Biomedical subjects

A J Senagore

Publications and source records attributed to A J Senagore.

At least 37 records · Page 2Linked to original sources

PubMed2001

Laparoscopic techniques in intestinal surgery.

Laparoscopic bowel surgery has developed slowly over the last decade, with virtually all procedures having been attempted with these laparoscopic techniques. The benefits of this approach to colorectal surgery have resulted in decreased lengths of stay, smaller incisions, and a potentially lower risk of small bowel obstruction. Resection of benign inflammatory disease presents particular challenges and may be expected to result in higher conversion rates. However, with increasing experience, even complicated diverticular disease and Crohn's disease can be managed laparoscopically. There is a growing body of data that suggests the early concerns regarding colon cancer resection, specifically port site recurrences, may have been exaggerated. Even more importantly, the early results of a number of prospective randomized trials are suggesting that survival and cure rates are not jeopardized by laparoscopic colectomy. The surgical techniques are demanding and require a level of standardization to achieve success. Laparoscopic colorectal surgery will have a definite role in the future.

Colorectal Neoplasms↗

PubMed2000

Molecular staging of colorectal cancer: K-ras mutation analysis of lymph nodes upstages Dukes B patients.

PURPOSE: Multiple attempts have been made to improve the clinical/pathologic staging system of Dukes to focus adjuvant therapy decisions. The purpose of this study was to determine whether K-ras mutational status of regional nodes in patients with Dukes B2 colorectal cancer could be used to stage their disease more accurately. METHODS: Using formalin-fixed, paraffin-embedded archival material, tumor samples were screened for K-ras mutations using a mutation-specific polymerase chain reaction method, followed by gel electrophoresis in a 96-well array. Patients with Dukes B2 tumors that have mutations in codon 12 or 13 of the K-ras gene were identified. RESULTS: Mutational analysis of the lymph nodes from these patients revealed an 80 percent (16/20) incidence of the same mutations in regional lymph nodes. None of the four patients with mutation-free nodes developed recurrence compared with 37.5 percent (6/16) with K-ras positive lymph nodes. CONCLUSIONS: The data suggest that patients with Dukes B2 colorectal cancers that have mutations in codon 12 or 13 of the K-ras gene are at high risk for the development of nodal metastases. Mutational analysis of the lymph nodes identifies high-risk patients who should be considered for adjuvant chemotherapy. Therefore, K-ras mutational analysis should be considered for molecular staging of colorectal cancer.

Adenocarcinoma↗

PubMed2000

Evaluation of transarterial embolization for lower gastrointestinal bleeding.

INTRODUCTION: Transcatheter arterial embolization has been used as a therapeutic maneuver for lower gastrointestinal bleeding. The availability of highly selective arteriography has made this procedure safer and warrants re-evaluation. METHODS: A retrospective chart review was done of all patients undergoing arteriography for presumed lower gastrointestinal bleeding at two acute-care community hospitals. Causes of bleeding, clinical outcome, and complications caused by transcatheter arterial embolization were recorded. RESULTS: There were 26 arteriographically identified bleeding sites in the colon and small bowel. The most frequent cause of bleeding was diverticulosis (12 patients), with the diagnosis being arterio venous malformation in two, and one unknown colonic source. Transcatheter arterial embolization was attempted for 17 separate bleeding episodes in 16 patients. Transfusion requirements were an average (+/- standard deviation) of 7 +/- 1.43 units per patient. Transcatheter arterial embolization was successful in stopping bleeding in 14 cases (82 percent). Two patients had surgery after transcatheter arterial embolization: one for colonic necrosis and one for persisting bleeding. There were two more unsuccessful procedures; one had a successful repeated transcatheter arterial embolization, and one stopped spontaneously. One patient rebled during the same hospitalization and was controlled with intra-arterial vasopressin. There were two deaths, both secondary to sepsis unrelated to the transcatheter arterial embolization or the gastrointestinal tract. CONCLUSIONS: Transcatheter arterial embolization is a relatively safe and successful procedure in patients with massive lower gastrointestinal hemorrhage. It is an excellent choice of therapy for patients that are poor candidates for surgery, but its role in other patients remains to be defined.

Aged↗

PubMed2000

Urgent colectomy in a patient with membranous tracheal disruption after severe vomiting.

IMPLICATIONS: We report a case of a patient who developed membranous tracheal disruption after severe vomiting. He subsequently required urgent colectomy for toxic megacolon under general anesthesia. With this challenging situation, we were able to successfully conduct general anesthesia in the presence of tracheal laceration, pneumothorax, and pneumomediastinum.

Adult↗

PubMed2000

Laparoscopic ileal ureter.

PURPOSE: We describe the operative technique of laparoscopic ileal ureter replacement. MATERIALS AND METHODS: A transperitoneal 3-port approach was used. Ileovesical and pyeloileal anastomoses were performed with intracorporeal laparoscopic freehand suturing and knot tying techniques. RESULTS: Operating time was 8 hours and blood loss was 200 cc. Both anastomoses were immediately watertight. Hospital stay was 4 days and a cystogram at 14 days confirmed widely patent anastomoses without extravasation. CONCLUSIONS: Laparoscopic ileal ureter replacement satisfactorily duplicates established open surgical principles. The laparoscopic technique is efficient and technically straightforward.

Aged↗

PubMed1999

Manage indirect practice expense the way you practice medicine: with information.

PURPOSE: Surgeons are increasingly faced with the pressures of maintaining the highest quality of patient care, while at the same time maintaining financial viability. The purpose of this project was to provide a framework for analyzing practice costs for colorectal surgeons using an activity-based cost accounting model. METHODS: A survey of 11 practices that were diverse in terms of geography, managed care penetration, academic vs. private practice style, and case distribution was performed. In activity-based costing the assignment of typical costs such as staff salaries are assigned to the appropriate business process. The business processes employed in this study were service patients in the office, perform in-office procedures, schedule cases in facilities, service patients in the hospital, insurance authorization, maintain medical records, billing, collections, resolve billing disputes, interaction with third parties, maintain professional education, sustain and manage the practice, maintain the facility, teaching and research, and performing drug studies. The final step is to assign the cost associated with all appropriate business processes to the appropriate cost object. The cost objects in this study were defined as a charge office visit, no-charge office visit, charge hospital visit, in-office procedures, in-facility procedures, and performing drug studies. The data were then analyzed to allow a comparison of four similar practices within the study group. RESULTS: The data demonstrated that the cost of seeing a charge office visit ranged from $55 to $105. Similarly, the cost of seeing a no-charge office visit during the global period ranged from $43 to $100. The study analyzed possible explanations for the wide variability in these costs. CONCLUSIONS: It is essential that physicians clearly understand the sources of expenses generated by the operation of their practices. A clear comprehension of costs will lead colorectal surgeons to make appropriate decisions regarding such important issues as office staffing ratios, office square footage, and instrumentation acquisitions.

Colorectal Surgery↗

PubMed1999

Limited hemorrhoidectomy: results and long-term follow-up.

PURPOSE: Three-column excision has traditionally been the preferred treatment for symptomatic hemorrhoidal disease in patients failing nonoperative treatments. There are few data evaluating focused surgical management of only the symptomatic hemorrhoidal complexes by limited hemorrhoidectomy. The purpose of this study was to evaluate patient outcome after one-quadrant or two-quadrant hemorrhoidectomy for symptomatic hemorrhoids. METHODS: We retrospectively studied patients undergoing a one-quadrant or two-quadrant hemorrhoidectomy as initial surgical treatment of symptomatic columns from April 1987 to July 1993. Patients undergoing a traditional three-quadrant hemorrhoidectomy during the same time period were used as controls. Statistical analysis was used to determine significance. RESULTS: There were 115 evaluable patients who had undergone a one-quadrant or two-quadrant hemorrhoidectomy. One hundred thirty-three three-quadrant patients were studied as the control group. The mean follow-up was 8.1 years and 7.2 years for the limited and three-quadrant hemorrhoidectomy group, respectively. The majority of patients (96 percent limited and 98 percent three-quadrant) experienced initial relief of symptoms after surgery. There was no significant difference between the two groups in the development of recurrent anorectal symptoms (34 percent limited and 29 percent three-quadrant), in the need for additional medical therapy (11.3 percent limited and 15.8 percent three-quadrant), or in the need for additional interventional therapy (2.9 percent limited and 0.8 percent three-quadrant). No patients in either group required additional surgical hemorrhoidectomy. CONCLUSIONS: The majority of patients with hemorrhoidal disease requiring excision can be managed effectively by focused treatment of the problematic columns. With this approach fewer than 2 percent of patients will require further procedural intervention of their hemorrhoidal disease.

Adult↗

PubMed1999

Abdominal closure using nonabsorbable mesh after massive resuscitation prevents abdominal compartment syndrome and gastrointestinal fistula.

Patients who receive high-volume resuscitation after massive abdominopelvic trauma, or emergent repair of a ruptured abdominal aortic aneurysm (RAAA), are at a significant risk for postoperative abdominal compartment syndrome (ACS). Absorbable prosthetic closure of the abdominal wall has been recommended as a means of managing ACS. However, use of absorbable prosthetic has been associated with very high rates of intestinal fistula formation and ventral hernia formation. The purpose of this study was to retrospectively review our experience with the use of nonabsorbable prosthetic abdominal closures in patients with documented ACS or at high risk for ACS. All patients managed by this technique from July 1995 through July 1997 after repair of ruptured abdominal aortic aneurysm or massive abdominopelvic trauma were evaluated. A total of 18 patients were identified: 15 primary prosthetic placements (Gore-Tex patch, 12; Marlex mesh, 2; and silastic mesh, 1) and 3 delayed prosthetic placements for ACS (Gore-Tex, 1 and Marlex, 2). The mortality rate was 22 percent (4 of 18) and resulted from multisystem organ failure (2 patients), cardiac arrest 1 hour postoperatively (1 patient), and severe closed head injury (1 patient). Secondary closure and prosthetic removal was possible in 16 of 18 patients, including the 2 patients who died of multisystem organ failure within the same hospitalization. Delayed abdominal closure at a subsequent admission was performed in two cases. This same patient developed an enterocutaneous fistula 2 months after discharge. Importantly, only 1 of 18 closed in this manner developed ACS requiring reoperation. The results indicate that use of a nonabsorbable prosthetic, particularly with Gore-Tex, is efficacious in the prevention of postoperative ACS in high-risk patients, while it enhances the possibility for delayed abdominal closure and minimizes the risk of gastrointestinal fistulization associated with other techniques.

Abdominal Injuries↗

PubMed1998

Pudendal nerve latency. Does it predict outcome of anal sphincter repair?

PURPOSE: Electrophysiologic evaluation has been suggested as a means of identifying prognostic factors for patients with fecal incontinence who undergo anal sphincter repair. The purpose of this study was to evaluate the results of anal sphincter repair in patients with documented pudendal neuropathy and to determine the usefulness of electrophysiologic studies for prognostication of sphincteroplasty. METHODS: A retrospective review of a series of patients undergoing electrophysiologic studies and anterior anal sphincteroplasty was performed. Data collected included age, standardized incontinence scores (preoperative, immediately postoperative, and current follow-up), and results of pudendal nerve terminal motor latency and monopolar electromyography. Outcomes of sphincteroplasty were designated as excellent, good, fair, or poor based on incontinence scores. Prolonged pudendal nerve terminal motor latency was defined as longer than 2.2 ms and elevated as unilateral or bilateral. RESULTS: During the time period of the study (1991-1996), 15 patients had electrophysiologic studies and underwent sphincteroplasty. Twelve patients (80 percent) were available for follow-up and form the basis for this study. All patients were women, with a mean age of 45 +/- 18.6 (27-75) years and a mean follow-up of 49.7 +/- 18.6 (20.4-72.6) months. Mean duration of incontinence preoperatively was 13 +/- 16.1 (range, 1-58) years. The incontinence score was 15.8 +/- 3.5 preoperatively, 5.4 +/- 4.5 postoperatively, and 5 +/- 5.1 currently for all 12 patients. There was one patient with normal pudendal nerve terminal motor latency. In the four patients with bilateral prolonged pudendal nerve terminal motor latency, the incontinence scores were 15 +/- 4.2 preoperatively, 8.5 +/- 5.3 postoperatively, and 6 +/- 6.1 (statistically significant compared with preoperation) currently. Seven patients were found to have unilateral prolonged pudendal nerve terminal motor latency with incontinence scores of 16.3 +/- 3.5 preoperatively, 4.4 +/- 3.2 (statistically significant compared with preoperation) postoperatively, and 5.1 +/- 4.9 (statistically significant compared with preoperation) currently. Based on incontinence scores, results of the sphincteroplasty at the most current follow-up were as follows: no neuropathy, excellent in one patient; unilateral neuropathy, five with good/excellent results, two with fair/poor results; bilateral neuropathy, two with good/excellent results, two with fair/poor results (P > 0.05 bilateral vs. unilateral). By monopolar electromyographic examination, external and sphincter denervation was noted in 11 patients; their incontinence scores were 15.5 +/- 3.5 preoperatively, 5.9 +/- 4.3 (statistically significant compared with preoperation) postoperatively, and 5.5 +/- 5.0 (statistically significant compared with preoperation) currently. Monopolar electromyographic results in the puborectalis included four normal examinations and six that were unobtainable. In the two patients with puborectalis denervation, the incontinence scores were 19.5 +/- 0.7 preoperatively, 8.5 +/- 4.9 postoperatively, and 2.5 +/- 3.5 (statistically significant compared with preoperation) currently. CONCLUSIONS: Anterior anal sphincteroplasty in patients with unilateral or bilateral prolonged pudendal nerve terminal motor latency can provide significant improvement in continence with minimum morbidity. Therefore, correction of the anatomic sphincter defect should still be considered, even in patients with documented pudendal neuropathy.

Adult↗

PubMed1998

Dilemmas in the diagnosis of blunt enteric trauma.

Early identification of enteric injuries following blunt trauma relies on clinical examination, diagnostic peritoneal lavage (DPL), and/or computed tomography (CT) scan. Limitations in each approach may result in diagnostic delays and potentially increased complications. The purpose of this study was to evaluate the ability of early DPL and CT scans in identifying enteric injuries requiring surgical repair and to determine the impact of injury time to definitive repair on complication rates. A retrospective review of patients admitted to the Butterworth Hospital Level I Trauma Center between January 1, 1990 and December 31, 1996 identified 69 appropriate patients. Three study groups were treated as follows: laparotomy on clinical examination (N = 7), laparotomy after initial DPL (N = 28), and laparotomy after initial CT (N = 34). Early DPL missed 5 (18%) enteric injuries, which was significantly fewer than the 13 (38%) missed by CT scan. Review of these 13 CT scans revealed 6 examinations not suggesting enteric injury and 7 with signs suggestive of injury. Four injuries missed by CT subsequently were found by delayed DPL. Morbidity rates in either group increased when injury time to definitive repair was >24 hours (18-50%). The results indicate that early DPL and CT have limitations in blunt enteric injuries. However, morbidity and mortality rates did not increase until repair was delayed >24 hours postinjury. Also, delayed DPL successfully identified these injuries in four patients after negative CT. Therefore, in patients at high risk for enteric injuries, there may be a role for delayed or repeat DPL after an initially negative DPL or CT.

Adult↗

PubMed1997

A newly identified pattern of K-ras mutations at codons 12 and 13 is associated with long-term survival in colorectal cancer.

BACKGROUND: Although K-ras mutations reportedly occur in 40% to 60% of all colorectal carcinomas, the relationship between specific mutations and clinical outcome is unclear. The purpose of this study was to assess the frequency and types of K-ras mutations in 89 colorectal cancer patients, comparing groups with short-term (less than 5 years) and long-term (more than 10 years) survival. METHODS: The group was divided into four cohorts by survival and modified Dukes classification (Dukes B2 and C2). DNA was extracted from formalin-fixed paraffin-embedded archival material. Mutational status was analyzed using a modification of allele-specific-polymerase chain reaction. RESULTS: Mutations in codon 12 were found in 11.2% of tumors, and 83% of tumors had mutations in codon 13. Gly > Asp accounted for 85.2% of the mutations. Tumors with mutations in both codon 12 and codon 13 occurred significantly more frequently in the long-term (21.3%) versus the short-term (2.4%) survival group. Gly > Asp mutations in either codon were related to long-term survival, and 80% of long-term survivors with mutations in both codons had Gly > Asp mutations in both. CONCLUSIONS: Simultaneous mutation in codons 12 and 13 of the K-ras gene appears to be a positive prognostic indicator in colorectal cancer.

Adult↗

PubMed1997

Adjuvant radiation therapy in resectable rectal cancer: should local recurrence rates affect the decision?

Adjuvant external beam pelvic radiotherapy (XRT) for resectable rectal cancer has been mandated by the National Cancer Institute because of reported 20 to 50 per cent reductions in local recurrence rates. However, these series' reported local recurrence rates are 18 to 39 per cent in the nonradiated patients, which seems extraordinarily high compared to the 3 to 5 per cent rates reported by surgeons advocating proctectomy with complete mesorectal excision. This fact, coupled with the high cost of XRT ($11,000-$14,000), the risk of radiation injury to small bowel and the neo-rectum, and the failure of XRT to provide any survival advantage, raises questions as to the precise role of XRT for rectal cancer. The purpose of this study was to perform a review of 212 consecutive patients undergoing curative resection via low anterior resection (LAR) or abdominoperineal resection (APR) for rectal cancer between 1989 and 1993, focusing on local and distant recurrence rates and survival. The choice of surgery alone (SUR), preoperative radiation (PRE) (45 Gy), or postoperative radiation (POST) (45-50 Gy) was at the surgeon's discretion. There were no significant differences in male:female ratio (SUR, 83:60; PRE, 14:8; POST, 34:13) or type of procedure (SUR-LAR, 112:APR, 31; PRE-LAR, 5:APR, 17; POST-LAR, 30:APR, 17) between the groups. There were no significant differences in age between the preoperative and postoperative radiation groups (PRE, 64.0 +/- 2.4; POST, 59.2 +/- 1.7); however, age was significantly different (P < 0.05) between the surgery-alone and the postoperative radiation groups (SUR, 68.5 +/- 0.8; POST, 59.2 +/- 1.7). With a median follow-up of 49 months, there were no significant differences in local recurrence (SUR, 4.2%; PRE, 4.5%; POST, 2.1%); however, there was a significantly longer survival for the SUR group compared to the other groups (SUR, 45.9 months; PRE, 36.4 months; POST, 39.3 months; P < 0.05 least significant difference). The PRE group also had shorter survival compared to the other groups when only Stage II and III lesions were studied (S, 40.0 months; PRE, 28.3 months; POST, 39.3 months). Local recurrences based on TNM stage were: T1N0 (S, 0 of 27; PRE, 0 of 3); T2N0 (S, 4 of 4S; PRE, 0 of 7); T2N1 (S, 0 of 9; POST, 1 of 5); T3,4N0 (S, 2 of 37; PRE, 1 of 9; POST, 0 of 10); and T3,4N1,2 (S, 0 of 21; PRE, 0 of 3; POST, 0 of 30). The results of this series support the contention that proctectomy with complete mesorectal excision yields a 4.2 per cent local recurrence rate without the need for adjuvant XRT. In this series, if all the patients had received adjuvant radiation, an additional $2.2 million would have been added to the costs of medical care. Therefore, the potential risks, costs, and benefits of adjuvant pelvic XRT for rectal cancer must be weighed against optimal benchmarks for local recurrence rate for surgery alone.

Adult↗

PubMed1997

Long-term outcome after ileocecal resection for Crohn's disease.

The decision to operate on ileocecal Crohn's disease is usually tempered by concern for early recurrence and the potential for multiple small bowel resections that will render the patients a gastroenterological cripple. However, delays in surgical management may unnecessarily prolong the patient's disease state and risk complications from both medications and unchecked disease. The aim of this study was to report the long-term clinical outcome of patients undergoing ileocecal resection for Crohn's disease between 1970 and 1993. One hundred eighty-one patients underwent ileocecal resection for Crohn's disease during the study period, with a median follow-up of 14.3 years. The mean age at the first resection was 32.7 +/- 0.9 years, and the male female ratio was 79:102. The indications for the initial resection were intractability in 119 (68.4%), obstruction in 45 (25.9%), enteric fistula in 27 (15.5%), perforation in 16 (9.2%), intra-abdominal abscess in 7 (4.0%), and hemorrhage in 5 (2.9%). Postoperative complications included prolonged ileus in 13 (7.5%), pneumonia/atelectasis in 15 (8.6%), wound infection in 11 (6.3%), urinary tract infection in 10 (5.7%), intra-abdominal abscess in 7 (4.0%), and wound dehiscence in 1 (0.6%). There were no operative mortalities. Fifty-six (30.9%) developed a recurrence requiring further surgery, with the mean time interval between initial ileocecal resection and operation for recurrence being 72.3 +/- 7.6 months. A second recurrence developed in 19 patients (10.5%) with a mean time interval of 52.3 +/- 8.3 months. The most frequent sites of first recurrence were the preanastomotic ileum in 49 (87.3%), the postanastomotic colon in 10 (17.9%), other colonic sites in 16 (28.6%), and other small bowel sites in 2 (3.6%) and other sites in 4 (7.1%). The types of resection for first recurrence were ileal resection in 28 (50%), right hemicolectomy in 17 (30.4%), segmental colectomy in 6 (10.7%), total proctocolectomy in 3 (5.4%), and proximal small bowel resection in 2 (3.6%). The long-term follow-up of this patient cohort indicated that 125 (69.1%) had only one resection, 37 (20.4%) required two resections, 15 (8.3%) required three resections, 4 (2.2%) required four resections. The results indicate that ileocecal resection of Crohn's disease had a high rate of disease control obtained with low morbidity, and a low frequency of three or more bowel resections (2.2%). Therefore, surgical resection of ileocecal Crohn's disease should not be unduly delayed for fear of risking short bowel syndrome. This approach should minimize overall disease-related patient morbidity by avoiding long periods of chronic illness.

Adult↗

PubMed1997

Outcome after incision and drainage with fistulotomy for ischiorectal abscess.

Concomitant anal fistulotomy (F) and incision and drainage (I&D) of ischiorectal abscesses (IA) are often avoided, for fear of irreversibly impairing anal continence. However, failure to identify and treat the frequently associated trans-sphincteric anal fistula dooms the patient to recurrent anal suppurative disease. We have employed an aggressive approach of performing I&D and F for IA at the time of initial presentation. Adequate drainage is assured by placement of counterincisions and Penrose drains to minimize the time for healing of the perianal wound. Drainage is followed by a careful examination of the anal canal for fistula localization followed by fistulotomy, or less frequently by cutting seton placement. We present our experience with this approach to IA, with special attention paid to the evaluation of recurrence rates and anal continence. This paper represents a retrospective review of 80 patients with IA managed from 1983 to 1996. Operative records and office records were reviewed, and follow-up data were obtained by telephone interview. Internal fistulous openings were identified in 55 (68.8%) patients. Surgeries included: 38 (47.5%) I&D and F, 8 (10%) I&D and seton, and 34 (42.5%) I&D alone. Follow-up data were available on 99 per cent of patients; mean, 44.3 months. Results showed a 44 per cent recurrence rate in those who underwent I&D as compared with 21.1 per cent following I&D and F. 11.8 per cent of patients treated with I&D experienced a change in their level of continence postoperatively as compared to 15.8 per cent treated with I&D and F. The results indicate that an aggressive approach to IA allows identification of a trans-sphincteric fistula in 57.5 per cent of patients with IA. Therefore, optimal surgical management for IA appears to be I&D and F, resulting in a lower recurrence rate and comparable morbidity as compared to I&D alone.

Abscess↗

PubMed1996

Relationship of pelvic radiation to intestinal blood flow.

Pelvic radiation remains the mainstay in the treatment of many malignancies. Chronic radiation injury represents an obliterative endarteritis. The purpose of our experiment was to investigate the chronic changes in blood flow that occurred in a model of pelvic radiation. Also, we investigated the potential benefits of an elemental diet, sodium meclofenamate, and vitamin A within the radiated large and small bowel. Female Sprague-Dawley rats, 200-250 g, were anesthetized and received 900 rads once a week for 5 weeks for a total of 4500 rads. Group B received sodium meclofenamate, group C elemental diet, and group D vitamin A. Group A received radiation only where control animals (group E) received anesthesia but no radiation. All animals were given treatments during the course of radiation therapy only. Blood flow was determined within the terminal ileum, proximal jejunum, and distal colon 1 week, 5 weeks, 6 months, and 1 year postradiation therapy. Blood flow was determined by strontium-labeled 15-microns microspheres. Results showed that radiation resulted in an increase in blood flow within the terminal ileum at 1 week postradiation of approximately 175% when compared to controls. Blood flow then decreased (59%) when compared to controls at 5 weeks and increased (141%) again at 6 months when compared to controls. No change in blood flow was noted at 1 year postradiation therapy. An elemental diet and sodium meclofenamate prevented these changes in blood flow at each of these times points. No change in blood flow was seen at any of the time points measured within the jejunum or colon.

Animals↗

PubMed1996

The single-stapled ileo pouch anal anastomosis: a reasonable compromise.

Minimal anal sphincter disruption and preservation of the transitional epithelium during ileal pouch anal anastomosis (IPAA) are believed to play important roles in improving functional outcome. As a result, many surgeons have abandoned the traditional mucosectomy in favor of a double-stapled technique. The natural history of the retained colonic epithelium that occurs with this approach is uncertain. The authors have employed a technique of single circular-stapled IPAA, which accomplishes both of the described goals, while insuring that all the colonic mucus is removed during mucosectomy. We present a series of patients (n = 39) undergoing IPAA with transanal mucosectomy and a circular stapled anastomosis. The series consists of 16 males and 23 females with a mean age of 33.4 +/- 1.7 years. Twenty-nine patients had temporary ileostomies (2 not closed yet), and 10 did not. Pelvic sepsis occurred in two patients. However, three (9%) patients developed anastomotic sinus tracts that delayed ileostomy closure. With a follow-up of 24.0 +/- 3.2 months, the mean number of bowel movements are: day 6.4 +/- 0.4; night 1.1 +/- 0.2. Continence has been good or excellent in 97 per cent of patients during the day and 86 per cent at night. Therefore, this series indicates that good to excellent functional results following IPAA in the vast majority of patients can be accomplished with a transanal mucosectomy and a single stapled IPAA anastomotic technique. These results are comparable with those obtained with the double stapling technique without risk of retained rectal mucosa. Therefore, this technique provides good functional results because of minimal anal sphincter stretching, while at the same time insuring removal of all abnormal colonic epithelium.

Adenomatous Polyposis Coli↗

PubMed1996

Prospective comparison of gastric emptying after laparoscopic-aided colectomy versus open colectomy.

Laparoscopic colectomy has been associated with a shorter postoperative ileus when compared to open colectomy, although the mechanism is unclear. This study is designed to evaluate gastric emptying following open colectomies (OC) versus laparoscopic-aided colectomies (LAC) using serial serum acetaminophen levels (ACE), which correlate with gastric emptying. The study groups were limited to patients undergoing either right or left colectomy who received general anesthetic. Patients with diabetes mellitus or other colon resections were excluded. Postoperative analgesia was provided with intramuscular ketorolac and opioids for breakthrough pain. Patients received 500 mg ACE at 24 and 48 hours postoperatively, and ACE levels were measured 5, 10, 20, 30, 45, 60, 90, and 120 minutes following ingestion. The OC and LAC groups were matched in terms of operation performed. There were multiple carcinomas in the OC group, and none in the LAC group. Normal control values were also obtained for ACE absorption curves. Of all the time intervals tested at both 24 and 48 hours, there was only a single time interval (30 minutes at the 48-hour testing interval) in which there was a significant difference between the OC and LAC groups. In both the OC and LAC groups, there were multiple time intervals when the ACE levels were significantly different when compared to controls. The results indicate no significant difference in gastric emptying as measured by acetaminophen absorption in postoperative colectomy patients. Therefore, although laparoscopic patients have a clinically shorter postoperative ileus, the mechanism for this reduction appears unrelated to gastric emptying.

Acetaminophen↗

PubMed1995

Laparoscopic-assisted vs. open resection. Rectopexy offers excellent results.

PURPOSE: Anterior resection +/- rectopexy effectively manages full-thickness rectal prolapse; however, morbidity is approximately 15 percent mainly because of the laparotomy wound. There has been no comparison of laparoscopic with laparotomy approaches to the repair of this disorder. The purpose of this paper is to compare an age/sex-matched series of laparoscopic-assisted (n = 8) with laparotomy (n = 10) resections/rectopexies. METHODS: A retrospective case review of laparoscopic-assisted (n = 8) vs. laparotomy (n = 10) resections/rectopexies from May 1989 to September 1993 was performed. Data collected included age, gender, technique, operative blood loss, operative time, length of bowel resected, length of hospital stay, return of bowel function, oral intake, and postoperative complications. RESULTS: No significant difference was noted in age, sex, length of bowel resected, mortality, significant morbidity, or recurrence (mean follow-up, 27.1 +/- 4.4 months) in either group. Estimated blood loss for the laparotomy group was greater than for the laparoscopic group (285.0 +/- 35.0 vs. 184.4 +/- 31.0 ml). Operative time was greater for the laparoscopic group (177.1 +/- 23.0 vs. 86.5 +/- 8.6 min). Length of stay (95.0 +/- 16.7 vs. 183.5 +/- 8.9 hours), time to passage of flatus (3.9 +/- 1.1 vs. 2.8 +/- 1.9 days), and resumption of oral intake (4.5 +/- 0.7 vs. 2.8 +/- 1.9 days) occurred earlier for the laparoscopic group. CONCLUSION: Therefore, laparoscopic-assisted resection/rectopexy effectively treats rectal prolapse without the morbidity of the laparotomy wound and significantly shortens hospitalization for this benign disease.

Anastomosis, Surgical↗