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Biomedical subjects

J M Church

Publications and source records attributed to J M Church.

At least 19 recordsLinked to original sources
PubMed1992

Newly designed occluder pin for presacral hemorrhage.

Conventional hemostatic measures are often unsatisfactory in presacral venous bleeding occurring during surgical mobilization of the rectum. We designed a new type of hemorrhage occluder pin, with a ridged shaft, which may be rapidly placed into the sacrum to control hemorrhage. The aims of this study were 1) to assess the best pin shaft length by measuring the thickness of human sacral vertebral bodies, 2) to measure the forces needed to pull the newly designed pin out of the human sacrum compared with conventionally shaped titanium thumbtacks, and 3) to assess clinically the efficacy of the new device. Four fresh cadaveric pelves were isolated and cut on a sagittal plane, and the thickness of each vertebral body was measured. Titanium pins, both with ridged and with smooth shafts, were used. Twelve-millimeter-shaft pins were used for S1 and S2, and 7-mm pins were used for S3, S4, and S5. Pins were inserted into each sacral vertebra, and the forces needed to extract them from the bone were measured by computerized dynamometry. Significantly more force was required to extract ridged vs. smooth pins, both with 12-mm and with 7-mm shafts. There was no significant difference between the forces needed to pull out 12-mm vs. 7-mm pins. The new pin was successfully used to stop presacral hemorrhage in three patients with no complications one, three, and six months after surgery. This newly designed hemorrhage occluder pin may represent an improved method of controlling presacral venous hemorrhage.

Adult↗
PubMed1992

Clinical conundrum of solitary rectal ulcer.

A retrospective study of 80 patients with biopsy-proven solitary rectal ulcer (SRU) was conducted to review its clinical spectrum. The median follow-up was 25 months. The female-to-male ratio was 1.4:1.0, and the mean age was 48.7 years (range, 14-76 years). Principal symptoms were bowel disturbances (74 percent) and rectal bleeding (56 percent). Twenty-one patients (26 percent) were asymptomatic and required no treatment. A previous "wrong" diagnosis was made in 25 percent. Rectal prolapse was identified in 28 percent (full-thickness, 15 percent; mucosal, 13 percent). The macroscopic appearance of the lesion seen in SRU varied widely and included polypoid lesions in 44 percent (the predominant finding in the asymptomatic group), ulcerated lesions in 29 percent (always symptomatic), and edematous, nonulcerated, hyperemic mucosa in 27 percent. Anorectal manometry provided little helpful information in the patients in whom it was performed. Management by bulk laxatives and bowel retraining led to symptomatic improvement in 19 percent of cases. In 29 percent of cases, symptoms persisted despite endoscopic healing of the lesion. Intractability of symptoms led to surgery in only 27 (34 percent) patients. Depending on the presence or absence of rectal prolapse, rectopexy or a conservative local procedure (such as local excision), respectively, appeared to be the optimal surgical treatment. The polypoid variety tended to respond to therapy more favorably than non-polypoid varieties. Thus, the macroscopic appearance of SRU has a significant bearing on the clinical course, and most cases do not require surgery.

Adolescent↗
PubMed1992

Noncytotoxic drug therapy for intra-abdominal desmoid tumor in patients with familial adenomatous polyposis.

Forty of 416 patients with familial adenomatous polyposis were noted to have intra-abdominal desmoid tumors, and a subgroup of 16 were treated with noncytotoxic drug therapy. Drugs used were sulindac (14 patients), sulindac plus tamoxifen (3 patients), indomethacin (4 patients), tamoxifen (4 patients), progesterone (DEPO-PROVERA; Upjohn Co., Kalamazoo, MI) (2 patients), and testolactone (1 patient). Therapy with these drugs for continuous periods of six months or more resulted in three complete and seven partial remissions. When treated patients were compared with untreated patients (n = 12), there were significant benefits for the treated group, both in reduction of desmoid size and in improvement of symptoms, despite the inherent selection bias against this. Sulindac was the only drug used in enough patients to permit independent evaluation of its effect, with one complete and seven partial reductions of tumor size. Some patients had a delayed response to sulindac, with tumor shrinkage occurring after an initial period of tumor enlargement. When using sulindac for the treatment of desmoid tumors, this phenomenon should be considered.

Abdominal Neoplasms↗
PubMed1992

Gastroduodenal polyps in patients with familial adenomatous polyposis.

A review of the endoscopy reports and pathology results from esophagogastroduodenoscopy (EGD) of all patients with familial adenomatous polyposis (FAP) undergoing such an examination was performed. Two hundred forty-seven patients were identified, with an overall prevalence of duodenal adenomas of 66 percent and of fundic gland polyps of 61 percent. Analysis of our more recent experience (1986 to 1990) shows the prevalence to be 88 percent and 84 percent, respectively. A normal-appearing papilla was adenomatous in 50 percent of cases. No case of periampullary carcinoma developed in patients under surveillance. Routine EGD is indicated for patients with FAP. Duodenal adenomas and fundic gland polyps will occur in the majority of patients.

Adenomatous Polyposis Coli↗
PubMed1992

Outcome of ileorectal anastomosis for Crohn's colitis.

One hundred thirty-one patients underwent ileorectal anastomosis (IRA) for Crohn's colitis. Preoperatively, 84 patients (63 percent) were found to have mild or moderate proctitis and 47 (37 percent) had rectal sparing. Sixty-eight (52 percent) had associated small bowel disease, and 20 (15 percent) had perianal disease. Sixty-five IRAs were performed at the time of subtotal colectomy, while 56 were done after previous surgery. Anastomotic leaks occurred in four patients. There were no operative deaths. Thirteen patients (10 percent) with protecting stomas never underwent closure. Among the remaining 118 patients with functioning IRAs, 30 (23 percent) required later proctectomy and 16 (13 percent) required proximal diversion, with the mean period with a functioning IRA in these 46 patients being 4.1 years (range, 6.2 months-12.7 years). An additional 13 patients required preanastomotic resection and neo-IRA, and 11 required proximal small bowel resection. The mean duration of function of all 118 IRAs was 9.2 years. At the time of review, after a mean follow-up of 9.5 years, 72 patients (61 percent) retained a functioning IRA, with 44 being free of disease, while 28 were being treated with steroids or antidiarrheal medication. The mean stool frequency was 4.7 per day. In patients with Crohn's colitis, IRA should be considered as an alternative to proctocolectomy if the rectum is not severely diseased and sphincter function is not compromised.

Adolescent↗
PubMed1992

Open sesame: tips for traversing the anal canal.

The key points for a minimally traumatic and pain-free anal intubation are an informed patient, gentle technique, plenty of lubricant, a relaxed, supportive atmosphere, and gradual inward pressure on the instrument or finger. Also important are knowledge of the direction of the anal canal, sideways introduction of the flexible endoscope, and the technique of gaining anal relaxation by asking the patient to push down.

Anal Canal↗
PubMed1992

Retinal pigment epithelium lesions as a biomarker of disease in patients with familial adenomatous polyposis. A follow-up report.

BACKGROUND: The sensitivity of retinal pigment epithelium (RPE) lesions as a predictive congenital marker for the development of familial adenomatous polyposis (FAP) is evaluated. METHODS: In a prospective study, 34 patients at 50% risk of inheriting FAP were examined. Based on the presence or absence of four or more RPE lesions, patients were categorized as those who had inherited or those who lacked the FAP genes. All patients received dilated fundus examinations with binocular indirect ophthalmoscopy and all RPE lesions were documented with fundus photography. All patients underwent annual sigmoidoscopy to determine the presence or absence of polyps. RESULTS: A 3-year follow-up analysis showed that 8 of 14 patients who were positive for RPE lesions later developed polyps. Of the 20 patients considered negative for FAP based on normal fundus examination, none has developed polyps. CONCLUSION: The authors urge all patient at risk of inheriting FAP to undergo dilated fundus examination with binocular indirect ophthalmoscopy and wide-angle fundus photography at the earliest age possible. All patients with 4 or more RPE lesions should undergo annual sigmoidoscopic examinations beginning before 10 years of age.

Adenomatous Polyposis Coli↗
PubMed1992

The expanding utility of endoluminal ultrasonography in the management of rectal cancer.

BACKGROUND: This study assessed the ability of endoluminal ultrasonography (ELUS) to determine extent of local invasion and lymph node (LN) metastasis of primary rectal tumors, to assist in ELUS-guided pelvic LN biopsies, and to assess invasion of locally recurrent rectal cancers compared to computed tomography (CT). METHODS: Eighty-one patients with rectal adenocarcinoma (n = 67) or villous adenoma of more than 3 cm (n = 14) underwent ELUS with a 360-degree 7.0-MHz transducer For LN biopsy (n = 10), ELUS was used with an 18-gauge core biopsy needle passed transrectally. ELUS and CT were compared in 14 locally recurrent tumors. RESULTS: Staging for primary tumors (ELUS compared with pathologic examination, TNM system) revealed ELUS accurately predicted wall penetration and LN status with 95% confidence intervals of 0.88 to 0.99 and 0.87 to 0.99. Eight cancers were overstaged, and two were understaged by ELUS. ELUS-guided LN biopsy revealed carcinoma (n = 3) or lymphoid tissue (n = 3) in six of 10 patients. Extent of pelvic organ involvement was predicted in 11 of 14 ELUS and eight of 14 CT examinations in recurrent rectal cancer. CONCLUSIONS: ELUS is accurate in staging rectal cancers, can guide biopsies of pararectal LNs, and may be more reliable than CT in assessing local recurrence. The role of ELUS in the management of rectal cancer is expanding.

Biopsy↗
PubMed1991

Surgical treatment of sigmoid diverticulitis.

The diagnosis and treatment of sigmoid diverticulitis presents several challenges to gastroenterologists and colorectal surgeons, challenges both logistical and technical. An algorithm is presented that may assist in the process of diagnosis and treatment. Young patients may be offered elective surgery after one proven severe attack of diverticulitis, but the timing of surgery in older patients with recurrent disease is more dependent on individual case-by-case decisions than a general rule. Important surgical principles are (1.) to resect all disease at the first operation; (2.) to avoid a primary anastomosis in the urgent situation unless all factors are favorable; (3.) to perform a minimal resection in the urgent case; (4.) to resect all distal disgmoid when operating definitively.

Algorithms↗
PubMed1991

Protein status and metabolic expenditure determine the response to intravenous nutrition--a new classification of surgical malnutrition.

To determine whether nutritional and metabolic factors affect the response to intravenous nutrition (IVN) 146 surgical patients were classified according to their protein and metabolic status using direct measurements of body protein and metabolic expenditure. The patients were grouped into four categories: category I, moderate to severe protein depletion without raised metabolic expenditure; category II, moderate to severe protein depletion with raised metabolic expenditure; category III, mild protein depletion without raised metabolic expenditure; and category IV, mild protein depletion with raised metabolic expenditure. After 2 weeks of IVN patients in category I gained a mean(s.e.m.) of 0.43(0.06) kg of body protein (P less than 0.001) and had significant rises in both plasma transferrin and prealbumin (P less than 0.05); patients in category II gained 0.30(0.11) kg of protein (P less than 0.005) and also had significant rises in transferrin and prealbumin (P less than 0.05). Patients in category III lost 0.24(0.11) kg protein (P less than 0.05) and had no changes in either transferrin or prealbumin and patients in category IV lost 0.51(0.13) kg of body protein (P less than 0.001) and although there was a significant rise in plasma prealbumin there was no significant change in plasma transferrin. When postoperative patients were examined separately, they did not differ significantly from preoperative patients except in category I, where their protein gain was only 0.19(0.10) kg, an amount not significantly different from that gained by patients in category II. In each of the four categories described, the changes in total body protein occurring with 2 weeks of IVN were determined by the relative effects of two competing processes; protein depletion and raised metabolic expenditure. With moderate to severe protein depletion (approximately 30 per cent depletion of body protein stores) there was a marked tendency to gain protein with IVN. When the patient had a raised metabolic expenditure or was postoperative this tendency of depleted patients to gain protein was still present but it was less. With only mild protein depletion (approximately 10 per cent depletion) increases in metabolic expenditure made it difficult, if not impossible, to prevent continuing protein loss in spite of aggressive nutritional support. The patient categories we have described determine the response to IVN and form the basis of a new clinical classification of surgical malnutrition.

Blood Proteins↗
PubMed1991

Systemic cytotoxic chemotherapy and radiation therapy for desmoid in familial adenomatous polyposis.

Forty-two of 416 familial adenomatous polyposis (FAP) patients in the FAP registry at the Cleveland Clinic had desmoid tumors. The role of cytotoxic chemotherapy and radiation therapy in the management of these patients was investigated. Eight intra-abdominal desmoid tumors were treated by systemic cytotoxic chemotherapy. Two had complete remission, and one had partial remission. Five patients died as a result of the desmoid tumor or late complications of chemotherapy. Three intra-abdominal desmoids were treated by radiation therapy with no response. Neither cytotoxic chemotherapy nor radiation therapy is recommended as a first-choice treatment for intra-abdominal desmoid tumors in patients with FAP.

Adenomatous Polyposis Coli↗
PubMed1991

Analysis of the colonoscopic findings in patients with rectal bleeding according to the pattern of their presenting symptoms.

Patients presenting with rectal bleeding were prospectively categorized according to the pattern of their presentation into those with outlet bleeding (n = 115), suspicious bleeding (n = 59), hemorrhage (n = 27), and occult bleeding (n = 68). All patients underwent colonoscopy and this was complete in 94 percent. There were 34 patients with carcinoma and 69 with adenomas greater than 1 cm diameter. The percentage of neoplasms proximal to the splenic flexure was 1 percent in outlet bleeding, 24 percent with suspicious bleeding, 75 percent with hemorrhage, and 73 percent with occult bleeding. Barium enema was available in 78 patients and was falsely positive for neoplasms in 21 percent and falsely negative in 45 percent. Colonoscopy is the investigation of choice in patients with suspicious, occult, or severe rectal bleeding. Bleeding of a typical outlet pattern may be investigated by flexible sigmoidoscopy.

Aged↗
PubMed1991

Pre-colonoscopy bowel preparation intolerance: a sign of upper gastrointestinal pathology.

Severe vomiting and abdominal pain were precipitated by polyethylene glycol-based gut lavage (PEG) in two patients out of 585 referred for colonoscopy in a 2 year period. Both patients had primary adenocarcinoma of the large bowel but both were also found to have gastroduodenal problems severe enough to need surgical treatment. Both cases are presented.

Adenocarcinoma↗
PubMed1989

Pouch ileitis.

Pouch ileitis is the most poorly understood complication of ileal reservoir surgery. Variability in definition of this syndrome may account for differences in incidence rate, associated symptoms, and response rate to therapy present in the literature. Outcomes of 19 episodes of pouch ileitis in patients having undergone prior colectomy and continent ileostomy construction for presumed ulcerative colitis were analyzed. An episode of pouch ileitis was characterized by: (1) abdominal pain, (2) increased ileal output, (3) mucosal inflammation within the continent ileostomy, and (4) absence of other recognized concurrent postoperative complications. The mean time of occurrence after construction of the continent ileostomy was 25 months (range 3-54 months). The mean length of follow-up of patients included in this analysis was 49 months from the time of continent ileostomy construction (range 22-101 months). Associated clinical symptoms included bloody effluent (53%), nausea or emesis (47%), and fever (42%). Endoscopic features were often nonspecific, with mucosal erythema (84%), edema (79%), friability (58%), and mucosal ulceration (53%) the most common. In those episodes of pouch ileitis where ileoscopy revealed no evidence of mucosal ulceration, complete resolution of the episode occurred 89% of the time, with 78% treated with antibiotics alone. In those episodes where mucosal ulceration was described on ileoscopy, 40% of episodes completely resolved after medical treatment, 20% with antibiotics alone. The varied clinical symptoms, endoscopic findings, and response to treatment raises the possibility that what has previously been described in the literature as pouch ileitis may be a heterogeneous group not of single etiology.(ABSTRACT TRUNCATED AT 250 WORDS)

Colectomy↗