Biomedical subjects
Publications and source records attributed to Steven D Wexner.
Many surgical methods have been described for the treatment of full-thickness rectal prolapse. Rarely, unusually large lengths of colon must be excised, thus resulting in a significant loss of the absorptive function of the remaining colon. We present an unusual case in which an extraordinary length of the colon was excised and a perineal reservoir was created in the form of a colonic J-pouch to improve continence.
Although significant work has been presented on this subject in pediatric, infectious disease, and epidemiologic literature, there is a noteworthy lack of information on Escherichia coli O157:H7 in any surgical journals. As this disease can present with signs and symptoms often ascribed to the acute abdomen, it is imperative that the general surgeon, pediatric surgeon, and colorectal surgeon are all familiar with this infection and its clinical ramifications. A case report followed by a review of the literature is presented.
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Severe chronic constipation is a debilitating condition. Patients not only experience infrequent bowel movements, but also are often frustrated by the sensation of incomplete evacuation; pain; straining; daily use of enemas; and continual concerns regarding diet, fluids, and medications. Diagnostic tests are performed to rule out organic causes of the condition. Common treatment options consist of dietary fiber supplementation, dietary instruction, adequate fluid intake, enemas, and laxatives; additional noninvasive management includes biofeedback training and botulinum toxin type A injections. Surgery is rarely recommended, although a select group of patients may benefit from antegrade continence enema procedure. A female patient presented with a history of long-standing constipation. When antegrade continence enema offered no improvement and other treatment measures failed, she underwent successful laparoscopic-assisted sigmoid resection and end colostomy. This approach may provide options for patients in similar circumstances.
INTRODUCTION: The aim of this study was to assess the outcome of patients with indeterminate colitis undergoing double-stapled ileal pouch anal anastomosis. METHODS: A retrospective review of demographic, disease-related, and outcome variables of all patients undergoing double-stapled ileal pouch anal anastomosis from August 1988 to January 2000 was undertaken. All patients were evaluated using the validated American Society of Colon and Rectal Surgeons Fecal Incontinence Severity Index. Patients with familial adenomatous polyposis, those who had undergone pouch revision or had S-configured pouches, and patients with a follow-up of less than three months were excluded from analysis. RESULTS: Three hundred ninety-five patients underwent the double-stapled ileal pouch anal anastomosis; of these 303 patients were included for analysis. The mean duration of follow-up was 40 months. Fifty-six (18.1 percent) had a preoperative diagnosis of indeterminate colitis. Postoperatively, indeterminate colitis was diagnosed in 13 (4.3 percent), mucosal ulcerative colitis in 285 (94 percent), and Crohn's disease in 5 (1.6 percent). The overall complication rate was 37.7 percent, 60 percent, and (30.7) percent in patients with mucosal ulcerative colitis, Crohn's disease, and indeterminate colitis, respectively. Postoperative hemorrhage, abscess, and fistula occurred in 2.4 percent, 6.3 percent, and 3.9 percent, respectively, in patients with mucosal ulcerative colitis, and 0 percent, 15.3 percent, and 7.7 percent, respectively, in patients with indeterminate colitis. Small-bowel obstruction occurred in 8.5 percent, 20 percent, and 7.7 percent of patients with mucosal ulcerative colitis, Crohn's disease, and indeterminate colitis, respectively. Pouchitis occurred in 4.6 percent of patients with mucosal ulcerative colitis but in none of the patients with indeterminate colitis. Dysplasia of the anal transition zone was seen in one patient each with mucosal ulcerative colitis and indeterminate colitis. These patients had consistent follow-up and neither showed any sign of evolution to neoplastic disease. None of the patients with indeterminate colitis had a postoperative diagnosis of Crohn's disease during the follow-up period. Functional outcome was comparable in all three patient groups. CONCLUSION: The outcome of the double-stapled ileal pouch anal anastomosis in patients with indeterminate colitis is similar to that of patients with mucosal ulcerative colitis. Therefore, it is a safe option in patients with indeterminate colitis.
PURPOSE: Postoperatively, some patients experience a prolonged inhibition of coordinated bowel activity, which causes accumulation of secretions and gas, resulting in nausea, vomiting, abdominal distension, and pain. This prolonged inhibition can take days or weeks to resolve and often is referred to as postoperative paralytic ileus lasting more than three days after surgery. This article reviews the etiology, pathophysiology, and treatment options of postoperative ileus. METHODS: The relevant literature from 1965 to 2003 was identified and reviewed using MEDLINE database of the U.S. Medical Library of Medicine. Both retrospective and prospective studies were included in this review. RESULTS: The pathophysiology of postoperative ileus is multifactorial. The duration of postoperative ileus correlates with the degree of surgical trauma and is most extensive after colonic surgery. However, postoperative ileus can develop after all types of surgery including extraperitoneal surgery. A variety of treatment options have been used to decrease the duration of postoperative ileus. However, it is difficult to compare these studies because of small sample sizes and differences in operations performed, anesthesia protocols provided both intraoperatively and postoperatively, patient comorbidities, and in the measured end points, such as the time to the presence of bowel sounds, flatus, or bowel movements, tolerance of solid food, or discharge from the hospital. However, despite these drawbacks, some conclusions can be made. CONCLUSIONS: Paralytic postoperative ileus continues to be a significant problem after abdominal and other types of surgery. The etiology is multifactorial and is best treated with a combination of different approaches. Currently, the important factors that could effect the duration and recovery from postoperative ileus include limitation of narcotic use by substituting alternative medications such as nonsteroidals and placing a thoracic epidural with local anesthetic when possible. The selective use of nasogastric decompression and correction of electrolyte imbalances also are important factors to consider.
Numerous proven surgical therapies now exist to compensate for loss of anal sphincter function or loss of rectal reservoir capacity. Fecal incontinence that results from the combined loss of rectal reservoir and anal sphincter tone remains a surgical challenge. This case describes what may be the first successful treatment of a patient with imperforate anus and familial adenomatous polyposis using an ileal J-pouch and artificial bowel sphincter.
HYPOTHESIS: Endoanal ultrasonographic results have demonstrated that clinically occult anal sphincter damage during vaginal delivery is common. This may or may not be associated with postpartum fecal incontinence (FI). Bayesian meta-analysis of the literature revealed that at least two thirds of obstetric sphincter disruptions are asymptomatic in the postpartum period. Women with postpartum asymptomatic sphincter damage may be at increased risk for FI with aging compared with those without sphincter injury. DESIGN: Case series. SETTING: Tertiary referral center. PATIENTS: After excluding patients with other possible causes of FI, the histories of 124 consecutive women with late-onset FI after vaginal delivery were analyzed. MAIN OUTCOME MEASURES: Endoanal ultrasonographic findings, pudendal nerve terminal motor latency assessment, and anal manometric results. RESULTS: Eighty-eight women (71%) with a median of 3 vaginal deliveries had sphincter defects on endoanal ultrasonographic results. The mean incontinence score, squeeze and resting pressures, median age at last delivery, and median duration of FI were not significantly different between patients with and without sphincter defects. Pudendal neuropathy was more frequent in patients without sphincter defects (10 [30.3%], left side; 12 [36.4%], right side) than in patients with sphincter defects (12 [14.3%] and 16 [19.3%], respectively), with the difference nearly reaching statistical significance (P =.054 and P =.059, respectively). The median age at onset of FI in patients with a sphincter defect was 61.5 years vs 68.0 years in those without a sphincter defect, which was not statistically significant (P =.08). CONCLUSION: Analysis of the current patient population revealed that 88 women (71%) with late-onset FI after vaginal delivery had an anatomical sphincter defect. Thus, FI related to anal sphincter defects is likely to occur even in an elderly population who had experienced vaginal deliveries earlier in life.
INTRODUCTION: Anorectal malformations are among the various etiologic factors causing fecal incontinence. Patients with imperforate anus are difficult to treat, specifically those with high lesions. The artificial bowel sphincter and electrically stimulated gracilis neosphincter are two relatively new techniques that have been used for the treatment of patients with severe refractory fecal incontinence. The aim of this study was to evaluate the results of these technologies in the treatment of patients with chronic fecal incontinence due to imperforate anus. METHODS: All patients with imperforate anus who had fecal incontinence and underwent either the artificial bowel sphincter procedure or the gracilis neosphincter procedure between February 1995 and December 2000 were evaluated. Preoperative and postoperative incontinence score (Cleveland Clinic Florida Incontinence Score; 0 = perfect continence; 20 = complete incontinence), quality of life, (Fecal Incontinence Quality of Life Scale, 29 items forming 4 scales), and manometric sphincter pressure results were compared. RESULTS: Eleven patients had artificial bowel sphincter and five had the gracilis neosphincter (one nonstimulated) procedure. There were 11 males and 5 females of a mean age of 25.3 (range, 15-45) years. The mean follow-up time was 1.7 years (5 months to 5.7 years). Eight (50 percent) complications occurred in six patients, including three with fecal impaction (all artificial bowel sphincter), three with device migration (two gracilis neosphincter, one artificial bowel sphincter), and two patients with concomitant wound infection (one gracilis neosphincter, one artificial bowel sphincter); no patients had the devices explanted. Fourteen patients had manometric data (10 artificial bowel sphincter and 4 gracilis neosphincter) available. The overall incontinence score decreased from a preoperative mean of 18.5 to a postoperative mean of 7.5 in the artificial bowel sphincter group (P < 0.01) and from 17.4 to 9.4 in the gracilis neosphincter group (P = 0.06). All four Fecal Incontinence Quality of Life scales increased in both the artificial bowel sphincter (lifestyle and depression/self-perception, P = 0.02; coping/behavior and embarrassment, P = 0.03) and the gracilis neosphincter (lifestyle and coping, P = 0.06; depression and embarrassment, P = 0.05) patients. As well, the mean resting and squeeze pressures increased with both techniques (artificial bowel sphincter: P = 0.008 and P = 0.02, respectively; gracilis neosphincter: P = 0.4 and P = 0.1, respectively). All results were statistically significant in the artificial bowel sphincter group. CONCLUSIONS: Artificial bowel sphincter and gracilis neosphincter are efficient methods to treat patients with imperforate anus. These techniques should be considered for patients with imperforate anus and severe fecal incontinence.
PURPOSE: Preoperative chemoradiation may downstage locally advanced rectal cancer and, in some cases, with no residual tumor. The management of complete response is controversial and recent data suggest that radical surgery may be avoided in selected cases. Transanal excision of the scar may determine the rectal wall response to chemoradiation. This study was designed to assess whether the absence of tumor in the bowel wall corresponds to the absence of tumor in the mesorectum, known as true complete response. METHODS: A retrospective review of the medical records of patients who underwent preoperative chemoradiation for advanced mid (6-11 cm from the anal verge) and low (from the dentate line to 5 cm from the anal verge) rectal cancer (uT2-uT3) followed by radical surgery with total mesorectal excision was undertaken. Patients in whom the pathology specimen showed no residual tumor in the rectal wall (yT0, "y" signifies pathologic staging in postradiation patients) were assessed for tumoral involvement of the mesorectum. RESULTS: A total of 109 patients underwent preoperative, high-dose radiation therapy (94 percent with 5-fluorouracil chemosensitization), followed by radical surgery for advanced rectal cancer. Preoperatively, 47 patients were clinically assessed to have potentially complete response. After radical rectal resection, pathology did not reveal any residual tumor within the rectal wall (yT0) in 17 patients. In two (12 percent) of these patients, the mesorectum was found to be positive for malignancy: one had positive lymph nodes that harbored cancer; one had tumor deposits in the mesorectal tissue. CONCLUSIONS: Compete rectal wall tumor eradication does not necessarily imply complete response, because the mesorectum may harbor tumor cells. Thus, caution should be exercised when considering the avoidance of radical surgery. Reliable imaging methods and clinical predictors for favorable outcome are important to allow less radical approaches in the future.
PURPOSE: Sexual dysfunction after total mesorectal excision may be caused by injury to the autonomic nerves. During surgery, nerve identification is not always achieved, and, to date, there has been no method to objectively confirm nerve preservation. The aim of this study was to assess the efficacy of a nerve-stimulating device (CaverMap) to assist in the intraoperative identification of the autonomic nerves during total mesorectal excision, and objectively confirm nerve preservation after proctectomy is completed. PATIENTS AND METHODS: Sexually active consecutive male patients undergoing total mesorectal excision were prospectively enrolled in this study. During pelvic dissection, the surgeon attempted to localize the hypogastric and cavernous nerves. CaverMap was used to confirm these findings and to facilitate the identification in cases of uncertainty. At the completion of proctectomy, the nerves were restimulated to ensure preservation. Factors that could affect the surgeon's ability to localize the nerves and CaverMap to confirm this were evaluated. RESULTS: Twenty-nine male patients with a median age of 58 years were enrolled in this study. An attempt to visualize the hypogastric nerves during dissection was made in 26 patients; the surgeon was able to identify the nerves in 19 (73 percent) patients. CaverMap successfully identified the nerves in six of the seven remaining patients, and failed to identify them in only one case. An attempt to localize the cavernous nerves during dissection was made in 13 patients, of which localization was successful in 8 (61.5 percent) patients. CaverMap improved the identification rate in four of the remaining five patients. After proctectomy, CaverMap successfully confirmed the preservation of both hypogastric and cavernous nerves in 27 of 29 (93 percent) patients. A history of previous surgery statistically correlated with failure to identify the hypogastric nerves by the surgeon (P = 0.005). There were no adverse events related to use of the device. CONCLUSION: CaverMap may be a useful tool to facilitate identification of the pelvic autonomic nerves during total mesorectal excision and to objectively confirm nerve preservation.
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The advantages of laparoscopy in the treatment of benign disease have been well demonstrated. Compared to open surgery, laparoscopy is associated with a shorter hospital stay, less ileus, decreased postoperative pain, earlier return to work, and better cosmesis. The role of laparoscopy for the cure of malignant disease, however, remains controversial. In order to elucidate the safety and efficacy of laparoscopy for malignancy, worldwide large controlled randomized trials were developed. While awaiting the results of large randomized trials, a review of the many published studies to date was undertaken demonstrating a high level of evidence of the superiority of laparoscopy over laparotomy in regard to short-term benefits, when performed by appropriately skilled surgeons in properly selected patients. The data also suggest similar or superior local recurrence and long-term survival rates. However, further follow-up and review of large, multicenter, randomized trials will be needed before widespread acceptance of the technique can be recommended.
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The introduction of new techniques and technologies in medical science is both stimulating and controversial. This article is a review of the current status of two such advances. Since its first description, the so-called "stapled hemorrhoidectomy" has been gaining increasing popularity, at first in Asia and Europe, and more recently in the United States. It is obviously a misnomer, since no excision of hemorrhoidal tissue is undertaken in this procedure. It is probably the most significant change in the surgical treatment of hemorrhoids since the introduction of conventional hemorrhoidectomy. Patients routinely experience less postoperative pain and have excellent control of symptoms, with few serious complications in most series. Despite a relatively simple operative technique, the procedure still has specific steps and features that must be followed and mastered to help insure success. The use of fibrin glue for treatment of perianal fistulae has also been a controversial issue, thus it is seldom included in any algorithm as a therapeutic step for fistula-in-ano. The reported success rates of the treatment range from 0% to 100% owing to the heterogeneity of the clinical trials, treatment protocols, patients, etiologies, and types of fistulae. However, the benign nature, simplicity, negligible morbidity, and repeatability of the treatment, potentially makes fibrin glue an attractive first line treatment for perianal fistulae.
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PURPOSE: This multicenter study evaluated the safety and efficacy of radio-frequency energy delivery to the anal canal for the treatment of fecal incontinence. METHODS: Fifty patients at five centers were enrolled. All reported fecal incontinence at least once per week for three months, and medical and/or surgical management failed to help their symptoms. At baseline and at six months, patients completed questionnaires (Cleveland Clinic Florida Fecal Incontinence score (0-20), fecal incontinence-related quality of life, Short Form-36, and visual analog scale) and underwent anorectal manometry, endoanal ultrasound, and pudendal nerve terminal motor latency testing. On an outpatient basis using local anesthesia, radio-frequency energy was delivered via an anoscopic device with multiple needle electrodes (Secca system) to create thermal lesions deep to the mucosa of the anal canal. RESULTS: Forty-three females and seven males (aged 61.1 +/- 13.4 (mean +/- standard deviation); range, 30-80 years) were treated. Mean duration of fecal incontinence was 14.9 years. Treatment time was 37 +/- 9 minutes. At six months, the mean Cleveland Clinic Florida Fecal Incontinence score improved from 14.5 to 11.1 (P < 0.0001). All parameters in the Fecal Incontinence Quality of Life scales were improved (lifestyle (from 2.5-3.1; P < 0.0001); coping (from 1.9-2.4; P < 0.0001), depression (from 2.8-3.3; P = 0.0004); embarrassment (from 1.9-2.5; P < 0.0001)). Responders, as assessed by a systematic referenced analog scale, reported a median 70 percent resolution of symptoms. The mean Short Form-36 social function improved from 64.3 to 76 (P = 0.003). There were no changes in endoanal ultrasound or pudendal nerve terminal motor latency assessment, or in anal manometry. Complications included mucosal ulceration (one superficial, one with underlying muscle injury) and delayed bleeding (n = 1). CONCLUSION: This multicenter trial demonstrates that radio-frequency energy can be safely delivered to the lower rectum and anal canal. The Secca procedure significantly improved the Cleveland Clinic Florida Fecal Incontinence score and the overall quality of life for most patients having undergone the procedure.