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Biomedical subjects

D A Rothenberger

Publications and source records attributed to D A Rothenberger.

At least 55 records · Page 3Linked to original sources
PubMed1992

Prognostic value of positive lymph nodes in rectal cancer.

Abdominal "curative" resections for rectal cancer in 109 patients with positive lymph nodes were prospectively studied. The best subdivision of patients for predicting outcome was into 1-3 and greater than 3 positive lymph node groups. Comparison with patients with greater than 3 positive lymph nodes demonstrated that patients with 1-3 positive nodes had less local (35.0 percent vs. 13.0 percent; P = 0.007) and less distant recurrence (45.0 percent vs. 26.0 percent; P = 0.04) and had much better crude five-year survival (58.2 percent vs. 17.0 percent; P less than 0.0001). For predicting postsurgical outcome in patients with positive lymph nodes, the results justify subdividing patients into the following two prognostic subgroups: 1) those with 1-3 involved lymph nodes and 2) those with metastatic tumor in four or more lymph nodes.

Adult↗
PubMed1992

Ileal pouch-anal anastomosis: state of the art.

IPAA surgery has evolved to assume a major role in the operative management of CUC and FAP. In experienced centres, the safety of performing this somewhat complex procedure, often in gravely ill patients, has been confirmed. A significant decrease in morbidity has accompanied increased experience and simplification of the operative techniques. Two major issues await resolution. The first has to do with the less than totally predictable functional results of IPAA surgery. While many patients do well, others, for no apparent reason, do poorly with excess frequency, urgency and incontinence. Whether operative modifications or preoperative testing can alter this outcome is at this time unclear. The second issue has to do with the potential long-term sequelae of IPAA surgery. Pouchitis and nutritional and metabolic consequences, including the potential for malignant transformation of ileal mucosa or of retained rectal mucosa, cannot be ignored. At present, these risks seem remote but only long-term follow-up will determine whether IPAA surgery deserves its current enthusiasm.

Adenomatous Polyposis Coli↗
PubMed1992

A prospective evaluation of distal margins in carcinoma of the rectum.

The controversy regarding the ideal distal margin after a "curative" anterior resection is currently unresolved. To clarify this issue, a prospective study was undertaken. Two hundred and forty-three patients who underwent "curative" anterior resection were included in this study. Patients were divided into 1 centimeter groups based upon the length of the distal margin (from 0.0 to 8.0 centimeters), and recurrence, local and distant, and survival were analyzed. There was no significant difference in local or distant recurrence or survival when each centimeter interval was studied to 1 centimeter. Patients with a distal margin of less than 0.8 centimeter (group 1) had more frequent anastomotic recurrences (30 percent) when compared with patients (group 2) with a distal margin greater than 0.8 centimeter (10.5 percent; p = 0.01). Both groups were well matched for age, gender, tumor size, length of proximal margin, number of positive lymph nodes, histologic factors, grade of differentiation, Dukes' classification, type of operation, preoperative and postoperative radiotherapy, follow-up evaluation and surgeon. Both groups had a similar pelvic area recurrence (5.0 versus 8.7 percent, p = NS) and distance recurrence rates (10.0 versus 14.2 percent, p = NS). The five year survival rate was adversely affected by a distal margin of less than 0.8 centimeter (49.3 percent in group 1 and 67.5 percent in group 2; p = 0.01). The data suggest that a distal margin of 1 centimeter in the pathologic specimen is adequate distal clearance for most carcinomas of the rectum.

Adenocarcinoma↗
PubMed1992

Long-term functional results of colon resection and rectopexy for overt rectal prolapse.

We reviewed the long-term functional results of colon resection and suture rectopexy for complete rectal prolapse in 47 patients followed for more than 3 yr (mean 65 months). Thirty-three patients underwent sigmoidectomy, eight patients underwent subtotal colectomy, and four patients underwent sigmoidectomy with subsequent subtotal colectomy. Three patients (6.3%) developed recurrent full-thickness prolapse, and four patients (8.5%) developed rectal mucosal prolapse. Twenty patients presented with constipation, 10 (50%) of whom improved after surgery. Constipation improved in seven (70%) patients who underwent subtotal colectomy. Twenty-one patients presented with incontinence, eight (38%) of whom improved. Continence worsened in six patients, and four patients developed significant diarrhea. These complications did not correlate with the extent of bowel resection. Three patients required subsequent stomas. Colon resection and rectopexy provides long-term control of rectal prolapse with an acceptable recurrence rate. Subtotal colon resection is frequently helpful in patients with associated constipation. However, colon resection of any magnitude entails a small risk of chronic diarrhea and/or diminished continence.

Colectomy↗
PubMed1991

Recurrence of Crohn's disease after resection.

Recurrent Crohn's disease develops in most patients after surgical resection if the patient is followed for sufficient time. This review examines various aspects of recurrent Crohn's disease. It is concluded that Crohn's disease is a diffuse condition of the gastrointestinal tract and that radical resection of Crohn's disease does not prevent recurrence. Assorted factors thought to be associated with recurrence are examined and the relevance of these factors to the surgeon treating Crohn's disease is discussed.

Adolescent↗
PubMed1991

Seton treatment of high anal fistulae.

Seventy-four patients who underwent seton treatment of high anal fistulae over a 6-year period have been reviewed. Four different techniques were used: staged fistulotomy (n = 24), cutting seton (n = 13), short-term seton drainage (n = 14) and long-term seton drainage in patients with Crohn's disease (n = 23). Recurrence developed in two patients (8 per cent) undergoing two-stage fistulotomy; two patients (14 per cent) undergoing short-term drainage and nine (39 per cent) of the patients with Crohn's disease. Three patients with Crohn's disease required proctectomy for progressive perianal disease. The remaining 11 patients with Crohn's disease (48 per cent) obtained a good result. None of the patients treated with a cutting seton developed a recurrence. Minor incontinence developed in 13 patients (54 per cent) undergoing two-stage fistulotomy and seven patients (54 per cent) treated with a cutting seton. When sphincter muscle was not divided, five patients (36 per cent) undergoing short-term drainage and six patients (26 per cent) undergoing long-term drainage developed minor incontinence. High complex fistulae can be successfully treated with only minor loss of continence using different seton techniques. In high Crohn's fistulae, long-term seton drainage preserves sphincter function, but recurrence is common if the seton is removed.

Adult↗
PubMed1991

Fistula-in-ano in Crohn's disease. Results of aggressive surgical treatment.

The outcome of aggressive surgical treatment of 64 symptomatic anal fistulas in 55 patients with Crohn's disease has been studied. Forty-one fistulas, in 33 patients, were treated by conventional fistulotomy (17 subcutaneous, 19 intersphincteric, 5 low transsphincteric fistulas). Thirty wounds (73 percent) healed within 3 months and eight more wounds (93 percent) healed within 6 months. Three wounds did not heal within 12-18 months. Two of these patients subsequently required proctocolectomy. Wound healing was not influenced by the presence of rectal Crohn's disease or granulomatous inflammation in the tract. No change in continence was experienced by 26 of the 33 patients who underwent fistulotomy. Three patients required proctocolectomy and the remaining four patients experienced minor degrees of incontinence postoperatively. Sixteen high transsphincteric, five suprasphincteric, and one extrasphincteric fistula in 22 patients were treated by laying open external tracts and placing a noncutting seton through the sphincter, which was left in place for prolonged periods to maintain drainage. During follow-up (6 months to 10 years, median 2.5 years), three fistulas healed and seven remained quiescent. Nine patients required further treatment by a new seton and three patients required proctocolectomy. Eight of the 22 patients who had a seton inserted had no change in continence, and six patients in this group developed minor changes in continence, mostly related to diarrhea associated with intestinal disease. Anal fistulas in Crohn's disease, which involve minimal sphincter muscle, can be successfully treated by fistulotomy. High fistulas should be treated with seton drainage to limit recurrent suppuration and preserve sphincter function.

Adolescent↗
PubMed1991

Sugar in the reduction of incarcerated prolapsed bowel. Report of two cases.

Incarcerated, prolapsed rectum, colostomies, and ileostomies, when viable, may be reduced using ordinary table sugar. The placing of sugar granules on the incarcerated bowel results in a decrease in tissue edema and spontaneous bowel reduction. The technique, case reports, and a review of the literature are herein reported.

Administration, Rectal↗
PubMed1991

Incontinence and rectal prolapse: a prospective manometric study.

A prospective, manometric study has been performed on 23 female patients with rectal prolapse and varying degrees of incontinence. Seven of the 14 incontinent patients regained continence after surgery, and a further two patients improved. Improvement in internal and external sphincter function follows correction of rectal prolapse. Preoperative resting anal pressure was significantly higher in continent patients than in incontinent patients (P less than 0.05), as was the maximum voluntary contraction pressure (P less than 0.027). Postoperatively there was a significant increase in the resting anal pressure (P less than 0.0001) and maximum voluntary contraction pressure (P less than 0.003) in the whole group. The preoperative resting anorectal angle was significantly more acute (P less than 0.028) in continent patients than in incontinent patients. There was no significant change in the resting anorectal angle following prolapse repair. Patients who remained incontinent had a significantly lower preoperative resting anal pressure (P less than 0.01) than patients who improved or regained continence. Similarly, maximum voluntary contraction pressure was lower preoperatively in these patients (P less than 0.02). Preoperative resting anal pressure below 10 mm Hg and maximum voluntary contraction pressure below 50 mm Hg are associated with persisting incontinence after surgery.

Adult↗
PubMed1990

Surgical approaches to anal incontinence.

Primary repair of acute anal sphincter injuries by direct apposition of the severed external sphincter without tension is advisable whenever feasible. However, the majority of patients who are candidates for surgical treatment of anal incontinence will undergo a secondary repair, the type of which will depend on the underlying aetiology and the surgeon's preference and experience. The most successful of these procedures is sphincter reconstruction with or without levatoroplasty for a disrupted anal sphincter (due to surgical, obstetrical or other trauma) in the absence of underlying neurological damage. Success rates are reported at 80-90%. Post-anal repair is advocated for patients with a poorly functioning sphincter with an obtuse anorectal angle, most of whom have a neurogenic basis for their incontinence. Success rates vary from 60 to 75% of cases but long-term results have been less satisfactory. Rectal procidentia is associated with faecal incontinence in 65-75% of cases. Abdominal repair (we favour suture rectopexy with sigmoid resection) restores continence in 50-80% of such patients. Patients with persisting incontinence are candidates for post-anal repair. Anal encirclement with an elastic, Dacron-impregnated Silastic sleeve has a limited role in selected patients. For more severe incontinence, muscle transfers (gracilis, gluteus maximus, etc.) can achieve some success but continence is less than perfect. We are currently assessing the use of an artificial anal sphincter (a modification of the AMS 800 urinary sphincter). For patients who fail all therapeutic options, a stoma will provide a better lifestyle than coping with the consequences of faecal incontinence.

Colorectal Surgery↗
PubMed1990

Rectal compliance: a critical reappraisal.

Compliance is a widely measured parameter of rectal function. Its value is determined clinically by recording pressure changes associated with volume infusion into a rectal balloon. This paper examines the inherent assumptions of the rectal balloon technique and discusses several of its shortcomings. A stricter definition of rectal compliance is needed, and in vivo compliance should be correlated with the directly measured mechanical properties of the rectal wall.

Catheterization↗
PubMed1990

Evaluation of an air-filled microballoon and mini-transducer in the clinical practice of anorectal manometry. Preliminary communication.

Anorectal manometry is becoming a commonly applied investigation in the field of colon and rectal surgery. Until now, however, most of this testing was performed in specialized units, which involved considerable expense and expertise to run. The authors assessed a commercially available mini-transducer and an air-filled microballoon catheter for their applicability to clinical anorectal manometry. This system is very accurate and is proving very useful in the ambulatory setting, on hospital wards, and in the operating room. It provides a simple alternative for areas where more sophisticated manometric systems are not available.

Adult↗
PubMed1990

Chronic pilonidal disease. An assessment of 150 cases.

During a four-year period, 150 consecutive patients were treated for chronic pilonidal disease by one of three different operative techniques. Patients with acute pilonidal abscesses or with complex or multiple recurrent pilonidal disease were excluded from this study. The average healing time was four weeks and the average length of hospital stay was one day. The overall recurrence rate was 8 percent (12 of 150 patients). The method of management most commonly used was fistulotomy with marsupialization of the sinus tract or cyst wall (125 of 150 patients). This simple and effective technique gave excellent results with a 6 percent recurrence rate (7 of 125 patients). On the basis of their experience, the authors propose that chronic pilonidal disease usually can be treated successfully on a same day surgery basis with fistulotomy, minimal excision, and marsupialization.

Adolescent↗
PubMed1990

Preoperative bowel preparation. A survey of colon and rectal surgeons.

A survey of 500 clinically active, board-certified colon and rectal surgeons in the United States and Canada was conducted to obtain data regarding current methods of bowel preparation for elective colorectal surgery. A review of recent publications on preoperative bowel preparation was used to compare the current literature recommendations with the actual practice among the group surveyed. Responses were received from 352 of 500 colorectal surgeons to whom questionnaires were sent (70 percent response rate). All respondents used a mechanical preparation and some form of antibiotics. The favorite antibiotic regimen was oral antimicrobials combined with systemic antibiotics (88 percent). Concomitant administration of oral neomycin-erythromycin base and a systemic second generation cephalosporin active against both anaerobic and aerobic colonic bacteria, together with oral polyethelene glycol electrolyte mechanical colonic cleansing, was the most popular method of preoperative bowel preparation (58 percent). The second most frequent method of mechanical bowel cleansing consisted of conventional enemas, dietary restrictions, and cathartic preparations (36 percent). Mannitol solution (5 percent), and whole-gut irrigation per nasogastric tube (1 percent) were the least popular methods of mechanical bowel cleansing. The literature supports the current methods of preoperative bowel preparation used by the vast majority of surgeons surveyed.

Anti-Bacterial Agents↗
PubMed1990

Endorectal ultrasound in the preoperative staging of rectal tumors. A learning experience.

The preoperative staging of rectal cancer has important implications for treatment as local therapies become increasingly utilized. Seventy-seven patients underwent preoperative staging using endorectal ultrasonography. All patients had complete pathologic staging and none had preoperative radiotherapy. Depth of invasion of the tumor was accurately predicted in 75 percent of cases in the entire group, with 22 percent overstaged and 3 percent understaged. Accuracy improved greatly over the study period, and in the past six months, 95 percent have been accurately staged for depth of invasion with 5 percent overstaged. Lymph nodes have been properly classified into positive and negative groups in 88 percent of cases in the past year, with a specificity of 90 percent and a sensitivity of 88 percent. Endorectal ultrasound is an accurate preoperative staging modality. Accuracy is improved greatly with increased experience and it has been found that the 5-layer anatomical model facilitates accurate staging. Introduction of the ultrasound probe through a previously placed proctoscope ensures complete scanning of the entire lesion and should be used for the majority of examinations.

Adult↗
PubMed1990

The ileoanal reservoir.

One hundred nine men and 71 women with a mean age of 31 years had construction of 164 S, 2 J, and 14 other ileoanal reservoirs. Postoperative gastrointestinal complications included small bowel obstruction in 11 percent and ileus, hemorrhage, and sepsis in 6 percent, 5 percent, and 11 percent, respectively. There was a 13 percent incidence of miscellaneous postoperative complications. Pouch perianal fistulas developed in 5 percent of patients, and pouch vaginal and other pouch fistulas developed in an additional 4 percent. During long-term follow-up, small bowel obstruction developed in 27 percent of patients, and enterolysis or enterectomy was required in 15 percent of patients. One hundred fourteen patients who were followed for a mean length of 5 years after ileostomy closure (range 16 to 88 months) were evaluated for functional outcome. Function improved with time in 63 percent of patients and remained stable in another 33 percent; only 4 percent had long-term deterioration. Ninety-five percent of patients would again choose an ileoanal reservoir over a permanent ileostomy. This long-term assessment shows that although the ileoanal reservoir is a viable option in the management of mucosal ulcerative colitis, it should not be recommended to every patient.

Adenomatous Polyposis Coli↗