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Biomedical subjects

J H Pemberton

Publications and source records attributed to J H Pemberton.

At least 127 records · Page 7Linked to original sources
PubMed1989

Quality of life after Brooke ileostomy and ileal pouch-anal anastomosis. Comparison of performance status.

Although the clinical results of Brooke ileostomy are good, patients are permanently incontinent of stool and gas. Alternative operations designed to restore enteric continence, such as ileal pouch-anal anastomosis, must not only be as safe and effective as Brooke ileostomy, but should provide an improved quality of life in order to establish long-term acceptability. Ileal pouch-anal anastomosis has been performed safely and good functional results have been reported. The quality of life after ileal pouch-anal anastomosis, however, has not been documented. Two hundred ninety-eight ileal pouch patients and 406 Brooke ileostomy patients who had the operations performed for chronic ulcerative colitis or familial adenomatous polyposis formed the basis of the study. After adjusting for age, diagnosis, and reoperation rate, logistic regression analysis of performance scores in seven different categories was used to discriminate between operations. Median follow-up was longer in Brooke ileostomy patients than in ileal pouch patients (104 months vs. 47 months, respectively), and Brooke ileostomy patients were slightly older (38 years vs. 32 years). A great majority of patients in each group were satisfied (93% Brooke ileostomy; 95% ileal pouch-anal anastomosis). Thirty-nine per cent of Brooke ileostomy patients, however, desired a change in the type of ileostomy they had. At 47 months, ileal pouch patients had a median of 5 stools per day and 1 at night, 77% did not experience any daytime incontinence, while 22% reported occasional spotting. In each performance category, the performance score discriminated between operations, with the probability of having had an ileal pouch-anal anastomosis operation increasing with improvement in performance scores (p less than 0.05). We concluded that after ileal pouch-anal anastomosis, patients experienced significant advantages in performing daily activities compared to patients with Brooke ileostomy and thus may experience a better quality of life. These results help further to establish ileal pouch-anal anastomosis as a safe, attractive, and valid alternative to Brooke ileostomy.

Activities of Daily Living↗
PubMed1989

Ileal pouch-anal anastomosis: comparison of results in familial adenomatous polyposis and chronic ulcerative colitis.

The aim of this study was to compare the immediate postoperative results and the long-term outcome of ileal pouch-anal anastomosis in 94 patients with familial adenomatous polyposis to those in 758 patients with ulcerative colitis. Two colitis patients died after operation (0.3%), but no polyposis patients died. Overall operative complications appeared in 26% and 29% of polyposis and colitis patients, respectively (NS). Reoperation for intestinal obstruction did not differ between the two groups, but sepsis requiring reoperation was more common in colitis patients (6%) than in polyposis patients (0%, p less than 0.04). At follow-up (mean, 3 years), polyposis patients had fewer daytime stools (4.5 stools per day), less nighttime fecal spotting (26%), and less pouchitis (7%) than colitis patients (5.8 stools per day; spotting, 40%; pouchitis, 22%; p less than 0.002). The conclusion was that polyposis patients tolerated the operation better and had less long-term disability than did colitis patients. The data suggest that postoperative sepsis, daytime stooling frequency, nocturnal incontinence, and pouchitis may be, at least in part, disease related and not surgeon or operation related.

Adenomatous Polyposis Coli↗
PubMed1989

Perineal approaches for the treatment of complete rectal prolapse.

Perineal approaches for rectal prolapse are particularly useful in high-risk patients or in patients presenting with strangulation. Each technique is useful in certain clinical situations. Altemeier's procedure, with the addition of rectopexy and levatorplasty (Dis Colon Rectum 29: 547-552, 1986) may be the best available perineal operation for long-term correction of prolapse and treatment of associated incontinence.

Colectomy↗
PubMed1988

A new bowel preparation for elective colon and rectal surgery. A prospective, randomized clinical trial.

A two-day cathartic/enema preparation with oral administration of erythromycin and neomycin was compared with an orthograde lavage preparation with oral administration of metronidazole and neomycin in a prospective randomized trial in 300 and 293 eligible patients, respectively, who were undergoing elective colon and rectal surgery. Patients were assessed for infections at six weeks after discharge from the hospital. The major infection rate was less than 1% and the minor infection rate was less than 4%. The overall infection rate was 4.2%. The type of bowel preparation used, the type of operation, and the addition of systemic antibiotic therapy did not affect infection rates significantly. We conclude that this one-day lavage technique, as described, is a safe, effective, economical, and preferred method of colonic preparation for elective colon and rectal surgery.

Adolescent↗
PubMed1988

Postoperative intra-abdominal and pelvic sepsis complicating ileal pouch-anal anastomosis.

In a series of 500 patients who underwent ileal pouch-anal anastomosis for ulcerative colitis or polyposis coli, significant intra-abdominal or pelvic sepsis developed in 30 (6%). Among the patients who did not require laparotomy because they responded to treatment with antibiotics or local drainage (surgical or radiologically guided) or both, no pouches were excised and the ileostomy closure rate (92%) was similar to that for the patients who did not have sepsis. The 17 patients whose sepsis did require laparotomy had a high rate of pouch excision (41%) (p less than 0.0001) and a low rate of ileostomy closure (29%) (p less than 0.0001). Factors identified as possibly associated with severe sepsis included female gender and ulcerative colitis complicated by toxicity or malignancy.

Adult↗
PubMed1988

Ileal pouch-anal anastomosis for chronic ulcerative colitis and familial polyposis coli complicated by adenocarcinoma.

Of 518 patients undergoing the ileal pouch-anal anastomosis (IPAA), 17 (13 with chronic ulcerative colitis [CUC] and four with familial polyposis coli [FPC] ) also had a total of 22 cancers of the colorectum. Tumors were concentrated distally (rectum 6; sigmoid colon 5; proximal colon 11) and were diagnosed preoperatively in eight patients. Histologic grade and stage were as follows: grade I, 36 percent; II, 23 percent; III, 23 percent; IV, 18 percent; stage A, 5 percent; B1, 32 percent; B2, 18 percent; C1 and C2, 45 percent. Median hospital stay was 17 days with no operative mortality. Relaparotomy was required in 35 percent (sepsis in four patients; obstruction in two) and minor procedures were done in 12 percent (anastomotic dilatation in one; rectovaginal fistula in one). Mean frequency of defecation was 6.4/day, 1.0/night; incidence of minor seepage, 17 percent (day), 50 percent night); incidence of pouchitis, 8 percent; intermittent dyspareunia, 17 percent of six women. One patient died from hepatic metastases nine months after operation. IPAA should be considered in favorable cancers complicating CUC or FPC, although it may be contraindicated in advanced rectal cancer, and may be unsuitable in advanced proximal cancer.

Adenocarcinoma↗
PubMed1988

Influence of splenectomy on survival rate of patients with colorectal cancer.

Between 1966 and 1980, 68 patients were identified who had a splenectomy before or concurrent with resection of a colorectal adenocarcinoma. Control subjects with concurrent disease were then matched with each study patient for age, sex, stage of disease, and date of operation. Follow-up was complete. Between splenectomy patients and control subjects, there was no difference in the site of primary disease (rectum versus colon), the number of patients receiving adjuvant therapy, the technique of resection (cure versus palliation), or the extent of regional disease. Overwhelming sepsis occurred in only one splenectomy patient. Splenectomy was associated with a significant decrease in survival at 5 years in patients with regional (stage C) disease but not in patients with localized (stage B) disease. More splenectomy patients received blood transfusions than control subjects, but an independent effect on survival could not be demonstrated. The mechanism responsible for this adverse impact of splenectomy is undefined. However, splenectomy should be considered a possible factor in the survival of patients operated on for regional colorectal cancer.

Adenocarcinoma↗
PubMed1988

Scintigraphic assessment of the anorectal angle in health and after ileal pouch-anal anastomosis.

To determine whether the anorectal angle was preserved after ileal pouch-anal anastomosis, a simple, safe, low-radiation, real-time method of imaging the anorectum was developed. A cylindrical balloon was placed in the neorectum and anal canal and filled with a solution of 99mTc in water. A gamma camera then imaged the angulation of the balloon while the subject was at rest, during sphincteric squeeze, and during a Valsalva maneuver. Thirteen healthy volunteers and six patients were studied after ileal pouch-anal anastomosis. An angle was identified in all controls and patients. In the lateral decubitus position at rest, the mean anorectal angle in controls (102 +/- 18 degrees; SD) and anopouch angle in patients (108 +/- 19 degrees) were similar (p = 0.3). Sitting straightened the angle in both groups (p less than 0.03), whereas sphincteric squeeze and a Valsalva maneuver sharpened the angle in both the sitting and standing positions (p less than 0.03). In the lateral decubitus position, however, the pouch group was less able to sharpen the angle than were the controls (p = 0.04). In controls, the anorectal junction descended during sitting and elevated during squeeze (p less than 0.03), but this did not occur in the pouch group. In conclusion, maneuvers favoring or stressing continence (squeeze, Valsalva) sharpened the anorectal angle and elevated the pelvic floor, whereas a maneuver favoring defecation (sitting) straightened the angle and caused the pelvic floor to descend. After ileal-anal anastomosis, the angle and its movements (except those while lying) were similar to controls. Elevation of the pelvic floor during squeeze, however, was decreased, indicating a decreased mobility of the pelvic floor after operation.

Adult↗
PubMed1988

Anal canal pressure and motility after ileoanal anastomosis.

This study was done to determine the effect of mucosal rectectomy and ileal pouch to anal anastomosis (IAA) on pressure and motility of the anal canal. Fifty patients, 22 +/- 2 months after operation (mean plus or minus standard error of the mean), and 30 healthy control volunteers were studied. Twenty-eight patients had excellent continence, while 22 had episodic minor incontinence. The maximum resting pressure in the anal canal was reduced in patients with episodic incontinence compared with continent patients and control volunteers. The increase in pressure with squeeze was slightly greater in continent than in incontinent patients. The frequency of the anal slow waves was less after IAA than in control volunteers and the amplitude of the waves was greater. The frequency and amplitude, however, were not related to continence or resting pressure. In conclusion, decreased anal canal resting and squeeze pressures after ileal pouch to anal anastomosis are associated with episodic minor incontinence, while altered motility patterns in the anal canal are not.

Adolescent↗
PubMed1987

Enteric continence and the ileal pouch-anal procedure.

The ileal pouch-anal procedure maintains enteric continence by preserving critical physiological mechanisms. The reservoir, although possessing somewhat different physiologic characteristics than the rectum, provides sufficient storage capacity to enable the patient to resume most daily activities. The intact anorectal angle continues to perform its pivotal role in the maintenance of gross fecal continence, while the functioning anal sphincter muscles fine-tune the system. The success of the procedure has shown that certain widely held "principles" of continence may be less important than previously believed. These include the requirement for a long rectal stump, the preservation of the rectosphincteric inhibitory reflex, and the maintenance of sensation to the upper half of the anal canal. Yet, results are not perfect, and it is possible that while these mechanisms are not required for gross fecal continence, their transgression results in a subtle reduction in function from that of the normal state. When one considers, however, that the only other curative procedure for patients with familial polyposis is total proctocolectomy with permanent ileostomy, the ileal pouch-anal operation represents an important advance. The disease is removed, yet reasonably effective control of enteric continence is restored such that quality of life appears to be enhanced when compared to that achieved after proctocolectomy and Brook ileostomy.

Adenomatous Polyposis Coli↗
PubMed1987

The relative prognostic value of flow cytometric DNA analysis and conventional clinicopathologic criteria in patients with operable rectal carcinoma.

The DNA histograms of resected rectal carcinomas from 121 patients were compared, along with a detailed clinicopathologic assessment of the same tumors, with the incidence of postresection tumor recurrence and patient survival over an extended period of 15-year follow-up. A poorer prognosis was found for patients with DNA aneuploid and DNA tetraploid rectal cancers as compared with patients with DNA diploid cancers. In addition, local tumor recurrence was twice as common among patients with DNA nondiploid rectal carcinomas. The DNA pattern of a rectal carcinoma was an independent prognostic variable in a Cox's multivariate analysis model. DNA nondiploid rectal carcinomas had a statistically significant increased incidence of vascular invasion, tumor fibrosis, and high Dukes' stage.

Aged↗
PubMed1987

Does rectal mucosa regenerate after ileoanal anastomosis?

Regeneration of rectal mucosa after rectal mucosectomy and ileoanal anastomosis (IAA) could jeopardize the long-term safety of the procedure. The aim of this study was to determine if rectal mucosal regeneration occurred after IAA. Pathologic specimens of the IAA and surrounding rectal muscular cuff were obtained from 29 patients who had required IAA excision 17 +/- 2 months (mean +/- SEM, range, 2 to 48 months) following construction. Multiple (greater than or equal to 6) coronal and sagittal sections of each specimen were made and examined histologically. The rectal muscle cuff was bound to ileal serosa by dense fibrous tissue. Small islets of residual rectal mucosa were identified between the denuded rectal cuff and the ileal pull-through in four patients (14 percent) and at the ileoanal anastomosis in two patients (7 percent). Active rectal mucosal disease, dysplasia, or reepithelialization of the denuded rectal muscle were not seen. It is concluded that small islets of rectal mucosa may remain after IAA. Up to four years after IAA, however, no evidence of rectal mucosal regeneration could be documented.

Adolescent↗
PubMed1987

Determinants of stool frequency after ileal pouch-anal anastomosis.

The aim of our study was to determine whether ileal pouch motility and evacuability and the 24 hour fecal output influence stool frequency after ileal pouch-anal anastomosis. In 23 patients, at a mean of 24 months postoperatively (range 22 to 26 months), ileal pouch motility was measured using an intraluminal bag and pressure-sensitive catheters. The pattern and efficiency of ileal pouch emptying was determined scintigraphically. A 24 hour stool collection was made and the stool output and stool frequency recorded. The volume of ileal pouch distention at which large amplitude propulsive waves appeared (the threshold volume) correlated closely with stool frequency. The larger the threshold volume, the fewer the stools per 24 hours (correlation coefficient -0.70; p less than 0.01). Also, the greater the 24 hour stool output, the greater the stool frequency (correlation coefficient 0.79, p less than 0.001). In contrast, the efficiency of ileal pouch evacuation was less strongly related to stool frequency (correlation coefficient -0.41, p = 0.05). We conclude that ileal pouch motility and stool output are major determinants of stool frequency after ileal pouch-anal anastomosis. Inefficient pouch emptying is less commonly associated with frequent bowel movements.

Adult↗
PubMed1987

Flow cytometric DNA patterns from colorectal cancers--how reproducible are they?

The heterogeneity of DNA ploidy patterns within individual colorectal carcinomas was investigated by analyzing 261 different samples from 30 fresh colorectal cancers. The results of DNA analysis of multiple superficial cup biopsy specimens, of multiple full-thickness fresh tumor slices, and of nuclei extracted from paraffin-embedded pathologic archival specimens with use of the Hedley technique were compared. The same DNA ploidy pattern was found in all specimens of 19 (63%) of the 30 tumors studied. Minimal heterogeneity for DNA ploidy pattern was noted in seven carcinomas (23%), and moderate to marked heterogeneity was found in an additional four tumors (13%). The DNA pattern of a full-thickness specimen from 79% of the carcinomas studied was the same when samples were obtained from any one of five possible sites. In addition, the DNA ploidy pattern of the majority of the carcinomas could have been accurately predicted by flow cytometric DNA analysis of superficial cup biopsy specimens. These results demonstrate that most colorectal carcinomas are DNA ploidy homogeneous. Therefore, measurement of this tumor property can be used in future clinical research studies with some degree of confidence.

Colonic Neoplasms↗
PubMed1987

Surgery for ulcerative colitis.

Ileal pouch-anal anastomosis is a relatively new surgical alternative to conventional ileostomy in patients with chronic ulcerative colitis. The rationale for the operation is that the disease is cured by the colectomy, proximal proctectomy, and distal endorectal mucosal resection, but enteric continence is maintained because the anal sphincters are preserved and the reservoir capacity is restored by incorporating an ileal pouch. This article describes the criteria for selecting appropriate patients, the surgical technique, the short- and long-term clinical results, and the physiologic consequences of the operation. The possible implications of this new procedure on the future management of patients with chronic ulcerative colitis are also presented.

Anal Canal↗