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Biomedical subjects

S D Wexner

Publications and source records attributed to S D Wexner.

At least 181 records · Page 10Linked to original sources
PubMed1996

Initial North American experience with botulinum toxin type A for treatment of anismus.

PURPOSE: Botulinum toxin type A (BTX-A), produced by Clostridium botulinum, is a potent neurotoxin. The purpose of this study was to evaluate the efficacy of BTX-A for treatment of anismus. MATERIALS AND METHODS: All patients treated with BTX-A for anismus were evaluated. Eligibility criteria included a history of chronic assisted evacuation (laxatives, enemas, or suppositories), demonstration of anismus by cinedefecogram and electromyography, and failure of a minimum of three sessions of supervised biofeedback therapy (BF). Contingent on body mass, 6 to 15 units of BTX-A was injected bilaterally under electromyography guidance into the external sphincter or the puborectalis muscle. Treatment was repeated as necessary for a maximum of three sessions during a three-month period. Success was considered as discontinuation of evacuatory assistance and was evaluated between one and three months and again at up to one year. RESULTS: Between July 1994 and May 1995, four patients ranging from 29 to 82 years in age (2 females, 2 males) had anismus that failed to respond to between 3 and 15 biofeedback sessions. All patients improved between one and three months after BTX-A injection, and two had sustained improvement for a range of three months to one year. There was no morbidity or mortality associated with BTX-A injection. CONCLUSIONS: BTX-A is extremely successful for temporary treatment of anismus that is refractory to BF management. However, because the mechanism of action is short, longer term results are only 50 percent successful. Hopefully, modifications in the strain of BTX-A and dose administered will allow longer periods of success or a repeat trial of BF. Nonetheless, this preliminary report is very encouraging in offering a method of managing this recalcitrant condition.

Adult↗
PubMed1996

Morbidity of medical therapy for ulcerative colitis: what are we really saving?

AIM: The true morbidity, cost and disability of medical therapy for ulcerative colitis are seldom delineated and are even less frequently compared to analogous parameters associated with surgical therapy. Therefore, we sought to assess and contrast medical versus surgical therapy for patients hospitalized due to severe ulcerative colitis. MATERIALS AND METHODS: Patients were matched for age, duration and severity of disease based upon Truelove and Witts' activity index, colonoscopic and histologic appearance and APACHE (Acute Psychological and Chronic Health Evaluation) II scores. Morbidity, cost and disability of 20 medically treated patients who required at least one hospital admission were compared to 20 patients treated by a three stage restorative proctocolectomy. Demographic data, number of hospital admissions, length of stay, total hospital charges including consultant's, surgeon's, and anesthesiologist's fees, morbidity of each approach and disability were assessed. Statistical analysis was performed using Mann-Whitney and Fisher exact tests. Significance was considered as P < 0.05. RESULTS: The mean age was 53.6 years in the medical group and 48.1 years in the surgical group (P = NS) and the average duration of disease was 10.5 years and 9.5 years, respectively (P = NS). The same severity of pancolitis was noted in both groups; APACHE scores of 13 and 14 in the medical and surgical groups, respectively, were noted. The total number of hospital admissions and total combined length of stay per patient in each group were not significant. Total mean hospital cost for the medical group was $28,477.00 per patient versus $33,041.00 for the three stage restorative proctocolectomy (P = NS). The mean duration of disability in the medical group was 6.4 months per patient versus 5.0 months in the surgical group (P = NS). However, patients in the medical group required more transfusions (25%) than did those in the surgical group (0%) (P < 0.05) and significant weight loss was more common in the medical group (45%) compared to the surgical group (5%) (P < 0.01). All patients in the surgical group were permanently weaned from steroids. Furthermore, while 65% of patients in the medical group had significant steroid-related complications, the major surgical complication rate was only 15% (P < 0.01). CONCLUSION: Medical treatment was associated with a significantly higher overall morbidity than surgical therapy. Additionally, a three stage restorative proctocolectomy was performed at no additional hospital cost or subsequent disability in patients with severe ulcerative colitis. The value of prolonged medical therapy in this select group of patients is questionable.

APACHE↗
PubMed1996

Laparoscopic surgery in Crohn's disease. Indications and results.

BACKGROUND: An effort was made to assess the feasibility, safety, and outcome of laparoscopic procedures performed in patients with Crohn's disease. METHODS: A prospectively maintained laparoscopic database was analyzed regarding operation time, intra- and postoperative complications, conversion to laparotomy, and length of hospitalization.Fifty-one patients (23 males and 28 females) with a mean age of 36 (20-79) years underwent a laparoscopic or laparoscopic-assisted procedure for Crohn's disease. The indications included terminal ileitis in 31 patients, colitis in 11, perianal disease in four, duodenal Crohn's disease in three, and rectovaginal and rectourethral fistula in one patient each. Thirty-two patients underwent an ileocolic resection; total abdominal colectomy with ileorectal anastomosis was performed in six patients with end ileostomy in one, take down of end ileostomy and ileorectal anastomosis in three, duodenal bypass gastrojejunostomy in three, and loop ileostomy in six patients. RESULTS: The mean operating time was 2.4 (0.6-4.5) h and the mean length of hospital stay was 5.1 (3-18) days. Eight complications were noted in seven patients (14%), which included enterotomy in two patients, bleeding in two, stoma obstruction in two, pelvic sepsis in one, and efferent limb obstruction in one. The procedure was converted to laparotomy in seven patients (14%) due to a large inflammatory mass in five and to bleeding in two patients; there was no mortality. CONCLUSION: Laparoscopic surgery is a feasible, versatile, and safe modality in the surgical management of Crohn's disease. Despite the often-malnourished state of these steroid-dependent patients with intraabdominal inflammatory conditions, morbidity, procedural length, and length-of-hospitalization data are all similar to results previously reported for less-challenging laparoscopic colorectal procedures.

Adult↗
PubMed1996

Laparoscopic surgery in the management of inflammatory bowel disease.

BACKGROUND: The role of laparoscopic surgery in the treatment of various upper and lower gastrointestinal disorders is still under investigation. However, a variety of laparoscopic procedures may be applied in the treatment of inflammatory bowel disease (IBD). PATIENTS AND METHODS: We present our initial results of laparoscopic and laparoscopic-assisted management of IBD in 72 consecutive patients (37 women and 35 men; mean age 36 years, range 20 to 79). The indications for surgery included: terminal ileitis in 29 patients, mucosal ulcerative colitis in 23 patients, Crohn's colitis in 11 patients, severe perianal Crohn's disease in 4 patients, duodenal Crohn's disease in 3 patients, Crohn's rectovaginal fistula in 1 patient, and rectourethral fistula in 1 patient. The procedures performed included: total abdominal colectomy (TAC) in 30 patients (22 with total proctocolectomy with ileoanal reservoir, 6 with TAC with ileorectal anastomosis, and 2 with TAC with end ileostomy), ileocolic resection in 30 patients, diverting loop ileostomy in 6 patients, closure of an end ileostomy as an ileorectal anastomosis in 3 patients who already underwent a TAC with end ileostomy, and duodenal bypass gastrojejunostomy in 3 patients. RESULTS: There were 16 complications in 13 (18%) patients: 3 enterotomies, 4 episodes of bleeding, 3 pelvic abscesses, 2 intestinal obstructions, 2 prolonged ileus, 1 anastomotic leak, and 1 efferent loop obstruction after gastrojejunostomy. However, only 3 patients required laparotomy for morbidity, and there was no mortality. In 7 (10%) patients, the laparoscopic procedure was converted to a laparotomy due to a large inflammatory mass with fistula in 4 patients, bleeding in 2 patients, and an enterotomy in 1 patient. The mean operating time was 2.9 hours (range 0.7 to 6) and the mean length of hospital stay was 6.5 days (range 3 to 19). When compared with ileocolic resection, total colectomy was associated with higher morbidity (30% versus 10%, P < 0.05) and longer hospitalization (8.7 days [range 4 to 19] versus 5.2 days [range 3 to 7], respectively; P < 0.05). CONCLUSIONS: According to this initial experience, laparoscopic surgery is a versatile and effective modality in the surgical management of inflammatory bowel disease in selected patients. However, laparoscopic total colectomy is associated with higher morbidity when compared with ileocolic resection.

Adult↗
PubMed1996

Randomized comparison of straight and colonic J pouch anastomosis after low anterior resection.

OBJECTIVE: The authors compared clinical bowel function and complications of a low anterior resection with either a straight or colonic J pouch anastomosis. SUMMARY BACKGROUND DATA: Urgency and frequent bowel movements after rectal resection with a low anastomosis have been related to the loss of rectal reservoir function. Reconstruction with a colonic J pouch possibly can obviate some of this dysfunction. Earlier reports have been favorable, but they must be verified in randomized trials. METHOD: One hundred patients with rectal cancer in whom a sphincter-saving procedure was appropriate were randomized to reconstruction with either a straight or a colonic J pouch anastomosis. RESULTS: The incidence of symptomatic anastomotic leakage was lower in the pouch group (2% vs. 15%, p = 0.03). Eighty-nine patients could be evaluated after 1 year. The pouch patients had significantly fewer bowel movements per 24 hours, and less nocturnal evacuations, urgency, and incontinence. Overall well-being owing to the bowel function was rated significantly higher by the pouch patients. CONCLUSION: Reconstruction with a colonic J pouch was associated with a lower incidence of anastomotic leakage and better clinical bowel function when compared with the traditional straight anastomosis. Functional superiority was especially evident during the first 2 months.

Adenocarcinoma↗
PubMed1996

The stimulated gracilis neosphincter for fecal incontinence: a new use for an old concept.

The stimulated gracilis neosphincter is a viable procedure in selected patients with fecal incontinence. The aim of this paper is to review the technique of this staged operative procedure and review the problems and complications. Stage 1 consists of the vascular "delay" of the gracilis muscle and the creation of a temporary stoma. Stage 2 consists of transposition of the muscle around the anus with implantation of the stimulator. Low-frequency electrical stimulation is applied to the muscle for 12 weeks, after which stage 3 (stoma closure) is undertaken. From March of 1993 to March of 1995, 14 patients (9 females and 5 males) with a mean age of 44 years (range 20 to 67 years) underwent the procedure. Two patients died within 1 year of the operation from unrelated causes. Two patients developed anal stenosis and required permanent stomas. Other complications noted during ascent of the learning curve included seroma, excoriation of the skin above the stimulator, transposition of the stimulator, premature battery discharge, wound infection, rupture of the gracilis tendon, fatigue during programming sessions, and electrode displacement or fibrosis from the nerve. However, 8 of the 10 eligible patients had stoma reversal; the manometric results showed an average mean squeeze pressure that increased from 43 mmHg prior to surgery to 151 mmHg after the operation (p < 0.01). Based on an objective functional questionnaire, 60 percent of the patients who could be evaluated reported improvement in continence, social interactions, and the quality of their life. In conclusion, despite a steep learning curve, the stimulated gracilis operation is a viable operation for selected patients with severe incontinence.

Adult↗
PubMed1996

Port site recurrences after laparoscopic and thoracoscopic procedures in malignancy.

PURPOSE AND METHODS: A review of the literature was performed to determine the number of cases of port site recurrences (PSR) after laparoscopy or thoracoscopy. CANCERLINE and MEDLINE were searched, as were citings from retrieved and related papers. RESULTS: There have been 35 reported cases of PSR after laparoscopic colectomy for colorectal carcinoma, and 23 cases after thoracoscopic procedures for lung neoplasms. All of these have been reported since 1993. Since 1991, 12 cases have been described after laparoscopic cholecystectomy of unsuspected gallbladder carcinoma, and another case after biopsy of a known gallbladder carcinoma. Ten cases of PSR have been reported after laparoscopic procedures for ovarian lesions, often in the presence of peritoneal seeding at diagnosis. Other rare PSRs have been documented after several procedures in various malignancies. CONCLUSION: Enrollment of patients onto the ongoing intergroup study evaluating open versus laparoscopic resection of colon cancer should be encouraged. Until valid prospective data on PSR frequency are available, laparoscopic or thoracoscopic resection of malignancy off-protocol should be undertaken with circumspection.

Colorectal Neoplasms↗
PubMed1996

Functional outcome of the double stapled ileoanal reservoir in patients more than 60 years of age.

Total proctocolectomy with creation of an ileoanal reservoir (IAR) is currently the preferred surgical treatment of mucosal ulcerative colitis and familial adenomatous polyposis. However, the creation of an IAR on older patients is controversial and commonly avoided because of anticipated poor functional results and increased morbidity. We prospectively studied 140 consecutive patients who underwent a double stapled IAR (DSIAR) between 1988 and 1993. We compared the outcome of 14 patients (Group I) 60 years of age or older (mean 65, range 60-71 years; 10 males and 14 females), to 126 patients (Group II) under the age of 60 (mean 37, range 12-59 years; 80 males and 14 females). Mucosal ulcerative colitis and indeterminate colitis were noted, respectively, in 12 (93%) and 1 (7%) patients in Group I and in 94 (75%) and 5 (4%) patients in Group II. In Group II, 21 (16%) patients had familial adenomatous polyposis, and 6 (5%) had a postoperative diagnosis of Crohn's disease. Subjective functional results and anal manometry were assessed in all 14 patients in Group I (100%) and in 110 of the 117 patients in Group II (94%) whose stomas were closed at a mean followup of 24 (3-60) months. Manometry was per- formed before, and 2 and 12 months after surgery. Patients in Groups I and II reported a mean of 6.2 and 5.2 bowel movements during the day (P=NS), and 2 and 1.1 at night, respectively (P<0.05). A total of 12 (86%) patients in Group I and 104 (95%) in Group II reported perfect or almost perfect continence at night (P=NS), and 12 (93%) patients in Group I and 104 (95%) in Group II reported perfect or almost perfect continence during the day (P=NS). The preoperative mean and maximal resting pressures were similar in both groups (71.7 mmHg and 94 mmHG in Group I and 71.6 and 88 mmHg in Group II respectively; P=NS). Postoperative resting pressure changes were also similar in both groups P=NS), with a similar significant decline 2 months after surgery, which recovered by 12 months after surgery in both groups. There were no significant changes between the pre- and postoperative mean and maximal squeeze pressures in either group. The overall morbidity and mortality rates in Groups I and II were 21 and 0 per cent, and 21 and 0.8 per cent, respectively (P=NS). DSIAR in patients 60 years of age or older is as safe and is associated with as good functional and physiologic results as it is in younger patients. Thus, this procedure may be offered to older patients with expectation of good outcome.

Adenomatous Polyposis Coli↗
PubMed1996

Is complete laparoscopic colectomy superior to laparoscopic assisted colectomy?

Much debate has centered around what constitutes a true laparoscopic colon resection. Purists argue that intracorporeal division of the mesentery and anastomosis confer a benefit over a "laparoscopic assisted" procedure. The aim of this study was to further examine this issue. Data were prospectively collected on 102 consecutive laparoscopic colon resections. Five procedures were converted to open cases and were excluded from analysis. Procedures were divided into two groups. Group 1 (n = 34) consisted of complete laparoscopic procedures (no abdominal incision was made): abdominoperineal resection (3), Hartmann's reversal (3), end colostomy (7), low anterior resection (5), proctectomy (1), sigmoid colectomy (15). Group 2 (n = 63) consisted of laparoscopic "assisted" procedures (i.e., an incision was made to facilitate anastomosis, division of the mesentery, and/or specimen retrieval): Ileocolic resection (6), restorative proctocolectomy (26), right colectomy (19), subtotal colectomy/end ileostomy (5), subtotal colectomy/ileorectal anastomosis (7). Length of hospitalization and duration of postoperative ileus were compared. A subset analysis of right colectomy (intracorporeal mobilization and extracorporeal division of the mesentery and anastomosis) versus sigmoid colectomy (intracorporeal mobilization, division of the mesentery and anastomosis) was also performed. There were no statistically significant differences in length of hospital stay (Group 1, 7.47 +/- 2.75 days; Group 2, 7.78 +/- 5.55 days) or duration of postoperative ileus (Group 1, 3.24 +/- 1.56 days; Group 2, 3.68 +/- 1.58 days). Similarly, in the sigmoid colectomy versus right colectomy subset analysis, there were no statistically significant differences in length of hospital stay (sigmoid colectomy, 7.92 +/- 2.90 days; right colectomy, 6.40 +/- 1.50 days) or duration of postoperative ileus (sigmoid colectomy, 3.36 +/- 1.39 days; right colectomy, 3.18 +/- 1.07 days). Our data demonstrate that intracorporeal division of the mesentery and anastomosis confer no advantage over the laparoscopic assisted procedures. Data were prospectively collected on 102 consecutive laparoscopic colon resections. There were no statistically significant differences in length of hospital stay or duration of postoperative ileus regardless of whether intracorporeal or extracorporeal mesenteric division and anastomosis were undertaken. These data demonstrate that a completely laparoscopic procedure does not appear to offer any advantage as compared to a laparoscopic assisted one.

Abdomen↗
PubMed1996

Adhesion formation after laparoscopic anterior resection in a porcine model: a pilot study.

Although decreased adhesion formation is one of the accepted advantages of laparoscopic colorectal surgery, no prospective studies have been done to support this claim. Therefore, we prospectively assessed adhesion formation following laparoscopic anterior resection of the rectum in a porcine model. Five domestic female pigs underwent the procedure with a double-stapled intracorporeal anastomosis. After completion of the laparoscopic procedure, 50 cm of ileum was retrieved through the right lower port site. Controlled serosal abrasion of the antimesenteric surface was performed using a fresh knife. The abraded loop was returned into the peritoneal cavity and the fascia closed at all port sites. All animals underwent a midline laparotomy 3 weeks later to assess adhesions using a 0-3 score according to the density vascularity, and extent of adhesions. All animals survived the study period. The mean level of the anastomosis was 8 cm (range, 7-10) above the anal verge; all anastomoses were intact and completely healed. None of the animals had adhesions to the port sites. The anastomotic site was completely free of adhesions in four animals, and only one animal (20%) had grade 1 adhesions between the urine horns and the anastomosis. Conversely, all animals had adhesions of the abraded loop involving 60 cm (range, 40-75) of bowel and 7 cm (range, 4-9) of the abdominal wall (remote to the port sites); no other adhesions were noted. In this pilot study, serosal abrasion of the small bowel resulted in severe adhesion formation in the porcine model. However, laparoscopic anterior resection of the rectum in the same animals was associated with only minimal insignificant adhesions. Furthermore, unlike in laparotomy incisions, adhesions to port sites did not occur.

Abdomen↗
PubMed1996

The role of laparoscopic colectomy and laparotomy with resection in the management of complex polyps of the colon.

Surgical options available to patients with endoscopically unresectable lesions include laparoscopic assisted colonscopy, colonscopic assisted laparoscopy, laparotomy with segmental resection, and laparoscopic colon resection. The choice of modality depends on the nature of the lesion as well as the choice of both the patient and the surgeon. The surgeon should be fluent in all available therapeutic modalities.

Colectomy↗
PubMed1996

Prevention of postoperative abdominal adhesions by a sodium hyaluronate-based bioresorbable membrane: a prospective, randomized, double-blind multicenter study.

BACKGROUND: Postoperative abdominal adhesions are associated with numerous complications, including small bowel obstruction, difficult and dangerous reoperations, and infertility. A sodium hyaluronate and carboxymethylcellulose bioresorbable membrane (HA membrane) was developed to reduce formation of postoperative adhesions. The objectives of our prospective study were to assess the incidence of adhesions that recurred after a standardized major abdominal operation using direct laparoscopic peritoneal imaging and to determine the safety and effectiveness of HA membrane in preventing postoperative adhesions. STUDY DESIGN: Eleven centers enrolled 183 patients with ulcerative colitis or familial polyposis who were scheduled for colectomy and ileal pouch-anal anastomosis with diverting-loop ileostomy. Before abdominal closure, patients were randomly assigned to receive or not receive HA membrane placed under the midline incision. At ileostomy closure eight to 12 weeks later, laparoscopy was used to evaluate the incidence, extent, and severity of adhesion formation to the midline incision. RESULTS: Data were analyzed for 175 assessable patients. While only five (6 percent) of 90 control patients had no adhesions, 43 (51 percent) of 85 patients receiving HA membrane were free of adhesions (p < 0.00000000001). The mean percent of the incision length involved was 63 percent in the control group, significantly greater than the 23 percent observed in patients who received HA membrane (p < 0.001). Dense adhesions were observed in 52 (58 percent) of the 90 control patients, but in only 13 (15 percent) of the 85 receiving HA membrane (P < 0.0001). Comparison of the incidence of specific adverse events between the groups did not identify a difference (P > 0.05). CONCLUSIONS: This study represents the first controlled, prospective evaluation of postoperative abdominal adhesion formation and prevention after general abdominal surgery using standardized, direct peritoneal visualization. In this study, HA membrane was safe and significantly reduced the incidence, extent, and severity of postoperative abdominal adhesions.

Adenomatous Polyposis Coli↗
PubMed1996

Laparoscopically assisted sigmoid colectomy in human immunodeficiency virus (HIV) patients: a good indication for laparoscopic surgery.

Laparoscopic colorectal procedures have been accepted for a variety of conditions. We present two cases of HIV-positive who underwent laparoscopic sigmoid colectomy and creation of a stoma for the treatment of sigmoid cancer and disseminated colorectal kaposi sarcoma, respectively. Laparoscopy may be a good option in selected HIV-positive patients.

Adenocarcinoma↗
PubMed1996

Laparoscopic port site recurrences in oncologic surgery--a review.

The aim of this paper was to review the world's literature regarding port site recurrences. A Medline search was performed for all port site recurrences published in the literature. These reports were analysed and port site recurrences studied to determine initial stage of cancers, time to recurrence and whether the port site was an isolated site of recurrence or part of widespread intra-abdominal disease. The possible aetiologies were similarly reviewed and several recent basic science reports assessed. To date, 93 port site recurrences have been published. These have occurred with colorectal cancers as well as ovarian, gastric, pancreatic and other malignancies. Often, these recurrences are isolated and most standard means of prevention of cell dissemination may not prevent their occurrence. Possible mechanisms include aerosolisation of tumour cells, exfoliation, and changes in immune function. Port site recurrences continue to be reported. Their aetiology is unclear but the occurrence is of concern and requires continued scrutiny for laparoscopic oncologic surgery.

Animals↗
PubMed1996

Outcome of laparoscopic colorectal surgery in older patients.

The object of this study was to assess the outcome of laparoscopic colorectal surgery in patients >60 years of age and compare it to a younger group of patients who underwent similar procedures. All consecutive patients who underwent a laparoscopic or laparoscopic-assisted procedure were evaluated. The parameters analyzed included gender, indication for surgery, procedure, complications, conversions, length of ileus, length of hospitalization, and comorbidity. The results of patients 60 years of age or older were compared to a procedure-matched group of younger patients. Between August 1991 and August 1995, 165 patients underwent a laparoscopic or laparoscopic-assisted colorectal procedure. Thirty-six patients were 60 years of age or older [mean age, 73 (60-88) years; 17 males and 19 females] and were compared with 36 younger patients [mean age, 44 (20-58) years; 13 males and 23 females]. The indications for surgery included Crohn's disease in 14 patients, polyps in 23, diverticular disease in 15, carcinoma in 11, fecal incontinence in 4, rectal prolapse in 2, radiation proctitis in 2, and sigmoidocele in 1. Identical procedures were performed in each group including right colectomy or ileocolic resection in 17 patients, sigmoidectomy in 14, loop ileostomy in 3, loop colostomy in 1, and abdominoperineal resection in 1 patient. Fourteen patients (38%) in the elderly group had comorbid conditions including ischemic heart disease (3), chronic obstructive pulmonary disease (3), hypertension (2), chronic renal failure (2), atherosclerotic vascular disease (2), congestive heart failure (1), and diabetes (1). All patients were cleared for surgery by their respective specialists. There were no statistically significant differences between the younger and older groups relative to the incidence of complications (11 vs 14%, respectively) and conversion (8 vs 11%, respectively) or the length of ileus (2.8 vs 4.2 days, respectively) or hospitalization (5.2 vs 6.5 days, respectively) (P = NS for all). There was no mortality in either group. The outcome of laparoscopic colorectal surgery in older patients is similar to that noted in younger patients. Advanced age should not be a contraindication to laparoscopic colorectal surgery.

Adult↗