UK centres 59 patients underwent peripheral nerve evaluation, with 46 (78 per cent) proceeding to permanent implantation. Of these 46 patients (40 women) all but two had improved continence at a median of 12 (range 1-72) months. Faecal incontinence improved from a median (range) of 7.5 (1-78) to 1 (0-39) episodes per week (P < 0.001). Urgency improved in all but five of 39 patients in whom ability to defer defaecation was determined, improving from a median of 1 (range 0-5) to 10 (range from 1 to more than 15) min (P < 0.001). Maximum anal squeeze pressure and sensory function to rectal distension changed significantly. Significant improvement occurred in general health (P = 0.024), mental health (P = 0.008), emotional role (P = 0.034), social function (P = 0.013) and vitality (P = 0.009) subscales of the Short Form 36 health survey questionnaire. There were no major complications. One implant was removed. CONCLUSION: SNS is a safe and effective treatment, in the medium to long term, for faecal incontinence when conservative treatment has failed.

Adult↗
PubMed2004

Neural network analysis of anal sphincter repair.

PURPOSE: Prediction of success after anterior sphincter repair for incontinence is difficult. Standard multivariate analysis techniques have only 75 to 80 percent accuracy. Artificial intelligence, including artificial neural networks, has been used in the analysis of complex clinical data and has proved to be successful in predicting the outcome of other surgical procedures. Using a neural network algorithm, we have assessed the probability of success after anterior sphincter repair. METHODS: Prospective anorectal physiology data of 72 patients undergoing anterior sphincter repair was collected between 1995 and 1999. Complete data sets of 75 percent of the series were used to train an artificial neural network; the remaining 25 percent were used for data validation. The output was continence grading, ranging from 0 to 4 (worse to continent). RESULTS: The outcome at 3, 6, and 12 months postoperatively was obtained and assessed. The best correlation between actual data value and artificial neural network value was found at 12 months (r = 0.931; P = 0.0001). Clear correlations also were found at three months (r = 0.898; P = 0.0001) and six months (r = 0.742; P = 0.002). Results of applying a net to details excluding pudendal nerve latency were poor. CONCLUSIONS: Artificial neural networks are more accurate (93 percent correlation) than standard statistics (75 percent) when applied to the prediction of outcome after anterior sphincter repair. This assessment also confirms the usefulness of pudendal latency in the prediction of anterior sphincter repair outcome. The results obtained highlight the obvious usefulness of artificial neural networks, which could now be used in a prospective evaluation for application of the technique.

Anal Canal↗
PubMed2003

Hyperbaric oxygen in the treatment of fecal incontinence secondary to pudendal neuropathy.

PURPOSE: Hyperbaric oxygen therapy has several physiologic effects on damaged nerves in animal models, which lead to an improvement in neurologic function. Idiopathic fecal incontinence secondary to pudendal neuropathy is usually treated with biofeedback, which shows improvement in only 50 percent of patients. METHODS: Thirteen patients (12 females, age range, 40-75 years) with chronic pudendal neuropathy and fecal incontinence were identified. They received 30 treatments of hyperbaric oxygen during a period of 6 weeks. Each treatment was at 2.4 atmospheres breathing pure oxygen for 90 minutes. Pudendal latencies were performed sequentially throughout the treatment and one and six months after it had finished. Questionnaires were used to assess improvements in symptoms and quality of life (Wexner fecal incontinence quality of life score). RESULTS: All patients completed the treatment without major complications. There was a consistent improvement of the latencies (on the left 2.36 msec initially, reduced to 2.08 msec at 6-month follow-up and on the right 2.23 msec, on the left reduced to 2.07 msec at 6 months). These improvements were significant (Wilcoxon's two-tailed, asymptomatic significance, comparing pretreatment to 6-month follow-up, left 0.005, right 0.003). Incontinence sores also improved (12.08 initially to 11.64 at the end of treatment, 10.55 at 1-month follow-up, and 10.45 at 6-month follow-up). Using the same test, the improvement in incontinence scores also was significant when comparing pre-end (0.05) and pre-one month (0.011) but not pre-six month (0.054). CONCLUSIONS: Hyperbaric oxygen therapy has improved pudendal nerve function and continence in this group of patients. The cause for this improvement in latencies is unclear at present but may be because of a direct effect on the nerve or an improvement in blood flow to the nerve through angiogenesis. However, these results are good enough to schedule further trials.

Adult↗
PubMed2002

Normal female anal sphincter: difficulties in interpretation explained.

PURPOSE: Our aims were to quantify the nature, characteristics, and frequency of variations in female anal sphincter anatomy. METHODS: Nulliparous patients from the antenatal clinic and healthy volunteers of both genders were studied. Sphincter length was determined by the position of the puborectalis sling. Defects in the external anal sphincter were defined at each level and recorded in degrees. Cylindric longitudinal images of the endoanal scans were created by a three-dimensional-representation software package. Manometry was performed by a pull-through technique. RESULTS: Fifty-seven nulliparous patients and 18 healthy volunteers were included in the study. The mean age was 39 years for males and 28.35 years for females. There was no significant difference in overall sphincter length or in the internal anal sphincter length as a percentage of overall sphincter length between genders. All nine males had a complete ring of external anal sphincter along the full sphincter length. In the external anal sphincter below the level of the puborectalis sling, a natural gap occurred in 43 nulliparous (75 percent) and all 9 female volunteers. The greater the size of the defect, the greater its extent (mean 1.33 cm for >90 degrees and 1.16 cm for <90 degrees; chi-squared P = 0.008, eight degrees of freedom). Manometry provided confirmatory evidence of the gaps seen. Anal manometry was analyzed by Mann-Whitney U test for continuous nonparametric data and t-test for comparison between genders. CONCLUSION: The female sphincter has a variable natural defect occurring along its anterior length. This makes interpretation of the isolated endoanal ultrasound difficult and explains previous overreporting of obstetric sphincter defects.

Adult↗
PubMed2001

Total mesorectal excision: assessment of the laparoscopic approach.

PURPOSE: Total mesorectal excision offers the lowest reported rates of local recurrence for rectal cancer; however, the ability to perform total mesorectal excision laparoscopically remains unproven. The aim of this study was to assess the feasibility and adequacy of a totally laparoscopic total mesorectal excision for rectal cancer. METHODS: A prospective review of all patients undergoing laparoscopic-assisted surgery for rectal cancer by a single surgeon was undertaken. These were compared with a control group undergoing open rectal resections by another colorectal consultant in the unit (n = 22). Comparison of total specimen length, longitudinal and radial excision margins, and lymph node yield was made between groups. RESULTS: Of 42 laparoscopic-assisted rectal resections attempted, 14 (33 percent) were converted to open procedures and six had their dissection completed open. One resection was considered noncurative. Twenty-one total mesorectal excisions (50 percent) were completed totally laparoscopically. No significant difference was detected between groups for specimen length, radial margin, or lymph node yield. Longitudinal margin of excision was longer in the laparoscopic group (4 (3.5-5) vs. 2.5 (1.05-3.5) cm; P = 0.02, Mann-Whitney). Operating time was significantly longer in the laparoscopic group (180 (168-218) vs. 125 (104-144) minutes; P = 0.003, Mann-Whitney). Data are medians (interquartile ranges). Four patients in the laparoscopic-assisted group had clinical anastomotic leakage vs. one in the open group (P = 0.329, Fisher's exact test). At median follow-up of 38 (range, 6-53) months, one local recurrence had occurred in each group and crude mortality rates were 29 and 23 percent in the laparoscopic-assisted and open groups, respectively (P = 0.736, Fisher's exact test). CONCLUSION: Totally laparoscopic excision of the mesorectum is feasible in 50 percent of patients and where possible yields histologic parameters comparable to open surgery. Early survival and recurrence figures also appear to be comparable.

Adult↗
PubMed2001

Outpatient hand held manometry: comparison of techniques.

OBJECTIVE: Anorectal manometry is an established important investigation in a number of disorders. The specialist ano-rectal laboratory is not always available, and a hand held manometer may be a useful tool in the outpatient setting to avoid an unnecessary visit to the anorectal physiology laboratory. Our aims were to determine whether the hand held manometer was as reliable as the standard system used in the anorectal laboratory, and to correctly compare the results from these two different techniques. PATIENTS AND METHODS: 24 patients visiting the Anorectal physiology laboratory were studies. Resting pressure, squeeze and cough pressures were recorded using the single channel hand held solid pressure transducer and with the dual channel pressure transducer MRP2 recorder. The first measurement by each method is used to illustrate the comparison of methods, the second measurement being used to study repeatability. RESULTS: The two methods correlate well for resting and squeeze pressures (Spearman coefficient with P < 0.01 for both) The level of agreement between the two methods was good for resting pressure recordings with a mean difference of 15 cm H2O. The same cannot be said for squeeze and cough pressures. Repeatability of both methods was good with mean differences on repeated recordings near zero. CONCLUSIONS: The hand held manometer is as repeatable as the laboratory but as some discrepancy occurs between the two methods they are not interchangeable. Thus the hand held manometer used alone in the outpatients Department is a useful screening and research tool.

Journal Article↗
PubMed2001

The dose response of the internal anal sphincter to topical application of glyceryl trinitrate ointment.

INTRODUCTION: Glyceryl trinitrate (GTN) ointment has been used for the treatment of chronic anal fissure based on the assumed pathophysiology that the fissure is due to internal anal sphincter hypertonia and that GTN causes relaxation. METHOD: 48 patients, with a diagnosis of haemorrhoids, underwent 24 h anal manometry following application of different concentrations (placebo, 0.1%, 0.2%, 0.4%) of GTN ointment. RESULTS: We have found that there was a progressive relaxation with increasing doses (placebo -8.8%, 0.1% GTN -21.9%, 0.2% GTN -27.2%, 0.4% GTN -33.1%). One way ANOVA showed this progression was significant (P=0.020), with the difference lying between placebo and 0.4% GTN (Tukey multiple comparisons, P=0.017). Only 3 patients experienced headaches and these were split evenly between the treatment arms. CONCLUSION: The internal anal sphincter has a dose related response to GTN and when dose application is strictly applied higher doses may be used without an increase in side-effects.

Clinical Trial↗
PubMed2000

Laparoscopic suture rectopexy without resection is effective treatment for full-thickness rectal prolapse.

PURPOSE: The study was undertaken to evaluate the role of laparoscopic suture rectopexy without resection as a safe and effective treatment for full-thickness rectal prolapse. METHOD: Data were prospectively collected and analyzed on 25 patients who underwent laparoscopic rectopexy without resection for full-thickness rectal prolapse between October 1994 and July 1998. Four patients had conversions from laparoscopic to open surgery. Two patients had recurrent prolapse previously managed by Delorme's procedure. Another two patients had solitary rectal ulcer syndrome associated with their full-thickness rectal prolapse. There were a total of three males. Mean age was 72 (range, 37-89) years. The preoperative and postoperative course of each patient was followed up, with attention paid to first bowel movement, hospital stay, duration of surgery, fecal incontinence, constipation, recurrent prolapse, morbidity, and mortality. Follow-up was made by clinic appointments and, if necessary, by telephone review. RESULTS: Median follow-up period was 26 (range, 1-41) months. Mean duration of surgery was 96 (range, 50-150) minutes. Postoperatively, the median time for first bowel movement was four (range, 2-10) days. Median hospital stay was seven (range, 3-23) days. Overall, 15 patients (60 percent) either improved or remained unchanged with respect to continence. There was an improvement in 10 of 20 patients (50 percent) among those with continence Grade 2 or more (P < 0.05). Seven patients (28 percent) remained incontinent. No patient became more incontinent after surgery. Constipation, which was present in 9 patients (36 percent) preoperatively, affected 11 patients (44 percent) after rectopexy (P > 0.05; not significant). Postoperative morbidity included a port site hernia and deep venous thrombosis in one patient, a repaired rectal perforation, a retroperitoneal hematoma with prolonged ileus (1 case), and a superficial wound infection (1 case). One patient with solitary rectal ulcer syndrome in the laparoscopic surgery group remained unhealed despite resolution of the rectal prolapse after rectopexy and required abdominoperineal resection. Two patients (laparoscopic surgery = 1 and open surgery = 1) had severe constipation after surgery and both required loop colostomies. There were no cases of operative mortality or recurrent prolapse. CONCLUSION: Laparoscopic suture rectopexy without resection is both safe and effective in this frequently frail population and offers a minimally invasive approach that may have potential advantages for selected groups of patients with full-thickness rectal prolapse.

Adult↗
PubMed2000

Laparoscopic ultrasound for the detection of hepatic metastases during laparoscopic colorectal cancer surgery.

PURPOSE: The search for liver metastases before surgery forms an accepted part of colorectal cancer surgical practice. Intraoperative ultrasound and manual palpation of liver together form the criterion standard as far as screening for metastases is concerned. However, extracorporeal imaging, such as ultrasound and magnetic resonance imaging, are also widely used. The purpose of this study was to demonstrate the efficacy of laparoscopic ultrasound scan in detection of liver metastases during laparoscopic colorectal cancer surgery by comparison with conventional imaging modalities. METHODS: A prospective, controlled study was undertaken. A total of 76 consecutive patients undergoing laparoscopic colorectal resections for malignancy were recruited. Patients underwent preoperative liver ultrasound scan and intraoperative blinded laparoscopic ultrasound scan examination performed by a single surgeon. Contrast-enhanced magnetic resonance imaging was performed within 30 days of surgery. RESULTS: Conventional ultrasound scan was negative in all cases. Metastases were identified during simple laparoscopic inspection of the liver in one case. Two cases shown by laparoscopic ultrasound scan to have definite metastases were confirmed by magnetic resonance imaging. In seven further instances laparoscopic ultrasound scan identified suspicious liver masses. In three cases these were confirmed to be metastases at magnetic resonance imaging; one was confirmed as a cyst, and the remaining three suspicious lesions were confirmed at serial magnetic resonance imaging scans to be benign and of no significance. CONCLUSION: Laparoscopic ultrasound scan with a flexible-tipped probe permits satisfactory hepatic examination. It is superior to conventional ultrasound scan and seems to be as effective as magnetic resonance imaging, although the latter modality is still required to delineate identified lesions.

Colorectal Neoplasms↗
PubMed2000

Improving the view in the rectal clinic: a randomised control trial.

BACKGROUND: Rigid sigmoidoscopy forms an integral part of the out-patient assessment of patients with colorectal symptoms. However, the value of this of this examination is often diminished by faecal loading of the rectum. This trial aimed to determine the ability of a single self-administered glycerine suppository to clear the rectum in preparation for rigid sigmoidoscopy, and considered patient acceptability of this practice. METHODS: Consecutive patients were randomly allocated to receive suppository or no suppository prior to out-patient rigid sigmoidoscopy. Assessment was made of patient compliance, the effectiveness of rectal examination, and the depth to which the sigmoidoscope was inserted. RESULTS: 131 patients were randomised into suppository (n = 66) or control groups (n = 65). The number of patients deemed to have good views of the rectum (> 75% of rectal mucosa seen) was significantly greater in suppository than control groups (79% versus 26.2%, P < 0.05 Chi square test), whilst that of poor examinations (< 50% of rectal mucosa seen) was significantly greater in control than suppository groups (44.6% versus 4%, P < 0.05). The depth of insertion of the sigmoidoscope was significantly greater in those receiving suppositories (54.5% versus 21.5% undergoing evaluation to 18 cm or more, P < 0.05). Compliance amongst those who received suppositories was high with only 3 of 53 (4.5%) patients in the suppository group evaluated by questionnaire reporting difficulty or concerns over their use. CONCLUSION: Self-administered suppositories are acceptable to patients and significantly improve the efficiency of outpatient rigid sigmoidoscopy. Their usage should become routine.

Adult↗
PubMed1999

Do routinely measured delivery variables predict anal sphincter outcome?

PURPOSE: Trauma to the anal sphincter is a recognized complication of primiparous childbirth. This damage may be compounded during subsequent deliveries leading to symptoms. Earlier work is inconclusive as to which delivery variables are associated with such damage and may prove useful in predicting its occurrence, thereby allowing the potential for intervention in these later deliveries to protect the traumatized anal sphincter. The purpose of the present study was to determine whether routinely recorded obstetric variables can be correlated to anal sphincter damage in a consecutive series of females. METHODS: A prospective study was undertaken in a single maternity unit. Patients delivering were assessed before discharge using a symptom questionnaire and endoanal ultrasound. Delivery data were collected prospectively and analyzed statistically to see if a significant difference existed in the presence of an anal sphincter defect. RESULTS: A total of 159 patients were assessed. Endosonography revealed sphincter injuries in 8.7 percent of the normal vaginal delivery group and 83 percent of the forceps delivery group. No correlation was found between head circumference, baby weight, maternal body mass index, epidurals, episiotomy, length of each stage of labor, and duration of active pushing. Forceps delivery was the only factor to be significantly associated with sphincter trauma. CONCLUSION: Besides forceps delivery, commonly measured delivery variables are not useful predictors of anal sphincter trauma. Normal vaginal deliveries do not warrant routine postnatal anorectal assessment, but this should be routine for all instrument deliveries.

Adult↗
PubMed1999

Obstetric anal sphincter injury: prospective evaluation of incidence.

PURPOSE: An obstetrically damaged anal sphincter is the principal cause of the development of fecal incontinence in otherwise healthy females. Reports suggest that such damage complicates as many as 35 percent of primiparous vaginal deliveries, with 13 percent of first-time mothers becoming symptomatic. In maternity units delivering 3,000 patients annually, it would follow that 390 symptomatic patients would develop new symptoms each year. This incidence of dysfunction does not reflect current clinical practice. We have investigated this discrepancy to establish the actual incidence of anal sphincter trauma associated with childbirth. METHODS: During a six-week period, 159 females (105 primiparous and 54 para-I) were prospectively assessed postnatally using a standardized symptom questionnaire, endoanal ultrasound, and anal manometry. This group constituted 84 percent of all eligible deliveries occurring in the unit during the study period. RESULTS: One patient developed fecal urgency after this delivery; there were no reports of fecal incontinence. Anal sphincter injuries were identified ultrasonically in 6.8 percent of primiparous patients, 12.2 percent of para-I patients having vaginal deliveries, and 83 percent of patients having forceps deliveries overall. Manometric data provided confirmatory evidence, with significantly reduced maximum squeeze pressures in patients with a disrupted anal sphincter (P<0.0005). CONCLUSIONS: A symptom questionnaire is inadequate to identify anal sphincter injuries. The incidence of sphincter injury in relation to vaginal delivery has been overestimated in previous published work. This study demonstrates that the true incidence is 8.7 percent overall and that symptoms of sphincter dysfunction are uncommon this is in keeping with current clinical practice.

Adolescent↗