Biomedical subjects
R D Madoff
Publications and source records attributed to R D Madoff.
Treatment of rectal prolapse in the elderly by perineal rectosigmoidectomy.
The results and complications of perineal rectosigmoidectomy for complete rectal prolapse in 114 patients have been reviewed. Most patients were elderly and high risk by virtue of other concurrent medical conditions. Fourteen patients (12 percent) developed significant postoperative complications. Hospital stay was short (median, four days). Ten patients were lost to follow-up. The remaining 104 patients were followed for 3 to 90 months. Eleven patients (10 percent) developed recurrent full-thickness rectal prolapse, six of them underwent repeat perineal rectosigmoidectomy. Sixty-seven patients had fecal incontinence prior to surgery. Eleven patients underwent concomitant levatoroplasty; 10 of them either improved or regained full continence of feces postoperatively. Twenty-six of the 56 patients who underwent perineal rectosigmoidectomy alone improved or regained full continence. Rectal prolapse can be successfully treated by perineal rectosigmoidectomy in elderly, high-risk patients with minimal morbidity. Levatoroplasty dramatically improves fecal incontinence occurring in association with rectal prolapse.
Long-term functional results of colon resection and rectopexy for overt rectal prolapse.
We reviewed the long-term functional results of colon resection and suture rectopexy for complete rectal prolapse in 47 patients followed for more than 3 yr (mean 65 months). Thirty-three patients underwent sigmoidectomy, eight patients underwent subtotal colectomy, and four patients underwent sigmoidectomy with subsequent subtotal colectomy. Three patients (6.3%) developed recurrent full-thickness prolapse, and four patients (8.5%) developed rectal mucosal prolapse. Twenty patients presented with constipation, 10 (50%) of whom improved after surgery. Constipation improved in seven (70%) patients who underwent subtotal colectomy. Twenty-one patients presented with incontinence, eight (38%) of whom improved. Continence worsened in six patients, and four patients developed significant diarrhea. These complications did not correlate with the extent of bowel resection. Three patients required subsequent stomas. Colon resection and rectopexy provides long-term control of rectal prolapse with an acceptable recurrence rate. Subtotal colon resection is frequently helpful in patients with associated constipation. However, colon resection of any magnitude entails a small risk of chronic diarrhea and/or diminished continence.
Comparative intrinsic and extrinsic compliance characteristics of S, J, and W ileoanal pouches.
Although compliance of the ileoanal reservoir pouch has been shown to affect function, previous compliance studies may have been influenced by the compliance of the small bowel proximal to the pouch and by supporting pelvic structures. The following study was designed to isolate the pouch and to compare intrinsic and extrinsic factors influencing pouch compliance. Thirty-three mongrel dogs underwent rectal mucosectomy and proctocolectomy with S-pouch (S) in nine, stapled J-pouch (SJ) in nine, handsewn J-pouch (HJ) in nine and handsewn W-pouch (SW) in six. At 2 weeks, each dog underwent laparotomy, the small bowel 2 cm proximal to the pouch was clamped, and in vivo pouch compliance was measured using anal balloon occlusion and continuous saline infusion manometry. The pouch was then removed and ex vivo measurements were repeated. Mean compliance slopes between 0 and 40 cm H2O were compared by ANOVA and paired t-tests. In vivo and ex vivo compliance in ml/cm H2O was 3.1 +/- 1.2 and 3.8 +/- 1.6 (P = 0.25) for the S-pouch, 3.1 +/- 0.6 and 5.2 +/- 1.7 (P less than 0.01) for the SJ-pouch, 2.3 +/- 0.5 and 4.8 +/- 0.7 (P less than 0.001) for the HJ-pouch, 3.6 +/- 0.6 and 6.0 +/- 0.7 (P less than 0.001) for the W-pouch. Pearson's correlation coefficient for in vivo and ex vivo measurements of the S, SJ, HJ, and W pouches were r2 = 0.066, 0.001, 0.039, and 0.379, respectively. It is concluded that: 1) Isolated pouch compliance can be accurately measured in experimental animals with proximal and distal occlusion and inflow manometry. 2) In vivo compliance is significantly less in the HJ compared with S, SJ, and W pouches. 3) Differences between in vivo and ex vivo compliance of SJ, HJ, and SW pouches are significant. 4) In vivo and ex vivo compliance determinations correlate poorly. 5) Extrinsic factors contribute significantly to pouch compliance.
Rectal compliance: a critical reappraisal.
Compliance is a widely measured parameter of rectal function. Its value is determined clinically by recording pressure changes associated with volume infusion into a rectal balloon. This paper examines the inherent assumptions of the rectal balloon technique and discusses several of its shortcomings. A stricter definition of rectal compliance is needed, and in vivo compliance should be correlated with the directly measured mechanical properties of the rectal wall.
Left ventricular function in malnutrition.
Twenty-one dogs were chronically instrumented with ultrasonic left ventricular dimension transducers and micromanometers to elucidate the effects of acute protein-calorie malnutrition on cardiac function. Ten dogs received a regular diet for 3 wk, whereas 11 dogs received a protein-calorie-deficient diet designed to achieve a mean weight loss of 20-25% over a 3-wk period. Studies of cardiac function were performed in awake intact animals at base line (1 wk postoperatively) and after 3 wk. In the malnourished dogs, cardiac mass was lost in proportion to total body mass loss. Mean cardiac mass fell from 115 to 91 g. This was largely due to wall thinning in this group. Heart rate dropped from 125 to 79 beats/min with malnutrition and ejection fraction increased from 29.8 to 34.6%. Cardiac output fell from 2.98 to 2.38 l/min, but cardiac index normalized to body surface area was unchanged. No significant changes in hemodynamics were observed in the control group. In the malnutrition group, global ventricular contractility, as measured by the load-independent index of systolic function or the slope of linear relationship between end-systolic pressure and end-systolic volume (EmaxPV), decreased slightly from 3.56 to 2.81 mmHg/ml (P = 0.07). However, Emax calculated from circumferential stress and strain data was unchanged. This indicates that depressed contractility was due to loss of cardiac muscle mass rather than any change in the myocardium per se. Response to beta-adrenergic stimulation was unchanged with starvation. Acute protein-calorie malnutrition causes significant cardiac atrophy that is reflected in decreased cardiac output and slightly reduced contractility but not in intrinsic properties of the myocardium.
Prolonged surgical intensive care. A useful allocation of medical resources.
To determine factors related to outcome following prolonged stays in the surgical intensive care unit (ICU), we reviewed the charts of all 59 patients who required surgical ICU stays of one week or longer during 1982 (63 admissions). Overall ICU survival was 58.7% and varied inversely with acute illness severity, length of ICU stay, and hospital cost. The need for renal dialysis and prolonged mechanical ventilatory support were associated with bad outcomes. Age did not affect ICU survival. Follow-up survival was 33% of the original group or 56.8% of ICU survivors. Poor chronic health was associated with a high late mortality. The functional status of surviving patients was satisfactory, with 18 of 21 patients living independently. We conclude that there is significant survival following prolonged ICU therapy, and that, although identifiable factors related to outcome exist, none alone permit the discontinuation of therapy on an individual basis.
Metabolic basis of multiple system organ failure.
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Cardiac beta-adrenergic responsiveness is well preserved in moderate protein calorie malnutrition from semistarvation.
Twenty-one dogs underwent instrumentation of the left ventricle with ultrasonic dimension to study the effects of acute protein-calorie malnutrition on the adrenergic responsiveness of the heart. This study allowed a chronic and dynamic measurement of the major cardiac axes and the ventricular wall thickness, which in turn can be used to derive sophisticated measurements of global and intrinsic left ventricular function. Of the 21 dogs, 11 received a protein- and calorie-deficient diet designed to achieve a mean weight loss from a baseline of 20-25% over a 4-week period. The other 10 dogs received a normal diet. Dogs were also randomized to receive either acute propranolol beta-receptor blockade (n = 9) or acute isoproterenol beta-receptor stimulation (n = 12) during their baseline studies. Of the nine dogs given propranolol, five were subsequently malnourished and four served as controls. Of the 12 given isoproterenol, six were rendered malnourished and six were controls. All dogs were studied at both baseline and 4 weeks and received drugs in an identical fashion during both studies. The significant changes with malnutrition consisted of decreases in heart rate, cardiac mass, and left ventricular wall thickness. The degree of change in stroke volume, ejection fraction, cardiac output, dp/dt, and Emax (index of left ventricular contractility), with the administration of propranolol or isoproterenol was unaltered by malnutrition. These data support the contention that moderate protein-calorie malnutrition is well tolerated in instrumented, unstessed dogs and that the left ventricle's capacity to respond to beta-stimulation and to tolerate beta-blockade is largely unimpaired.