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Biomedical subjects

B J Moran

Publications and source records attributed to B J Moran.

At least 19 recordsLinked to original sources
PubMed2003

Optimal preoperative assessment and surgery for rectal cancer may greatly limit the need for radiotherapy.

BACKGROUND: Radiation is being used increasingly in the management of patients with rectal cancer. Over the past decade the Basingstoke Colorectal Research Unit has combined precision total mesorectal excision with the highly selective use of preoperative radiotherapy. METHODS: One hundred and fifty consecutive patients who underwent major surgical excision for cancers of all stages comprised the study group. Preoperative clinical assessment was based largely on tumour size, fixation and distance from the anal verge. Only preoperative radiotherapy was considered and this only for tumours judged to be at high risk of mesorectal fascia involvement. RESULTS: During a 5-year period 35 of 150 patients were selected for preoperative irradiation. In the non-irradiated patients the local recurrence rate after a median follow-up period of 870 (range 51-1903) days was 2.6 per cent (three of 115 patients), compared with 17.1 per cent (six of 35 patients) in those chosen for irradiation. Sixty patients (52.2 per cent) who were not irradiated were node positive. The local recurrence rate for the whole group was 6.0 per cent. CONCLUSION: The great majority of patients undergoing major excision for rectal cancer can be managed without radiation therapy if the preoperative assessment of the mesorectal fascia and surgery are performed optimally.

Adult↗
PubMed2003

A 5-cm colonic J pouch colo-anal reconstruction following anterior resection for low rectal cancer results in acceptable evacuation and continence in the long term.

BACKGROUND: Optimal treatment for low rectal cancer is total mesorectal excision, with most patients suitable for low colo-rectal or colo-anal anastomosis. A colon pouch has early functional benefits, although long-term function, especially evacuation, might mitigate against its routine use. The aim of this study was to assess evacuation and continence in patients with a colon pouch, and to examine the impact of possible risk factors. METHODS: In 1998, all 102 surviving patients with a colon pouch, whose stoma had been closed for more than one year, were sent a postal questionnaire. A composite incontinence score was calculated from questions on urgency, use of a pad, incontinence of gas, liquid or faeces; and a composite evacuation score from questions on medication taken to evacuate, straining, the need and number of times returned to evacuate. RESULTS: The response rate was 90% (50 M, 42 F), with a median age of 68 years (IQR 60-78) and median follow-up of 2.6 years (IQR 1.7-3.9). The anastomosis was 3 cm or less from the anus in 45/92 (49%), and incontinence scores were worse in this group (P = 0.001). There were significantly higher incontinence scores in females (P = 0.014). Age, preoperative radiotherapy, part of colon used for anastomosis, postoperative leak and length of follow-up had no demonstrable effect on either score. CONCLUSION: Gender and anastomotic height were the only variables which influenced incontinence. Ninety percent of patients reported that their bowel function did not affect their overall wellbeing, and none would have preferred to have a stoma.

Aged↗
PubMed2003

Predicting risk and diminishing the consequences of anastomotic dehiscence following rectal resection.

Anastomotic dehiscence is a serious, life-threatening complication of any rectal anastomosis and may be associated with an increased risk of local cancer recurrence. The leak rate following low anterior resection is in the region of 10% as supported by the recent randomised Dutch rectal cancer trial. Although accurate prediction of risk is impossible, certain factors are known to influence leak rates. There is an inverse relationship between the height of anastomoses from the anal verge and leak rate, with the lower anastomoses carrying the highest risk. Proximal defunctioning mitigates the consequences of leakage but does not abolish risk. There is little difference in rates of dehiscence between stapled and sutured colorectal anastomoses. A short colon pouch may reduce the chance of leakage. The highest risks are in unprotected anastomoses less than 5 cm from the anal verge in men who smoke and/or drink excessively, particularly if they have received pre-operative chemotherapy or chemo-radiotherapy. A high index of suspicion is required in detecting the early nonspecific signs of a leak and urgent surgical intervention is usually required to avert a life-threatening situation. Judicious use of faecal diversion should never be regarded as surgical timidity.

Anastomosis, Surgical↗
PubMed2001

Postoperative adhesions: ten-year follow-up of 12,584 patients undergoing lower abdominal surgery.

PURPOSE: Postoperative adhesions are a significant problem after colorectal surgery. However, the basic epidemiology and clinical burden are unknown. The Surgical and Clinical Adhesions Research Study has investigated the scale of the problem in a population of 5 million. METHODS: Validated data from the Scottish National Health Service Medical Record Linkage Database were used to define a cohort of 12,584 patients undergoing open lower abdominal surgery in 1986. Readmissions for potential adhesion-related disease in the subsequent ten years were analyzed. The methodology was conservative in interpreting adhesion-related disease. RESULTS: In the study cohort 32.6 percent of patients were readmitted a mean of 2.2 times in the subsequent ten years for a potential adhesion-related problem. Although 25.4 percent of readmissions were in the first postoperative year, they continued steadily throughout the study period. After open lower abdominal surgery 7.3 percent (643) of readmissions (8,861) were directly related to adhesions. This varied according to operation site: colon (7.1 percent), rectum (8.8 percent), and small intestine (7.6 percent). The readmission rate was assessed to provide an indicator of relative risk of adhesion-related problems after initial surgery. The overall average rate of readmissions was 70.4 per 100 initial operations, with 5.1 directly related to adhesions. This rose to 116.4 and 116.5, respectively, after colonic or rectal surgery-with 8.2 and 10.3 directly related to adhesions. CONCLUSIONS: There is a high relative risk of adhesion-related problems after open lower abdominal surgery and a correspondingly high workload associated with these readmissions. This is influenced by the initial site of surgery, colon and rectum having both the greatest impact on workload and highest relative risk of directly adhesion-related problems. The study provides sound justification for improved adhesion prevention strategies.

Abdomen↗
PubMed2001

Stoma-related complications are more frequent after transverse colostomy than loop ileostomy: a prospective randomized clinical trial.

BACKGROUND: The consequences of leakage from low colorectal or coloanal anastomoses are reduced by the use of a loop stoma to divert the faecal stream. Controversy continues as to whether loop ileostomy (LI) or loop transverse colostomy (LTC) is the optimal method of defunctioning such anastomoses. METHODS: Patients requiring defunctioning following anterior resection and total mesorectal excision were randomized to receive either LI or LTC. Comparison was made between the groups regarding the difficulty of stoma formation and closure, the recovery after stoma closure and stoma-related complications. The minimum follow-up after stoma closure was 6 months (median 36 months). RESULTS: Between October 1995 and August 1999, 70 patients were randomized (LTC 36, LI 34) of whom 63 underwent stoma closure (LTC 31, LI 32). There were no significant differences in the difficulty of formation or closure, or in the postoperative recovery between the groups. However, there were ten complications related directly to the stoma in the LTC group: faecal fistula (one patient), prolapse (two), parastomal hernia (two) and incisional hernia during follow-up (five). None of these complications occurred in the LI group. CONCLUSION: In this randomized study, the frequency of herniation before or after colostomy closure supports the choice of LI as a method of defunctioning a low anastomosis. Both methods appear to provide satisfactory protection for the low anastomosis.

Adult↗
PubMed2001

Risk factors for, and management of anastomotic leakage in rectal surgery.

Anastomotic leakage is one of the most serious early complications of any rectal anastomosis. Proximal defunctioning mitigates the consequences of leakage but does not abolish the risk. The lower the anastomosis the higher the risks of leakage. There is evidence that a short colon pouch reduces the risks of leakage. A high index of suspicion is required to detect the early non-specific signs of anastomotic leakage. Urgent surgical intervention is usually required to avert a life threatening situation. Reports of the demise of temporary defunctioning of the low anastomosis are premature, and judicious use of faecal diversion should never be regarded as surgical temerity.

Journal Article↗
PubMed2001

Surgical decisions in the elderly: the importance of biological age.

Surgeons will sometimes advise against an operation because the patient is 'old and frail'. A simple starring system (one to five), based on performance and lifestyle, has been devised to assess the biological age of elderly patients. 10 consultant surgeons and 10 trainees answered questions about their treatment recommendations for hypothetical patients of standard age and medical history but with various star ratings and surgical conditions. 1000 decisions were available for analysis. The four and five star patients (those leading an independent existence) were recommended 266 interventions, the one and two star patients 55. Trainees were more inclined to intervene than consultants, recommending operations in half the patients rather than one-third. These results indicate that decisions on surgical management are strongly influenced by the patient's star rating or biological age. If the starring method proves reproducible in other patient groups and settings, it could allow better communication on an important factor in clinical decisions.

Age Factors↗
PubMed2000

Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm. Stockholm Colorectal Cancer Study Group, Basingstoke Bowel Cancer Research Project.

BACKGROUND: The Stockholm I and II randomised trials demonstrated the value of preoperative radiotherapy in preventing local recurrence in rectal cancer. This, study investigated the potential for further improvement by introduction of the concept of total mesorectal excision (TME) to surgeons in Stockholm, Sweden. METHODS: Workshops started in 1994 and included 11 television-based demonstrations and two histopathology sessions. The study population consisted of all patients who underwent abdominal operations for rectal cancer in Stockholm County during 1995-96 (TME project; n=447). Outcomes at 2 years were compared with those from the Stockholm I (n=790) and II (n=542) trials as historical controls. FINDINGS: For patients with curative abdominal resections, there were no differences between the Stockholm I (n=686), Stockholm II (n=481), and TME project (n=381) groups in 30-day mortality (30 [4%], six [1%], and 12 [3%]), anastomotic leakage (27 [10%], 18 [9%], and 23 [9%]), or all complications (204 [30%], 169 [35%], and 134 [35%]). This similarity was achieved despite a decrease in the proportion of abdominoperineal procedures from 55-60% to 27%. Local recurrence occurred in significantly fewer of the TME group than of the Stockholm I and II groups (21 [6%] vs 103 [15%] and 66 [14%], p<0.001) as did cancer-related death (35 [9%] vs 104 [15%] and 77 [16%], p<0.002). INTERPRETATION: A surgical teaching initiative had a major effect on cancer outcomes. The proportion of abdominoperineal procedures and the local recurrence rate decreased by more than 50% and there is already evidence of a decline in rectal-cancer mortality.

Adult↗
PubMed2000

Impact of previous surgery on time taken for incision and division of adhesions during laparotomy.

PURPOSE: Adhesions from previous surgery constitute a major problem in general surgery. Much is known of the consequences of adhesions in terms of morbidity, but there has been little documentation of the effect of previous surgery on the time taken to reoperate. METHODS: Information on incision time and division of adhesion time was recorded on 120 patients (89 elective cases and 31 emergencies) undergoing midline laparotomy under the care of a single colorectal surgeon. RESULTS: Fifty-one percent of elective and 71 percent of emergency cases had previously had abdominal surgery. Previous surgery prolonged the median incision time from 5 (range, 3-10) to 8 (range, 4-39) minutes (P < 0.001) and the median division of adhesion time from 0 (range, 0-30) to 15 (range, 0-12) minutes (P < 0.0001). CONCLUSIONS: Previous surgery significantly increases the operating time during subsequent surgery by a median of 18 minutes. This information may be of use in the planning of surgical workload and highlights the needs for cost-effective adhesion prevention strategies.

Abdomen↗
PubMed1999

Adhesion-related hospital readmissions after abdominal and pelvic surgery: a retrospective cohort study.

BACKGROUND: Adhesions after abdominal and pelvic surgery are important complications, although their basic epidemiology is unclear. We investigated the frequency of such complications in the general population to provide a basis for the targeting and assessment of new adhesion-prevention measures. METHODS: We used validated data from the Scottish National Health Service medical record linkage database to identify patients undergoing open abdominal or pelvic surgery in 1986, who had no record of such surgery in the preceding 5 years. Patients were followed up for 10 years and subsequent readmissions were reviewed and outcomes classified by the degree of adhesion. We also assessed the rate of adhesion-related admissions in 1994 for the population of 5 million people. FINDINGS: 1209 (5.7%) of all readmissions (21,347) were classified as being directly related to adhesions, with 1169 (3.8%) managed operatively. Overall, 34.6% of the 29,790 patients who underwent open abdominal or pelvic surgery in 1986 were readmitted a mean of 2.1 times over 10 years for a disorder directly or possibly related to adhesions, or for abdominal or pelvic surgery that could be potentially complicated by adhesions. 22.1% of all outcome readmissions occurred in the first year after initial surgery, but readmissions continued steadily throughout the 10-year period. In 1994, 4199 admissions were directly related to adhesions. INTERPRETATION: Postoperative adhesions have important consequences to patients, surgeons, and the health system. Surgical procedures with a high risk of adhesion-related complications need to be identified and adhesion prevention carefully assessed.

Abdomen↗
PubMed1999

Comparisons of a proposed five-seed assay method with the single-seed and batch assay methods for I-125 seeds in ultrasound-guided prostate implants.

A simple five-seed assay method was proposed and investigated. A commercial well ion chamber system with an NIST-traceable single-seed calibration constant was used for the single-seed assays. A batch seed holder was used for batch assays. For the five-seed assays, a second single-seed holder was modified such that all five seeds were loaded in a central region of the well ion chamber. Compared with the same seed in the standard single-seed holder, the relative chamber responses for the five seed positions were 0.993, 0.993, 1.000, 1.001, and 0.977, respectively, indicating little or no position-dependent chamber response and no self-attenuation among seeds. Subsequent comparison of assays with the single-seed and five-seed methods indicated only 0.4% difference in charge collection. The five-seed calibration constant was therefore taken to be the same as the single-seed calibration constant. The reproducibility of the five-seed assay method was found to be better than 0.8%. When a dummy seed replaced an active seed, a nearly 20% reduction in charge was found, indicating that the proposed five-seed assay method can detect a dead seed. Clinical comparison of all three assay methods showed that they produced qualitatively the same assay results when the batch assay method was performed with extra care. Compared with the single-seed assay method, the five-seed method is equally simple, rigid, and reproducible, but it demands much less assay time. Compared with the batch assay method, the five-seed method is much more reproducible and reliable because of its rigid assay geometry; it only demands a moderate amount of assay time and can detect dead seeds. The American Association of Physicists in Medicine Task Group 40 (AAPM TG40) states that, for brachytherapy, ideally every (i.e., 100%) loose seed should be calibrated. For procedures involving large number of loose seeds, it then recommends that 10% of seeds be calibrated. The proposed five-seed assay is very simple to implement. It will facilitate the compliance of the "10%" recommendation from the AAPM TG40; it will make the "ideally 100%" statement from AAPM TG40 a more realistic and practical QA procedure in seed assaying.

Brachytherapy↗
PubMed1999

A review of the management of small bowel obstruction. Members of the Surgical and Clinical Adhesions Research Study (SCAR).

Small bowel obstruction is a significant surgical problem and is commonly caused by postoperative adhesions. Patients suffering from this condition are often difficult to assess and require careful evaluation and management. Articles regarding the diagnosis, evaluation and management of small bowel obstruction have been identified from the Ovid, Embase and Silver Platter electronic databases and then reviewed by the authors. Particular emphasis has been placed on randomised controlled trials or large prospective series. Anecdotal reports or those containing small numbers have been largely excluded, but where they have been included it has been made clear in the text. The management of small bowel obstruction is predominantly the management of obstruction due to postoperative adhesions. The selective use of radiological techniques, such as water soluble contrast and CT studies, often help to characterise the nature of the obstruction and may even help with its resolution. Techniques involving the use of laparoscopy and barrier membranes may reduce morbidity but there is a need to evaluate these strategies further with prospective clinical trials.

Humans↗
PubMed1998

Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978-1997.

OBJECTIVE: To examine the role of total mesorectal excision in the management of rectal cancer. DESIGN: A prospective consecutive case series. SETTING: A district hospital and referral center in Basingstoke, England. PATIENTS: Five hundred nineteen surgical patients with adenocarcinoma of the rectum treated for cure or palliation. INTERVENTIONS: Anterior resections (n = 465) with low stapled anastomoses (407 total mesorectal excisions), abdominoperineal resections (n = 37), Hartmann resections (n = 10), local excisions (n = 4), and laparotomy only (n = 3). Preoperative radiotherapy was used in 49 patients (7 with abdominoperineal resections, 38 with anterior resections, 3 with Hartmann resections, and 1 with laparotomy). MAIN OUTCOME MEASURES: Local recurrence and cancer-specific survival. RESULTS: Cancer-specific survival of all surgically treated patients was 68% at 5 years and 66% at 10 years. The local recurrence rate was 6% (95% confidence interval, 2%-10%) at 5 years and 8% (95% confidence interval, 2%-14%) at 10 years. In 405 "curative" resections, the local recurrence rate was 3% (95% confidence interval, 0%-5%) at 5 years and 4% (95% confidence interval, 0%-8%) at 10 years. Disease-free survival in this group was 80% at 5 years and 78% at 10 years. An analysis of histopathological risk factors for recurrence indicates only the Dukes stage, extramural vascular invasion, and tumor differentiation as variables in these results. CONCLUSIONS: Rectal cancer can be cured by surgical therapy alone in 2 of 3 patients undergoing surgical excision in all stages and in 4 of 5 patients having curative resections. In future clinical trials of adjuvant chemotherapy and radiotherapy, strategies should incorporate total mesorectal excision as the surgical procedure of choice.

Adenocarcinoma↗
PubMed1998

Embryology and anatomy of the rectum.

Rectal cancer surgery is difficult due to the rectum's relatively inaccessible pelvic position and its direct relation to many vital structures. The surgeon is challenged to restore intestinal continuity while working in a confined space. Despite the importance of these issues, the embryology and surgical anatomy of the rectum have been poorly understood. In recent years, cadaver dissections and operative resection under direct vision have provided a clearer picture of the structure of the rectum and mesorectum, their innervation, blood supply, and surrounding structures. New imaging techniques will shed further light on the anatomy of these structures and their anatomic variations.

Anastomosis, Surgical↗