Biomedical subjects

J W Milsom

Publications and source records attributed to J W Milsom.

At least 91 records · Page 5Linked to original sources

PubMed1993

Predicting the functional result of anastomoses to the anus: the paradox of preoperative anal resting pressure.

UNLABELLED: This article examines the effect of ileal pouch-anal (n = 134) and coloanal (n = 16) anastomoses on resting anal canal pressures in 150 patients. METHODS: Patients underwent anal manometry before ileal pouch-anal anastomosis (IPAA) and coloanal anastomosis (CAA) and again six weeks after ileostomy closure following these procedures. A water-perfused catheter system with four radial ports was used for manometry, pressures being recorded during both station and continuous pull through. RESULTS: Patients with IPAA were younger than those with CAA (34 years vs. 50 years) and had a different ratio of hand-to-stapled anastomosis (1:2.6 vs. 1.3:1). All CAA patients had had rectal cancer while IPAA patients suffered mainly from ulcerative colitis (n = 114) or familial polyposis (n = 10). The mean preoperative resting pressure for all patients was 79 mmHg (75-87, 95 percent confidence limit) and the mean fall in this pressure after surgery was 25 mmHg (-21 to -29, 95 percent confidence limit). There was no difference in preoperative pressure or fall between handsewn and stapled anastomoses, or between IPAA and CAA. CONCLUSION: There was a significant relationship between preoperative pressure and change in pressure that held true for all subgroups (change = -0.7 x preoperative pressure + 31, r = 0.69). Analysis of the functional results confirmed that patients with high preoperative pressure are at risk for severe falls after surgery and are not guaranteed a good result. Conversely, patients with low preoperative pressures may actually have an increase with surgery and are not always incontinent. Patients with low preoperative anal resting pressures should not be denied anastomosis to the anus if they are continent.

Adolescent↗

PubMed1993

Pelvic abscess after colon and rectal surgery--what is optimal management?

PURPOSE: The aim of this study was to compare treatment outcomes in the management of pelvic abscess (PA) after rectal surgery. METHODS: Over a 12-year period all PAs occurring in the patients undergoing colorectal resection were retrospectively reviewed. The APACHE II Score was used to stratify illness. RESULTS: Postoperative PA developed in 56 patients after cancer (32 percent), ulcerative colitis (26 percent), diverticular disease (24 percent), and Crohn's colitis (18 percent)/surgery. Overall, 24 (43 percent) of PAs were after operations for inflammatory bowel disease and 43 (77 percent) of PAs were after intrapelvic intestinal anastomoses. PAs were treated by 1) antibiotics alone (11/56), 2) percutaneous computerized tomography-guided catheter drainage (13/56), 3) transperineal drainage (15/56), or 4) laparotomy (17/56). Recurrent PAs developed in 11/56 (19 percent) after initial treatment, of which 7 required additional surgery. These recurrences were evenly distributed between treatment groups. There were three deaths as a result of PA, two after laparotomy and one after percutaneous drainage. Long-term sequela in patients with intestinal anastomosis included loss of intestinal continuity (10/43) and anastomotic stenosis (7/43). There was no difference in APACHE II Score among the four treatment groups. The mortality rate was 75 percent among patients whose APACHE II Scores were greater than 15. The development of a PA after colon and rectal surgery was associated with a 5 percent mortality and 41 percent functional morbidity (23 percent permanent stoma and 18 percent symptomatic stricture rate). CONCLUSION: Using clinical judgment, if PA is amenable to computerized tomography-guided percutaneous or transperineal drainage, one of these techniques should be attempted initially in the hemodynamically stable nonseptic patient. Long-term functional disability is common after PA in rectosigmoid surgery in patients who undergo pelvic/intestinal anastomosis.

Abscess↗

PubMed1993

Clinical and pathologic factors associated with delayed diagnosis in solitary rectal ulcer syndrome.

Solitary rectal ulcer syndrome (SRUS) often goes unrecognized or is misdiagnosed. Of 98 patients with a final clinicopathologic diagnosis of SRUS, an initially incorrect diagnosis had been made in 25 patients (26 percent). In these 25 patients with a misdiagnosis, the median age was 43 years and the female-to-male ratio was 3.2:1. The median duration of incorrect diagnosis was five years (range, three months to 30 years), and seven patients received prednisone (> 30 mg/day) for a mistaken diagnosis of inflammatory bowel disease. The main clinical symptoms were rectal bleeding (84 percent) and a disturbance of bowel function (56 percent). Rectal prolapse was present in 13 patients. Original rectal biopsy specimens from 23 patients were reviewed; inadequate specimens and failure to recognize diagnostic features of SRUS contributed to delayed diagnosis in 13 and 10 patients, respectively. The most common clinicopathologic misdiagnoses in SRUS patients with rectal ulcers or mucosal hyperemia were Crohn's disease and mucosal ulcerative colitis. In patients with "polypoid" SRUS, diagnostic confusion was usually with a neoplastic polyp. Persistent bowel symptoms and rectal lesions led to review of the presentations and repeat biopsy directed toward the edge of the rectal ulcers or from within the polypoid or hyperemic rectal lesions, finally establishing the diagnosis of SRUS. Intractable symptoms led to surgery in 15 patients (60 percent), with symptomatic improvement in over two-thirds.

Adolescent↗

PubMed1993

Long-term follow-up of strictureplasty in Crohn's disease.

Because Crohn's disease of the small bowel is often diffuse, strictureplasty has been advocated as an alternative or adjunct to resection(s) of strictured segments. We reviewed 116 patients with obstructive Crohn's disease undergoing 452 primary strictureplasties (Heineke-Mikulicz, 405; Finney, 47). The median age was 34 years (range, 13-72 years); the male-to-female ratio 1.4:1; and the median follow-up was three years (range, six months to seven years). Seventy-six patients (66 percent) had at least one previous small bowel resection. Perforative disease was present in 18 patients (15 percent), and synchronous resections were performed in 71 patients (61 percent). The median number of strictureplasties was three (range, 1-15). There was no mortality. Septic complications (intra-abdominal abscess/fistula) occurred in seven patients (6 percent), and reoperation for sepsis was needed in two patients. Relief of obstructive symptoms was achieved in 99 percent of the patients. After surgery, the median weight gain was 4 kg, and two-thirds of the patients were weaned off steroids. Symptomatic recurrence occurred in 28 patients (24 percent), and 17 patients (15 percent) needed reoperation. Rates of restricture and new stricture/perforative disease were 2.8 percent and 24 percent, respectively.

Adolescent↗

PubMed1993

Tauromustine is more effective than conventional chemotherapy in the treatment of colonic tumors.

Despite recent advances in chemotherapy, the prognosis of advanced colorectal cancer remains poor. Although the taurine-based nitrosourea tauromustine (TCNU) has demonstrated schedule-dependent synergism with 5-fluorouracil (5-FU) and leucovorin (LV) against a variety of tumors in vitro, its efficacy relative to and in combination with these drugs in vivo remains unknown. To study this, BALB/C mice had C26 tumor implanted subcutaneously five days prior to the following treatment (doses and route of administration being the same in all groups): Group 1--no treatment; Group 2--TCNU (30 mg/kg by gavage); Group 3--LV (100 mg/kg intraperitoneally [IP]) and, one hour later, LV plus 5-FU (100 mg/kg IP); Group 4--LV and, one hour later, LV plus 5-FU and TCNU; and Group 5--TCNU and, on the following day, LV and, one hour later, LV plus 5-FU. All treatments were repeated seven days later. Body weight and tumor weight were measured twice weekly, and survival was noted. Postmortems were performed in all animals, and evidence of primary or secondary tumor was recorded. All surviving animals were sacrificed at 60 days. We found that 1) 87 percent of animals receiving TCNU and 60 percent of animals receiving LV, 5-FU, and TCNU survived to day 60; none of these animals had evidence of tumor when sacrificed; 2) animals in all other groups died by day 34; 3) evidence of metastases was found in five animals in Group 1 and one each in Groups 2 and 5; and 4) administering TCNU 24 hours prior to 5-FU plus LV resulted in death from toxicity in all animals. Thus, while synergism between TCNU and 5-FU plus LV was not seen, the antitumor properties of TCNU are significantly greater than those of conventional chemotherapy.

Animals↗

PubMed1993

Endoluminal ultrasound is preferable to electromyography in mapping anal sphincteric defects.

Assessment of complex sphincteric defects in patients with fecal incontinence by digital rectal examination and intraoperative dissection can be difficult in the presence of excessive scarring. Adjunctive investigation such as endoluminal ultrasound (ELUS) and needle electromyography (EMG) may provide objective evidence of the nature and extent of the sphincteric defects. In a series of 11 patients, ELUS of the anal canal with a 10-MHz transducer (focal zone of 1-4 cm) accurately detected defects in the external anal sphincter (EAS) in seven of seven patients, defects in the internal anal sphincter (IAS) in eight of eight patients, and integrity of both sphincters in two patients. These findings were confirmed by needle EMG of the EAS alone in five patients, by operative findings at a perineal sphincteroplasty operation in six patients, and by both in two patients. ELUS was associated with less pain than was needle EMG (pain score 4 vs. 10, 10 being most painful) and provided high-resolution radial images of both the EAS and the IAS. Thus, ELUS seems preferable to EMG in mapping anal sphincteric defects and can be a useful anatomic adjunct to physiologic studies of anorectal function in patients with fecal incontinence.

Adult↗

PubMed1993

Similar functional results after restorative proctocolectomy in patients with familial adenomatous polyposis and mucosal ulcerative colitis.

Restorative proctocolectomy (RP) is generally considered to achieve better results in patients with familial adenomatous polyposis (FAP) than in those with mucosal ulcerative colitis (MUC). We studied 39 pairs of patients (FAP versus MUC), individually matched for surgeon (n = 4), types of ileal pouch (19 S-pouches and 20 J-pouches), technique of ileal pouch-anal anastomosis (21 stapled, 18 handsewn with mucosectomy), duration of follow-up after pouch function (median: 32 months; range: 6 months to 8.5 years), age (median: 30 years; range: 12 to 60 years), and gender (male-to-female ratio: 1.4:1.0). The median duration of operation (3.2 hours), hospital stay (9 days), and the amount of blood loss (about 650 mL) were similar between the two groups. The patients in the MUC group tended to have a higher overall complication rate (28% versus 21%) and more pouch-related septic complications (13% versus 8%, p = 0.6 by chi 2 analysis). Functional results were similar for daytime (median: 5 per day) and nighttime (median: 1 per night) stool frequency and the median duration that defecation could be deferred (median: about 1.5 hours). Perfect continence was present in 34 (87%) patients during the day and in 19 (49%) patients during the night in each group. The use of antidiarrheal medications did not differ between the two groups. According to an analogue scale (from 1 to 10, with 10 being best), the quality of life and health and satisfaction with outcome (median score: 9) were identical between the groups. Thus, in closely matched groups of patients with FAP and MUC, the functional outcome after RP was similar. However, pouchitis was more common in the MUC group (33% versus 10%, p < 0.05 by chi 2 analysis).

Adenomatous Polyposis Coli↗

PubMed1993

Pathogenesis of colorectal cancer.

This article takes the reader from colorectal lumen to the intracellular environment in an effort to explain the processes of tumorigenesis in colorectal cancer. The molecular changes seen in colorectal cancer development also are discussed, along with the potential for genetic manipulation and diagnostic molecular techniques. An era of major advances in understanding the pathogenesis of colorectal cancer has begun.

Adenoma↗

PubMed1993

Laparoscopically assisted ileocolectomy in Crohn's disease.

Laparoscopically assisted intestinal surgery has been described in a variety of different intestinal diseases but not in inflammatory bowel disease. The study shows that laparoscopically assisted ileocolectomy is feasible in patients with Crohn's disease with low morbidity.

Colectomy↗

PubMed1992

Omeprazole-induced hypergastrinemia does not influence growth of colon carcinoma.

Colonic mucosa and adenocarcinoma are known to possess gastrin receptors. Recent studies have suggested that some patients with large intestinal cancers and polyps have elevated serum gastrin levels and that gastrin may stimulate growth of colonic neoplasms. The aim of the present investigation was to determine whether endogenous hypergastrinemia--induced by the proton pump inhibitor omeprazole--would influence growth in a subcutaneously implanted murine colonic cancer. The results show that despite a fivefold increase in serum gastrin levels (193 pg/ml median value, range 186-252, in the omeprazole-treated group vs 36 pg/ml median value, range 28-37 in controls), there were no differences in tumor size or survival of tumor-bearing animals. Additionally, there were no differences in serum gastrin values between tumor- (29 pg/ml, range 25-38) and non-tumor- (34 pg/ml, range 25-30) bearing, untreated animals. Endogenous elevation of the serum gastrin hormone to five times the normal level does not demonstrate trophic effects on the murine colon tumor MC-26.

Adenocarcinoma↗

PubMed1992

Direct comparison between Czerny-Lembert and circular-stapled anastomotic techniques in colorectal anastomosis: a similar pattern of healing for both.

There are scant experimental data directly comparing the healing of the circular-stapled (CS) anastomotic technique with the standard Czerny-Lembert two-layer hand-sewn (HS) anastomotic technique during the acute and chronic phases of healing. The purpose of this study, therefore, was to serially evaluate wound healing in CS and HS anastomoses in the normal porcine colorectum. Forty-two adult female mixed-breed pigs randomly underwent either HS or CS anastomosis at the sacral promontory. Laser Doppler velocimetry (LDV), was used to measure perianastomotic blood flow. Groups of animals underwent a second surgery at 3, 5, 11, 60, or 120 days postoperatively, and anastomoses were restudied using LDV, gross and microscopic grading of inflammation, bursting pressures, and hydroxyproline content. Additionally, the 60-day and 120-day groups of animals underwent preoperative biplanar barium enemas to identify leaks or stenoses. No significant differences in perianastomotic blood flow between the HS and CS techniques were obtained over the entire 120-day study period. Serial evaluation of wound healing revealed no significant differences between the two anastomotic techniques with respect to bursting pressures, gross or microscopic inflammatory scores, or hydroxyproline content. There were no leaks or stenoses with either technique. Despite earlier reports to the contrary, there appears to be no fundamental difference in the mode of healing in the porcine colorectum comparing the HS technique with the CS technique.

Anastomosis, Surgical↗

PubMed1992

Endoluminal ultrasound defines anatomy of the anal canal and pelvic floor.

The aims of this study were to determine whether endoluminal ultrasound (ELUS) could identify various layers of the normal anal canal and to evaluate whether a 10-MHz probe provided better image resolution than a 7-MHz probe. Sonographic anatomy of the anal canal on ELUS was directly correlated with anatomic dissection of various layers (mucosa-submucosa, internal anal sphincter, and external anal sphincter) in cadavers. Sonographic appearance of the anal sphincters was further evaluated in patients by "tagging" various layers using sonodense needles. A higher frequency 10-MHz ultrasound probe (focal length, 1-4 cm) provides improved sonographic images of the anal canal, compared with the 7-MHz probe (focal length, 2-5 cm). ELUS can also successfully identify various structures of the pelvic floor including the puborectalis, urethral sphincter, vagina, and outlines of the pelvis and ischiorectal fossae. Its role in the evaluation of anorectal disorders appears promising.

Anal Canal↗

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

Does a proximal colostomy affect colorectal anastomotic healing?

Fecal diversion has been implicated as an etiologic factor in anastomotic stenosis following colorectal surgery, particularly following the use of circular anastomotic stapling devices. However, experimental confirmation of the effects of fecal diversion on anastomotic healing is virtually nonexistent. The purpose of this study was to serially evaluate colorectal anastomotic healing with proximal colostomy (COL) and without it (CON; control) using two anastomotic techniques in a porcine model. Fifty-two (28 CON; 24 COL) mixed-breed female pigs had colorectal anastomoses using either a two-layer hand-sewn (HS) or an EEA (U.S. Surgical Corporation, Norwalk, CT) circular stapled (CS) technique. Anastomotic blood flow was measured using laser Doppler velocimetry (LDV). At second surgery (5, 11, 60, or 120 days postoperatively), the following data were collected: repeat LDV, gross and microscopic anastomotic inflammatory scores, anastomotic diameter, and bursting pressure. There were no significant differences in anastomotic blood flow (LDV), inflammatory scores, or incidence of leak or stenosis between the CON and COL groups or between anastomotic techniques. Bursting pressure was significantly lower for the COL group at day 11 but not any other postoperative day (POD). Proximal colostomy does not appear to exert adverse effects on colorectal anastomotic healing. The choice of colorectal anastomotic technique should not be influenced by the need for proximal colostomy.

Anastomosis, Surgical↗

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

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

Preoperative radiation therapy produces an early and persistent reduction in colorectal anastomotic blood flow.

Preoperative external beam radiation therapy (RT) is an increasingly popular form of adjunct therapy for rectal cancer; however, little is known about its effects on healing of colorectal anastomoses. We serially evaluated colorectal anastomotic healing following moderate dose RT. Twenty-four adult female pigs were administered 4250 centiGrays (cGy) of external beam pelvic RT over 4 weeks followed by rectosigmoid resection with handsewn or circular stapled anastomosis. Groups of animals were then sacrificed at 5, 11, 60, and 120 days postoperatively. A control group (N = 24) was studied similarly but not irradiated. Perianastomotic blood flow was measured using laser doppler velocimetry at each time interval. Nonirradiated anastomoses demonstrated significantly higher blood flows compared to irradiated anastomotic segments at each study interval. In addition, early (Days 5 and 11) postoperative gross inflammatory scores and microscopic inflammatory score (all intervals) were significantly higher for irradiated animals. Anastomotic complications were more frequent in irradiated animals (7/24) vs controls (2/24, P < 0.05). These results indicate that a preoperative dose of 4250 cGy results in an early and persistent decrease in colorectal mural blood flow independent of anastomotic technique. This is the first experimental study which attempts to quantitate the effects of preoperative pelvic radiation therapy on anastomotic blood flow.

Anastomosis, Surgical↗

PubMed1992

Resident research award: tumor necrosis factor alpha selectively enhances growth and cytotoxic activity of tumor infiltrating lymphocytes from human colorectal cancer.

Adoptive immunotherapy with tumor-infiltrating lymphocytes (TIL) and interleukin-2 (IL2) can induce regression of tumor metastases in animal models and in human metastatic malignant melanoma. We investigated the potential of colorectal cancer TIL as a source of killer cells and the effect of tumor necrosis factor alpha (TNF alpha) in combination with IL2 on their cytotoxic activity. Tumor-infiltrating lymphocytes were isolated from surgical specimens using a mechanical and enzymatic dissociation process. Autologous lamina propria mononuclear cells (LPMC) were used as control. Tumor-infiltrating lymphocytes and LPMC were cultured in the presence of IL2 with/without TNF alpha (1000 U/ml each) for 5 to 8 weeks. Cytotoxicity (% lysis) was tested against Daudi target cells in a 4-hr 51Cr-release assay. The combination of IL2 and TNF alpha resulted in a significantly greater-fold expansion of TIL than IL2 alone (P less than 0.01). Lamina propria mononuclear cells expanded less than TIL, and TNF alpha had an inhibitory effect on their growth (P less than 0.05). Tumor-infiltrating lymphocytes and LPMC showed comparable cytotoxicity when cultured with IL2 alone. However, the addition of TNF alpha augmented the killer activity of TIL while inhibiting that of LPMC (P = 0.035). These results indicate that TNF alpha selectively increases the IL2-induced growth and cytotoxic function of colorectal cancer TIL, but not those of gut mucosal lymphoid cells, suggesting that TIL and LMPC differ in their response to TNF alpha. Therefore, this combination of cytokines may hold more promise than single agents for the immunotherapy of colorectal cancers with TIL.

Aged↗