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Biomedical subjects

R F McKee

Publications and source records attributed to R F McKee.

At least 37 records · Page 2Linked to original sources
PubMed1999

Identification of patients likely to benefit from biofeedback for outlet obstruction constipation.

BACKGROUND: Biofeedback for outlet obstruction constipation has a varying success rate. The aim of this study was to identify which patients are likely to respond to biofeedback. METHODS: Thirty patients with severe outlet obstruction constipation were treated by a specialist nurse using three or four sessions of visual and auditory feedback of anal sphincter pressures. All patients were assessed by evacuating proctography, whole-gut transit studies and anorectal physiology before treatment. RESULTS: Two patients did not complete the course of biofeedback. Nine patients improved. Before treatment these patients had predominantly normal anorectal physiology and were all able to open the anorectal angle at evacuating proctography. Nineteen patients did not improve, of whom only three had no measured abnormality other than inability to empty the rectum. Ten of these patients had abnormal anorectal physiology which may have been due to previous vaginal delivery. CONCLUSION: Biofeedback for outlet obstruction constipation is more likely to be successful in patients without evidence of severe pelvic floor damage.

Adolescent↗
PubMed1998

Long-term clinical outcome of surgery for solitary rectal ulcer syndrome.

BACKGROUND: When severe symptoms of solitary rectal ulcer syndrome persist despite medical management, surgery may be necessary. METHODS: A retrospective review was carried out of 81 patients undergoing surgery for solitary rectal ulcer syndrome in the 10-year period from 1984 to 1993 to determine the long-term outcome at a minimum follow-up of 12 months. Of the 81 patients, 15 were excluded from further analysis (11 were followed up for less than 12 months, two died and two were lost to follow-up). Sixty-six patients were studied (median age 38 (range 15-77) years; 53 female). Of these, 49 underwent rectopexy, nine Delorme's operation, two anterior resection and four creation of a stoma as the initial operation. RESULTS: At a median follow-up of 90 (range 12-177) months, the rectopexy had failed in 22 of 49 patients; 19 of these patients underwent further surgery, including rectal resection with coloanal anastomosis (four with three failures), colostomy (11) and other procedures (four). Ultimately, 14 required a stoma. Constipation was the indication for a stoma in nine of the 11 patients who had colostomy as the first procedure after failure of rectopexy. Nine patients had Delorme's operation as the first procedure. At median follow-up of 38 (range 19-107) months, there were four failures. Two of these ultimately required a stoma. Of the seven patients who underwent anterior resection as the initial or subsequent procedure, a stoma was finally necessary in four. Anterior resection used as a salvage procedure was not successful. The overall stoma rate was 30 per cent (20 patients). Of 11 symptoms assessed before operation only incontinence and incomplete evacuation were related to a poor outcome following surgery. CONCLUSION: Antiprolapse operations result in a satisfactory long-term outcome in about 55-60 per cent of patients having surgery for solitary rectal ulcer syndrome. Results of anterior resection are disappointing.

Adolescent↗
PubMed1997

Results of hospital cancer registry surveys by the American College of Surgeons: outcomes of prostate cancer treatment by radical prostatectomy.

BACKGROUND: The number of prostate cancer patients treated by radical prostatectomy has increased. Different data sources have yielded various estimates of the outcomes of this treatment and the need for additional therapy. To provide additional perspective on these issues, the American College of Surgeons conducted surveys of cancer registries and reviewed related data. METHODS: In 1993, in the first phase of the study, hospital cancer registries and programs were sent survey forms and instructions requesting data on up to 5 patients treated by radical prostatectomy at their institutions in 1990. In 1996, in the second phase of the study, additional data were requested on treatment administered to the 1990 patients up to 5 years after surgery, and hospitals were also invited to submit new data on patients diagnosed in 1993. Responses were received from 482 hospitals concerning 2122 patients for 1990, and 265 hospitals provided data on 1304 patients diagnosed in 1993. Follow-up data on 1076 of the 1990 patients were provided by 258 hospitals. Kaplan-Meier survival curves were calculated to determine the probability of additional treatment after radical prostatectomy. RESULTS: Similar surgical pathology outcomes were reported for the 1990 and 1993 patients. For 1990 and 1993, respectively, it was reported that 27.5% and 29.7% of patients maintained erectile function adequate for intercourse after surgery. For 1990 and 1993, respectively, complete control or only occasional urinary incontinence requiring no pads was reported for 81.3% and 79.8% of patients. The surgical mortality rates were less than 1% for both the 1990 and the 1993 patients. The 5-year cumulative probability of any additional treatment after radical prostatectomy was 10.5%. Seminal vesicle involvement, positive surgical margins, lymph node involvement, capsular penetration, high Gleason score, and high prostate specific antigen were significantly associated with greater probability of additional treatment. CONCLUSIONS: Hospital cancer registries are valuable sources of data on patterns of care and outcome for prostate cancer patients. Continuing evaluation of the outcomes of prostate cancer treatments is needed to reconcile the differences in outcomes reported from different data sources.

Erectile Dysfunction↗
PubMed1997

The impact of the development of restorative proctocolectomy on the management of inflammatory bowel disease in the north of Scotland.

In the North of Scotland, 40 out of 196 patients who had surgery for colitis between 1986 and 1992 underwent restorative proctocolectomy. The problems of the development of experience in a new technique were reduced by cooperation between two consultant surgeons from centres 100 miles apart who performed the first 30 operations together. Over 7 years, the standard operative technique evolved from perimuscular dissection of the rectum with formation of an S pouch and hand sutured endo-anal anastomosis to perimesenteric rectal dissection with a stapled J pouch and double stapled anastomosis. There was no mortality and no pelvic sepsis requiring urgent re-operation. One pouch has been removed subsequently because of Crohn's disease. One patient required revisional surgery for severe stricture of the ileo-anal anastomosis. At 1 year post-operatively, 35 out of 40 patients were highly satisfied with the result of surgery. The proportion of patients undergoing restorative proctocolectomy rather than panproctocolectomy for ulcerative colitis has risen from 15 to 52%. The number of total colectomies performed as initial procedures for colitis has increased. The age of patients who have restorative proctocolectomy has widened to include teenagers as well as a few patients over 50 years of age.

Adolescent↗
PubMed1996

Perianal Crohn's disease--is it all bad news?

PURPOSE: The outcome of treatment of perianal Crohn's disease was assessed in 127 patients. METHODS: A retrospective review of the case notes of 415 patients who were seen in the North East of Scotland between 1985 and 1989 was undertaken. RESULTS: A total of 127 of 415 patients with Crohn's disease had perianal involvement. In 56 patients, perianal disease was the presenting complaint. Ninety-nine of the 127 patients had colonic involvement. Thirty-two were treated with metronidazole and 41 were treated with azathioprine, with at least temporary improvement in 91 and 68 percent, respectively. Seventy patients had treatment for fistula-in-ano, and in 50 percent of patients permanent healing was achieved. In general, treatment and outcome were largely related to the extent and severity of gut involvement. Proctectomy was performed in 32 patients (in 11 because of ongoing colonic disease). Only seven patients had proctectomy solely because of perianal disease. Proctectomy was necessary in 32 of 99 patients with colitis and perianal disease but in none of 28 patients without colonic involvement. Primary healing of the perineal wound was obtained in 17 patients, and only one patient has an unhealed perineal wound at the time of reporting. CONCLUSION: Perianal Crohn's disease does not inevitably lead to panproctocolectomy. Cautious surgery for fistula when rectal inflammation is quiescent is worthwhile. Loss of bowel continuity is more likely when colitis coexists with perianal disease. Panproctocolectomy is often indicated because of the combination of colitis and perianal disease rather than for perianal disease alone.

Adolescent↗
PubMed1995

Colectomy for acute colitis: is it safe to close the rectal stump?

We report 62 operations for acute colonic inflammatory bowel disease in which the rectal stump was closed. Operative findings were of severe colitis in 46, toxic megacolon in 8 and faecal peritonitis in 8 patients. Histology showed ulcerative colitis in 48, Crohn's disease in 9 and indeterminate colitis in 5 patients. Clinical evidence of stump leakage occurred in only one of 53 patients with a long rectal stump in contrast to 3 of 9 patients who had a short rectal stump. Leaving a very short stump also led to difficulty at subsequent proctectomy in 3 patients and at restorative proctocolectomy in 1 patient. This suggests that careful closure of the rectum above the peritoneal reflection can be a safe means of dealing with the rectal stump after total colectomy and ileostomy for acute colitis.

Acute Disease↗
PubMed1994

A trial of elective versus on demand sclerotherapy in "poor risk" patients with variceal haemorrhage.

A prospective randomised trial of "planned" chronic injection sclerotherapy (at three weekly intervals) versus "demand" injection sclerotherapy (after variceal bleeds only) was performed in 40 patients who had endoscopically proven variceal bleeding, and who were either graded as modified Child's grade C or were more than 65 years of age. 45% of patients survived for one year and 37% for two years. There was no significant difference in survival between the groups at either one or two years (p < 0.5; p < 0.1). In the "planned" sclerotherapy group 24 gastrointestinal bleeds occurred in 11 patients over the first nine months after study entry. In the "demand" group 35 bleeds occurred in 13 patients over the first 18 months after study entry. In this small group of "poor risk" patients, planned chronic injection sclerotherapy was not associated with improved survival.

Esophageal and Gastric Varices↗
PubMed1993

Radiological investigation in acute diverticulitis.

Optimal management of acute sigmoid diverticulitis depends on evaluation of the severity of the inflammatory process, in which radiological investigation is a useful but probably underutilized adjunct to clinical assessment. Plain abdominal radiography shows abnormalities in 30-50 per cent of patients but these tend to be non-specific and more accurate information is obtainable from a contrast enema. Although the quality of images produced by a water-soluble contrast agent is inferior to that with barium, the former is less hazardous in the presence of perforation and provides sufficient information to permit rational management decisions to be made. Ultrasonography and computed tomography (CT) are particularly useful in visualizing abscesses. They may be helpful in following the progression or resolution of suppuration and in guiding percutaneous aspiration when appropriate. Despite early reports to the contrary, CT is no more specific than a contrast enema in the diagnosis of acute diverticulitis. Radionuclide scans have little role in the routine assessment of acute diverticulitis and magnetic resonance imaging has not been adequately evaluated. Water-soluble contrast enema is safe, widely available and probably the most useful early supplementary investigation.

Barium Sulfate↗
PubMed1993

Thyroid neoplasia coexistent with chronic lymphocytic thyroiditis.

During a 6-year period 115 patients presenting with thyroid enlargement had evidence of chronic lymphocytic thyroiditis on fine-needle aspiration cytology. Of 27 patients in whom histological analysis was carried out, 16 had neoplasms (follicular adenoma, four; follicular carcinoma, one; papillary carcinoma, four; lymphoma, seven). Assuming that neoplasia was not overlooked in the absence of histological examination, the overall incidence was 14 per cent and that of malignant disease 10 per cent. All patients with carcinoma had cytological features suspicious of neoplasia on the first or subsequent aspirates in addition to those of thyroiditis. Cytology was suspicious of lymphoma in only two of seven patients but increasing size of the thyroid swelling was a consistent feature. Evidence of chronic lymphocytic thyroiditis may lead to neoplasia being overlooked. Repeated cytological analysis is helpful in identifying coexistent carcinoma but unreliable in excluding lymphoma.

Adenocarcinoma, Follicular↗
PubMed1993

Sandostatin therapy of acute oesophageal variceal bleeding.

This communication deals with the emergency control of variceal bleeding rather than the prevention of rebleeding. The current main options of oesophageal tamponade, emergency sclerotherapy and drug therapy are discussed, with particular reference to the use of somatostatin. Sandostatin (Sandoz, Basel), a synthetic long-acting somatostatin analogue, was found to reduce transhepatic venous gradient by 30% with no effect on systemic haemodynamics in a study of 16 stable cirrhotic patients. In a trial comparing intravenous infusion of Sandostatin (SMS) to oesophageal tamponade (OT) in active variceal bleeding, 18 of 20 bleeds in the SMS group and 19 of 20 bleeds in the OT group were controlled at 4 h. Ten in the SMS group and 14 in the OT group had no further bleeding during the 48-hour study period. Thus SMS may be useful in the temporary control of active variceal bleeding.

Acute Disease↗
PubMed1992

Plasma concentrations of endogenous heparinoids in portal hypertension.

Bleeding as a complication of liver disease can occur in the absence of recognised haemostatic defects. It is now possible to measure the concentration of endogenous heparinoid substances in the blood using a competitive binding assay. One such substance, heparan sulphate (normal range < 600 ng/ml) was assayed in the plasma of 49 patients admitted because of oesophageal varices. In 27 patients with recent upper gastrointestinal bleeding the median plasma heparan sulphate value was 1700 ng/ml (interquartile (IQ) range 900-3900) compared with 390 ng/ml (IQ range 256-800) in 22 patients with no recent bleed (p < 0.01). As heparan sulphate is metabolised by the same route as exogenous heparin, an attempt to establish a cause for the raised heparan concentrations was made by measuring the clearance of exogenous heparin in 10 portal hypertensive patients and 10 controls. The median half life of heparin in plasma in the portal hypertensive patients (25.5 minutes; IQ range 22-34) was significantly longer (p < 0.007) than the median half life in the controls (18.7 minutes; IQ range 17-21.5). Thus, there is evidence of raised concentrations of endogenous heparin like substances in portal hypertensive patients after gastrointestinal bleeding. These high concentrations may result from reduced hepatic clearance.

Esophageal and Gastric Varices↗
PubMed1992

Fibronectin as a prognostic indicator in portal hypertension.

Plasma fibronectin levels were measured in 33 patients with portal hypertension and compared with modified Child's grading and a previously described prognostic index. Outcome at one year from blood sampling was recorded. Mean plasma fibronectin level was 304.1 mg/ml (sem 24.3) and significantly lower levels were found in patients who had had a variceal bleed within the previous seven days. Plasma fibronectin levels tended to be lower in patients with poor liver function as assessed by modified Child's grading but this did not achieve statistical significance. Plasma fibronectin alone was not an accurate predictor of one year survival in these patients but only one of seven patients who had a plasma fibronectin level below 300 mg/l in association with a poor prognostic index survived for one year.

Esophageal and Gastric Varices↗
PubMed1992

A comparison of SMS 201-995 and oesophageal tamponade in the control of acute variceal haemorrhage.

Forty endoscopically proven active variceal bleeds were entered in a prospective trial comparing oesophageal tamponade with SMS 201-995 infusion. Oesophageal tamponade controlled 19 of 20 bleeds over the first four hours and 14 of 18 bleeds over 48 hours. SMS 201-995 infusion controlled 18 of 20 bleeds over the first four hours and 10 of 20 bleeds over 48 hours (p = 0.15). No significant differences between the groups were seen in time to control of bleeding, amount of blood transfused or number of patients crossed over to the opposite treatment. Complications in the oesophageal tamponade group were discomfort due to the tube (17 patients) and chest infection (10 patients), while in the SMS 201-995 group 7 chest infections and one episode of hyperglycaemia occurred, with no symptomatic complaints. The patient survived the admission in 15 of the oesophageal tamponade bleeds and all of the SMS 201-995 bleeds (p = 0.047). An intravenous infusion of SMS 201-995 appears to have comparable efficacy to oesophageal tamponade in variceal bleeding.

Acute Disease↗
PubMed1992

A prospective randomized study of abdominal rectopexy with and without sigmoidectomy in rectal prolapse.

Eighteen patients with full-thickness prolapse of the rectum were randomized to rectopexy alone (group 1) or with sigmoidectomy (group 2). Three months postoperatively, seven patients in group 1 and two in group 2 complained of severe constipation. One patient in group 1 and three patients in group 2 remained incontinent. The results of colonic marker studies showed a significant increase in the number of markers at day 5 for those in group 1 (preoperative, 7.7 +/- 2.6; postoperative, 14.6 +/- 2.2; t test, p less than 00.1) but no significant increase in group 2 (preoperative, 4.6 +/- 2.2; postoperative 6.8 +/- 2.3; t test, p less than 0.01). No significant changes or differences between the groups were seen in the anorectal angle on videoproctogram. The results of anorectal physiologic studies done postoperatively showed no differences between the groups in maximum resting pressure, sphincter length or saline solution infusion test; however, the patients in group 1 had a significantly greater rectal compliance (group 1, 0.24 +/- 0.02 millimeters mercury per milliliter; group 2, 0.1 +/- 0.02 millimeters mercury per milliliter; p less than 00.1). This may occur because the redundant loop of sigmoid colon causes hold-up of intestinal content and kinking at the junction between the sigmoid colon and the rectum.

Aged↗
PubMed1991

Injection sclerotherapy for bleeding varices: risk factors and complications.

Risk factors for complications after injection sclerotherapy were studied in 163 patients undergoing 667 treatments for bleeding oesophageal varices. The overall mortality rate was 7 per cent per injection sclerotherapy session; 16 per cent per acute session and 2.4 per cent per elective session. Acute variceal bleeding was controlled by injection sclerotherapy in 91 per cent of patients. Complications occurred after 16 per cent of injection sclerotherapy sessions. Deaths and complications were significantly associated with poor modified Child's grading (P less than 0.001), the first variceal bleed (P less than 0.001), acute injection sclerotherapy (P less than 0.001) and the use of the rigid oesophagoscope (P less than 0.001).

Esophageal and Gastric Varices↗
PubMed1989

Esophageal tamponade in the management of acute variceal hemorrhage.

Over a seven-year period, 138 patients with portal hypertension presented on 223 occasions with endoscopically proven acute variceal hemorrhage. Hemorrhage ceased spontaneously on 92 occasions (41%). On 126 occasions (57%) passage of the four-lumen modification of the Sengstaken-Blakemore tube was required, and hemorrhage was successfully controlled in 98%. Intubation was refused on five occasions (2%). Hemorrhage recurred during these 223 admissions on 47 occasions (21%); on 11 occasions a second rebleed occurred and on two occasions, a third. Tamponade was required during all of these rebleeds and arrest of hemorrhage was achieved in 87%. Hemorrhage in patients with poorer modified Child's grade was less likely to cease with intubation. The overall rate of control in the 186 episodes of hemorrhage requiring tamponade was 94%. There were 28 complications attributed to the use of tamponade in 186 episodes of hemorrhage (15%). On 12 occasions these complications proved fatal (6.4%). In four further patients failure of tamponade to control hemorrhage was fatal.

Adolescent↗
PubMed1989

Clinical evaluation of angiotensin II enhanced perfusion scintigraphy in metastatic liver disease.

The hepatic perfusion index (HPI) may be of value in the diagnosis of liver micro-metastases. However, raised values of HPI also occur in some benign liver conditions (e.g. cirrhosis), thereby weakening the diagnostic power of this test. It has been suggested that infusion of the vaso-active agent angiotensin II might improve the predictive value of dynamic scintigraphy because it has been shown to alter liver perfusion in patients with metastatic liver disease. Basal HPI values were not significantly different in a group of patients with metastases (n = 10) and a group with cirrhosis (n = 9). A significant rise in HPI occurred in the metastatic group using angiotensin II enhancement (p less than 0.01, Wilcoxon test). In the cirrhotic group there was no significant increase in the HPI with angiotensin II enhancement. Within the groups, there was considerable variation in response, with eight of ten metastatic and five of nine cirrhotic patients showing a rise in HPI during an angiotensin II infusion. As a result, there was complete overlap in the angiotensin II enhanced HPI for the two groups. Angiotensin II enhancement of HPI is therefore unlikely to improve the diagnostic power of dynamic scintigraphy in individual patients with established hepatic disease.

Angiotensin II↗