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Biomedical subjects

J H Pemberton

Publications and source records attributed to J H Pemberton.

At least 109 records · Page 6Linked to original sources
PubMed1991

Evaluation and surgical treatment of severe chronic constipation.

Patients with chronic constipation may have one of several physiologic disorders, not all of which are amenable to operative therapy. The aim of this study was to test colonic and pelvic floor function preoperatively, to identify patients suitable for surgery based on these studies, and to determine operative outcome over time. Between 1987 and January 1991, 277 patients referred for severe symptoms of chronic intractable constipation underwent colon transit studies, measurement of anal canal pressures and reflexes, and measurements of anorectal angle movements and efficiency of evacuation. Balloon expulsion studies, electromyography of the pelvic floor, and defecating proctograms also were done. Based on these studies, patients were categorized as having: slow transit constipation (STC), 29 patients; pelvic floor dysfunction (PFD), 37 patients; STC + PFD, combined slow transit and pelvic floor dysfunction, 14 patients; and irritable bowel syndrome (IBS), 197 patients. Slow transit constipation patients underwent abdominal colectomy and reanastomosis. Pelvic floor dysfunction patients underwent pelvic floor retraining only. Patients with STC + PFD underwent pelvic floor retraining followed by abdominal colectomy. Irritable bowel syndrome patients were treated symptomatically. Among the 38 patients operated on (STC and STC + PFD), there was no operative mortality. Prolonged ileus developed in 13%, and small bowel obstruction occurred in 11% of patients. On follow-up, a mean of 20 months after ileorectostomy, no patient was constipated, none required a laxative, and none was incontinent. The mean number of stools per day was four. The authors concluded that a prospective evaluation of colonic and pelvic floor function reliably delineated constipated patients with slow transit, suitable for operative management, from those with pure pelvic floor dysfunction or irritable bowel syndrome, who were not. Abdominal colectomy and ileorectostomy in the slow transit patients was safe and effective, resulting in prompt and prolonged relief of constipation.

Adolescent↗
PubMed1991

Variations in muscle tone of the human rectum: recordings with an electromechanical barostat.

Rectal wall tone (the contractile state of the rectal tunica muscularis) should mediate accommodation and influence rectal emptying. Such changes in tone however can be only inferred from changes in baseline pressure recorded with conventional manometry. We used an isobaric volumetric device, the rectal electromechanical barostat, to quantify variations in tone of the rectal wall in response to feeding and to perturbations in response to the pharmacological agents neostigmine and glucagon. The barostat quantitates muscular wall tone indirectly by measuring its reciprocal, e.g., the volume of air within a flaccid intraluminal bag that is maintained at a constant and preselected pressure, by an electronic feedback mechanism. The barostat as well as a three-channel perfused manometric catheter were positioned in the rectum of 14 healthy volunteers. Three patterns of changes were observed: 1) respiratory fluctuations, 2) rapid volume waves, and 3) slow volume changes. Rectal tone varied little during fasting; rapid or slow changes in intrabag volume were infrequent. Ingestion of a standard meal was followed by a significant decrease in barostat bag volume (85 +/- 6 ml fasting vs. 50 +/- 8 ml fed, P less than 0.05). Pharmacological agents also induced predictable responses; neostigmine decreased bag volume and induced phasic pressure activity, whereas glucagon abolished phasic pressure activity and increased barostat bag volume. Perfused manometric catheters showed no concomitant changes in baseline pressure. We concluded that a rectal barostat measured variations in human rectal tone, which were not recorded by conventional manometric techniques. These changes in rectal tone might have important functional significance.

Adult↗
PubMed1991

Quality of life after proctocolectomy. A comparison of Brooke ileostomy, Kock pouch, and ileal pouch-anal anastomosis.

Recent work has shown that patients undergoing proctocolectomy and ileal pouch-anal anastomosis experience a better quality of life than those undergoing proctocolectomy and Brooke ileostomy. To assess whether the improvement with the pouch is due to the absence of a stoma or the preservation of fecal continence, functional and performance activities were assessed in 406 patients with Brooke ileostomies (stoma present, incontinent), 313 with Kock pouches (stoma present, continent), and 298 with ileal pouch-anal anastomoses (stoma absent, continent). All patients underwent proctocolectomy for ulcerative colitis or familial adenomatous polyposis. After adjusting for age, sex, diagnosis, attitude towards the operation, dietary satisfaction, and ability to work, the likelihood of an impact on performance was estimated for the three types of operation using logistic regression analysis. Patients with ileal pouch-anal anastomoses had fewer restrictions in sports and sexual activities than those with Kock pouches (P less than 0.05), whereas those with Kock pouches in turn had fewer restrictions in these activities but more restrictions in travel than those with Brooke ileostomies (P less than 0.05). In contrast, performance in the categories of social life, recreation, work, and family was similar between groups. It is concluded that both the presence of a stoma and fecal incontinence impair the quality of life after proctocolectomy. Ileal pouch-anal anastomosis, which avoids both stoma and incontinence, offers the best quality of life between the three operations studied.

Adenomatous Polyposis Coli↗
PubMed1990

Transducer manometry and the effect of body position on anal canal pressures.

Anal canal manometry is performed conventionally with balloons, sleeves, perfused or nonperfused open-tipped catheters, or with multiport probes. The authors constructed a new manometer with four transducers embedded in a probe (15 mm outside diameter) and oriented radially, 90 degrees apart. The transducer probe was validated in 27 healthy volunteers by comparing its performance to that of a standard four-port perfused manometer and then used to measure anal canal and rectal pressures in body positions more physiologic (standing, sitting) than that usually employed (left lateral) for such measurements. Both devices measured similar anal canal resting pressure in the left lateral position (mid canal, 58 +/- 3 mm Hg perfused vs. 62 +/- 4 mm Hg transducer; P greater than 0.05). The transducer probe, however, recorded higher squeeze pressures (mid canal, 100 +/- 6 mm Hg perfused vs. 143 +/- 14 mm Hg transducer; P less than 0.05). The transducer probe detected higher intrarectal and resting anal canal pressures when subjects were standing or sitting, compared with the left lateral position (rectum, 3 +/- 1 mm Hg left lateral; 17 +/- 2 mm Hg standing; 20 +/- 1 mm Hg sitting; P less than 0.05; mid anal canal, 57 +/- 3 mm Hg left lateral; 86 +/- 4 mm Hg standing; 81 +/- 5 mm Hg sitting, P less than 0.05). The rise in resting anal canal pressure was uniform circumferentially. Neither anal canal length nor squeeze pressure changed with change in position. The authors concluded that 1) transducer manometry recorded similar resting but higher squeeze pressures compared with perfused manometry; 2) transducer manometry recorded the same radial variation in anal canal resting and squeeze pressures as that recorded by the perfused manometer; and 3) standing and sitting caused a four-fold rise in intrarectal pressure, which was associated with a concomitant rise in resting anal canal pressure.

Adult↗
PubMed1990

Ileal pouch-anal anastomosis. Reoperation for pouch-related complications.

The aim was to assess the value of reoperative surgery for pouch-related complications after ileal pouch-anal anastomosis (IPAA) for chronic ulcerative colitis and familial adenomatous polyposis. Between January 1981 and August 1989, 114 of 982 IPAA patients (12%) seen at the Mayo Clinic had complications directly related to IPAA that required reoperation. Among the 114 patients, the complications prevented initial ileostomy closure in 33 patients (25%), occurred after ileostomy closure in 68 patients (60%), and delayed ileostomy closure in the remaining patients. The salvage procedures performed included anal dilatation under anesthesia for anastomotic strictures, placement of setons and/or fistulotomy for perianal fistulae, unroofing of anastomotic sinuses, simple drainage and antibiotics for perianal abscesses, abdominal exploration with drainage of intra-abdominal abscesses with or without establishment of ileostomy, and complete or partial reconstruction of the reservoir for patients with inadequate emptying. None of the reoperated patients died. Reoperation led to restoration of pouch function in two thirds of patients and, of these, 70% had an excellent clinical outcome. However approximately 20% of the 114 pouches required excision. Excision was common, especially among patients who had pelvic sepsis. Salvage procedures for pouch-specific complications can be done safely and will restore pouch function in two thirds of patients. Complications after reoperation, however, may ultimately lead to loss of the reservoir in one in five patients.

Adenomatous Polyposis Coli↗
PubMed1990

Anorectal and pelvic floor disorders: putting physiology into practice.

The pathophysiology of the pelvic floor syndromes is complex and confusing. Childbirth is the only aetiological agent to have been clearly identified, but its role is not universal. Learned or psychogenic pelvic floor incoordination is likely to play a part. The conditions are so intertwined that an increasingly comprehensive battery of tests has become necessary to try to unravel the component disorders; anorectal physiology testing has therefore assumed an important position in the evaluation of these patients. It is only by careful application of physiological studies in clinical practice that further advances can be made. The investigations currently available can contribute significantly to determining the optimum management of these difficult patients. Surgical indications continue to be refined. The results of careful clinical and laboratory follow-up studies have led to changes in practice. The pelvic floor syndromes have only recently been defined; there is still much work to be done.

Anal Canal↗
PubMed1990

The elderly healthcare consumer: a critical review of information source use and advertising recommendations.

A critical review of the literature is undertaken to examine the state of the art and degree of articulation of theories, methods, and findings between health care marketing and the traditional "generic" marketing literature as related to knowledge of information use by and advertising to the elderly consumer. Evaluative criteria suggestive of scientific rigor are applied to this domain as consistencies, discrepancies, and gaps are identified. Recommendations for future research are advanced.

Advertising↗
PubMed1990

A chance to cut is a chance to cure?

Fifty-seven patients underwent local excision of an invasive distal rectal cancer as an initial operative procedure with curative intent. Five-year survival was 82.5%, and the rectal cancer specific mortality rate was only 10.5%. The level of wall invasion, vascular permeation, tumor ulceration, mobility, and differentiation were the criteria studied for prognosis. Poor prognostic factors included mucinous cell differentiation and full thickness invasion, and in these cases, abdominoperineal resection was recommended. None of the 27 patients without these adverse prognostic factors died from rectal cancer. The other factors did not appear to influence the outcome, and local excision of distal rectal cancer would be the treatment of choice in such selected patients.

Humans↗
PubMed1990

Pouchitis and extraintestinal manifestations of inflammatory bowel disease after ileal pouch-anal anastomosis.

Although the etiology of pouchitis after ileal pouch-anal anastomosis (IPAA) is unknown, its manifestations resemble those of nonspecific inflammatory bowel disease, including, anecdotally, the apparent ability to evoke extraintestinal manifestations (EIM) of inflammatory bowel disease (IBD). Our aim was to determine in what manner pouchitis and EIMs were associated. The computerized records of 819 consecutive patients who underwent IPAA between January 1981 and December 1988 were reviewed. Eighty-five patients were excluded (because of incomplete follow-up, death, or permanent ileostomy). Follow-up of the remaining 734 patients was complete (mean, 41 months). The mean age was 32 years and the ratio of men to women was 1:1. Ileal pouch-anal anastomosis was performed for chronic ulcerative colitis in 91% of patients and for familial adenomatous polyposis in 9%. Pouchitis occurred in 31% of chronic ulcerative colitis patients and 6% of familial adenomatous polyposis patients (p less than 0.01). The mean time to first occurrence was 17 months. Pouchitis recurred in 61% of patients at risk. Patients with preoperative and postoperative EIMs had significantly higher rates of pouchitis than did patients without EIMs (39% preoperative EIMs versus 26% with no EIMs, p less than 0.001; 53% postoperative EIMs versus 25% with no EIMs, p less than 0.001). Of patients with pouchitis in whom EIMs resolved after IPAA but then recurred (n = 12), EIMs recurred when pouchitis occurred and abated when pouchitis was treated in seven patients. We concluded that pouchitis occurred frequently after IPAA and that patients with EIMs were at higher risk of developing pouchitis than were patients who never had EIMs. Furthermore some patients experienced a temporal relationship between flares of EIMs and pouchitis. These results imply that pouchitis may be a novel manifestation of inflammatory bowel disease persisting after operation.

Adult↗
PubMed1989

Localization of hematoporphyrin. Derivative to human colorectal cancer.

This study documents the affinity of hematoporphyrin derivative (HpD) for human colorectal cancer by analysis of surface fluorescence. Ten patients undergoing elective surgery for primary colorectal cancer received intravenous HpD (2-5 mg/kg) either 3 or 72 hours preoperatively. Fluorescent photographs were taken of freshly resected specimens and analyzed using a computerized videodensitometric technique. This technique subtracted contaminating non-HpD fluorescence and facilitated estimation of HpD tissue levels. The HpD-specific fluorescence localized to tumors in all cases, and the mean HpD concentration was six-fold greater in malignant tissue than in surrounding normal mucosa (0.6 microgram/g versus 0.1 microgram/g, P less than 0.001). The authors conclude that HpD preferentially localizes to human colorectal cancer and this is relevant to the photodetection and phototherapy of colorectal neoplasia.

Adult↗
PubMed1989

Comparison of portal and peripheral blood levels of carcinoembryonic antigen, CA 19-9, and CA 125 tumor-associated antigens in patients with colorectal and pancreatic cancer.

Synchronous serum specimens from the systemic and portal circulations of 43 patients with gastrointestinal cancer were assayed for levels of carcinoembryonic antigen, CA 19-9, and CA 125 tumor-associated antigens. The number of patients having a mean ratio of portal to systemic levels greater than 1 and the observed quantity of tumor-associated antigens were significant for carcinoembryonic antigen and CA 125 only in patients with colorectal cancer. No correlations were noted with the surgical stage of disease or with high or low (normal) levels of the three tumor-associated antigens. These findings suggest that peripheral concentrations of these antigens are in equilibrium with shedding from tumors and that hepatic clearance of a single pass does not significantly alter peripheral concentrations.

Antigens, Tumor-Associated, Carbohydrate↗
PubMed1989

Anal and ileal pouch manometric measurements before ileostomy closure are related to functional outcome after ileal pouch-anal anastomosis.

Anal canal length, and canal resting and squeeze pressures, ileal pouch capacity and pouch compliance were measured in 104 patients after ileal pouch-anal anastomosis but before ileostomy closure. The intention was to determine if such parameters were associated with late functional outcome after re-establishment of intestinal continuity. Functional outcome in terms of stool frequency (day and night), incontinence (day and night), perianal pad use, perianal skin irritation, and the use of constipating agents was assessed for all 104 patients 1 year or more (median 438 days) after ileostomy closure. A low mean anal sphincter resting pressure before ileostomy closure was associated with subsequent nocturnal incontinence (P less than 0.05) and, to a lesser extent, the need to use constipating agents (P = 0.08). Pouch compliance if low before ileostomy closure was associated with an increased frequency of nocturnal stool frequency after 1 year (P less than 0.05). Anal canal length, and sphincter squeeze pressure and pouch capacity before ileostomy closure were not related to subsequent functional outcome in these patients.

Adolescent↗
PubMed1989

Clean sweep of the colon. The use of intraoperative colonoscopy.

Since 1982, intraoperative colonoscopy has been performed on 66 patients. Preoperative intent was to perform a colonoscopic polypectomy during an intra-abdominal procedure in 44 patients, localize lesions that might subsequently lead to either colon resection or colotomy and polyp excision in 13, localize bleeding sites in 4, determine the extent of inflammatory bowel disease in 2, survey the colon in 2 who did not have preoperative colon radiography, and assess bowel viability in 1. Surgery proceeded as planned in 54 patients; however, colonoscopic findings extended the resection to include additional segments of bowel in 4. In four patients, polypectomy or bowel resection was avoided as a result of the colonoscopic findings. Intraoperative colonoscopy was not possible in four patients. No complications were related directly to this procedure. Intraoperative colonoscopy is a useful adjunct for localizing lesions or "clearing" the colon. In some patients, colonoscopic findings may change the extent of resection performed.

Aged↗
PubMed1989

Outcome of "indeterminant" colitis following ileal pouch-anal anastomosis.

To establish whether patients with indeterminant colitis (patients with ulcerative colitis whose surgical specimens also show features of Crohn's colitis) have an adverse outcome after ileal pouch-anal anastomosis (IPAA), the authors reviewed the pathologic reports and postoperative status of 514 consecutive patients who underwent IPAA for chronic ulcerative colitis (CUC). Twenty-five patients (5 percent) had features of indeterminant colitis (IC), including unusual distribution of inflammation, deep linear ulcers, neural proliferation, transmural inflammation, fissures, creeping fat, and retention of goblet-cell population. The clinical and functional outcome of these 25 IC patients was compared with that of the remaining 489 CUC patients. The mean follow-up was 38 +/- 18 months. No significant differences in complication rates, pouch function, incidence of "pouchitis," or requirement for pouch excision were detected in the two groups at follow-up. Although the authors are continuing to perform IPAA on patients with IC, a better definition of the IC patient and a more objective, prospective analysis of outcome of IC following IPAA is required before confident and specific treatment policies can be recommended.

Adult↗
PubMed1989

Small intestinal obstruction complicating ileal pouch-anal anastomosis.

Small bowel obstruction remains the most common complication after proctocolectomy with ileal pouch-anal anastomosis. Of 626 patients who underwent this operation between January 1981 and October 1986 for ulcerative colitis (544 patients), familial adenomatous polyposis (72 patients), or indeterminate colitis (ten patients), 17% developed small bowel obstruction, 7.5% of whom required surgical intervention. The obstruction occurred either before or after closure of the temporary ileostomy. Patients who had a temporary Brooke ileostomy were more likely to develop obstruction (four of 32 patients, 12.5%) than those who had a loop ileostomy (25 of 564 patients, 4.6%) (p = 0.07). Also, patients who had had previous operations were at greater risk of obstruction (8.5%) than those who had not (2.2%) (p less than 0.04).

Adenomatous Polyposis Coli↗