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Biomedical subjects

K E Matzel

Publications and source records attributed to K E Matzel.

At least 19 recordsLinked to original sources
PubMed2001

Complications of dynamic graciloplasty: incidence, management, and impact on outcome.

PURPOSE: Dynamic graciloplasty can improve continence in patients with severe refractory fecal incontinence, but associated morbidity is high. The purpose of this study was to identify complications associated with dynamic graciloplasty and to characterize their treatment and impact on patient outcome. METHODS: In 121 patients enrolled in a prospective trial of 20 centers and eligible for safety analysis, all complications of dynamic graciloplasty were recorded at the time of their occurrence and followed up until resolution. Severe treatment-related complications were defined as those requiring hospitalization or surgical intervention. RESULTS: In 93 patients, 211 complications occurred. Of these, 89 (42 percent) in 61 patients were classified as severe treatment-related complications and resulted from the following: major infection, 19; minor infection, 10; thromboembolic events, 3; device performance and use, 13; pain, 16; noninfectious gracilis problems, 8; noninfectious wound-healing problems, 3; other surgery-related complications, 3. In addition, severe treatment-related complications resulted from constipation in ten and stoma creation or closure in ten. The recovery rate (full or partial) was 87 percent overall, and for severe treatment-related complications, was 92 percent. Of the types of complications, only major infections had an adverse effect on outcome. CONCLUSION: Severe complications occur frequently after dynamic graciloplasty, but are usually treatable. They often require one or more reoperations and can lead to significant delays in completion of therapy. In most cases therapy can be salvaged.

Anal Canal↗
PubMed2001

Large lymph node metastasis gives hint to a glicentin positive small endocrine rectal carcinoma.

In a patient with a small endocrine carcinoma of the rectum, an unusually large lymph node metastasis was the only preoperative clinical finding. Low anterior rectal resection with total mesorectal excision and lymph node dissection was performed. The tumor demonstrated some highly unusual characteristics: it was classified as a small, low-grade neuroendocrine rectal carcinoma of L-cell type with three large lymph node metastases and morphological consistency with an endocrine tumor and focal positivity of glicentin, demonstrating a proliferation of smooth muscle cells. The established Capella classification of endocrine tumors of the rectum by morphological findings would have characterized this primary tumor as benign. In this case, however, clinical and histopathological findings more accurately reflected its malignant potential.

Aged↗
PubMed2000

p27(kip1) expression in rectal cancer correlates with disease-free survival.

BACKGROUND: The cell-cycle inhibitor p27(kip1) is a potential tumor suppressor and might serve as a prognostic marker in rectal cancer, in particular with regard to patient selection for adjuvant therapy. MATERIALS AND METHODS: Immunohistochemical analysis was performed, using an anti-p27(kip1) monoclonal antibody, on paraffin sections of two matched [age, gender, UICC stage, year of operation (1982-1991)] groups of patients (n = 2 x 82) with rectal carcinoma curatively treated by surgery alone. The groups differed only in subsequent metachronous distant metastatic spread. All patients had to meet the selection criterion "free of local disease," in order to exclude surgical influence. Follow-up was prospective (median of 74 months). The intensity of staining (-, +, ++, ) and rate of positive cells (as a percentage of total tumor volume) were judged separately for cytoplasms and nuclei. RESULTS: On multivariate analysis, cytoplasmic staining intensity proved to be the best prognostic factor of disease-free survival and approached statistical significance (P = 0.0552, Cox regression). On univariate analysis, considering cytoplasmic staining alone, intensely stained ( ) tumors showed significantly poorer disease-free survival (vs ++, +, -; Kaplan-Meier, logrank, P = 0.0185). CONCLUSIONS: The demonstrated correlation between cytoplasmic compartmentalization of p27(kip1) and increased metastatic spread as well as disease-free survival underscores the role of p27(kip1) in rectal cancer. However, since other reports emphasize the importance of nuclear p27(kip1) expression, the mechanisms of steady-state and subcellular distribution of p27(kip1) remain unclear, and further investigation is needed.

Adenocarcinoma↗
PubMed2000

Standards for anal sphincter replacement.

PURPOSE: Anal sphincter replacement offers a new treatment option for patients with severe refractory fecal incontinence or for those who require abdominoperineal resection for localized malignancy. The purpose of this study was to review the current status of anal sphincter replacement, formulate a consensus statement regarding its current use, and outline suggestions for future development. METHODS: Four areas of interests were selected: indications for sphincter replacement, continence scoring and quality of life, choice of therapy, and dissemination of new technology. A questionnaire regarding these issues was developed and circulated to working party members; its results served as the basis for this consensus document. RESULTS: Both electrically stimulated skeletal muscle neosphincter and artificial anal sphincter are options for patients with end-stage fecal incontinence. Electrically stimulated skeletal muscle neosphincter is also appropriate for reconstruction after surgical excision of the anorectum in selected cases. Avoidance of complications requires strict attention to sterile technique, prophylactic antibiotics, and deep venous thrombus prophylaxis. A standardized scoring system is proposed that evaluates both continence and evacuation. Quality of life is a critical endpoint for assessing sphincter replacement, and use of The American Society of Colon and Rectal Surgeons incontinence-specific quality-of-life instrument is recommended. As the efficacy of sphincter replacement becomes proven, dissemination of the technique should occur in a controlled manner to ensure adequate surgeon training, minimization of complications, and optimization of results. CONCLUSIONS: Sphincter replacement by electrically stimulated skeletal muscle neosphincter and artificial anal sphincter provide a continent option for patients with end-stage fecal incontinence and those requiring abdominoperineal resection. The guidelines offered in this document are intended to facilitate the controlled and safe development and acceptance of these new techniques.

Anal Canal↗
PubMed2000

Safety and efficacy of dynamic graciloplasty for fecal incontinence: report of a prospective, multicenter trial. Dynamic Graciloplasty Therapy Study Group.

PURPOSE: Dynamic graciloplasty has been used for intractable fecal incontinence, and good results have been reported. The aim of this study was to assess prospectively the safety and efficacy of dynamic graciloplasty for intractable fecal incontinence in a prospective, multicenter trial. METHODS: A total of 123 adults were treated with dynamic graciloplasty at 20 institutions. Continence was assessed preoperatively and postoperatively by use of 14-day diaries. RESULTS: There was one treatment-related death. One hundred eighty-nine adverse events occurred in 91 patients (74 percent). Forty-nine patients (40 percent) required one or more operations to treat complications. One hundred seventy (90 percent) events were resolved. Sixty-three percent of patients without pre-existing stomas recorded a 50 percent or greater decrease in incontinent events 12 months after dynamic graciloplasty, and an additional 11 percent experienced lesser degrees of improvement. Twenty-six percent were not improved, worsened, or exited. In patients with pre-existing stomas, 33 percent achieved successful outcomes at 12 months. This number increased to 60 percent at 18 months. Seventy-eight percent of patients had increased enema retention time, and mean anal canal pressures improved significantly at 12 months. Significant changes in quality of life were also observed. CONCLUSIONS: Objective improvement can be demonstrated in the majority of patients with end-stage fecal incontinence treated with dynamic graciloplasty. Reduction in incontinence episodes can be correlated with improved quality of life. Adverse events are frequently encountered, but most resolve with treatment.

Adolescent↗
PubMed2000

Extensive surgery after high-dose preoperative chemoradiotherapy for locally advanced recurrent rectal cancer.

PURPOSE: This was a pilot study of high-dose preoperative concurrent radiation and chemotherapy before extensive surgery in patients with locally advanced recurrent rectal cancer. Here we report on curative resectability, acute toxicities during chemoradiotherapy, surgical complications, local control, and three-year survival rates achieved with this aggressive multimodal regimen. METHODS: Between 1994 and 1997, 35 previously nonirradiated patients with pelvic recurrence of rectal cancer were entered in the study. All patients presented with tumor contiguous or adherent to adjacent pelvic organs and were not deemed amenable to primary curative surgery. A total radiation dose of 50.4 Gy with a small-volume boost of 5.4 to 9 Gy was delivered in conventional fractionation (single dose, 1.8 Gy). 5-Fluorouracil was scheduled as a continuous infusion of 1,000 mg/m2/day on Days 1 to 5 and 29 to 33. Six weeks after completion of chemoradiotherapy, patients were reassessed for resectability, and radical surgery was attempted whenever feasible. RESULTS: After preoperative chemoradiotherapy 28 of 35 patients (80 percent) underwent resection with curative intent. In 16 of 35 patients (57 percent) extended resection of adjacent organs was performed. Resections with negative margins were achieved in 17 patients (61 percent); 9 patients had microscopic, and 2 patients had gross residual disease. There was no postoperative mortality. Fourteen patients (44 percent) experienced postoperative complications. Toxicity from chemoradiotherapy occurred mainly as diarrhea (National Cancer Institute Common Toxicity Criteria Grade 3; 23 percent), dermatitis (Grade 3; 11 percent), and leucopenia (Grade 3; 11 percent). One patient died of tumortoxic multiple organ failure during chemoradiotherapy. With a median follow-up of 27 months, local re-recurrence after curative resection was observed in only three patients (18 percent); six patients developed distant metastases. Three-year actuarial survival rate was significantly improved after complete resection (82 percent) as compared with noncurative surgery (38 percent; P = 0.03). CONCLUSION: A combination of high-dose preoperative chemoradiotherapy followed by extended surgery can achieve clear resection margins in more than 60 percent of patients with recurrent rectal tumor not amenable to primary surgery. An encouraging trend evolved for this multimodal treatment to improve long-term local control and survival rate.

Adult↗
PubMed2000

[Can continence function after rectal resection be prognostically estimated?].

AIM: To determine clinical and physiologic parameters enabling the prognosis of continence after protective ileostomy closure secondary to rectal resection for rectal cancer. METHODS: Patients who had undergone rectal resection (n = 65, of whom 24 had had radiochemotherapy) were evaluated by clinical examination, anorectal manometry and orthograde contrast enema before ileostomy closure. Continence was evaluated by clinical findings 91 +/- 52 weeks after stoma closure with the help of standardized questionnaires and classified according to the Wexner continence score. The relationship between findings before stoma closure and continence score was calculated with Pearson's correlation coefficient. RESULTS: Correlations were found to be significant between the continence score and the level of anastomosis (r = -0.58, p < 0.001), median resting pressure (r = -0.52, p < 0.001), rectal compliance (r = -0.43, p < 0.001). Additionally, radiochemotherapy impairs continence (p = 0.0001). Correlations were not significant between continence and functional sphincter length, squeeze pressure, threshold for perception, urge and maximal tolerable volume, and continence for semiliquid contrast medium. CONCLUSION: Incontinence after rectum resection is multifactorial: the level of anastomosis, resting pressure, rectal compliance and radiochemotherapy all play a dominant role. Based on these findings, the continence score can be calculated before closure of a diverting ileostomy by applying multivariate analysis with the help of the following formula: Continence score = 18.23 - 0.94 x level of anastomosis - 0.18 x resting pressure + 3.72 x radiochemotherapy.

Adult↗
PubMed1998

Possibilities of extensive surgery.

Advances in surgical technique and knowledge of tumor biology have led to an algorithm of surgical treatment of rectal cancer, which offers three options: transanal local excision, sphincter-saving procedures (low anterior resection and, recently, intersphincteric abdomino-peranal resection), and abdomino-perineal resection of the rectum. The choice of operative procedure aiming to fulfill both oncological and functional criteria is determined by the anatomic location of the tumor, the tumor differentiation, the depth of tumor invasion, and preoperative anal sphincter function. Following the algorithm of treatment, a clear decrease can be noted during recent years in the number of abdomino-perineal resections and a shift towards sphincter-sparing procedures, without jeopardizing long-term survival. Although anal sphincter morphology can usually be maintained, preserving the anal sphincter does not necessarily mean preserving the sphincter function. The functional outcome must be judged by objective, measurable parameters and by the impact of operative sequelae on quality of life and its acceptance by the patient. Future work must focus on further improving long-term survival and functional outcome. Technical advances (Goligher et al. 1979; Heald 1980) and an improved understanding of tumor biology, especially metastatic behavior, have resulted in varied strategies for the operative treatment of rectal cancer. The common aims of these techniques are local control, avoidance of local recurrence, and--while still satisfying oncologic requirements--preservation of the anal sphincter. Until the 1970s, abdominoperineal excision was the treatment of choice. Subsequently, a shift toward anterior and low anterior resection of the rectum took place. Initially these procedures were limited to the treatment of tumors in the upper and mid rectum (Table 1) (Gall and Hermanek 1992), but the indication for anterior resection was later extended to tumors of the lower rectum (Table 2) (Hohenberger and Hermanek 1992).

Abdomen↗
PubMed1998

Sphincter preservation with chemoradiation in anal canal carcinoma: abdominoperineal resection in selected cases?

PURPOSE: This study contained herein assessed long-term results, toxicity, and prognostic variables following combined modality therapy of patients with International Union Against (Cancer Classification T1-4, N0-3, M0 squamous-cell carcinoma of the anal canal. PATIENTS AND METHODS: Between 1985 and 1996, 62 patients completed treatment with combined modality therapy. A median total dose of 50 Gy was given to the primary, perirectal, presacral, and inguinal nodes followed by a local boost in selected cases. 5-Fluorouracil was scheduled as a continuous infusion of 1,000 mg/m2 per 24 hours on days 1 to 5 and 29 to 33 and mitomycin C as a bolus of 10 mg/m2 on days 1 and 29. Routinely processed paraffin-embedded sections were stained using monoclonal antibodies for detection of proliferating cell nuclear antigen and MIB1 (Ki-67) antigen to determine the labeling index. In addition, DNA ploidy was assessed after Feulgen staining. RESULTS: Actuarial cancer-related survival, no evidence of disease survival, and colostomy-free survival rates at five years were 81, 76, and 86 percent, respectively. In univariate analysis, T category (T1/2 vs. T3/4) was predictive for no evidence of disease survival (87 vs. 59 percent; P = 0.03) and colostomy-free survival (94 vs. 73 percent; P = 0.05). N category (N0 vs. N1-3) influenced actuarial cancer-related survival (85 vs. 58 percent; P = 0.002) and no evidence of disease survival (80 vs. 53 percent; P = 0.02). A higher proliferative potential as measured by the MIB1 labeling index was associated with a better colostomy-free survival (90 vs. 50 percent; P = 0.04). In multivariate analysis, actuarial cancer-related survival was only influenced by the N category (P = 0.03) and no evidence of disease survival by N category (P = 0.03) and mitomycin C dose (P = 0.04). Salvage abdominoperineal resection achieved long-term control in only four of seven patients with local failures. CONCLUSION: Treatment with a combination of radiotherapy and chemotherapy is safe and effective for patients with anal canal carcinoma. Abdominoperineal resection is indicated as a salvage procedure in nonresponding and recurrent lesions and may be of benefit in a small subgroup of patients with poor prognostic factors.

Adult↗
PubMed1998

Low-field magnetic resonance imaging of the pelvis in patients with anal dynamic graciloplasty: initial experience.

The aim of this study was to determine whether low-field magnetic resonance (MR) imaging can safely and accurately depict inflammatory changes in patients with anal dynamic graciloplasty, in whom high-field MR imaging is contraindicated and ultrasonography and computed tomography are inadequate. A 0.2-T field-strength MR examination was performed in six patients with anal dynamic graciloplasty malfunction in whom reoperation was contemplated. The following sequences were applied: T2-weighted turbo spinecho with fat saturation, T1-weighted conventional spin-echo, and contrast-enhanced T1-weighted conventional spin-echo with fat saturation. Results indicated that none of the patients experienced relevant discomfort, pacemaker malfunction, or electrode dislocation with low-field MR imaging. Inflammatory pelvic changes were visualized in four patients and atrophy of the transposed gracilis muscle in another. Surgery was thus avoided in the four, who underwent conservative treatment for their pelvic inflammation. It was concluded that these preliminary results demonstrate the feasibility of MR imaging with a low field strength in patients with anal dynamic graciloplasty. In such patients, in whom diagnostic imaging had been problematic, the potential for safe and accurate visualization will be a boon to treatment planning.

Adult↗
PubMed1998

[Treatment of insufficiency of the anal sphincter by sacral spinal nerve stimulation with implantable neurostimulators].

The feasibility of permanent electrostimulation of the sacral spinal nerves was studied in patients with fecal incontinence and no detectable morphological lesions and thus not amenable to conventional surgical management. Applying acute percutaneous stimulation with needle electrodes, the most relevant sacral spinal nerve for striated sphincter muscle function was identified (sacral spinal nerve S3 or S4). The therapeutic potential of stimulation was tested by subchronic stimulation with temporary wire electrodes and, if effective, permanent electrodes were implanted in four patients. Long-term sacral spinal nerve stimulation persistently improved anal continence and increased the function of the striated muscular anal sphincter.

Adult↗
PubMed1997

Continence after colorectal reconstruction following resection: impact of level of anastomosis.

In 48 patients who had undergone anterior resection for rectal cancer with straight colorectal reconstruction, clinical and manometric results were correlated with the level of anastomosis. Patients were divided into four groups by anastomotic level: < or = 3, 4-6, 7-9, and > or = 10 cm. Functional outcome with regard to frequency of bowel movements, minor leakage, fecal incontinence. ability to defer stool and to differentiate consistency showed increasing impairment the lower the anastomotic level. Frequency, leakage owing to the inability to defer stool, incontinence for solid stool, inability to discriminate flatus from stool, and incomplete emptying were significantly different (P < 0.05) between the patients with an anastomotic level between 3-6 cm and between 7-9 cm. Manometric data revealed no trend or significant differences among the groups with regard to anal resting pressure and maximal and median squeeze pressure. Rectoanal inhibitory reflex was abolished in 60% of the patients. Clear changes, with a trend toward reduced function with lower anastomotic levels, were seen in the volume that produced a feeling of urgency, maximal tolerable volume, and neorectal compliance (between anastomotic levels 7-9 and > or = 10 cm the differences were significant; P < 0.05). Analysis by length of residual rectum (< 1.5, 1.5-4.0, 4.1-6.5, > 6.5 cm) demonstrated similar findings, suggesting that impaired function after rectal resection is due to reduced function of the neorectum. Thus, as much residual rectum as possible should be preserve without risking cure. If the level of the anastomosis is expected to be below 6 cm, or if the residual rectum is less than 4 cm, the construction of a colon pouch to increase neorectal capacity should be considered.

Adult↗
PubMed1997

[Long-term outcome of continence function after ileo-anal pouch reconstruction].

An important aim of proctocolectomy with ileal pouch-anal anastomosis (IPAA) is to maintain anal continence. Anal sphincter disruption during IPAA is felt to play an important role in loss of continence, which is described in up to 30% of the treated patients in the early postoperative period. Although sphincter function recovers gradually after surgery, some patients stay incontinent. In our investigation of possible parameters involved in preservation of continence after this operative procedure, we focused on changes in anal manometry. We compared these findings with the functional results obtained by questioning the patients and physical examination. Anal manometry was performed with a low-compliance hydraulic perfusion system. All patients underwent a J-pouch procedure with a short rectal cuff for ileoanal reconstruction. We examined 25 patients, 13 underwent operation for the treatment of ulcerative colitis, 12 because of adenomatous polyposis. In the colitis and polyposis group, 28% of the patients reported events of soiling. Three patients (12%) were incontinent. The remaining 15 patients were completely continent. The median time after operation was 58 months, ranging from 12 to 96 months. Comparing the results of anal manometry with standard values of ten age- and gender-matched healthy volunteers, it was found that there was a significant increase in the threshold of balloon awareness and urge to defecate. These sensations were sometimes elicited by pouch contractions. Median pouch-compliance was also clearly elevated in comparison to rectal compliance (P < 0.005). Inhibitory reflexes during balloon inflation could not be evoked in any of the patients. Comparing continent with incontinent patients there were significant differences in balloon awareness, urge to defecate, and stool frequency (P < 0.01, P < 0.01 and P < 0.001, respectively). But in contrast to other publications, we could not find significant differences in anal sphincter length, resting and squeezing, anal canal pressure. Pouch compliance was lowered in incontinent patients and negatively correlated with stool frequency (P < 0.001, r = -0.82). In conclusion, our study indicates that anal sphincter resting pressure alone is not a crucial factor in continence preservation in the long-term after total proctocolectomy and IPAA. Poor pouch-compliance and concomitant higher stool frequencies seem to be related to incontinence in this patient group.

Adenomatous Polyposis Coli↗
PubMed1995

Electrical stimulation of sacral spinal nerves for treatment of faecal incontinence.

Functional deficits of the striated anal sphincteric muscles without any apparent gross defect often result in a lack of ability to postpone defaecation by intention or in faecal incontinence in response to increased intra-abdominal or intra-rectal pressure. We applied electrostimulation to the sacral spinal nerves to increase function of the striated muscles of the anal sphincter. Of three patients followed for 6 months, two gained full continence and one improved from gross incontinence to minor soiling. Closure pressure of the anal canal increased in all. Preliminary data indicate that anal closure pressure increases with the duration of stimulation. Continuous stimulation of sacral spinal nerves can help some patients with faecal incontinence. It may be possible to promote continence with intermittent stimulation.

Adult↗
PubMed1995

[Direct electrostimulation of sacral spinal nerves within the scope of the diagnosis of anorectal function].

A technique is demonstrated to evaluate the functional relevance of the sacral spinal nerves regarding anal sphincter function. Sacral spinal nerves S2, S3, S4 can be reached selectively for electrical stimulation by a dorsal approach through the sacral foramina. Electrical stimulation of S3 and S4 results in visible contraction of the different striated muscular anal sphincter components and in an increase of anal canal closure pressure. These effects differ among individuals. Thus, the functional relevance of each single sacral spinal nerve on the striated muscular anal sphincter can be tested specifically.

Anal Canal↗
PubMed1995

[Permanent electrostimulation of sacral spinal nerves with an implantable neurostimulator in treatment of fecal incontinence].

Functional deficits of the striated muscular anal sphincter frequently result in faecal incontinence. The therapeutic options for patients without a defined muscular defect are limited. Our patient without defined lesion, but with a clinically relevant reduction of the voluntary force of the anal sphincter resulting in daily loss of stool, underwent an electrostimulation procedure of the sacral spinal nerves. The procedure was divided in three steps: acute percutaneous testing, temporary percutaneous nerve evaluation and permanent electrostimulation phase with an implantable neurostimulation device. In all three phases electrostimulation of the third sacral spinal nerve resulted in a positive clinical effect and an increase of the anal canal closure pressure. By application of permanent electrostimulation of the third sacral spinal nerve the patient became completely continent.

Adult↗