Biomedical subjects
Publications and source records attributed to T M Young-Fadok.
The advanced laparoscopic skills required for laparoscopic resection of the colon and rectum have precluded wide dissemination of this procedure. By applying certain key principles, laparoscopic right hemicolectomy can be made simple, reproducible, easy to teach, easy to learn, and cost-effective.
PURPOSE: The aim of this study was to determine rates of complications and extent of benefits for laparoscopic-assisted colectomy compared with open colectomy in patients older than age 75. METHODS: Forty-two patients undergoing laparoscopic-assisted colectomy (1992-1998) were matched to 42 open colectomy patients for gender, age, year of surgery, operating surgeon, and procedure. Health status (American Society of Anesthesiology score), previous abdominal surgery, conversion rate, surgical outcome, and need for assistance at admission and dismissal (independence vs. home with assistance vs. nursing facilities) were reviewed. RESULTS: Mean ages were 81.2 and 80.5 years for laparoscopic-assisted colectomy and open colectomy, respectively (P = not significant). Twenty-one laparoscopic-assisted colectomy and 23 open colectomy patients were females. American Society of Anesthesiology scores were comparable, as were rates of previous abdominal surgery (57 percent for laparoscopic-assisted colectomy vs. 62 percent for open colectomy; P = not significant). Mean operative times were longer for laparoscopic-assisted colectomy (190 minutes for laparoscopic-assisted colectomy vs. 142 minutes for open colectomy; P < 0.001); operating room times progressively decreased from 221 minutes in 1992 to 1995 to 147 in 1998 for laparoscopic right hemicolectomy (P < 0.001). The conversion rate for laparoscopic-assisted colectomy was 14.3 percent. There were no deaths in either group, and laparoscopic-assisted colectomy was associated with fewer morbidities (14.3 percent for laparoscopic-assisted colectomy vs. 33.3 percent for open colectomy; P = 0.04), narcotic usage (2.7 vs. 4.8 days; P < 0.001), time to return to bowel movements (3.9 vs. 5.9 days; P < 0.001), and length of hospital stay (6.5 vs. 10.2 days; P < 0.001). Independent status at admission in 37 laparoscopic-assisted colectomy and 38 open colectomy patients was maintained at discharge by 35 laparoscopic-assisted colectomy vs. 29 open colectomy patients (P = 0.025). CONCLUSIONS: Laparoscopic-assisted colectomy is safe and beneficial, including preservation of postoperative independence, to the elderly when compared with open colectomy.
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OBJECTIVE: To clarify the true benefits of laparoscopic-assisted colectomy by comparing clinical outcomes from a series of laparoscopic right colectomies with matched open colectomies, all performed for the singular indication of polyp not amenable to colonoscopic removal. PATIENTS AND METHODS: A retrospective case-matched study was performed of consecutive patients undergoing laparoscopic-assisted right hemicolectomy for polyps between January 1992 and July 1997. Each case was matched to a control undergoing the equivalent open procedure for the same indication during the same time period. RESULTS: Thirty-eight patients undergoing laparoscopic-assisted right hemicolectomy for polyps were identified, and matches were found. The conversion rate was 18.4% (7/38), 21.4% early in the series and 10% in later experience. Operative times were longer for laparoscopic-associated colectomy (median, 208 minutes vs 150 minutes, P < .001). Laparoscopic-assisted colectomy resulted in shorter postoperative ileus (time to flatus, 3.0 vs 4.0 days, P < .001; time to bowel movement, 3.5 vs 5.0 days, P < .001) and in earlier tolerance of regular diet (3.5 vs 6.0 days, P < .001). Fewer days of narcotic administration were required by the laparoscopic group (3.0 vs 4.5 days, P < .001). This resulted in a significantly shorter length of hospital stay (4.0 vs 7.0 days, P < .001). There was no significant difference in the incidence of postoperative complications. CONCLUSIONS: Laparoscopic right hemicolectomy has significant patient benefits. These benefits are apparent when procedures of equal complexity and equivalent indications are compared. Laparoscopic-assisted resection has become our preferred approach for polyps not amenable to colonoscopic polypectomy.
INTRODUCTION: Although basal cell carcinoma remains the most common cutaneous malignancy, its occurrence in the perianal region is very rare. Earlier reports have suggested that basal cell carcinoma in this region may be more aggressive than basal cell carcinoma in other regions of the body. METHODS: A chart review of patients with perianal basal cell carcinoma who presented consecutively during a 20-year period (ending December 1996) was performed. Patients included were those with a histologically proven diagnosis of basal cell carcinoma in the perianal region. RESULTS: Twenty-one cases were identified (15 male) with a mean age at diagnosis of 67 (range, 43-81) years. Follow-up data were available on 19 patients with a mean follow-up time of 72 (range, 2-214) months. Seventeen patients were treated by local excision, one by electrocautery, and one by Moh's surgery. No patients developed a local recurrence. Seven patients (33 percent) had multiple basal cell carcinomas at other anatomic sites. Four patients died of other causes during the follow-up period. CONCLUSIONS: Perianal basal cell carcinoma is a rare tumor. Given the significant association with multiple lesions at other sites, a diagnosis of perianal basal cell carcinoma should prompt an examination of all cutaneous surfaces. It does not seem to be more aggressive in this region than in other areas. Local excision seems to provide adequate control.
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UNLABELLED: Controversy exists regarding the role of prophylactic oophorectomy during resection for primary colorectal cancer. PURPOSE: A prospective, randomized trial was initiated to evaluate the influence of oophorectomy on recurrence and survival in patients with Dukes Stages B and C colorectal cancer. METHOD: Between November 1986 and March 1997, 155 patients were randomized to oophorectomy or no oophorectomy at laparotomy for resection of colorectal cancer. RESULTS: No incidence of gross or microscopic metastatic disease to the ovary was found among 77 patients randomized to oophorectomy, in contrast to previous reports. Preliminary crude survival curves suggested a survival benefit for oophorectomy between two and three years from surgery, but Kaplan-Meier survival analysis indicated that this was not statistically significant and the benefit does not appear to persist at five years. Kaplan-Meier curves of recurrence-free survival, however, suggest a more substantial separation of the curves, with 80 percent vs. 65 percent five-year disease-free survival for oophorectomy vs. nonoophorectomy, but further patient accrual is necessary to provide sufficient statistical power. CONCLUSIONS: Occult colorectal carcinoma metastatic to the ovaries has not been documented in this series of putative Dukes Stages B and C tumors. The possibility of a recurrence-free survival advantage emphasizes the need to continue this preliminary work.
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UNLABELLED: Ileosigmoid fistulas are found in Crohn's disease and may present a surgical dilemma. PURPOSE: This study was designed to examine surgical practice to determine types of intervention, enumerate complications, and elicit guidelines for surgical management. METHOD: The medical records of patients with ileosigmoid fistula and Crohn's disease from 1975 to 1995 were reviewed. RESULTS: Ninety patients (44 men) were studied. A preoperative diagnosis of ileosigmoid fistula was made in 77 percent of patients. Sigmoid repair was performed in 43 patients (47.8 percent), sigmoid resection in 32 patients (35.6 percent), 12 patients (13.3 percent) underwent more extensive procedures, and 3 patients (3.3 percent) either had surgery elsewhere or were observed. The fistula was never directly responsible for a stoma. The repair and resection groups were similar with respect to age, length of Crohn's disease, and preoperative symptoms. There was no significant difference between groups in the incidence of postoperative complications; there were no postoperative deaths. Average length of stay was 8.3 days following repair and 9.9 days after resection. Reasons for resection included significant purulence or inflammation, a large fistula defect, a defect on the mesenteric border of the sigmoid, and active sigmoid Crohn's disease. Surgeon's assessment of the presence of Crohn's disease in the sigmoid correlated with pathologic examination and was aided by knowledge of recent endoscopic appearance and biopsy results; intraoperative frozen section and colonoscopy were helpful in distinguishing serosal inflammation from active Crohn's disease. CONCLUSION: Contrast studies identified 77 percent of ileosigmoid fistulas preoperatively. Performing repair rather than resection does not increase the risk of complications, if standard surgical principles are followed. Preoperative or intraoperative endoscopy assists the surgical evaluation of the sigmoid.
Previous studies of renal transplant recipients have demonstrated that allograft rejection is accompanied by an increase in plasma and urinary levels of interleukin 2 and its soluble receptor before the development of clinical symptoms. After measuring interleukin 2 and interleukin 2 receptor levels in the plasma, bile, and urine of liver transplant recipients, we found that rejection is preceded by elevation of plasma and biliary levels of both substances, that cyclosporine toxicity did not affect either of these levels, and that urinary levels of the substances are unaffected in either condition. Levels of interleukin 2 and interleukin 2 receptors increased in bile earlier than in plasma, and interleukin 2 levels did not overlap among stable patients and those experiencing rejection, whereas levels of interleukin 2 receptors did. Serial measurements of interleukin 2 levels, particularly in the product of the transplanted organ, provide a reliable assessment of the immunologic status of the allograft.
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Laparoscopic approaches are increasingly being applied to colorectal surgical procedures. Initial concerns regarding the existence of benefits from the laparoscopic approach have now been addressed. Even as these were being addressed, however, further concerns arose regarding the appropriateness of this technique in malignancy. Colorectal cancer is the only intra-abdominal malignancy that is knowingly resected employing laparoscopic techniques. This controversy was highlighted by reports of early wound implants. With careful technique, training and experience, however, wound recurrences are rarely seen, suggesting that this phenomenon, in the clinical setting, is primarily technique-related. Lack of rigorous evidence either condemning or supporting the laparoscopic approach for colorectal cancer resulted in the establishment of several large-scale randomized, prospective trials, all currently in progress, that aim to determine if laparoscopic resection of colorectal cancer results in oncologic outcomes comparable to the open approach.