PubMed Health⌕ Search

Biomedical subjects

S D Wexner

Publications and source records attributed to S D Wexner.

At least 235 records · Page 13Linked to original sources
PubMed1994

Role of pudendal nerve terminal motor latency assessment in constipated patients.

UNLABELLED: The importance of pudendal nerve terminal motor latency assessment for the evaluation of incontinence is well established. However, its role in constipated patients remains unclear. PURPOSE: The purpose of the present study was to assess the incidence of pudendal neuropathy in constipated patients and its correlation with others variables including age, sex, anal pressures, and anal electromyography. RESULTS: From 1988 to 1993, 161 patients with chronic constipation underwent pudendal nerve terminal motor latency assessment, anal electromyography, and anal manometry. The overall incidence of pudendal neuropathy was 23.6 percent; females and males had a similar incidence (24 percent vs. 23 percent, respectively; P > 0.05). Patients over 70 years old had a significantly higher incidence of pudendal neuropathy than did patients under 70 years (37 percent vs. 12 percent, respectively; P < 0.01). Patients with paradoxical puborectalis contraction on anal electromyographic assessment had a higher incidence of bilateral neuropathy, paradoxical puborectalis contraction (+)23 percent vs. paradoxical puborectalis contraction (-)8 percent, P < 0.05. Patients with pudendal neuropathy also had a higher incidence of decreased motor units potential recruitment than did patients without pudendal neuropathy (31.5 percent vs. 17 percent, respectively; P > 0.05). CONCLUSIONS: Pudendal nerve terminal motor latency assessment was able to detect unsuspected pudendal neuropathy in 24 percent of patients. This finding correlated with age and with the presence of paradoxical puborectalis contraction but not with manometric anal pressures, motor unit potentials recruitment, or the presence of polyphasia. However, the often espoused relationship between pudendal latency and external sphincter function could not be demonstrated.

Adolescent↗
PubMed1994

The lactulose hydrogen breath test as a measure of orocaecal transit time.

OBJECTIVE: To establish normal values and assess the reproducibility of the lactulose hydrogen breath test in measuring orocaecal transit time in control subjects, and to report results in a group of patients with chronic constipation as a result of colonic inertia. DESIGN: Open study. SETTING: Academic clinic. SUBJECTS: 42 Control subjects (29 women and 13 men) in 25 of whom the test was repeated within 2-4 weeks, and 19 patients. INTERVENTIONS: Lactulose hydrogen breath test. MAIN OUTCOME MEASURES: Sustained increase in hydrogen production of 3 ppm or more. RESULTS: Coefficient of variation within subjects was 8% compared with 38% between subjects; 3 of the control subjects (7%) and 3 of the patients (16%) did not ferment lactulose, the the incidence was similar in men (1/13, 8%) and women (2/29, 7%). Mean (SD) orocaecal transit time was significantly shorter among the 29 women (60 (27) minutes) than among the 11 men (89 (24) minutes) (p < 0.005). There were no significant differences between men in the control group and those with constipation. CONCLUSIONS: The lactulose hydrogen breath test is valuable to assess orocaecal transit time. It is simple, non-invasive, and reproducible, and may be of value in differentiating between generalised hypomotility and colonic inertia.

Adult↗
PubMed1994

Effect of xylene clearance of mesenteric fat on harvest of lymph nodes after colonic resection.

OBJECTIVE: To find out if clearance of surgical colectomy specimens with xylene gave a higher yield of lymph nodes and more accurate staging than the traditional step-sectioning technique. DESIGN: Consecutive open study. SETTING: Private hospital, United States. MATERIAL: 84 specimens from colonic resections, 4 of which were total colectomies and the remaining 80 segmental resections. INTERVENTIONS: The first 41 (2 colectomies and 39 segmental resections) were cleared by step-sectioning alone (to establish baseline values). The remainder (n = 2 and 41, respectively) were step-sectioned, the lymph nodes were removed, and then the residual tissue was cleared with xylene. MAIN OUTCOME MEASURES: The number of lymph nodes found, and if the diagnosis was changed by the finding of additional nodes. RESULTS: The baseline values in the two total colectomy specimens were 76 and 101, and the mean (range) after segmental colectomy was 21 (1-98). The values after total colectomy in the second group were 33 and 73, and after xylene clearance an additional 12 and 17 nodes were found. After segmental colectomy a mean (range) of 13 (0-43) was found, and an additional 4 (0-12) were found after xylene clearance. No additional nodes containing metastases were found in total colectomy specimens after xylene clearance, and only 6 additional nodes after segmental resection contained metastases. These changed the histological stage of the disease in only 2 patients. CONCLUSIONS: Xylene clearance offers little advantage over careful traditional step-sectioning of specimens, but may be of value if the histopathologist does not do routine meticulous step-sectioning.

Case-Control Studies↗
PubMed1994

Colorectal physiological tests: use or abuse of technology?

OBJECTIVE: To assess the value of colorectal physiological tests in patients with functional disorders of defecation. DESIGN: Prospective study. SETTING: Academic hospital. SUBJECTS: 308 consecutive patients. INTERVENTIONS: Routine history and physical examination, followed by colonic transit study, and manometry, cinedefecography, electromyography of the anal sphincter, and assessment of terminal motor latency of the pudendal nerve. MAIN OUTCOME MEASURES: Number of diagnoses made after physiological tests compared with routine history and examination alone. RESULTS: Definitive diagnoses were made after history and physical examination alone in 15/180 (8%) with constipation, 9/80 (11%) with incontinence, and 11/48 (23%) with intractable rectal pain. The figures after physiological tests were 135/180 (75%), 53/80 (66%), and 20/48 (42%), respectively. Among the diagnoses made by physiological testing alone were: in patients with constipation, paradoxical puborectalis contraction (n = 59), colonic inertia (n = 31), rectocele (n = 19), and intussusception (n = 18); in those with incontinence, loss of muscle fiber (n = 21), neuropathy (n = 10), and both (n = 15); and in those with rectal pain, neuropathy (n = 6) and paradoxical puborectalis contraction (n = 3). The numbers of patients that remained undiagnosed in the three groups were 45 (25%), 27 (34%), and 28 (58%), respectively. Treatable conditions were diagnosed by physiological testing in 120/180 patients with constipation (67%) and 44 patients with incontinence (55%). Only 9 patients with rectal pain had treatable causes identified by physiologic testing. CONCLUSION: The value of colorectal physiological tests is greatest in patients who present with constipation or incontinence; they are of little value in those with chronic intractable rectal pain.

Adolescent↗
PubMed1993

Laparoscopic colorectal surgery: a prospective assessment and current perspective.

Between August 1991 and June 1993, 74 laparoscopic and laparoscopically assisted colonic and rectal operations were performed. A variety of procedures were carried out including 32 total abdominal colectomies (group 1), 32 segmental resections (group 2) and ten constructions of a diverting stoma without formal resection (group 3). Indications for surgery were mucosal ulcerative colitis in 20 patients, carcinoma in 12, polyposis in six, Crohn's disease in seven and other conditions in the remaining 29. The 74 comprised 42 male and 32 female patients of mean age 45 (range 12-88) years. The median (range) duration of the procedure was 3.0 (1.0-6.5) h for the entire group, 3.9 (2.5-6.5) h for group 1, 2.9 (1.5-5.5) h for group 2 and 1.8 (1.0-2.5) h for group 3. The median (range) length of ileus was 3.0 (2-7) days overall; respective times for groups 1-3 were 3.5 (2-7), 3.0 (2-7) and 2.0 (1-4) days. The median (range) length of hospitalization was 7.0 (2-40) days, 8.1 (4-19) days in group 1, 7.0 (4-20) days in group 2 and 6.0 (2-40) days in group 3. Ten patients (14 per cent) developed intraoperative and 15 (20 per cent) postoperative complications; there were no deaths. These results failed to confirm any significant advantages of laparoscopic or laparoscopically assisted colorectal surgery. Specifically, neither the operating time, nor length of ileus, nor length of hospitalization was improved over standard procedures. Advances in technology and surgical technique may improve such findings in the future.

Adolescent↗
PubMed1993

Anorectal manometry in the diagnosis of paradoxical puborectalis syndrome.

This prospective study was undertaken to compare the utility of anorectal manometry (ARM) with that of anal electromyography (EMG) and cinedefecography (CD) in the diagnosis of paradoxical puborectalis syndrome (PPS). One hundred sixteen consecutive patients with a history of chronic constipation were prospectively assessed. These 35 males and 81 females were of a mean age of 60 years, ranging from 18 to 84 years. The incidences of PPS were 63 percent for ARM, 38 percent for EMG, and 36 percent for CD. The correlations of PPS were suboptimal: ARM and EMG, 70 percent; and ARM and CD, 61 percent. A two-tiered system for the manometric classification of PPS was developed. First, the evacuation pressure curve pattern was classified as a normal relaxed downward (Type A; n = 43), a nonrelaxed flat or equivocal (Type B; n = 36), and a paradoxical upward (Type C; n = 37). PPS was noted with increasing incidence within curve types (21 percent in Type A, 64 percent in Type B, and 95 percent in Type C). Second, an evacuation index (EI = evacuation pressure/squeeze pressure) was defined: Group I (EI < 0; n = 43), Group II (0 < or = EI < 0.25; n = 24), Group III (0.25 < or = EI < 0.5; n = 27), and Group IV (EI > or = 0.5; n = 18). The finding of PPS also correlated with the EI group: 21 percent in Group I, 67 percent in Group II, 74 percent in Group III, and 100 percent in Group IV. This subdivision of curve types and EI groups may provide a role in the diagnosis of PPS.

Adolescent↗
PubMed1993

Perineal rectosigmoidectomy in the elderly.

Between April 1989 and October 1991, 20 consecutive patients underwent perineal rectosigmoidectomy and coloanal anastomosis for full-thickness rectal prolapse. These 16 females and 4 males, with a mean age of 82 (range, 68-101) years, were evaluated by detailed functional assessment and physiologic testing. A grading scale from 0 to 24 was based upon the frequency and type of incontinence, 0 representing full continence. The mean preoperative continence score was 14.5, while the mean postoperative continence score was 8.4. The mean length of resected rectosigmoid was 23 cm. There was one postoperative death and one significant complication, a postoperative pelvic hematoma that required reoperation. There were no full-thickness recurrences at a mean follow-up of 26 months. Six of the 10 patients who underwent preoperative pudendal nerve terminal motor latency (PNTML) testing had evidence of severe neuropathy (latencies greater than 2.5 milliseconds). Prolonged PNTML, however, was not shown to be an accurate predictor of postoperative incontinence because four of the six patients with neuropathy regained excellent to good control. In conclusion, perineal rectosigmoidectomy is a safe operation for the treatment of full-thickness rectal prolapse in the elderly patient. Improved postoperative continence was noted in 90 percent of patients, with improvement seen even in those patients with severe pudendal neuropathy.

Aged↗
PubMed1993

MMPI assessment of patients with functional bowel disorders.

This prospective study was undertaken to assess personality differences among patients with chronic pelvic floor disorders. Sixty patients (43 females and 17 males) of a mean age of 58 (range, 33-87) years with fecal incontinence (n = 19), constipation (n = 30), or levator spasm (n = 11) had a mean duration of symptoms of 35 (range, 2-50) years. The Minnesota Multiphasic Personality Inventory (MMPI) was utilized for psychologic assessment for all patients prior to treatment. Mean scores for scales 1 (hypochondriasis), 2 (depression), and 3 (hysteria) were significantly elevated for the levator spasm group (71, 75, and 73, respectively). A similar pattern was seen for the constipation group, where the mean scores for scales 1 and 2 were significantly elevated (70 and 74, respectively) with a moderate elevation on scale 3 (68). The hypochondriasis (1), depression (2), and hysteria (3) scales are referred to as the "neurotic triad," and profile patterns such as these indicate that these subjects may manifest their psychologic distress as physical symptoms. By contrast, the fecal incontinence patients were within the normal range on all scales. The information from these MMPI profiles can be used to understand the personality and emotional composition of these patients to assist in their evaluation and treatment.

Adult↗
PubMed1993

Does perineal descent correlate with pudendal neuropathy?

A prospective study was undertaken to assess the potential correlation between increased perineal descent (IPD) and pudendal neuropathy (PN) in 213 consecutive patients. These 165 females and 48 males of a mean age of 62 (range, 18-87) years had constipation (n = 115), idiopathic fecal incontinence (n = 58), or chronic intractable rectal pain (n = 40). All 213 patients underwent cinedefecography (CD) and bilateral pudendal nerve terminal motor latency (PNTML) assessment. Perineal descent (PD) of more than the upper limit of normal of 3.0 cm during evacuation was considered increased. Pudendal neuropathy was diagnosed when PNTML exceeded the upper limit of normal of 2.2 milliseconds. Although 65 patients (31 percent) had PD, only 16 (25 percent) of these 65 patients had neuropathy. Moreover, PN was also found in 42 (28 percent) of 148 patients without IPD. Conversely, only 16 (28 percent) of the 58 patients who had PN also had IPD, and IPD was present in 49 (32 percent) of 155 patients without PN. The frequency of PN according to the degree of IPD was: 3.0 to 4.0 cm, 6 of 27 patients (22 percent); 4.1 to 5.0 cm, 4 of 15 (27 percent); 5.1 to 6.0 cm, 4 of 12 (25 percent); 6.1 to 7.0 cm, 2 of 8 (25 percent); and > 7.0 cm, 0 of 3 (0 percent). Linear regression analysis was undertaken to compare the relationships between measurements of PD at rest (R), push (P), and change (C = P-R) and values of PNTML. These values for all 213 patients were: R, r = 0.048; P, r = 0.031; and C, r = -0.050. The correlation coefficients were equally poor for all the individual subgroups analyzed, including the patient's sex or diagnosis. In summary, no correlation was found between PD and PNTML. The lack of a relationship was seen for the entire group as well as for those patients with either neuropathy or increased perineal descent. Therefore, the often espoused relationship between increased PD and PN was not supported by this prospective evaluation. Although increased PD and prolonged PNTML are frequently observed in patients with disordered defecation, they may represent independent findings.

Adolescent↗
PubMed1993

Laparoscopic colectomy: a critical appraisal.

A multicenter retrospective study was undertaken to assess the efficacy and safety of laparoscopy in colon and rectal surgery. To minimize potential bias in interpretation of the results, all data were registered with an independent observer, who did not participate in any of the surgical procedures. Sixty-six patients underwent a laparoscopic procedure. Operations performed included sigmoid colectomy (19), right hemicolectomy (15), low anterior resection (6), colectomy with ileal pouch-anal anastomosis (IPAA) (5), and abdominoperineal resection (APR) (3). The conversion rate from laparoscopic colectomy to celiotomy was 41 percent. Major morbidity and mortality were 24 percent and 0 percent, respectively. Length of stay, hospital costs, and lymph node harvest were compared between the sigmoid resection and right hemicolectomy subgroups. Data from traditional sigmoid colectomies and right hemicolectomies were obtained from the same institutions for comparison. Mean postoperative stay for laparoscopically completed sigmoid and right colectomies was significantly less than that for either the converted or the traditional groups (P < 0.02). Total hospital cost for traditional right hemicolectomy was significantly less than that for the converted group (P < 0.05) but not the laparoscopic group. Laparoscopic sigmoid resection showed no significant total hospital cost difference among traditional, converted, and laparoscopic groups. Lymph node harvest in resections for carcinoma was comparable in all groups. These preliminary data suggest that laparoscopic colon and rectal surgery can be accomplished with acceptable morbidity and mortality when performed by trained surgeons. Length of stay is shorter, but there is no proven total hospital cost benefit. Appropriate registries will be necessary to adequately assess long-term outcome.

Adolescent↗
PubMed1993

Etiology and management of fecal incontinence.

Fecal incontinence is a challenging condition of diverse etiology and devastating psychosocial impact. Multiple mechanisms may be involved in its pathophysiology, such as altered stool consistency and delivery of contents to the rectum, abnormal rectal capacity or compliance, decreased anorectal sensation, and pelvic floor or anal sphincter dysfunction. A detailed clinical history and physical examination are essential. Anorectal manometry, pudendal nerve latency studies, and electromyography are part of the standard primary evaluation. The evaluation of idiopathic fecal incontinence may require tests such as cinedefecography, spinal latencies, and anal mucosal electrosensitivity. These tests permit both objective assessment and focused therapy. Appropriate treatment options include biofeedback and sphincteroplasty. Biofeedback has resulted in 90 percent reduction in episodes of incontinence in over 60 percent of patients. Overlapping anterior sphincteroplasty has been associated with good to excellent results in 70 to 90 percent of patients. The common denominator between the medical and surgical treatment groups is the necessity of pretreatment physiologic assessment. It is the results of these tests that permit optimal therapeutic assignment. For example, pudendal nerve terminal motor latencies (PNTML) are the most important predictor factor of functional outcome. However, even the most experienced examiner's digit cannot assess PNTML. In the absence of pudendal neuropathy, sphincteroplasty is an excellent option. If neuropathy exists, however, then postanal or total pelvic floor repair remain viable surgical options for the treatment of idiopathic fecal incontinence. In the absence of an adequate sphincter muscle, encirclement procedures using synthetic materials or muscle transfer techniques might be considered. Implantation of a stimulating electrode into the gracilis neosphincter and artificial sphincter implantation are other valid alternatives. The final therapeutic option is fecal diversion. This article reviews the current status of the etiology and incidence of incontinence as well as the evaluation and treatment of this disabling condition.

Fecal Incontinence↗
PubMed1993

Evaluation and treatment of chronic intractable rectal pain--a frustrating endeavor.

A study was undertaken to assess the evaluation and treatment of chronic intractable rectal pain. Sixty consecutive patients, 23 males and 37 females with a mean age of 69 (range, 29-87) years and a mean length of symptoms of 4.5 years, were evaluated by questionnaire, office examination, anal manometry, electromyography, cinedefecography, and pudendal nerve study. In all cases, organic abdominopelvic and anorectal etiologies for the pain were excluded by extensive radiologic and endoscopic evaluation. All patients had failed conservative and medical therapy. Ninety-five percent of patients had one or more associated factors: constipation or dyschezia (57 percent), prior pelvic surgery (43 percent), prior anal surgery (32 percent), prior spinal surgery (8 percent), irritable bowel syndrome (10 percent), or psychiatric disorders (depression or anxiety; 25 percent). Possible etiologies for the pain included levator spasm or anismus in 62 percent, coccygodynia in 8 percent, and pudendal neuropathy in 24 percent of patients. Therapy for pain control included electrogalvanic stimulation (EGS) in 29, biofeedback (BF) in 14, and steroid caudal block (SCB) in 11 patients. Pain control was assessed by an independent observer at a mean of 15 (range, 2-36) months after completion of therapy. Continued successful pain relief was classified by patients as good or excellent after EGS in 38 percent, after BF in 43 percent, and after SCB in 18 percent; overall success was reported by 47 percent of patients. The presence of levator spasm, coccygodynia, or pudendal neuropathy did not influence outcome. The routine use of physiologic investigation of rectal pain may not be justifiable. Moreover, more than half of the patients were refractory to all three therapeutic options used in this study.

Adult↗
PubMed1993

Anal endosonography for recurrent anal fistulas: image enhancement with hydrogen peroxide.

Anal endosonography is a new technique that is useful in the preoperative assessment of patients with anal fistulas. Endosonographic images are created by the reflection of sound waves from the interfaces between tissues of varying densities. In order to accentuate tissue interface layers at the level of the fistula tract, we introduced hydrogen peroxide into the fistula tract through the external opening during anal ultrasonography in two patients with recurrent anal fistula. Hydrogen peroxide injection resulted in hyperechoic imaging of the preinjection hypoechoic horseshoe fistula tract. Endosonographic findings were confirmed at the time of surgery in both patients. We conclude that hydrogen peroxide enhancement of the fistula tract is a simple, effective, and safe method of improving the accuracy of endoanal ultrasound assessment of recurrent anal fistula.

Endoscopy, Gastrointestinal↗
PubMed1993

Is aggressive management of perianal ulcers in homosexual HIV-seropositive men justified?

A study was undertaken to assess the etiology, optimal diagnostic method, and incidence of healing of perianal ulcers in HIV-seropositive men. Between March 1990 and December 1991, 26 HIV-seropositive homosexual or bisexual males were referred with perianal ulcerations. According to CDC criteria, three (12 percent) were Class II, six (23 percent) were Class III, and 17 (65 percent) were Class IV. Eighteen patients had one ulcer, five had two ulcers, and two had three ulcers. In one patient the ulcer was circumanal. Patients with superficial erosions were not included. Biopsies were obtained in 23 patients for routine microscopy, HIV, cytomegalovirus, herpes simplex virus, and acid-fast bacilli. Biopsy revealed an immunoblastic lymphoma in one patient. A comparison of microscopy and culture results revealed culture to be more helpful in determining the etiology of these ulcers. Medical treatment included reverse transcriptase inhibitors (zidovudine, dideoxyinosine, and dideoxycytosine), oral and topical Zovirax (Burroughs Wellcome, Research Triangle Park, NC), ganciclovir, and oral broad-spectrum antibiotics. Surgical treatment included lateral internal sphincterotomy in three patients and seton placement in one patient. Follow-up for at least four weeks was obtained in 22 patients. Overall, healing occurred in 15 patients (68 percent): three (20 percent) were Class II, four (27 percent) were Class III, and eight (53 percent) were Class IV. Healing occurred in all four patients who underwent surgical treatment. In conclusion, aggressive diagnostic maneuvers allow the use of both medical and conservative surgical measures to successfully treat the majority of perianal ulcers in this patient population.

Adult↗
PubMed1993

Loop ileostomy is a safe option for fecal diversion.

This study was undertaken to prospectively assess all morbidity and mortality associated with temporary loop ileostomy. Eighty-three consecutive patients of a median age of 45 years required temporary fecal diversion after either ileoanal or low colorectal anastomosis (n = 72), for perianal Crohn's disease (n = 5), or for other reasons (n = 6). All loop ileostomies were supported with a rod, and fecal diversion was maintained for a mean of 10 weeks. To date, 67 patients have had re-establishment of intestinal continuity. Stoma closure was affected through a parastomal incision in 64 patients; in three, a laparotomy was required. The closure was stapled side to side in 49 patients, while a hand-sewn anastomosis was done in the other 18 patients; all skin wounds were left open. The mean length of surgery for ileostomy closure was 56 minutes, and the mean hospital stay was five days. Nine patients (10.8 percent) developed 10 complications, nine of which required hospitalization. Specifically, four patients developed dehydration and electrolyte abnormalities secondary to high stoma output, and two had anastomotic leaks that spontaneously healed following conservative management. One patient developed a superficial wound infection that spontaneously drained itself. One patient developed a partial small bowel obstruction that resolved without surgery after a four-day hospitalization. One stoma retracted after supporting rod removal and prompted premature closure. There was no stomal ischemia, hemorrhage, prolapse, or mortality in this series. Thus, loop ileostomy is a safe way to achieve fecal diversion.

Adolescent↗
PubMed1993

Cinedefecography and electromyography in the diagnosis of nonrelaxing puborectalis syndrome.

A prospective study was undertaken to assess the correlation between electromyography (EMG) and cinedefecography (CD) for the diagnosis of nonrelaxing puborectalis syndrome (NRPR). Clinical criteria for NRPR included straining, incomplete evacuation, tenesmus, and the need for enemas, suppositories, or digitation. EMG criteria included failure to achieve a significant decrease in electrical activity of the puborectalis (PR) during attempted evacuation. CD criteria included either paradoxical contraction or failure of relaxation of the PR along with incomplete evacuation. In addition, other etiologies for incomplete evacuation, such as rectoanal intussusception or nonemptying rectocele, were excluded by proctoscopy and defecography in all cases. One hundred twelve patients with constipation, 81 females and 31 males, with a mean age of 59 (range, 12-83) years were studied by routine office evaluation, CD, and EMG. Forty-two patients (37 percent) had evidence of NRPR on CD (rectal emptying: none, 24; incomplete, 18). Twenty-eight of these patients (67 percent) also had evidence of NRPR on EMG. EMG findings of NRPR were present in 12 of 70 patients (17 percent) with normal rectal emptying. Conversely, 14 of 72 patients (19 percent) with normal PR relaxation on EMG had an NRPR pattern on CD. The sensitivity and specificity for the EMG diagnosis of NRPR were 67 percent and 83 percent, and the positive and negative predictive values were 70 percent and 80 percent, respectively. Conversely, if EMG is considered as the ideal test for the diagnosis of NRPR, CD had a sensitivity of 70 percent, a specificity of 80 percent, and positive and negative predictive values of 66 percent and 82 percent, respectively. In summary, sensitivity, specificity, and predictive values of EMG and CD are suboptimal. Therefore, a combination of these two tests is suggested for the diagnosis of NRPR.

Action Potentials↗