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Biomedical subjects

S D Wexner

Publications and source records attributed to S D Wexner.

At least 253 records · Page 14Linked to original sources
PubMed1993

Laparoscopic colorectal resection for cancer: the Cleveland Clinic Florida experience.

Since the first successful laparoscopic cholecystectomy was performed in 1987, surgeons have begun to focus their attention on more diverse procedures. The last few years have brought a tremendous amount of enthusiasm toward laparoscopic surgery, which has finally reached the colorectal surgical communities. Currently, laparoscopic bowel surgery is undergoing critical appraisal. Through meaningful prospective data retrieval, answers are being obtained to questions dealing with the efficacy and utility of this technique for colorectal diseases. Specifically, although laparoscopic colorectal surgery is feasible, one cannot definitively attest to its superiority or even equivalence to standard open laparotomy. Furthermore, it will take 5 years before we begin to collect data regarding survival rates and local recurrence for the patient with colorectal carcinoma. This article discusses the technique utilized, and our own experience with laparoscopic colorectal surgery for malignancy.

Adult↗
PubMed1993

Bacterial, fungal, parasitic, and viral colitis.

Colitides of bacterial, fungal, parasitic, and viral origin require an organized approach for diagnosis and treatment. Many colitides are transmitted through poor hygienic practices. However, increasing numbers of patients are at risk because of immunocompromise. This population includes the elderly, individuals taking steroids or immunosuppressive agents, and HIV-seropositive individuals. This latter group of individuals is at high risk not only because of immunocompromise but also because of practices such as oroanal intercourse with infected partners. These facts suggest that both the prevalence and the geographic scope of infectious colitides will continue to expand. Undoubtedly, the surgeon will be called on to assist in the diagnosis and management of the complications.

Bacterial Infections↗
PubMed1993

Anorectal manometry: techniques and clinical applications.

Anorectal manometry has gained wide acceptance as a helpful method to objectively assess the apparatus of defecation provided by the anorectal sphincter. The standard manometric evaluation enables measurement of resting and squeeze pressures, as well as of the length of the functional anal canal (high pressure zone [HPZ]). More detailed assessment of radial and longitudinal pressure profiles can also be generated from vector volume and vector symmetry index assessment. Adjuvant techniques using an intrarectal balloon allow assessment of the rectoanal inhibitory reflex (RAIR), rectal sensitivity, capacity, and compliance. Although anorectal manometry can be used as a diagnostic test in diseases such as Hirschsprung's disease, more often it is used to assess common disorders such as chronic idiopathic constipation and fecal incontinence. Anorectal manometry has also been considered as a preoperative evaluation in patients having abdominal and anorectal procedures during which the state of continence can be jeopardized.

Anal Canal↗
PubMed1992

How reliable are currently available methods of measuring the anorectal angle?

A prospective study was undertaken to compare two different methods of measuring the anorectal angle (ARA), balloon proctography (BP) and cinedefecography (CD), as well as to evaluate the reproducibility of this measurement using each technique. One hundred four consecutive patients (75 women and 29 men) with constipation (63 patients), fecal incontinence (25 patients), or rectal pain (16 patients) underwent both BP and CD. The ARA was measured by taking lateral radiographs of the pelvis during rest (R), squeeze (S), and push (P). The same interpretation process was performed 2 to 12 months later by the same observer, blinded as to diagnosis and initial measurements. There were highly significant differences in each measurement category, R (P less than 0.0001), S (P less than 0.0001), and P (P less than 0.0004) between BP and CD. However, the correlation between the first and second measurements was excellent (P less than 0.0001). BP was consistently more difficult to interpret because of balloon configuration. Although BP and CD have poor correlation with each other, each examination can be reliably interpreted. CD appears to be a superior examination because of the added ability to delineate rectoceles, intussusceptions, and other structural defects.

Adolescent↗
PubMed1992

Prospective assessment of biofeedback for the treatment of paradoxical puborectalis contraction.

Eighteen patients with chronic constipation were diagnosed as having paradoxical puborectalis contraction (PPC) as the cause for their constipation. The diagnosis of PPC was made after office evaluation, colonic transit study, manometry, cinedefecography, and electromyography (EMG). These 18 patients had a mean duration of symptoms of 26.9 years; none of these patients had unassisted bowel movements. Fourteen patients had a mean of 4.6 laxative-induced bowel evacuations per week, and 11 patients had a mean of 4.4 enema-induced bowel evacuations per week. Patients underwent a mean of 8.9 one-hour EMG-based biofeedback sessions. At a mean follow-up of 9.1 (range, 0.5-12) months, these 18 patients had a mean of 7.3 unassisted bowel actions per week (P less than 0.0001). In addition, persistent laxative use was reported by only two patients, and, in both cases, this was once a week or less (P less than 0.001). Similarly, enema use was reported by only three patients, one once weekly and the other two thrice weekly (P less than 0.002). No biofeedback-related complications were identified. EMG-based biofeedback is a valuable technique associated with an 89 percent success rate in the treatment of PPC.

Adolescent↗
PubMed1992

Laparoscopic total abdominal colectomy. A prospective trial.

The aim of this study was to prospectively assess the impact of laparoscopy upon the outcome of total abdominal colectomy (TAC). Specifically, patients underwent standard laparotomy with TAC and ileoproctostomy (TAC + IP), TAC and ileoanal reservoir (TAC + IAR), laparoscopically assisted TAC + IP (L-TAC + IP), or laparoscopically assisted TAC + IAR (L-TAC + IAR). Parameters studied included the length of surgery, length of ileus, length of hospitalization, morbidity, and mortality. Five patients underwent standard TAC (Group I), and five underwent L-TAC (Group II). Group I consisted of five patients of a mean age of 32 (range, 24-51) years who had mucosal ulcerative colitis (n = 1), familial adenomatous polyposis (n = 3), or colonic inertia (n = 1). Group II consisted of five patients of a mean age of 33 (range, 17-43) years who had mucosal ulcerative colitis (n = 1), familial adenomatous polyposis (n = 3), or colonic inertia (n = 1). This preliminary prospective study indicates that laparoscopically assisted TAC is feasible. L-TAC resulted in a slightly longer length of ileus and length of hospitalization; these differences were not statistically significant. Moreover, the length of time required for the laparoscopic procedures was 35 percent longer than for the open procedures. Although these results may improve as more cases are performed, dramatic differences in rates of postoperative recovery have not yet been realized. In conclusion, L-TAC, while technically feasible, dose not appear to offer any immediately recognizable benefits to the patient as compared with standard laparotomy.

Adolescent↗
PubMed1992

Retained mucosa after double-stapled ileal reservoir and ileoanal anastomosis.

A study was undertaken to assess the incidence of inflammation and dysplasia in retained mucosa after double-stapled ileoanal reservoir (IAR) for mucosal ulcerative colitis (MUC). Between September 1988 and February 1992, 56 patients with MUC underwent an IAR. Forty-five patients had a double-stapled IAR (DS-IAR), seven patients had a transanal pursestring stapled IAR (PS-IAR), and four patients had a PS-IAR with mucosectomy. Distal donuts obtained from the stapled IAR were submitted for pathologic review in 55 patients. Nine patients had only small bowel, connective tissue, and/or muscle noted on review. Mucosa was qualified as squamous epithelium (SE), transitional epithelium (TE), or columnar epithelium (CE). All samples were examined for evidence of inflammation and dysplasia. Four patients had SE only, one patient had TE, and 18 had CE. In addition, three patients had SE and CE, seven patients had SE and TE, two patients had CE and TE, and nine patients had all three types. The distance from the dentate line to the anastomosis ranged from 0 to 2.5 cm (mean, 1 cm). In 19 patients (35 percent), the distal donut revealed MUC. Of these 19 patients, six had persistent MUC (43 percent) at the time of subsequent biopsy. An additional four patients had MUC evident on follow-up biopsy but not on distal donuts; two of these four patients had no mucosa in their distal donuts. Only one of the patients with evidence of MUC on donuts and/or biopsy experienced any symptoms referable to active MUC (1.8 percent). None of the specimens examined had any evidence of dysplasia. In 31 patients, no MUC was present in the initial donuts or follow-up biopsies. Although the double-stapled technique appears safe, periodic monitoring is suggested.

Adolescent↗
PubMed1992

Laparoscopic bowel resection: advantages and limitations.

Laparoscopic surgery has been successfully employed for many years by gynecologic surgeons. Over the last several years, a tremendous increase in the enthusiasm towards laparoscopic surgery has reached the general and colorectal surgical communities. This enthusiasm was initially directed towards laparoscopic cholecystectomy but subsequently has expanded to laparoscopic appendectomy and laparoscopic bowel resection. Currently, laparoscopic bowel surgery is undergoing critical appraisal. Through meaningful prospective data retrieval, answers are being obtained to questions dealing with the efficacy and utility of this technique for colorectal diseases. Specifically, although laparoscopic colorectal surgery is feasible, one cannot definitively attest to its superiority over or even equivalence to standard open laparotomy at the present time. However, in small select series, including our own, our preliminary experience indicates that laparoscopic surgery may well, in the near future, be an acceptable substitute for standard laparotomy. This article will discuss the techniques of, instrumentation for, and preliminary results with a program of laparoscopic bowel resection.

Adolescent↗
PubMed1991

Colectomy for constipation: physiologic investigation is the key to success.

The results of total abdominal colectomy (TAC) with ileorectal anastomosis as a treatment for colonic inertia (CI) were prospectively assessed. One hundred sixty-three patients were evaluated for chronic constipation between July 1988 and November 1990. Patients underwent pancolonic transit times, anorectal manometry, cinedefecography (CD), and electromyography (EMG). CI was defined as diffuse marker delay on transit study without evidence of puborectalis contraction on CD or EMG. Sixteen patients (10 percent; 15 females and 1 male) with a mean age of 45 years (range, 24-75 years) with CI underwent TAC. Preoperative bowel frequency ranged from three per week to one per month; all 16 patients evacuated only with high doses of laxatives, enemas, or both. TAC was performed with no postoperative mortality or major morbidity; three patients were readmitted four times for successful conservative treatment of partial small bowel obstruction. At a mean follow-up of 15 months (range, 2-35 months), these 16 patients reported a mean frequency of spontaneous bowel evacuations of 3.5 per day (range, one to six per day). Patient satisfaction with the operation was "excellent" or "good" in 15 cases (94 percent). Thorough preoperative physiologic evaluation permits the selection of a small group of patients with CI who may benefit tremendously from TAC.

Adult↗
PubMed1991

Neurophysiologic assessment of the anal sphincters.

One hundred twenty consecutive patients with either fecal incontinence (60 patients), chronic constipation (41 patients), or idiopathic intractable pelvic pain (19 patients) were prospectively assessed. Patients underwent concentric needle electromyography (EMG), bilateral pudendal nerve terminal motor latency evaluation, anorectal manometry, and cinedefecography. The most common EMG finding in patients with fecal incontinence was decreased recruitment of motor units with squeezing and polyphasic motor unit potentials; these are consistent with an injury pattern. The most common EMG finding in the constipated patients was paradoxical puborectalis contraction. This latter abnormality was also a frequent finding in patients with rectal pain, as was prolongation of pudendal nerve latency. Paradoxical puborectalis contraction was diagnosed more frequently with EMG than with cinedefecography. Inter-examination correlation was best in the incontinent group between EMG and manometry. Cinedefecography had poor correlation with EMG in all patient groups but was valuable in the detection of additional pathology such as rectoanal intussusception and anterior rectocele. Electromyography including pudendal nerve terminal motor latency assessment is a valuable adjunct in the evaluation of disorders of evacuation. The information it yields is complementary to that offered by more routine physiologic examinations.

Anal Canal↗
PubMed1991

Does metoclopramide reduce the length of ileus after colorectal surgery? A prospective randomized trial.

Between August 1988 and September 1989, 100 consecutive patients who underwent elective abdominal colorectal surgical procedures were prospectively randomized to receive or not to receive metoclopramide. Metoclopramide was intravenously administered every 8 hours from the completion of surgery until a solid food diet was able to be tolerated. Seven patients were not included in the final tabulations because of one death, one small bowel obstruction requiring laparotomy, one anastomotic leak requiring laparotomy, and four protocol violations. Ninety-three patients, 37 men and 56 women (mean age, 59.5; range, 14-89 years) underwent 40 segmental colectomies, 13 total abdominal colectomies, 8 abdominoperineal resections, 8 ileoanal pouch procedures, 7 small bowel resections, and 17 other colorectal procedures. The 40 patients who received postoperative metoclopramide were in Group 1, and the 53 who did not were in Group 2. The mean length of time between laparotomy and commencement of oral fluid and oral solid intake in Groups 1 and 2 were 3.5 and 4.8 days, and 3.5 and 5.0 days, respectively. These differences were not statistically significant (P greater than 0.05). Prolonged ileus was seen in seven patients in Group 1 and in eight patients in Group 2. These differences were also not statistically significant (P greater than 0.05). Prolonged ileus was defined as the need for nasogastric tube reinsertion or discontinuation of oral intake. We conclude that metoclopramide does not significantly alter the course of postoperative ileus.

Adolescent↗
PubMed1991

The double-stapled ileal reservoir and ileoanal anastomosis. A prospective review of sphincter function and clinical outcome.

Fifteen consecutive patients (nine males and six females) who underwent construction of a double-stapled ileoanal reservoir (DS-IAR) were prospectively evaluated. Mean and maximal resting pressures preoperatively, before ileostomy closure, and at 12 months, were 53 and 84 mm Hg, 39 and 62 mm Hg, and 62 and 81 mm Hg. Mean and maximal squeeze pressures at those same time periods were 96 and 153 mm Hg, 111 and 173 mm Hg, and 95 and 168 mm Hg. There were no significant decreases in either resting or squeeze pressure between preoperative values and those obtained 12 months after surgery. However, the length of the high pressure zone decreased from 3.8 cm preoperatively to 2.3 cm at 12 months. This reflects the sacrifice of the cephalad 1.5 cm of the internal anal sphincter necessary to effect this anastomosis at a mean of 1.4 cm from the dentate line. However, this maneuver did not result in poor continence. Eleven patients whose ileostomies were closed for a mean of 9 months, ranging from 3 to 15 months, were evaluated regarding functional outcome. Only one patient had any incontinence and this patient had incomplete circular-stapled tissue rings, which necessitated transanal suture repair of the anastomotic defect. Similarly, three of the four patients who sometimes or rarely use a pad at night had transanal-suture reinforcement. Ten of the 11 patients never wear a pad during the day. No pelvic or perianal sepsis occurred. Stratified squamous epithelium was found in 6 of the 13 distal stapler "donuts" that were examined. In addition, 10 patients underwent biopsy of the tissue immediately caudad to the circular staple line at the time of ileostomy closure; in five, only stratified squamous epithelium was noted. The DS-IAR is associated with excellent objective physiologic and subjective functional results.

Adenomatous Polyposis Coli↗
PubMed1991

The role of sphincteroplasty for fecal incontinence reevaluated: a prospective physiologic and functional review.

Sixteen female patients (mean age 54.1 years; range 34-74 years) with a 9.8-year (range 1-25 years) history of incontinence to solid stool underwent overlapping sphincteroplasty with internal sphincter imbrication without fecal diversion. All patients were prospectively evaluated with preoperative anorectal manometry, electromyography, and pudendal nerve motor latency assessment, postoperative anorectal manometry, and preoperative and postoperative functional evaluation. Mean and maximal resting pressures increased from 30 mm Hg and 49 mm Hg preoperatively to 40 mm Hg and 57 mm Hg, respectively, postoperatively. Likewise, mean and maximal squeeze pressures increased from 27 mm Hg and 48 mm Hg preoperatively to 39 mm Hg and 73 mm Hg, respectively, postoperatively (P less than 0.01). Furthermore, anal canal high pressure zone length was increased by sphincteroplasty from a mean of 0.9 cm (range 0-3 cm) to a mean of 2.1 cm (range 1-4 cm). These objective physiologic improvements correlated well with subjective functional improvement. Subjectively, functional outcome was rated by patients as excellent in 38 percent, good in 38 percent, fair in 19 percent, and poor in only 5 percent of cases. Overlapping sphincteroplasty with internal sphincter imbrication improves both the anal sphincter physiologic profile and fecal continence.

Adult↗
PubMed1990

Sexually transmitted diseases of the colon, rectum, and anus. The challenge of the nineties.

During the past two decades, an explosive growth in both the prevalence and types of sexually transmitted diseases has occurred. Up to 55 percent of homosexual men with anorectal complaints have gonorrhea; 80 percent of the patients with syphilis are homosexuals. Chlamydia is found in 15 percent of asymptomatic homosexual men, and up to one third of homosexuals have active anorectal herpes simplex virus. In addition, a host of parasites, bacterial, viral, and protozoan are all rampant in the homosexual population. Furthermore, the global epidemic of AIDS has produced a plethora of colorectal manifestations. Acute cytomegalovirus ileocolitis is the most common indication for emergency abdominal surgery in the homosexual AIDS population. Along with cryptosporidia and isospora, the patient may present to the colorectal surgeon with bloody diarrhea and weight loss before the diagnosis of human immunodeficiency virus (HIV) disease. Other patients may present with colorectal Kaposi's sarcoma or anorectal lymphoma, and consequently will be found to have seropositivity for HIV. However, in addition to these protean manifestations, one third of patients with AIDS consult the colorectal surgeon with either condylomata acuminata, anorectal sepsis, or proctitis before the diagnosis of HIV disease. Although aggressive anorectal surgery is associated with reasonable surgical results in some asymptomatic HIV positive patients, the same procedures in AIDS (symptomatic HIV positive) patients will often be met with disastrous results. It is incumbent upon the surgeon, therefore, to recognize the manifestations of HIV disease and diagnose these conditions accordingly.

Acquired Immunodeficiency Syndrome↗
PubMed1990

The ileoanal reservoir.

One hundred nine men and 71 women with a mean age of 31 years had construction of 164 S, 2 J, and 14 other ileoanal reservoirs. Postoperative gastrointestinal complications included small bowel obstruction in 11 percent and ileus, hemorrhage, and sepsis in 6 percent, 5 percent, and 11 percent, respectively. There was a 13 percent incidence of miscellaneous postoperative complications. Pouch perianal fistulas developed in 5 percent of patients, and pouch vaginal and other pouch fistulas developed in an additional 4 percent. During long-term follow-up, small bowel obstruction developed in 27 percent of patients, and enterolysis or enterectomy was required in 15 percent of patients. One hundred fourteen patients who were followed for a mean length of 5 years after ileostomy closure (range 16 to 88 months) were evaluated for functional outcome. Function improved with time in 63 percent of patients and remained stable in another 33 percent; only 4 percent had long-term deterioration. Ninety-five percent of patients would again choose an ileoanal reservoir over a permanent ileostomy. This long-term assessment shows that although the ileoanal reservoir is a viable option in the management of mucosal ulcerative colitis, it should not be recommended to every patient.

Adenomatous Polyposis Coli↗
PubMed1989

Long-term functional analysis of the ileoanal reservoir.

Since November 1980, 180 patients underwent abdominal colectomy, rectal mucosectomy, ileoanal reservoir construction, and ileoanal anastomosis at the authors' institutions. One hundred twenty-nine patients had restoration of intestinal continuity before the end of 1986. One hundred fourteen of these patients (88 percent) were available for follow-up at a mean length of time of 5.0 years from ileostomy closure (range, 16 to 88 months). The mean number of pouch evacuations was 5.4 +/- 2.5 during the day (range, 1 to 12) and 1.5 +/- 1.0 at night (range, 0 to 6). Ninety-one percent of patients reported perfect or almost perfect daytime continence, and 74 percent found this true at night. Sixty-three percent of patients believed their pouch function continued to improve over many years. Ninety-five percent of patients questioned would choose an ileoanal reservoir again instead of a permanent ileostomy. This long-term assessment of the function of the ileoanal reservoir confirms that it is a viable, although not perfect, option in the management of ulcerative colitis and familial adenomatous polyposis.

Activities of Daily Living↗