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Biomedical subjects

R Gilliland

Publications and source records attributed to R Gilliland.

At least 19 recordsLinked to original sources
PubMed2006

A prospective randomized single-blind comparison of three methods of bowel preparation for outpatient flexible sigmoidoscopy.

BACKGROUND: Preparation for outpatient flexible sigmoidoscopy using a self-administered phosphate enema is the standard practice in our unit, but it provides acceptable bowel preparation in only 80% of patients. This study compared two methods of bowel preparation with the current standard in an attempt to improve efficacy and acceptability. METHODS: From January to September 2003, patients scheduled for out-patient flexible sigmoidoscopy were prospectively randomized to 3 groups: group 1: one Fleet enema 2 h pre-procedure; group 2: two Fleet enemas, one on the evening prior to sigmoidoscopy and one 2 h pre-procedure; group 3: lactulose 30 ml orally 48 and 24 h prior to sigmoidoscopy, plus a single Fleet enema 2 h pre-procedure. A patient questionnaire was used to assess side effects and tolerance. The endoscopists questionnaire assessed the indication for the procedure, quality of preparation, depth of insertion, and pathological findings identified. Power calculations were based on the 80% acceptable preparation rate obtained using a single enema. RESULTS: For this study, 305 patients were randomized to the three groups. Patient data were available for 261 patients (group 1 = 105; group 2 = 81; group 3 = 75), and endoscopist data were available for 251 patients (group 1 = 97; group 2 = 79; group 3 = 75). No difference was noted between the groups with regard to age, gender, procedure indication, grade of endoscopist, or patient acceptability variables (ease of use: p = 0.09; assistance required: p = 0.11; cramps experienced: p = 0.84; alternative method: p = 0.25). There was no significant difference between the groups in terms of depth of insertion (p = 0.42-chi-squared test) or abnormalities noted (p = 0.34-chi-squared test). Nor was there any difference in the quality of preparation of patients in group 1 versus group 2 (p = 0.39-Fishers exact test) or group 1 versus group 3 (p = 0.13-Fishers exact). However, lactulose + Fleet resulted in significantly fewer patients with acceptable preparation compared with those who administered two Fleet enemas (p = 0.02- Fishers exact test). CONCLUSIONS: The addition of a Fleet enema or oral lactulose over and above a single Fleet enema gives no significant improvement in the acceptability or efficacy of bowel preparation.

Adult↗
PubMed2006

Increased cholecystectomy rate in the laparoscopic era: a study of the potential causative factors.

BACKGROUND: It has been suggested that an increased cholecystectomy rate in the laparoscopic era may be due to a reduced threshold for surgery or diagnostic confusion with irritable bowel syndrome (IBS). This study aims to determine the validity of these suggestions. METHODS: Questionnaires were sent to patients who had undergone cholecystectomy between 1988-1990 (open) and 1998-2000 (laparoscopic). Patients were asked about abdominal pain, fatty food intolerance, jaundice, and indigestion pre- and postoperatively. Questionnaires included Rome II criteria for the diagnosis of IBS and SF-36 quality-of-life data. Histological severity of gallbladder disease was assessed using a standard scoring system. RESULTS: A total of 124 of 196 patients in the open group and 264 of 400 patients in the laparoscopic group replied. There was no difference between the groups in gender, age at surgery, IBS incidence, or quality-of-life scores. The laparoscopic group reported a lower incidence of preoperative fat intolerance (45.8 vs 58.1%, p < 0.05) and a higher incidence of persistent postoperative abdominal pain (27.3 vs 17.7%, p < 0.05). Mean histopathology severity scores were higher in the open group (4.42 vs 3.95, p < 0.01). CONCLUSIONS: Increased cholecystectomy rate in the laparoscopic era cannot be attributed to diagnostic confusion with IBS. However, a reduction in the threshold for surgery may have contributed to the increased rate of cholecystectomy.

Abdominal Pain↗
PubMed2005

The effectiveness of flexible sigmoidoscopy as the primary method for investigating colorectal symptoms in low-risk patients.

BACKGROUND: Flexible sigmoidoscopy as the preferred initial investigation for patients with low-risk colorectal symptoms requires formal evaluation. METHODS: From August 1999 to July 2001, 323 patients (166 men) attended the one-stop colorectal clinic. All the patients were examined using a 60-cm flexible sigmoidoscope. Presenting symptoms and findings were reviewed. RESULTS: The mean age of the study patients was 38.6 +/- 11.87 years, with the majority (89.1%) younger than 50 years. Rectal bleeding was the most common problem (86.6%), followed by bowel habit change (13.7%). For 65.6% of the patients, a view to the proximal sigmoid was obtained. The main reason for incomplete assessment was poor bowel preparation (67.5%). The most common finding, in 202 patients (64%), was haemorrhoids. Polyps were found in 9.9% of the patients, whereas four patients (1.2%) with cancer were identified. Overall, 269 patients (83.4%) required no further investigation. CONCLUSION: Flexible sigmoidoscopy is an effective method for assessing low-risk patients.

Adult↗
PubMed2004

Feeding jejunostomy: is there enough evidence to justify its routine use?

BACKGROUND AND AIM: Intraoperative placement of feeding jejunostomy is a well-established method of providing access to enteral feeding. However, some studies describe serious complications related to this procedure. A retrospective study was undertaken to look at the technical complications related to the procedure. PATIENTS AND METHODS: Patients undergoing feeding jejunostomy in the thoracic and upper gastrointestinal surgical units at the Royal Victoria Hospital between January 1998 and December 1998 were included in the study. The charts of all the patients were studied retrospectively. RESULTS: Forty-two patients underwent a feeding jejunostomy in the time period studied. Thirty-one patients had a jejunostomy as an adjunct to major oesophageal or gastric surgery. In 5 patients, feeding jejunostomy was performed in conjunction with other palliative procedures and in 6 patients, it was performed as a sole procedure. Nine (21.4%) patients had procedure-related complications. Of these, 7 (16.7%) were minor including dislodgment of the tube (n = 4), blocked tube (n = 2), and intraoperative catheter damage (n = 1). Two (4.7%) patients had major complications requiring emergency laparotomy. One of these patients died as a result of a procedure- related complication. CONCLUSION: Feeding jejunostomy is associated with high morbidity and mortality. Its routine use may not be justified in the absence of evidence to support its use.

Adult↗
PubMed2004

Use of vacuum-assisted closure for healing of a persistent perineal sinus following panproctocolectomy: report of a case.

Perineal sinus is a troublesome complication after proctectomy for inflammatory bowel disease or rectal cancer. The results from treatment with simple dressings with or without surgical debridement are suboptimal. Definitive management may require complex operations with muscular or musculocutaneous flaps. Vacuum-assisted dressings have been used successfully for management of chronic wounds and soft tissue defects. This technique was successfully used in the management of a perineal sinus, which occurred after proctectomy for rectal cancer developing on a background of inflammatory bowel disease and preoperative radiotherapy.

Bandages↗
PubMed2000

Postanal repair for fecal incontinence--is it worthwhile?

PURPOSE: Patients with idiopathic or neurogenic incontinence without an isolated sphincter defect may be suitable candidates for a postanal repair. The aim of this study was to assess the results of postanal repair in patients with idiopathic or neurogenic fecal incontinence and to evaluate the role of various parameters, including preoperative physiologic testing on outcome. METHODS: Postanal repair was offered by a single surgeon to patients meeting the following criteria: incontinence score of at least 12 of 20, absence of an isolated anterior external anal sphincter defect, and failed conservative, medical, and biofeedback management. Physiologic investigation and clinical findings of female patients who had postanal repair for fecal incontinence between 1992 and 1998 were reviewed. Physiologic investigation included anorectal manometry, pudendal nerve terminal motor latency, concentric needle electromyography, and endoanal ultrasonography. Follow-up was obtained by telephone questionnaire; moreover, patients were asked to grade the outcome of their surgery as excellent or good (success) or as fair or poor (failure). RESULTS: Twenty-one patients of median age 68 (range, 40-80) years had a mean duration of fecal incontinence before postanal repair of 6.8 (range, 0.5-22) years. Twenty patients (95 percent) were available for at least one year of follow-up. Seventeen patients (80.9 percent) had at least one prior vaginal delivery, and prior sphincteroplasty had been performed in 10 patients (47.6 percent). The morbidity and mortality rates were 5 and 0 percent, respectively. After a mean follow-up period of three (range, 1-7.5) years, seven patients (35 percent) considered surgery to be successful and had a statistically significant decrease in their incontinence score. Neither prolongation of pudendal nerve terminal motor latency nor external sphincter damage as noted on electromyography or any of the preoperative manometric parameters correlated with outcome. Furthermore, patients' ages at surgery did not correlate with the degree of postoperative improvement in continence scores nor did the duration of the patients' symptoms, number of vaginal deliveries, or a history of previous surgery for fecal incontinence. CONCLUSION: None of the factors assessed was demonstrated to be predictive of outcome after postanal repair; moreover, the currently available preoperative testing has not altered the success rate, which remains low (35 percent). Despite the low success rate, the absence of any mortality and the low morbidity suggest that postanal repair may be a valid therapeutic approach. However, it should be offered only to selected patients with persistent, severe fecal incontinence despite an anatomically intact external anal sphincter who are not candidates for or refuse all other operative modalities.

Action Potentials↗
PubMed1999

Cinedefecographic evidence of difficult evacuation in constipated patients with complex symptoms.

Patients with constipation may have various pelvic complaints of difficult evacuation coexisting with infrequent evacuation and other abdominal complaints, and the overlapping of symptoms makes it difficult to select appropriate therapy based on clinical history and routine office examination alone. Cinedefecography is an objective method for examining patients who have complex subjective symptoms. This study assessed the value of cinedefecography for evaluating patients with constipation with multiple complaints. We divided 185 patients with constipation into two those with (group 1) or without (group 2) cinedefecographic evidence of difficult evacuation. These groups were compared relative to complaints, manometric results, cinedefecography findings, and the success of biofeedback treatment. Group 1 patients were further evaluated according to the type of abnormal findings: sigmoidocele, rectocele, intussusception, and perineal descent. We found no significant differences in patient complaints between the groups. However, there were more patients in group 2 with intussusception than in group 1; there were also significant differences between the groups in mean resting pressure, maximum resting pressure, and maximum squeeze pressure. In group 1 patients with rectocele complained more frequently of excessive straining, and those with intussusception complained more frequently of incomplete evacuation. Sensory threshold and maximal tolerable capacity were significantly higher in patients with intussusception. Rectocele was predominant in women, and biofeedback treatment was extremely advantageous (86%) for patients in group 1 with a rectocele in association with other pathology. Whether the intussusception or the descent causes decreased mean resting and mean and maximum squeeze pressures is unknown but is an additional and potentially important finding which needs further elucidation for it to have therapeutic significance.

Adolescent↗
PubMed1999

The influence of cigarette smoking on cytokine levels in patients with inflammatory bowel disease.

Anecdotal reports suggest that smoking may be beneficial for patients with inflammatory bowel disease (IBD) as nicotine may act through inflammatory mediators within the colonic mucosa. Furthermore, there is increasing evidence that cytokines play a pathologic role in IBD. Our aim was to determine the effects of cigarette smoking on cytokine levels in the colonic mucosa of patients with and without IBD. Mucosal biopsies were obtained from 10 patients with Crohn's disease (CD), 10 with ulcerative colitis (UC), and 10 healthy controls. Five of 10 patients in each of the three groups were smokers and five were nonsmokers. Concentrations of interleukin (IL)-1beta, IL-2, IL-6, and IL-8 were determined using enzyme-linked immunosorbent assay (ELISA). Cytokine levels of smokers were compared with nonsmokers in each group and with controls. Results were analyzed using the Mann-Whitney test; significance was set at p<0.05. The concentration of IL-8 was significantly higher in healthy controls who smoke compared with nonsmokers and significantly reduced in smokers with CD compared with nonsmokers with CD. Moreover, concentrations of IL-1beta and IL-8 were significantly reduced in smokers with UC compared with nonsmokers with UC. Smokers had significantly elevated levels of IL-8 in the colonic mucosa. Smokers with IBD had a significant reduction in cytokine levels; specifically, IL-1beta and IL-8 for patients with UC and IL-8 for patients with CD. Further studies are warranted to determine if this reduction in cytokine levels is histologically and clinically significant.

Case-Control Studies↗
PubMed1998

Pudendal neuropathy is predictive of failure following anterior overlapping sphincteroplasty.

PURPOSE: This study assessed the efficacy of anterior overlapping sphincteroplasty and parameters predictive of a successful outcome. METHODS: Clinical findings and physiologic investigations of female patients who underwent anterior overlapping sphincteroplasty for fecal incontinence between 1988 and 1996 were reviewed. The extent of sphincter damage was assessed at needle electromyography as the number of quadrants exhibiting decreased motor unit potentials. Prolonged pudendal nerve terminal motor latencies were those of greater than 2.2 ms. The size of the endoanal ultrasound defect was assessed as degrees circumference of the external sphincter in which viable muscle was absent. Patients were reviewed by telephone questionnaire and were asked to grade the outcome of their surgery as excellent or good (success) or fair or poor (failure). Incontinence was graded using a scoring system of 0 (perfect continence) to 20 (complete incontinence). RESULTS: There were 100 patients who had an overlapping sphincteroplasty; complete follow-tip information was obtained for 77 patients at a median of 24 (range, 2-96) months. The median age was 47 (range, 25-80) years and they had a median duration of incontinence of four (range, 0.1-39) years. Prior sphincteroplasty had been performed in 30 patients with a median of one (range, 1-7) operations. Investigations performed included electromyography (n = 49), pudendal nerve terminal motor latency (n = 71), endoanal ultrasound (n = 49), and manometry (n = 67). Sixty percent of patients had improved continence and 42 (55 percent) considered their surgery to have been successful as attested to by a significant decrease in their incontinence score (from 15.1 +/- 4.5 to 4.3 +/- 4.2; P < 0.0001). Neither patient age, parity, prior sphincteroplasty, cause or duration of incontinence, extent of electromyography damage, size of the endoanal ultrasound defect, nor any manometric parameter correlated with outcome. However, 62 percent of 59 patients with bilaterally normal pudendal nerve terminal motor latencies had a successful outcome compared with only 16.7 percent of 12 patients with unilateral or bilateral prolonged pudendal nerve terminal motor latencies (P < 0.01). CONCLUSION: Bilateral normal pudendal nerve terminal motor latencies are the only factors predictive of long-term success after overlapping sphincteroplasty.

Adult↗
PubMed1998

Is age relevant to functional outcome after restorative proctocolectomy for ulcerative colitis?: prospective assessment of 122 cases.

OBJECTIVE: Restorative proctocolectomy for mucosal ulcerative colitis is well established. However, the effect of age on physiologic sphincter parameters is poorly understood. Our objective was to determine whether age at the time of restorative proctocolectomy correlates with physiologic changes. SUMMARY BACKGROUND DATA: In the approximately 20 years during which restorative proctocolectomy has been performed for ulcerative colitis, the indications have changed. Initially, the procedure was recommended only in patients under approximately 50 years. However, the procedure has been considered in older patients because of the increasing age of our population, the increasing frequency of recognition of patients during the "second peak" of mucosal ulcerative colitis, and the decreasing morbidity rates, due to the learning curve and to newer techniques, such as double-stapling. Few authors have presented data analyzing the effects of this operation in older patients. METHODS: One hundred twenty-two patients who had undergone a two-stage restorative proctocolectomy for mucosal ulcerative colitis were divided into three groups according to age: group I (>60 years), 11 men, 6 women; group II (40-60 years), 29 men, 18 women; and group III (<40 years) 29 men, 29 women. The patients were prospectively evaluated using anal manometry and subjective functional results. Comparisons were made before surgery, after colectomy and before closure of ileostomy, and at 1 or more years after surgery. RESULTS: There were no significant differences among the groups relative to manometric results, frequency of bowel movements, incontinence scores, or overall patient satisfaction. The postoperative mean and maximum resting pressures were significantly reduced (p < 0.001), and conversely the sensory threshold (p < 0.005) and capacity (p < 0.001) were increased in all groups up to 1 year after surgery. There were no statistically significant changes in the squeeze pressure or length of the high-pressure zone in any group at any point in time. After surgery, the mean and maximum resting pressures had returned to 80% of their original values. CONCLUSION: Although anorectal function is transiently somewhat impaired after restorative proctocolectomy, the impairment is not an age-related phenomenon.

Adult↗
PubMed1997

Biofeedback for intractable rectal pain: outcome and predictors of success.

PURPOSE: A number of modalities have been used for the treatment of intractable rectal pain, with varying degrees of success. Electromyography (EMG)-based biofeedback therapy has been used in the treatment of this condition during the past six years. MATERIALS AND METHODS: Medical records of 86 patients who completed at least one session of biofeedback for rectal pain between February 1989 and August 1995 were retrospectively reviewed. All sessions were one-hour outpatient encounters with a trained biofeedback therapist. There were 31 male and 55 female patients with a median age of 68 (range, 12-96) years. Surgery (19.8 percent) or stress (15.1 percent) were frequently cited as precipitating factors for the development of rectal pain. Eleven patients completed only one session of biofeedback and were excluded from further analysis. Of the remaining patients, 28 complained of concomitant constipation. Assessment of the benefit of therapy was based on the patients' subjective reports of the level of symptoms, aided by a linear analog scale. RESULTS: Twenty six patients (34.7 percent) reported an improvement in symptoms. Outcome was not influenced by patients' ages (P = 0.63), duration of symptoms (P = 1.0), or a prior history of surgery (P = 0.14). Alleviation of symptoms was not significantly related to the presence of paradoxical puborectalis contraction demonstrated on either EMG (P = 1) or defecography (P = 0.12). Importantly, outcome was significantly improved in patients who completed the treatment schedule compared with those who self-discharged (P < 0.001). CONCLUSIONS: Although idiopathic rectal pain is difficult to treat, EMG-based biofeedback can produce alleviation of symptoms. However, success depends on patients' willingness to pursue a full course of therapy.

Aged↗
PubMed1997

"Wineglass" confabulations among brain-damaged alcoholics on the Wechsler Memory Scale-Revised visual reproduction subtest.

Confabulation is a clinically well-documented accompaniment of selective types of memory impairment, especially in brain-damaged alcoholics. This study reports specific occurrences of visual confabulation consisting of spontaneous alterations of Card D of the Visual Reproduction subtest of the Wechsler Memory Scale-Revised. The resemblance of a wineglass was fashioned by a 90-degree rotation into a "bowl and stem", observed in six of 30 brain-damaged alcoholics. There were no such instances in 132 other patients, including alcoholic controls, those with Parkinson's Disease, temporal lobe epileptics (pre- or post-surgery), and those with neurotoxic exposure. When asked, the subjects who identified the figure as a wineglass or similar drinking instrument reported that they had drawn it as originally shown to them. "Wineglass" confabulators had shorter periods of abstinence, longer drinking histories and lower intellectual functioning than their brain-damaged peers or an alcoholic control group. These findings lend support for the association of alcohol-related confabulation with visual, as well as previously-documented verbal material among brain-damaged alcoholics.

Adult↗
PubMed1997

Complicated anorectal sepsis.

These complex anorectal conditions are difficult to diagnose because clinical features overlap. In general, an aggressive approach is reserved for hidradenitis suppurativa and necrotizing infections. Patients with Crohn's disease, hematologic disorders, or AIDS are often treated more conservatively, but the correct timing and degree of aggressiveness of surgical intervention may considerably improve the overall outcome. The increasing incidence of AIDS and the frequency with which infected patients present to surgical clinics make it imperative that all surgeons have a working knowledge of the conditions associated with this syndrome. Expertise is required not only to diagnose and treat these conditions but also to protect oneself and others from being inadvertently infected with the HIV. A high index of suspicion and constant vigilance permit the successful resolution of many of these challenging problems.

Acquired Immunodeficiency Syndrome↗
PubMed1997

DNA denaturation sensitivity may invalidate bromodeoxyuridine--DNA flow cytometric analysis of potential doubling times in colorectal tumours.

BACKGROUND: Flow cytometric analysis of 5-bromo-2'-deoxyuridine (BrdU)-substituted DNA has been used to calculate tumour cell proliferation rate. In this methodology, DNA denaturation, commonly by hydrochloric acid, is essential to expose incorporated BrdU for quantification with monoclonal antibodies. This study was designed to establish the validity of this technique by examining the change in flow cytometric DNA profiles introduced by DNA denaturation procedures. METHODS: Four experiments were performed using suspensions of nuclei derived from human colorectal tumours exposed in vivo to 150 mg/m2 BrdU 8-11 h before sampling. RESULTS: After denaturation with hydrochloric acid 2 mol/l a significant decrease was observed in the DNA aneuploid G1 population (P < 0.001) with a concurrent increase in the DNA aneuploid S phase fraction (P < 0.05). These changes were independent of the washing-centrifugation step and were maximal at different hydrochloric acid concentrations for different tumours. CONCLUSION: Hydrochloric acid denaturation introduces a tumour-specific non-linear variation in the analysis of BrdU.

Aged↗
PubMed1997

Outcome and predictors of success of biofeedback for constipation.

BACKGROUND: A study was undertaken to determine outcome and to identify predictors of success for biofeedback for constipation. METHODS: Patients who had at least one biofeedback session were evaluated whether or not they completed a treatment course. Parameters assessed included use of cathartics, number of spontaneous bowel movements per week, presence of rectal pain, number of biofeedback sessions and results of anorectal physiology. RESULTS: A total of 194 patients (59 male, 135 female) of median age 71 (range 11-96) years, including 30 with concomitant rectal pain, were treated. The median number of spontaneous bowel movements per week before treatment was 0. Some 35 per cent of patients had complete success (three or more spontaneous bowel movements per week with discontinuation of cathartics), 13 per cent had partial success (fewer than three spontaneous bowel movements per week with continued use of cathartics) and 51 per cent had no improvement. Neither patient age, sex nor duration of symptoms significantly affected outcome. Only 18 per cent of patients who had between two and four sessions had complete success, compared with 44 per cent of those who had five or more (P < 0.001). A total of 63 per cent of patients who completed the treatment protocol experienced complete success, compared with 25 per cent of those who self-discharged (P < 0.0001). CONCLUSIONS: This large study indicates that the success rate of biofeedback for patients with constipation is less than previously reported. However, the success rate improves significantly after five or more sessions and is significantly related to the patient's willingness to complete treatment.

Adolescent↗
PubMed1996

Colorectal cell kinetics.

The assessment of cell proliferation in colorectal tissue may provide information with both prognostic and therapeutic implications. A variety of methods are available, including flow cytometric estimations of S phase fraction, immunohistochemical and autoradiographic visualization of exogenous and endogenous proliferation proteins, and morphological and stathmokinetic techniques. There is some correlation between Dukes stage and proliferation state features, and there is increased proliferative activity throughout the adenoma-carcinoma sequence. Data on cell proliferation rates are difficult to obtain. When correctly applied, the metaphase arrest technique remains the 'gold standard' of measuring proliferation, but its usefulness in clinical practice is limited. Recent studies have employed dual measurement flow cytometry and double labelling techniques to produce rate data.

Biomarkers↗