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Biomedical subjects

J W Fleshman

Publications and source records attributed to J W Fleshman.

At least 19 recordsLinked to original sources
PubMed1992

Accuracy of transrectal ultrasound in predicting pathologic stage of rectal cancer before and after preoperative radiation therapy.

Transrectal ultrasound (TRUS) and CT scan staging of rectal cancers before, and TRUS staging after, 45 Gy of irradiation were compared with the pathologic stage of the resected specimen in 19 patients. Accuracy of TRUS before and after irradiation, and of CT scan before irradiation, was 32 percent, 63 percent, and 53 percent, respectively. CT scan before and TRUS after irradiation predicted lymph node involvement in 79 percent and 68 percent of cases, respectively. Positive predictive value for lymph node involvement before irradiation was 60 percent for CT scan and 37.5 percent for TRUS; after irradiation, it was 50 percent for TRUS. Negative predictive value was 100 percent for CT scan and TRUS before radiation and 88 percent for TRUS after irradiation. Preoperative radiation therapy makes TRUS and CT scan less effective as staging techniques. The absence of lymph nodes on TRUS and CT scan before and after irradiation is reliable.

Female↗
PubMed1992

Early effect of external beam radiation therapy on the anal sphincter: a study using anal manometry and transrectal ultrasound.

The early of pelvic irradiation on the anal sphincter has not been previously investigated. This study prospectively evaluated the acute effect of preoperative radiation on anal function. Twenty patients with rectal carcinoma received 4,500 cGy of preoperative external beam radiation. The field of radiation included the sphincter in 10 patients and was delivered above the anorectal ring in 10 patients. Anal manometry and transrectal ultrasound were performed before and four weeks after radiotherapy. No significant difference in mean maximal squeeze or resting pressure was found after radiation therapy. An increase in mean minimal sensory threshold was significant. Histologic examination revealed minimal radiation changes at the distal margin in 8 of 10 patients who underwent low anterior resection and in 1 of 3 patients who underwent abdominoperineal resection. We conclude that preoperative radiation therapy has minimal immediate effect on the anal sphincter and is not a major contributing factor to postoperative incontinence in patients after sphincter-saving operations for rectal cancer.

Adult↗
PubMed1992

Practice parameters for the management of anal fissure. The Standards Task Force American Society of Colon and Rectal Surgeons.

It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Fissure in Ano↗
PubMed1992

Outpatient protocol for biofeedback therapy of pelvic floor outlet obstruction.

Pelvic floor outlet obstruction is a rare cause of severe constipation. Anal myectomy, subtotal colectomy, and medical therapy have limited success. The purpose of this study was to develop a short outpatient treatment using biofeedback techniques. Nine patients with severe constipation and straining resulting from pelvic floor outlet obstruction underwent complete investigation of the pelvic floor musculature and anal sphincter mechanism. Patients were unable to expel a 60-cc rectal balloon and had nonrelaxing puborectalis on defecography. The treatment protocol utilized anal surface electromyography to document improper straining and retrain pelvic floor muscles to relax during defecation. Sensory retraining with a rectal balloon, behavioral relaxation techniques, and defecation of simulated stool using a 120-cc Metamucil (Procter & Gamble, Cincinnati, OH) slurry in the rectum allowed re-establishment of normal defecation in all nine patients. Repeat training was required in three patients during follow-up. Treatment of pelvic floor outlet obstruction with outpatient retraining techniques is possible.

Adult↗
PubMed1992

Balloon expulsion test facilitates diagnosis of pelvic floor outlet obstruction due to nonrelaxing puborectalis muscle.

We compared balloon expulsion, defecography, colonic transit times, anal manometry, and electromyography in 21 patients with severe constipation. Defecography demonstrated nonrelaxation of the sphincter during straining in all patients. Only 12 patients were unable to expel a balloon. Colonic transit was normal (five) or showed rectosigmoid delay (seven). All 12 patients were offered biofeedback. The nine patients able to expel a balloon had normal colonic transit (six) or colonic inertia (two). Rectosigmoid delay was due to severe intussusception in one patient. Anal manometry and pudendal nerve latencies revealed no difference between those who could and those who could not expel a balloon. Balloon expulsion seems to be a more reliable way to diagnose pelvic floor outlet obstruction due to nonrelaxation of the puborectalis muscle. Nonrelaxation of the sphincter on defecography should be correlated with balloon expulsion and colonic transit studies.

Adult↗
PubMed1992

Tumor localization and radioimaging with mixtures of radioiodinated monoclonal antibodies directed to different colon cancer associated antigens.

After demonstrating enhanced tumor cell binding with a mixture of monoclonal antibodies (MAbs) in vitro, biodistribution and immunoscintigraphy studies with 3 radioiodinated anti-colon cancer MAbs and a non-specific control MAb (MOPC) were conducted in a human colon cancer (GW-39)-hamster model system. Each of the specific MAbs, but not MOPC, demonstrated extensive tumor binding and in scintigrams affected visualization of all large tumors (greater than 0.85 g) over background. Using single MAbs, few small tumors (0.19-0.50 g) were defined above background (0-29%). However, with combinations of these specific MAbs small tumors were more frequently defined in scintigrams (43-67%). Radioimages using higher doses of MAbs and small, younger tumors more clearly demonstrated the superiority of a MAb mixture. These results confirmed that combinations of MAbs to different antigens can detect smaller tumors with better tumor localization when compared to component MAbs used singly. This study supports the concept that tumor targeting and detection may be enhanced with appropriate mixtures of MAbs.

Animals↗
PubMed1992

The surgical management of constipation.

The anal physiology laboratory plays a very important role in the selection of patients for surgical treatment for constipation. Any report which does not include reference to these methods of evaluation will not be helpful since there are several causes of constipation. The current recommended treatment for slow transit constipation is still total abdominal colectomy with ileorectal anastomosis. Treatment of pelvic floor outlet obstruction seems to be best accomplished using muscle/sensory retraining techniques since this is a functional disorder rather than an anatomical or physiological disorder. Combinations of colonic inertia, pelvic floor outlet obstruction and internal intussusception should be treated to correct the pelvic floor outlet obstruction initially, followed by correction of the colonic inertia. In this way failure will be avoided at the time of surgical treatment of the constipation.

Anal Canal↗
PubMed1991

Anal sphincter repair for obstetric injury: manometric evaluation of functional results.

Anal manometry before and after surgical repair on a homogeneous group of patients with anterior sphincter defect caused by obstetric injury defined the parameters affected by the repair to achieve anal continence. Between November 1985 and April 1989, 28 patients who underwent anterior anal sphincter reconstruction were studied using anal manometry and were graded for continence. Anal function was improved for 27 of 28 patients (96 percent) relative to their preoperative symptoms, and total control of solid and liquid stools was restored in 21 patients (75 percent). Anal manometry demonstrated that complete control of continence could be achieved if anal sphincter length, resting pressure, and squeeze pressure were restored to normal. Our results showed that sphincter length was improved in 20 patients (71 percent), resting pressure in 16 patients (57 percent), and squeeze pressure in 22 patients (79 percent). The most important factor in achieving normal function of the anal sphincter is restoration of a normal squeeze pressure.

Adult↗
PubMed1991

Anal sphincter reconstruction: anterior overlapping muscle repair.

Anal sphincter reconstruction for anal incontinence was performed in 55 women between 1973 and 1987 at The Jewish Hospital of St. Louis. The mean age was 34 years (range, 22-75 years). Incontinence was due to obstetric injury in 48 patients and to fistulotomy in 7 patients. Patients suffered from complete incontinence (41), incontinence of liquid stool and flatus (11), or incontinence of flatus only (3). All patients underwent an anterior overlapping sphincter muscle reconstruction, and one patient also had a posterior repair. Complete continence was restored in 28 patients, and partial continence was achieved in 24 patients. Only three patients remained totally incontinent. Clinical assessment did not accurately reflect functional outcome after 1 year of follow-up. No factor predicting outcome was found retrospectively. Clinical assessment of a patient's outcome may be inaccurate unless specific questions are asked. The use of a perineal drain reduced infection but did not affect outcome. Previous repair or associated rectovaginal fistula does not affect outcome. Sphincter injury owing to fistula disease may result in poor outcome after repair.

Adult↗
PubMed1991

Squamous cell carcinoma of the anal canal.

Between 1979 and 1988, 33 patients with squamous cell carcinoma of the anal canal were treated with chemoradiation. There were 24 women and 9 men, from 37 to 90 years of age (median: 63 years). Complete tumor regression occurred in 29 of the 33 patients (88%), only one of whom later developed recurrence. In the other four patients, there was persistent tumor after 3 months; three of these patients died within 2 years; and one is alive with distant metastases 2 years later. During the first 5 years of the study, seven patients with complete tumor regression underwent planned abdominoperineal resection following chemoradiation. Four of the abdominoperineal resection specimens were free of tumor, but three were not. These three patients, who had abdominoperineal resection within 3 months of chemoradiation, are disease-free. Ten of the 29 patients who had complete tumor regression had biopsies of the primary site 3 months after treatment. All biopsies were negative for residual carcinoma. At present, 26 patients (79%) are alive and disease-free from 2 to 10 years post-treatment (median: 4 years). Two patients died of unrelated causes, four of cancer, and one is alive with cancer. Complications of the chemoradiation required surgical intervention in two patients, and two others developed severe hematologic toxicity, for a complication rate of 12% (4 of 33 patients). There was no treatment-related mortality. These results support the efficacy of chemoradiation treatment for carcinoma of the anal canal. They suggest that abdominoperineal resection no longer need be part of the planned initial management, and that posttreatment biopsy of the primary site is unnecessary, unless palpable or visible abnormalities are present 3 months after treatment.

Adult↗
PubMed1990

Computer simulation of group Ia EPSPs using morphologically realistic models of cat alpha-motoneurons.

1. Morphological and electrophysiological data on the electrotonic structure of six triceps surae alpha-motoneurons and on the number and location of 202 Group Ia synapses making contact with ankle extensor motoneurons, previously obtained in this laboratory, were used to construct computer models to examine the generation of composite monosynaptic Group Ia excitatory postsynaptic potentials (EPSPs). 2. A total of 300 active synapses, each generating conductance transients based on voltage-clamp data and having activation times temporally dispersed (range approximately 1.3 ms) according to the conduction velocity profile of Group Ia-afferents, were used to generate composite EPSPs. 3. The shape indexes (foot-to-peak rise times and half widths) of simulated EPSPs matched those of experimentally observed Ia EPSPs reasonably well, although the rise times were, on average, approximately 0.25 ms longer in the simulated EPSPs. This may indicate that the effective temporal dispersion of actual Group Ia monosynaptic EPSPs is less than that the temporal asynchrony used in the simulations. 4. The peak amplitudes of simulated composite EPSPs (6-14 mV), as well as EPSPs produced by single somatic synapses (80-300 microV), were comparable to those found in experimental data. 5. Simulated EPSPs in motoneuron models with two forms of nonuniform Rm distribution ("step" increase from low values of Rm on the soma to much higher but uniform values in the dendrites, versus gradual monotonic "sigmoidal" increases from soma to distal dendrites) were similar in shape and amplitude. This prevented choosing one or the other Rm model as more "correct." 6. Transmembrane voltages at synaptic sites in motoneuron dendrites during generation of composite Ia EPSPs had peak amplitudes less than twice those of the somatic EPSP. The amount of nonlinearity during EPSP production was assessed by making the delivery of synaptic current independent of the local transmembrane voltage. This non-linearity was modest (less than 10%) during composite EPSP generation, consistent with previous experimental evidence. 7. The local voltages produced in various parts of different dendrites during composite EPSP generation depended on the number and location of active synapses and on the electrotonic structure of the particular dendrite. The results show that dendrites that project in different directions away from the motoneuron soma could, in principle, exhibit different degrees of interaction between Ia and other synaptic inputs. 8. Although produced by the same number of active synapses, the simulated composite Ia EPSPs varied over a two-fold range of peak amplitude in relation to motor-unit type, cell input resistance, and cell size (total membrane area).(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗
PubMed1990

Muscarinic cholinergic and alpha 2-adrenergic receptors in the epithelium and muscularis of the human ileum.

The aim of this study was to characterize the binding and functional properties of muscarinic cholinergic (MCh) and alpha 2-adrenergic receptors in the human ileum to provide insight into pharmacologic strategies for managing urinary and fecal incontinence after bladder and rectal replacement with intestinal segments. MCh and alpha 2-adrenergic binding sites were characterized in the epithelium and muscularis of eight human ileal segments with 3H-N-methylscopolamine and 3H-rauwolscine, respectively. The dissociation constant for 3H-N-methylscopolamine in the epithelium and muscularis was 0.32 +/- 0.07 nmol/L and 0.45 +/- 0.10 nmol/L, respectively (p = 0.32). The MCh receptor content was approximately eightfold greater in the muscularis compared with the epithelium (p = 0.008). The dissociation constant for 3H-rauwolscine in the muscularis and epithelium was 2.55 +/- 0.42 nmol/L and 2.03 +/- 0.19 nmol/L, respectively (p = 0.29). The alpha 2-adrenoceptor density was twofold greater in the epithelium compared with the muscularis (p = 0.05). Noncumulative concentration-response experiments were performed with carbachol, an MCh agonist, and UK-14304, a selective alpha 2-adrenergic agonist. The epithelium did not contract in the presence of high concentrations of carbachol and UK-14304. The muscularis preparations were responsive only to carbachol. The muscularis contains primarily MCh receptors mediating smooth muscle contraction. The alpha 2-adrenoceptors are localized primarily to the epithelium and may regulate water secretion in the intestine. The distribution and functional properties of ileal MCh and alpha 2-adrenergic receptors provide a theoretic basis for the treatment of incontinence after bladder and rectal replacement with intestinal segments.

Epithelium↗
PubMed1989

Multiple blood transfusions reduce the recurrence rate of Crohn's disease.

In order to determine whether perioperative blood transfusion affects the recurrence of Crohn's disease, the authors reviewed the records of 79 patients with Crohn's disease who underwent their initial intestinal resection at their institution. Recurrence of Crohn's disease was documented by radiographic studies, endoscopy, or laparotomy. During the hospital admission for resection, 45 patients received multiple red blood cell transfusions. Recurrence developed in 22 percent of these patients by 36 months, and the median time to recurrence was 35 months. In the 34 patients who did not receive multiple transfusions, recurrence was found in 44 percent by 36 months, and the median time to recurrence was 20 months. These differences are significant, using the Kaplan-Meier analysis (P less than 0.04). Recurrence in patients with disease limited to the small bowel or to the colon was not significantly affected by the transfusion status. However, recurrence developed in only 10 percent of multiply transfused patients with ileocolic disease by 36 months, whereas recurrence developed in 45 percent of the patients who were not multiply transfused. (Significance, P = 0.057). The authors believe that the observed decreased rate of recurrence of Crohn's disease in patients receiving multiple perioperative transfusions may represent another example of clinically significant immunosuppression from blood transfusion.

Adolescent↗
PubMed1989

Perforation of the rectum and sigmoid colon during barium-enema examination. Management and prevention.

Perforation of the rectum or sigmoid colon complicated 5 of 2200 barium-enema examinations performed during a 4-year period. Three patients with rectal perforations manifested by air extravasation were successfully treated with intravenous antibiotics and complete bowel rest. Two patients with barium extravasation were treated with immediate operation and colostomy. All five patients recovered. Perforation was found to be associated with a rectal stricture due to ulcerative colitis, a rectal cancer, an incarcerated inguinal hernia, fulminant ulcerative colitis, and a normal colon in an elderly patient. To determine the pressure in the rectum that could potentially be generated during a barium-enema examination, the pressures created by a standard barium delivery set were measured, using 1-meter columns of water, 25 percent diatrizoate sodium (Hypaque), 20 percent barium, and 80 percent barium. The columns generated pressures of 70, 85, 95, and 120 mm Hg respectively. Squeezing the delivery bag increased the pressure 21 to 79 percent or a maximum of 55 mm Hg. Colorectal perforation during barium-enema examination that was not accompanied by barium extravasation could be successfully treated nonoperatively. The associated pathology and our studies of pressures generated during a barium-enema examination allow us to suggest that the incidence of colorectal perforation during barium-enema radiography can be reduced by 1) performing proctoscopy prior to barium enema, 2) avoiding the use of the rectal balloon in patients with known rectal lesions, 3) avoiding barium studies in patients with active colitis, 4) avoiding generation of pressure greater than that created by a column of barium suspension of one meter, and 5) using a lower concentration of barium when possible.

Aged↗