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Biomedical subjects

T Bayless

Publications and source records attributed to T Bayless.

10 recordsLinked to original sources
PubMed2001

Laparoscopic surgery for Crohn's disease: reasons for conversion.

OBJECTIVE: To examine factors influencing conversion from a laparoscopic to an open procedure in patients requiring surgery for Crohn's disease. SUMMARY BACKGROUND DATA: Laparoscopic management of patients with complications of Crohn's produces better outcomes than traditional open approaches, but it is difficult to determine before surgery who will be amenable to laparoscopic management. In this series, a laparoscopic approach was offered to virtually all patients to determine reasons for laparoscopic failure. METHODS: Data regarding patients who underwent attempted laparoscopic procedures for Crohn's (January 1993 to June 2000) were collected prospectively. The bowel was mobilized laparoscopically and extracorporeal anastomoses were performed. Conversion to open surgery was defined as creation of an incision of more than 5 cm. RESULTS: One hundred ten patients (age 37 +/- 1.1 years, 58% female) underwent 113 attempted laparoscopic interventions. Indications for surgery included obstruction (77%), failure of medical management (35%), fistula (27%), and perineal sepsis (4%). Sixty-eight procedures (60%) were completed laparoscopically. Procedures completed laparoscopically included ileocecectomy (n = 46), small bowel resection (n = 22), fecal diversion (n = 7), intestinal stricturoplasty (n = 7), resection of prior ileocolonic anastomosis (n = 5), segmental colectomy (n = 1), and lysis of adhesions (n = 1). Forty-five procedures (40%) were converted as a result of adhesions (n = 21), extent of inflammation or disease (n = 9), size of the inflammatory mass (n = 7), inability to dissect a fistula (n = 5), or inability to assess anatomy (n = 3). Factors associated with conversion were internal fistula as an indication for surgery, smoking, steroid administration, extracecal colonic disease, and preoperative malnutrition. In laparoscopic patients, mean times to passage of flatus and first bowel movement were 3.6 +/- 0.2 days and 4.4 +/- 0.2 days, respectively. Mean time to discharge was 6 +/- 0.2 days. CONCLUSIONS: Attempted laparoscopic management is safe and effective if there is an appropriate threshold for conversion to an open procedure. Conversion factors identified in this study largely reflect technical challenge and severity of disease. Patients taking steroids and those with known fistulas or colonic involvement threaten laparoscopic failure, but many of these patients can be managed laparoscopically and have better outcomes. By understanding the reasons for conversion, it is hoped that the chances of laparoscopic success can be improved by modifying standard preoperative medical management or using additional technological capabilities (e.g., robotics).

Adult↗
PubMed2001

Utilisation of erythrocyte 6-thioguanine metabolite levels to optimise azathioprine therapy in patients with inflammatory bowel disease.

BACKGROUND AND AIM: The immunosuppressive properties of 6-mercaptopurine and its parent compound azathioprine are mediated by their intracellular metabolism into active 6-thioguanine (6-TG) metabolites. Measurement of erythrocyte 6-TG metabolite levels has been proposed as a useful clinical tool for assessing treatment efficacy in patients with inflammatory bowel disease (IBD). AIM: The purpose of the study was to establish a therapeutic index of treatment efficacy based on measurement of erythrocyte 6-TG metabolite levels, and apply it clinically to guide therapy. METHODS: Heparinised blood was obtained from 82 adult patients with IBD on long term (more than three months) antimetabolite therapy (63 Crohn's disease; 19 ulcerative colitis). Erythrocyte 6-TG metabolite levels were measured using reverse phase high performance chromatography, and correlated with treatment efficacy. In 22 patients with refractory Crohn's disease despite long term azathioprine therapy, their dosage was increased by 25 mg/day at eight week intervals as needed. Serial erythrocyte 6-TG metabolite levels were measured at each clinic visit and correlated with treatment efficacy. RESULTS: Clinical remission, as defined by a low disease index score in patients weaned off or on a low alternate day dose (<20 mg on alternate days) of corticosteroid, was achieved in 68% of patients on long term antimetabolite therapy. Treatment efficacy correlated with erythrocyte 6-TG levels greater than 250 pmol/8x10(8) red blood cells in patients with colonic and fistulising Crohn's disease (p<0.01) but not in patients with ileocolonic disease. Eighteen of 22 patients with incompletely responsive Crohn's disease achieved disease remission by optimising their dose of azathioprine therapy. Median (range) erythrocyte 6-TG metabolite levels increased from 194 (67-688) to 303 (67-737) pmol/8x10(8) red blood cells (p<0.05). Clinical response associated well with a reduction in corticosteroid requirements. Mean (SEM) white blood cell count decreased from 8.6 (0.9) to 6.9 (0.6) x10(3)/microl with adjustment in azathioprine dosage. No patient incurred azathioprine induced leucopenia. CONCLUSION: Measurement of erythrocyte 6-TG metabolite levels is helpful in determining the adequacy of azathioprine dosage and can be used to optimise the dose of antimetabolite therapy to achieve an improved clinical response without inducing leucopenia. Patients who are clinically refractory to azathioprine therapy despite achieving high erythrocyte 6-TG levels (>250) should be considered for adjunct or alternative forms of immunosuppressive therapy or surgery.

Adolescent↗
PubMed1997

A randomized, double-blind study of the effect of olestra on disease activity in patients with quiescent inflammatory bowel disease. Olestra in IBD Study Group.

PURPOSE: To determine the effects of olestra, a zero-calorie fat substitute that is neither digested nor absorbed, on the well-being and disease state of persons with chronic inflammatory bowel disease (IBD) in remission. PATIENTS AND METHODS: Eighty-nine patients with mild to moderate ulcerative colitis (n = 43) or Crohn's disease (n = 46) in remission, with a history of disease of 2 years or longer, were enrolled in this prospective study from nine private practices, three university-based medical centers, and one Veterans Administration medical center in the United States. Forty-four patients were randomly assigned to receive olestra and 45 to receive triglycerides in chips or cookies daily for 4 weeks. At Week 4, patients were classified as in remission, worsened, or relapsed according to an investigator's global assessment based on sigmoidoscopy (for ulcerative colitis) or the Crohn's disease activity index, laboratory findings, and clinical course. RESULTS: At Week 4, the olestra and triglyceride groups did not differ significantly with respect to the percentages of patients who relapsed (P = 0.494; difference = 2.4%; upper 95% CL = 8.8%) or with respect to the percentages of patients who experienced any worsening of their symptoms (P = 0.630; difference = 0.2%; upper 95% CL = 13.3%). Of evaluable patients, 90% (37 of 41) given olestra remained in remission with no worsening, compared with 90% (38 of 42) given triglycerides. Gastrointestinal symptoms were comparable between the treatment groups, and there were no treatment-related laboratory abnormalities. Six patients were excluded from analysis for reasons unrelated to treatment. CONCLUSION: Olestra did not affect the activity of quiescent mild to moderate IBD.

Abdominal Pain↗
PubMed1996

Simple radiographic evaluation of ileoanal pouch volume.

PURPOSE: Total colectomy and mucosal protectomy with ileal reservoir and anal pull-through is used in the treatment of ulcerative colitis or familial polyposis, with one complication being frequent bowel movements. A simple radiographic test to predict frequency of bowel movements and measure spasticity was evaluated. METHODS: Fourteen patients underwent evaluation after ileal reservoir and anal pull-through J-pouch construction. Barium sulfate suspension was instilled into the pouch via the anus in the standing position until reflux flowed into the small intestine proximal to the pouch and patients felt the urge to defecate. Total volume infused (VOLtot), volume to reflux (VOLrflx), and volume voided (VOLvoid) were measured. RESULTS: VOLvoid and the "voiding efficiency" (VOLvoid/VOLtot) correlated significantly with stool frequency (R=-0.744, P<0.002 and R=-0.754, P<0.002, respectively). Time from operation was correlated with VOLvoid and stool frequency (R=-0.723, P<0.003 and RO.573, P<0.032, respectively). CONCLUSIONS: The addition of quantitative measurements to this radiographic test gives useful information about pouch performance. Furthermore, the data imply that spasticity, as measured by voiding quantum and efficiency, rather than actual pouch volume is a major determinant of bowel movement frequency.

Adult↗
PubMed1996

The preservation of good medicine is dependent on information.

BASIS FOR THE ARGUMENT. Virtually all physicians feel a growing loss of control in their private practices and a sense of disillusionment with today's medicine. In the good ole days of modern medicine, medicine was a profession and a physician had a special bond with his patient and his community. In a constructive sense, a physician had power which was used to practice good medicine and provided part of the basis for a satisfying practice. As modern medicine evolved, the complexity of the science and the cost of technology forced new, non-physician players into the process of providing patient care. Over time, costs seemed to become the predominant theme and medicine became a business. One fact is certain, that as a result of this process, physicians lost power. Less provable, but widely believed, is that patient care suffered. There is also a growing concern that clinical outcomes are less than optimal and that health care services are more costly than they need to be because of wide variations in the diagnostic and treatment processes.

Communication↗
PubMed1992

Cytokeratin polypeptide profile of Merkel cells in human fetal and adult skin: difference of expression of cytokeratins in epidermal and dermal Merkel cells.

The origin of Merkel cells is uncertain, although current evidence by immunohistochemical keratin marker studies favors an epidermal derivation. We studied the expression of keratin species in Merkel cells of human fetus and adult using 19 anti-keratin antibodies. Epidermal and dermal Merkel cells contained not only simple epithelium-type but also some stratified epithelium-type keratins. Interestingly, expression of some keratins was different between epidermal and dermal Merkel cells, for example, AN3 (50, 58 kD) and CKB1 (50 kD) recognized epidermal Merkel cells, but not dermal Merkel cells. These results suggest that surrounding keratinocytes influence the expression of cytokeratins in Merkel cells or that dermal Merkel cells undergo a modification from keratin-producing epidermal Merkel cells to a more neural cell type by the association with nerve endings in the upper dermis. On the other hand, certain cytokeratin polypeptides recognizable with Ks19.1 (40 kD), CK5 (45 kD), and CAM5.2 (52.5 kD) were expressed in both epidermal and dermal Merkel cells. The expression of simple epithelium-type keratins in Merkel cells remained even after the epidermal basal cells gradually lost their expression.

Adult↗