Biomedical subjects

M R Keighley

Publications and source records attributed to M R Keighley.

At least 19 recordsLinked to original sources

PubMed1997

Pouch salvage. Long-term outcome.

PURPOSE: The aim of this study was to determine the outcome of pouch salvage operations and the factors that may influence successful reconstructions. METHODS: This retrospective review includes data from 198 patients who had undergone restorative proctocolectomy at a single institution during an 11-year period. All patients who had undergone attempted pouch salvage and who still had a pouch in situ were reviewed by both postal questionnaire and at interview in the outpatients clinic. RESULTS: Of 198 patients who underwent restorative proctocolectomy and ileal pouch-anal anastomosis, 27 (13.6 percent) presented with pouch-specific complications requiring pouch salvage. A further five patients requiring pouch salvage were referred from other centers. Of 32 patients who underwent attempted pouch salvage, 16 (50 percent) had a successful outcome, 12 (37.5 percent) had pouch excision, and 3 (9 percent) are still defunctioned. There was one death (3 percent) in this series. Pelvic sepsis was a major cause of pouch failure, being present in 50 percent (8/16) of failed salvage procedures, and accounting for 58 percent (7/12) of pouch excisions. CONCLUSIONS: Salvage surgery for major complications following ileoanal pouch construction is worthwhile in the absence of major pelvic sepsis. Overall success rate is 50 percent, and these results may be acceptable to highly motivated patients.

Adult↗

PubMed1997

Causes of failure and life expectancy of the ileoanal pouch.

180 ileoanal pouches constructed over 10 years and followed for at least 2 years (154 for Inflammatory Bowel Disease (IBD) and 26 for Familial Adenomatous Polyposis (FAP)) were reviewed. 23 pouches have been excised to date, 8 remain defunctioned (pouch failure FAP 7.7%, IBD 18.8%). The reasons for excision were: ischemia (n = 6), pelvic sepsis (n = 5), severe stenosis (n = 3), underlying Crohn's disease (n = 3), poor function (n = 5) and fistula (n = 1). The reasons for defunction were: Crohn's disease (n = 1), pelvic sepsis (n = 5) and ileoanal stenosis (n = 2). The projected overall pouch survival rate (Life table analysis) at 5 years was 81% (confidence interval 74-87%). Beyond 7 years, the figures to calculate survival became unreliable (small numbers). There was a significant association between pouch failure and pelvic sepsis (Fisher's exact test P < 0.0001) and between failure and fistula formation (P < 0.02). Multiple regression analysis showed pelvic sepsis and recurrent pouchitis to be independent factors of pouch failure. Pouch failure can occur many years after initial operation. Long-term follow up is recommended.

Adenomatous Polyposis Coli↗

PubMed1997

Pitfalls and outcome in ileo-anal pouch surgery for ulcerative colitis.

We have examined the long-term results of pouch surgery in 154 patients initially thought to have ulcerative colitis. Pouch survival was 81% at 5 years and 72% at 10 years. Chronic sepsis was the commonest factor for pouch failure (P < 0.001). Re-operations were required in 60 patients (39%). Pouch salvage was used in 30 patients and was successful in 16. Function using a 12-point score was good (0-3) in 40%, moderate (4-6) in 31% or poor (> 6) in 29%. Quality-of-life assessment indicated that 81% were satisfied, but anxiety was associated with a poor outcome. Age over 60 years was not associated with impaired function. So far, 21 patients are thought to have Crohn's disease, of whom 5 have small bowel involvement above the pouch, 11 have had their pouch excised or are permanently defunctioned.

Colitis, Ulcerative↗

PubMed1997

Faecal incontinence after childbirth.

OBJECTIVE: To measure the prevalence and severity of postpartum faecal incontinence, especially new incontinence, and to identify obstetric risk factors. DESIGN: A cohort study with information on symptoms collected in home-based interviews and obstetric data from hospital casenotes. SETTING: Deliveries from a maternity hospital in Birmingham. PARTICIPANTS: Nine hundred and six women interviewed a mean of 10 months after delivery. MAIN OUTCOME MEASURES: New faecal incontinence starting after the birth, including frank incontinence, soiling and urgency. RESULTS: Thirty-six women (4%) developed new faecal incontinence after the index birth, 22 of whom had unresolved symptoms. Twenty-seven had symptoms several times a week, yet only five consulted a doctor. Among vaginal deliveries, forceps and vacuum extraction were the only independent risk factors: 12 (33%) of those with new incontinence had an instrumental delivery compared with 114 (14%) of the 847 women who had never had faecal incontinence. Six of those with incontinence had an emergency caesarean section but none became incontinent after elective sections. CONCLUSIONS: Faecal incontinence as an immediate consequence of childbirth is more common than previously realised, and medical attention is rarely sought. Forceps and vacuum extraction deliveries are risk factors, with no protection demonstrated from emergency caesarean section. Identification and treatment is a priority.

Adult↗

PubMed1996

Results from pouch salvage.

Over an 11-year period, 17 salvage procedures were performed on a failed ileal pouch-anal anastomosis carried out for ulcerative colitis from a series of 157 patients. Ten pouches were saved, four excised and three defunctioned. Salvage procedures included five operations for fistulas (three of five successful), six reoperations on the ileoanal anastomosis (five of six successful), three new pouches after previous pouch excision (all failed), and three miscellaneous: excision of an efferent limb (successful), pouchpexy for a pouch prolapse (successful) and postanal repair for incontinence (failed). Pouch salvage may be successful in the motivated patient who wishes to avoid a permanent ileostomy.

Adolescent↗

PubMed1996

Audit of sphincter repair. Factors associated with poor outcome.

PURPOSE: This study was designed to critically analyze the outcome of sphincter repair and, if possible, to identify high-risk factors. METHODS: Clinical and physiologic assessment was made of all sphincter repairs (42 patients) performed in one unit by two surgeons during five years. RESULTS: Forty-two patients (10 men, 32 women) underwent sphincter repair. Only three of five men with anterior defects of the anorectum from perineal trauma were rendered continent. Only three of five men with defects from fistula operations became continent, but one improved by later graciloplasty. All six women with fistula-related injuries eventually achieved continence, but two required repeat sphincter repairs because of early breakdown from sepsis. The worst results were in 26 women with third-degree obstetric injuries, of whom 11 remain incontinent; poor results in this group were associated with gross perineal descent, obesity, and age older than 50 years; two or more of these factors indicated a poor outcome. Preoperative anorectal physiology did not identify a poor-risk group. CONCLUSIONS: Poor results were identified in women with anterior defects from obstetric trauma, especially if they were obese, older than 50 years of age, and had perineal descent.

Adult↗

PubMed1996

Review article: the management of pouchitis.

Pouchitis occurs in 10-35% of patients in the first 10 years after pouch construction for ulcerative colitis. Pouchitis must be carefully defined and should not include patients with poor function or Crohn's disease. Most patients have only a single attack of pouchitis which rapidly resolves with metronidazole. Chronic pouchitis suggests some other abnormality of function which, if responsible for persistent poor function, may necessitate pouch excision.

Diagnosis, Differential↗

PubMed1996

A randomised trial comparing mesalazine and prednisolone foam enemas in patients with acute distal ulcerative colitis.

Distal ulcerative colitis can be treated with oral or rectal mesalazine, or both. A foam enema preparation has been developed and its efficacy investigated. The aim of this study was to evaluate the efficacy and safety of mesalazine foam enemas compared with prednisolone foam enemas in the treatment of patients with acute distal ulcerative colitis. Patients aged over 18 years presenting with a relapse of distal ulcerative colitis were randomly allocated treatment with mesalazine foam enema (n = 149 evaluable patients) and prednisolone foam enema (n = 146 evaluable patients) for four weeks. A randomised multicentre investigator blind parallel group trial was conducted. It was found that after four weeks of treatment, clinical remission was achieved by 52% of mesalazine treated patients and 31% of patients treated with prednisolone (p < 0.001). There was a trend in favour of more patients in the mesalazine group achieving sigmoidoscopic remission (40% v 31%, p = 0.10). Histological remission was achieved by 27% and 21% of patients receiving mesalazine and prednisolone respectively. Symptoms improved in both treatment groups. Significantly more mesalazine patients had no blood in their stools after four weeks of treatment (67% v 40%, p < 0.001). Prednisolone treated patients had significantly fewer days with liquid stools than mesalazine patients, with a median of 0 and 1 days respectively by week 4 (p = 0.001). In this study mesalazine foam enema was superior to prednisolone foam enema with regards to clinical remission, this was supported by favourable trends in sigmoidoscopic and histological remission rates. Both treatments were well tolerated.

Acute Disease↗

PubMed1996

Comparison of sutured and stapled closure of loop ileostomy after restorative proctocolectomy.

Twenty consecutive stapled loop ileostomy closures in patients treated by restorative proctocolectomy were compared with the previous 20 sutured loop ileostomy closures in a non-randomised audit. Complications occurred in six of 20 stapled closures compared with seven of 20 sutured closures. Operating time and hospital stay were similar. The additional expense of stapling does not seem justified as complication rates, operating time and hospital stay are similar to sutured closures.

Adolescent↗

PubMed1995

Activities of phospholipase A2 and diacylglycerol lipase are increased in human colorectal cancer.

Experimental, clinical and epidemiological studies have implicated arachidonic acid and its metabolites as important mediators in colorectal carcinogenesis. Although arachidonic acid levels are increased in tumour membrane lipids, its availability for metabolic processes is not known. The activities of phospholipase A2 (PLA2) and diacylglycerol lipase therefore were assessed in tumour and normal mucosal specimens from 20 patients with colorectal cancer using 14C-radiolabelled substrates. The median (interquartile range) PLA2 activity was increased in tumour tissue (10.5 (6.0, 18.5) pmol arachidonic acid mg-1 h-1) compared with that in normal mucosa (5.6 (2.5, 8.5) pmol arachidonic acid mg-1 h-1) (P < 0.001, Wilcoxon signed rank test). Activity of diacylglycerol lipase was also greater in tumoral tissue (47.4 (21.6, 82.1) pmol arachidonic acid mg-1 h-1) than in mucosa (19.1 (9.4, 42.9) pmol arachidonic acid mg-1 h-1) (P < 0.005). There was no correlation between either PLA2 or diacylglycerol lipase activity and myeloperoxidase activity, suggesting that these increases were not directly attributable to tumour inflammatory cell infiltrate. Augmentation of arachidonic acid release in colorectal tumours may have implications for therapy.

Aged↗

PubMed1995

Bile acid absorption from ileoanal pouches using enema scintigraphy.

It is unclear whether bile acid absorption is affected by ileoanal pouch construction. Bile acid absorption was measured in the abdomen of 16 patients with pouches (nine with good and seven with poor pouch function based on a clinical score) and in six patients with an end ileostomy using a radiolabelled synthetic bile acid (75SeHCAT) enema and dynamic scintigraphy. The median (interquartile range) 75SeHCAT absorption was 81 (79-87) per cent in patients with ileostomy, 46 (43-53) per cent in patients having well functioning pouches, and 24 (18-38) per cent in the group with poor pouch function (P < 0.01). Log transformation of the absorption curves revealed a two-component uptake (fast component t1/2 = 1.4-7.2 min; slow component t1/2 = 16-144 min) in all patients with ileostomy, in eight of nine patients with pouches with good function, and in one of seven patients with a poorly functioning pouch (P < 0.05); in the other six patients with poorly functioning pouches, only the slow component of absorption was present. This test showed significantly reduced bile acid absorption in patients with an ileoanal pouch and gave an objective discrimination between well and poorly functioning pouches.

Adolescent↗

PubMed1995

The position of the patient does not adversely influence the results of the most clinically important measurements of anorectal function.

Anorectal physiological measurements were carried out in three groups of patients: Controls (n = 11), slow transit constipation (n = 21) and neuropathic faecal incontinence (n = 14) to examine whether the position of the patient influenced the result of tests of anorectal function. Measurements were made in both the conventional left lateral and the seated position. No significant differences were observed in the pressures within the anal canal at 2 cm from the anal verge, the usual site of maximum resting and maximum squeeze pressures, although, at 4 cm pressures were significantly different in the two positions. With all other tests including rectal compliance, anorectal inhibitory reflex and rectal sensation there was no significant difference due to position in any of the three clinical groups. We conclude that the left lateral position is generally satisfactory for measurement of the most clinically important aspects of anorectal function.

Adult↗

PubMed1995

Stimulated gracilis neosphincter--not as good as previously thought. Report of four cases.

PURPOSE: We report the outcome of four patients who had stimulated gracilis neosphincter for fecal incontinence to highlight functional problems, particularly in patients with impaired rectal evacuation. METHODS: The gracilis neosphincter operation consisted of a three-stage procedure in four patients with intractable incontinence, three of whom had had a pelvic floor repair. RESULTS: Despite successful muscle transposition and nerve stimulation, only one of four patients has a functioning neosphincter. One patient could not tolerate stimulation, and two were unable to evacuate the rectum. All three now have stomas, and even the functioning neosphincter patient requires regular bisacodyl (Dulcolax; CIBA Consumer Pharmaceuticals, Woodbridge, NJ) suppositories to achieve evacuation. CONCLUSION: The neosphincter is a successful sphincter but has no role for patients who cannot evacuate from the rectum.

Administration, Rectal↗

PubMed1995

Disruption of a stapled anastomosis following therapeutic ultrasonics--is there a risk? Report of a case.

PURPOSE: We examined the theoretic possibility that therapeutic ultrasound can disrupt a stapled gastrointestinal anastomosis. METHOD: A case is reported in which leakage of a stapled ileocolic anastomosis occurred following therapeutic ultrasound. Calculations are performed on the power of the ultrasound beam and its adsorption and dispersion in the tissue between the probe and anastomosis to establish its intensity at the anastomosis. RESULTS: Ultrasound intensity at the anastomosis in this patient was calculated at 10 to 46 mW/cm2. CONCLUSION: Although the calculated ultrasound intensities at the anastomosis do not appear to be very high, other factors such as "pressure doubling" and "stress concentration" at the stapled surface suggest that therapeutic ultrasound may cause staple disruption.

Anastomosis, Surgical↗

PubMed1995

Cytokine production in pouchitis is similar to that in ulcerative colitis.

PURPOSE: Controversy exists as to whether pouchitis represents a reactivation of the immunologic mechanisms that lead to ulcerative colitis (UC). The aims of this study were to determine local levels of the cytokines: interleukin-1 beta (IL-1 beta), interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor alpha (TNF alpha) in the mucosa of patients with "asymptomatic" ileoanal pouch (n = 25), pouchitis (n = 9), active UC (n = 20), normal ileum (n = 15), proctitis (n = 10), and normal colon (n = 15). METHODS: Lamina propria mononuclear cells were isolated from mucosal biopsies by enzymatic dispersion and cultured for 48 hours. Proinflammatory cytokine levels were measured in the supernatants by enzyme-linked immunosorbent assay. RESULTS: IL-1 beta, IL-6, IL-8, and TNF alpha secretions were significantly greater in pouchitis and active UC than in the noninflamed ileoanal pouch and normal controls (P < 0.001). There was significant correlation (r = 0.63, P < 0.05) between levels of cytokines expressed in pouchitis and active UC. CONCLUSIONS: Increased cytokine expression occurs in both active UC and pouchitis and to a lesser extent in the long-standing ileoanal pouch.

Adolescent↗

PubMed1995

Randomized trial to determine the optimum level of pouch-anal anastomosis in stapled restorative proctocolectomy.

PURPOSE: This study was undertaken to identify the optimum level of stapled ileal pouch-anal anastomosis. METHOD: A prospective, randomized trial was completed to compare double-stapled ileoanal anastomosis placed at the top of anal columns (high, n = 26) with anastomosis at the dentate line (low, n = 21). RESULTS: There was no significant difference in the overall complication rate between operations (high, n = 7, vs. low, n = 8; P < 0.21). Pouch-anal functional score (scale 0-12; 0 = excellent, 12 = poor) was significantly better in the high anastomosis group (median (range): 2 (1-9) vs. 5.5 (1-12); P < 0.05). Incontinence occurred in only two patients randomized to high anastomosis compared with six in the low anastomosis group. Nocturnal soiling was reported in three patients after high anastomosis and in six patients after dentate line anastomosis. Both operations caused a significant but comparable reduction of maximum and resting pressure (31 percent after high anastomosis (P < 0.05); 23 percent after low anastomosis (P < 0.05)). However, a significant fall in functional length of the anal canal was only seen after a low pouch-anal anastomosis (P < 0.05). CONCLUSION: Stapled pouch-anal anastomosis at the top of anal columns gives better functional results compared with a stapled anastomosis at the dentate line.

Adenomatous Polyposis Coli↗

PubMed1995

Randomized trial of internal anal sphincter plication with pelvic floor repair for neuropathic fecal incontinence.

PURPOSE: This study was designed to examine the role of adjuvant internal anal sphincter plication in women with neuropathic fecal incontinence undergoing pelvic floor repair. METHODS: We completed a randomized trial with symptomatic and physiologic assessment before and after surgery. RESULTS: There was no symptomatic advantage of adding internal sphincter plication; the mean improvement of functional score was 3.61 +/- 1.82 (standard deviation; P < 0.01) following pelvic floor repair alone compared with 2.80 +/- 1.66 (standard deviation; P < 0.01) when adjuvant internal and sphincter plication was added. The addition of internal sphincter plication was associated with a significant fall in maximum anal resting and squeezing pressures (P < 0.01). CONCLUSIONS: Addition of internal sphincter plication is not advised in women with neuropathic fecal incontinence treated by pelvic floor repair.

Adult↗

PubMed1995

Dietary omega-3 fats reduce proliferation and tumor yields at colorectal anastomosis in rats.

BACKGROUND & AIMS: Colorectal anastomoses show increased mucosal crypt cell proliferation rates (CCPRs) and often form the site for tumor recurrence after resection of colorectal cancer. The aim of this study was to assess the effects of a 20% omega-3 fat diet on CCPRs and anastomotic tumor formation compared with an isocaloric 20% saturated fat diet in experimental colorectal cancer. METHODS: One hundred sixty male Wistar rats were administered azoxymethane or saline for 6 weeks, after which a colonic anastomosis or sham operation was performed. CCPR, mucosal fatty acids, and tumor yield were analyzed at the anastomosis and proximal and distal colon sites at 15 and 23 weeks. RESULTS: Diet, carcinogen treatment, and surgery all had significant effects on CCPR with omega-3 fats producing the lowest CCPR at all sites. There were fewer tumors (P < 0.02), including a marked reduction of anastomotic tumors in omega-3 fat-fed animals that was associated with a significant reduction of arachidonic acid in mucosal and tumor lipids. CONCLUSIONS: Dietary omega-3 fat significantly reduced colonic CCPR and tumor yield, including at the site of anastomosis. Dietary omega-3 fats may be of value to patients after colorectal resection and anastomosis for cancer and warrant further testing.

Anastomosis, Surgical↗