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Biomedical subjects

J K Ritchie

Publications and source records attributed to J K Ritchie.

At least 19 recordsLinked to original sources
PubMed1996

Stenosis of the pouch anal anastomosis following restorative proctocolectomy.

PURPOSE: To compare the incidence of stenosis after hand-sewn and stapled ileoanal anastomosis. Stenosis of the ileoanal anastomosis occurs in 5-16% of patients undergoing a restorative proctocolectomy but the incidence using a stapled technique is unknown. METHODS: Between 1976 and 1990, 266 patients underwent restorative proctocolectomy or proctectomy at one hospital. In two hundred and eighteen the anastomosis was hand sewn and stapled in 48 (single 33; double 15). RESULTS: Stenosis occurred in 31 (14.2%) of the hand-sewn and in 19 (39.6%) of the stapled anastomoses. This difference was highly significant (P < 0.001). Stenosis was not related to the size of the staple head used or to the stapling technique. There was no relationship between the development of stenosis and pelvic sepsis. Twenty six (hand-sewn 16, stapled 10) of the 48 patients with stenosis needed dilatation under general anaesthetic. CONCLUSION: Stapled anastomoses may result in a high incidence of anastomotic stenosis.

Adolescent↗
PubMed1994

Long-term neoplasia risk after azathioprine treatment in inflammatory bowel disease.

The incidence of various cancers, especially non-Hodgkin lymphoma (NHL), is higher among patients who receive azathioprine for immunosuppression after organ transplants than in the general population. We have studied the risk of neoplasia after azathioprine in 755 patients treated for inflammatory bowel disease. The patients received 2 mg/kg daily for a median of 12.5 months (range 2 days to 15 years) between 1962 and 1991; median follow-up was 9 years (range 2 weeks to 29 years). Overall there was no significant excess of cancer: 31 azathioprine-treated patients developed cancer before age 85 compared with 24.3 expected from rates in the general population (observed/expected ratio 1.27, p = 0.186). There was a difference in the frequency of colorectal (13) and anal (2) carcinomas (expected 2.27; ratio 6.7, p = 0.00001); these tumours are recognised complications of chronic inflammatory bowel disease. There were 2 cases of invasive cervical cancer (expected 0.5), but no case of NHL. Among patients with extensive chronic ulcerative colitis there was no difference in cancer frequency between 86 who had received azathioprine and 180 matched patients who had never received it. Thus, azathioprine treatment does not substantially increase the risk of cancer in inflammatory bowel disease.

Adenocarcinoma↗
PubMed1994

Coloanal sleeve anastomosis in the treatment of diffuse cavernous haemangioma of the rectum: long-term results.

Diffuse cavernous haemangioma of the rectum is an unusual lesion. In 1971 Parks and co-workers described resection and coloanal sleeve anastomosis as an alternative operation in the treatment of this rare malformation. The clinical presentation, diagnosis and long-term results of patients with this condition managed by such a surgical technique are described. Resection and coloanal sleeve anastomosis offers major advantages such as a lower risk of intraoperative bleeding, no risk of damaging the pelvic nerves, sparing of continence and avoidance of a permanent colostomy. It should therefore be considered the treatment of choice for this uncommon condition.

Adolescent↗
PubMed1994

Overlapping anal sphincter repair for faecal incontinence due to sphincter trauma: five year follow-up functional results.

Disruption of the anal sphincter results from obstetric injury, ano-rectal operations or external trauma. Obstetric or surgical division of the sphincteric mechanism may not be immediately apparent and the clinical presentation of incontinence may occur several years later [1, 2]. Reconstruction of the sphincter using a fascial sling or direct end-to-end repair of the disrupted sphincter result in a high failure rate. Failure after direct end-to-end repair is usually caused by break down of the suture line owing to retraction of the muscle ends [3]. Parks advocated an overlapping repair [4] in which the disrupted ends of the sphincter were mobilised and wrapped around each other. This paper reports the results of overlapping sphincter repair for faecal incontinence resulting from trauma, after a 5 year follow-up period.

Adult↗
PubMed1994

Lower gastrointestinal malignancy in Crohn's disease.

An increased incidence of carcinoma of the small bowel and colon has been described in patients with Crohn's disease. Tumours arising in the rectum and anus are reported less often. Between 1940 and 1992, of some 2500 patients with Crohn's disease seen at this hospital, 15 are known to have developed carcinoma of the lower gastrointestinal tract. Malignancy occurred in the colon in two patients, in the upper two thirds of rectum in one, in the lower third of rectum in seven, and in the anus in five. The 12 patients with carcinoma arising in the anus or lower rectum had longstanding severe anorectal Crohn's disease, which included a stricture in four, fistula in four, proctitis in one, abscess in two, and enlarged anal skin tags in one. The development of malignancy in patients with Crohn's disease may apply particularly to those with chronic complicated anorectal disease.

Adenocarcinoma↗
PubMed1994

The first 10 years' experience of restorative proctocolectomy for ulcerative colitis.

Between 1976 and 1985, 110 patients had restorative proctocolectomy or proctectomy for ulcerative colitis and 103 were followed up until death or February 1992. There was one postoperative and one late death related to surgery. The cumulative probability of pouch failure was 12% at five years: half of the failures occurred within one year. The commonest reasons were perianal/pelvic sepsis and probable Crohn's disease. The cumulative probability of readmission, excluding that for ileostomy closure, was 68% at five years. There were 152 operations carried out during readmissions. These included 44 laparotomies. Function was assessed in 80 patients at a mean of 99.3 months after ileostomy closure. For 66 patients with spontaneous evacuation, average minimum diurnal frequency was 3.8, maximum 4.9, with 35 evacuating at night. One patient experienced major continence problems, 30 had minor leaks, and 49 were completely continent. Postoperatively, five patients gave birth to nine babies, four had renal stones, two myasthenia gravis, and two severe anaemia: seven had pre or postoperative thyroid dysfunction.

Adolescent↗
PubMed1994

Surgery for ulcerative colitis in the era of the pouch: the St Mark's Hospital experience.

The choice of operation for ulcerative colitis among 422 patients having all their surgery at one hospital between 1976 (the year of the first restorative proctocolectomy) and 1990, was reviewed. The 15 year period was divided into three quinquennia (1976-80, 1981-85, 1986-90). Elective surgery was performed in 316 patients with one operative death. The proportions of conventional proctocolectomy, colectomy with ileorectal anastomosis, and restorative proctocolectomy for the three quinquennia were 36/60, 17/60, 4/60; 29/111, 30/111, 35/111; 30/145, 17/145, 75/145. Of 106 urgent operations with three postoperative deaths, 12 had a conventional proctocolectomy and 86 a colectomy with ileostomy and preservation of the rectum. Of 85 survivors of the latter there were two late deaths and in 13 no further surgery had been done at the time of this assessment. In the remaining 70 having subsequent surgery the proportion of conventional proctocolectomy, colectomy with ileorectal anastomosis, and restorative proctocolectomy for the three quinquennia respectively were 19/27, 4/27, 14/27; 11/21, 2/21, 8/21; 5/22, 4/22, 13/22. Of the 76 patients having colectomy with ileorectal anastomosis 12 (16%) no longer had a functioning rectum at the end of 1990. Of the 153 patients having an ileoanal pouch procedure, 11 (7%) no longer had, a functioning anus. The study showed an increase in the numbers of patients having elective surgery for ulcerative colitis during the three quinquennia. It also showed a rise of restorative over conventional proctocolectomy with diminution in elective colectomy with ileorectal anastomosis in the last five year period.

Aged↗
PubMed1993

Temporary loop ileostomy for restorative proctocolectomy.

The aim of a defunctioning ileostomy after restorative proctocolectomy is to mitigate the consequences of pelvic sepsis, should it occur. However, there are complications related to the ileostomy itself. Of 310 patients (174 male and 136 female; mean age 33.2 years) who underwent restorative proctocolectomy between 1976 and 1990, 296 had a covering ileostomy and 14 did not. The stoma has been closed in 263 (88.9 per cent) at a median interval from formation of 12.0 weeks. Ileostomy-related complications before closure occurred in 17 patients (5.7 per cent). Laparotomy for obstruction due to the ileostomy was required in seven patients (2.4 per cent). Retraction requiring revision occurred in three patients (1.0 per cent), an abscess behind the stoma in one (0.3 per cent) and miscellaneous appliance problems in seven (2.4 per cent). Following closure, 59 patients overall (22.4 per cent) developed an ileostomy-related complication. There were 30 cases of small bowel obstruction, treated conservatively in 19 (7.2 per cent) and by laparotomy in 11 (4.2 per cent). Peritonitis requiring laparotomy occurred in three patients (1.1 per cent) and two (0.8 per cent) developed an enterocutaneous fistula. There were 14 (5.3 per cent) wound infections and 16 (6.1 per cent) other miscellaneous problems. Significant complications associated with a temporary ileostomy were less frequent in this series than in some other reports. Obstruction was the most common complication and fistula was rare.

Adolescent↗
PubMed1993

Reappraisal of radical local excision for carcinoma of the rectum.

Outcome in all 167 patients treated by radical local excision for rectal carcinoma between 1948 and 1984 at St Mark's Hospital was assessed in terms of the original tumour differentiation except for 15 patients with incomplete follow-up or ungraded tumours. Fifty-six of the 152 patients had low-grade tumours, with one death from carcinoma in this group. Of 81 patients with average-grade tumours, ten died from carcinoma of the rectum: two after early reoperation and eight following recurrence. Six of 15 patients with high-grade tumours underwent early reoperation and three of these died from carcinoma. Among the nine patients who did not undergo early reoperation there were three related deaths (two from carcinoma, one after rectal excision for recurrence). Local excision remains a valid therapy for suitable patients with low-grade tumours but is not recommended for those with average-grade lesions. The necessity for early reoperation in patients with high-grade tumours is questioned.

Adult↗
PubMed1993

Bone marrow toxicity caused by azathioprine in inflammatory bowel disease: 27 years of experience.

Myelosuppression is an important and potentially lethal complication of azathioprine treatment. The blood count has been reviewed in all patients treated with azathioprine for inflammatory bowel disease over 27 years in one hospital. Altogether 739 patients (422 with Crohn's disease, 284 with ulcerative colitis, and 33 with indeterminate colitis) were treated with 2 mg/kg/day azathioprine for a median of 12.5 months (range 0.5-132) between 1964 and 1991. Full blood counts were performed monthly for the duration of treatment. In 37 patients (5%) who developed bone marrow toxicity, the drug was withdrawn or the dose reduced. Thirty two of these patients were asymptomatic and five developed symptoms. Leucopenia (white blood count less than 3.0 x 10g/l) occurred in 28 (3.8%) patients, in nine of whom it was severe (white blood count < 2.0 x 10(9)/l). Of these nine patients, three were pancytopenic: two died from sepsis and the other had pneumonia but recovered. A further two patients with severe leucopenia developed a mild upper respiratory infection only. Thrombocytopenia (platelet count < 100,000 x 10(6)/l) in 15 patients was associated with leucopenia in six and developed in isolation in a further nine (total 2%). Isolated thrombocytopenia was never clinically severe. Myelotoxicity from azathioprine developed at any time during drug treatment (range 2 weeks-11 years after starting the drug) and occurred either suddenly or over several months. Bone marrow suppression as a result of azathioprine treatment is uncommon when a moderate dose is used, but is potentially severe. Leucopenia is the commonest and most important haematological complication. Regular monitoring of the full blood count is recommended during treatment.

Adolescent↗
PubMed1991

Natural history of indeterminate colitis.

The long-term outcome of patients with a pathological diagnosis of indeterminate colitis on a colectomy specimen was investigated. The case records of 46 such patients operated on for inflammatory bowel disease between 1960 and 1983 were reviewed. Using the preoperative clinical information, pathological and radiological reports, it was possible to divide the patients into three groups: group 1, probable Crohn's disease (19 cases); group 2, probable ulcerative colitis (11 cases); and group 3, indeterminate colitis (16 cases). The patients were followed for a minimum of 2.5 years (median 10, range 2.5-28 years). During this period the probable diagnosis changed in five cases only. One patient in group 1 (Crohn's disease) was subsequently considered to have ulcerative colitis (group 2). The other four patients were all in group 3. Three were reclassified as ulcerative colitis and the fourth as Crohn's disease on the finding of a single granuloma in a rectal biopsy. No case in group 3 required subsequent small bowel surgery. These data suggest that patients continuing with a diagnosis of indeterminate colitis in spite of careful preoperative and postoperative assessment are unlikely to show features of Crohn's disease in the long term. This may be important when considering a subsequent restorative proctectomy.

Adolescent↗
PubMed1991

Blood transfusion and recurrent Crohn's disease.

The effect of blood transfusion on the postoperative recurrence of Crohn's disease has been investigated. Clinical and pathological data from 197 patients treated by right hemicolectomy between 1947 and 1988 have been analysed. Symptomatic recurrences confirmed radiologically or histologically have been recorded and cumulative recurrence rates calculated for transfused and non-transfused patients. Perioperative blood transfusion does not influence the development of recurrent disease (log rank test, chi 2 = 0.112).

Adolescent↗
PubMed1991

Pyoderma gangrenosum in inflammatory bowel disease.

Since 1954, 34 patients have attended St. Mark's Hospital with pyoderma gangrenosum in association either with ulcerative colitis (22 patients) or Crohn's disease (12 patients). Lesions were multiple in 71 per cent and over half were situated below the knees. Ulcerative colitis was active in 11 patients (50 per cent) and Crohn's disease was active in nine (75 per cent) when pyoderma gangrenosum was diagnosed. Associated illnesses--most commonly a seronegative arthritis affecting large joints--were present in 55 per cent and 92 per cent of cases respectively. A diffuse pustular rash appeared in six patients, synchronously with pyoderma in five. In a further seven patients (two with ulcerative colitis, five with Crohn's disease) the onset or course of pyoderma might have been linked to the presence of non-dermatological suppuration. Pyoderma resolved without intestinal resection in two-thirds of patients. When present at the time of surgical resection (15 procedures in 13 patients), pyoderma healed promptly in six cases, only with additional therapy in four cases and very slowly or not at all in five cases. Pyoderma gangrenosum occurs in both ulcerative colitis and Crohn's disease. Healing after intestinal resection is unpredictable both with respect to timing and extent of resection.

Adolescent↗
PubMed1990

High versus low ligation of the inferior mesenteric artery in rectal cancer.

The argument for and against high ligation of the inferior mesenteric artery in rectal cancer has yet to be resolved. Between 1948 and 1983, 4250 patients underwent surgery for rectal carcinoma at St. Mark's Hospital, London. From these, 250 patients were selected who had undergone curative anterior resection of a Dukes' C adenocarcinoma and their records were examined. In 150 (60 per cent) the inferior mesenteric artery was ligated above the origin of the left colic artery. The outcome was analysed using the Dukes', Gastrointestinal Tumour Study Group and Astler-Coller classifications, either alone or in combination. Tumour differentiation and extent of local invasion were also considered. Despite this detailed analysis, no improved survival was seen in patients when the inferior mesenteric artery was ligated above the origin of the left colic artery.

Adenocarcinoma↗
PubMed1990

Safety of azathioprine in pregnancy in inflammatory bowel disease.

Although azathioprine has been reported to be safe during pregnancy in renal transplant recipients and patients with systemic lupus erythematosus, opinions vary whether it should be continued in pregnancy in inflammatory bowel disease. A retrospective analysis of the outcome of 16 pregnancies in 14 women receiving azathioprine for inflammatory bowel disease was performed. There was one infective complication of pregnancy (hepatitis B virus infection), but there were no congenital abnormalities or subsequent health problems in the children. This preliminary study suggests that azathioprine is safe in pregnancy in inflammatory bowel disease patients and that termination of pregnancy is not mandatory for those who conceive while taking the drug.

Adult↗
PubMed1990

Precancer and cancer in extensive ulcerative colitis: findings among 401 patients over 22 years.

Patients with extensive ulcerative colitis who do not need early surgery have been offered regular examination with the aim of detecting precancerous change (dysplasia) or early colorectal carcinoma. Outpatient visits with clinical examination, sigmoidoscopy, and biopsy were supplemented by two-yearly colonoscopy after the disease course reached 10 years. During the 22 year period from the beginning of 1966 to the end of 1987, 401 patients entered the programme and together contributed 4048 patient-years of observation. Apart from nine patients who left the country, follow up is complete until 1986 or 1987. Colorectal carcinoma developed in 22 patients and, in a further 12, biopsy evidence of precancer, described as severe/high grade dysplasia, was confirmed in a colectomy specimen. The cumulative probability of developing carcinoma was 3% at 15 years, 5% at 20 years, and 9% at 25 years; corresponding figures for precancer or carcinoma, or both were 4%, 7%, and 13%. Five patients died of colorectal carcinoma, two while under regular observation and three after developing carcinoma four to six years after their last attendance. Among the 17 patients who developed carcinoma while under observation, the Dukes stage was A or B in 12. Patients with extensive colitis whose disability does not warrant early surgery have a clinically important cancer risk after the disease has been present for 10 years. Our results suggest that follow up in the manner described reduces the mortality from this complication. Further work is needed to define the optimum method of surveillance and show if it is cost effective.

Adult↗
PubMed1989

Conservative proctocolectomy: a dubious option in ulcerative colitis.

Conservative proctocolectomy was performed for ulcerative colitis in 19 patients, Crohn's disease in three and familial adenomatous polyposis in one. Healing was uncomplicated in only three patients (13 per cent). Eleven developed an anal discharge and nine an infected pelvic haematoma despite peranal drainage. Fourteen patients developed pelvic sepsis and, despite surgical curettage in 11, none healed. Six of these patients have had the anal sphincter divided, with healing in only one, and the anal canal has been excised in two. Eleven patients have ultimately healed at a median time of 28 months and eight have persistent sepsis after a median period of 45 months. Two patients with sepsis have had a successful ileoanal anastomosis. Conservative proctocolectomy cannot be recommended as a definitive operation for ulcerative colitis even though it may permit a subsequent restorative procedure.

Adult↗