Biomedical subjects
Publications and source records attributed to D A Rothenberger.
Attention to detail is crucial to the success of the operation described. Surgeons contemplating performing it should first be experts in pelvic surgery and are advised to personally observe and participate in the procedure performed by surgeons currently experienced in this technique.
Rectal carcinoma remains a common, lethal form of malignancy. Despite improvement in overall survival due to increased resectability, decreased operative mortality, and possibly earlier detection at a more favorable stage, the cancer-specific survival rate stage for stage following operative treatment is unchanged in recent decades. Overall survival rate should increase further if earlier diagnosis can be made at a time when all lesions are locally confined and resectable for cure and if operative mortality can consistently be kept under 2 percent. The latter will require not only improvement in surgeons' skills to conduct these operations efficiently but also, and perhaps more important, improvement in surgeon's abilities to better select which patients can and should safely undergo a major resection. Improvement in cancer-specific survival rate stage for stage is not likely to result from operative methods but probably depends upon development of effective forms of adjuvant therapy or of totally new forms of therapy designed to supplement or supplant operative intervention. At present, it is discouraging that no such development has occurred, though radiation therapy may prove useful.
A retrospective analysis of 90 patients who underwent a curative surgical resection for a carcinoma of the middle third of the rectum was carried out to determine the preliminary recurrence rates associated with stapled coloproctostomy. Acknowledging the obvious limitations of this preliminary report, the liberal use of restorative resections for these lesions does not appear to be resulting in an obvious increase in tumor recurrence, and the use of the circular intraliminal staplers has significantly decreased the number of abdominoperineal resections required to treat these lesions. We will continue to use stapled coloproctostomy for the majority of these lesions; however, definitive statements regarding the over-all effect of this approach upon survival time await further studies incorporating larger numbers and longer follow-up studies.
Explore the source record for details and available documents.
When defects of the anal sphincter are caused by trauma, surgical correction can be successful even in long-standing cases. At the University of Minnesota, we used overlapping sphincteroplasty in 79 patients with fecal incontinence from 1952 to 1982. There were 62 women and 17 men. Ages ranged from 17 to 68 years. Incontinence had been present from three weeks to 40 years and had been caused by childbirth, previous anorectal surgery, trauma or rectal prolapse. Following overlapping sphincteroplasty, there was one postoperative death and 13 complications. Complications included temporary difficulty in voiding, excessive bleeding, abscess formation, fecal impaction, and hematoma. Seventy-six of the 78 surviving patients were followed for an average of 35 months. Results ranged from excellent to poor with only one failure. From our experience it was concluded that several factors were important for good surgical results. 1) The patient must have intact neuromuscular bundle with detectable voluntary sphincter contraction. 2) If a primary repair has failed, a minimum duration of three months should elapse before overlapping sphincteroplasty is attempted. 3) Scar tissue from the severed muscles should not be excised. 4) The internal and external sphincter muscles should not be separated. 5) A temporary concomitant colostomy is not necessary.
Although operative injury to the spleen continues to account for a large number of splenectomies, the incidence of injury during operations upon the colon and rectum has not previously been reported. Of 993 consecutive colonic and rectal excisions, the spleen was injured in eight and splenectomy resulted in three. Two hundred and sixty patients had the splenic flexure of the colon mobilized. All splenic injuries occurred in this group (3.1 per cent) for an incidence of splenectomy during splenic flexure mobilization of 1.15 per cent. In all patients, splenic injury consisted of a capsular tear and was a result of traction on spleno-omental peritoneal bands in 50 per cent. The spleen was salvaged using topical hemostatic agents in 63 per cent of the injuries. A method of splenic flexure mobilization which improves visualization of splenic attachments and avoids traction injuries is discussed. The morbidity and mortality from traumatic splenectomy are also reviewed.
Coloproctostomy or colocolostomy by peranal insertion of a circular stapling device was performed on 265 patients between January 1978, and June 1981. A low anterior resection was performed in 174 patients. Stapler-related technical complications occurred in 52 patients (20 per cent). Complementary transverse colostomies were performed in 11 patients, of which seven were performed on the first 30 patients. Intraoperative complications occurred in 18 patients (7 per cent). Twenty-six major postoperative complications occurred (10 per cent), and clinical anastomotic leaks occurred in eight patients (3 per cent). Four postoperative deaths occurred (1.5 per cent). This study concludes that (1) coloproctostomy or colocolostomy can be safely performed by transanal insertion of a circular stapling device, (2) these instruments allow a sphincter-preserving procedure to be performed for lesions in the low and midrectum (5 to 10 cm from the anal verge) with an acceptable early morbidity and mortality, and (3) the majority of stapler-related technical complications can be managed without protecting colostomy.
Explore the source record for details and available documents.
An initial experience with a technique of restorative proctocolectomy utilizing a rectal mucosectomy, total colectomy, and ileal reservoir (Parks S-pouch) with ileoanal anastomosis for patients with ulcerative colitis and familial polyposis is presented. Although there were no deaths, significant morbidity did occur and was attributed to the use of a temporary loop ileostomy which may not be necessary. Early functional results are promising and to date, patient satisfaction is very high.
Explore the source record for details and available documents.
Forty-eight patients treated for chronic incapacitating constipation by surgical resection were reviewed. Thirty-seven had subtotal colectomy, eight had left colectomy, two had right hemicolectomy, and one had ileostomy, colectomy, and a Hartmann pouch. There were significant complications (21 per cent) and one mortality (2 per cent). A long-term successful outcome was found in 81 per cent of the patients on follow-up. Physiologic studies are recommended to improve the selection of patients.
Perinatal death due to maternal injury is unusual unless associated with extensive maternal trauma or death. An unusual case of neonatal death due to in utero traumatic splenic rupture in the absence of significant maternal injury is presented. The case alerts physicians responsible for neonatal care to the existence of treatable causes of neonatal distress following maternal trauma.
Thirty-three peripheral arterial injuries were observed in 29 patients following blunt trauma. Motor vehicle accidents were the most common initiating event. The mechanism of injury was fracture or dislocation in 21 patients, acute traction on the extremity in five patients, and contusion in three patients. Pulses were absent distal to the site of arterial injury in all patients. Complete arterial disruption was documented in 19 arteries; intimal or intimal and medial tears were observed in 10 arteries. Four arteries not surgically explored. If possible, debridement and primary anastomosis was the preferred method of revascularization. Saphenous vein interposition grafts were the second choice. Five amputations, four major and one minor, were required. Although patient vascular reconstructions may be uniformly achieved, long-term functional results are frequently affected by the duration of limb ischemia before revascularization, and concomitant injuries to bone, nerve, and soft tissue.
To avoid an unnecessary radical operation, it is important for surgeons to identify a clinically benign villous tumor of the rectum, especially in the middle third area, where a transanal approach may not be feasible. If the high accuracy of this clinical impression can be achieved, alternative methods such as piecemeal snare excision, or electrocoagulation, or both are justified. To evaluate the diagnostic accuracy of a benign rectal villous tumor, 151 patients with totally excised rectal tumors were reviewed. All of these patients had soft and nonulcerated lesions and were judged to be benign. Induration and ulceration of the lesions signified malignancy and were excluded. One hundred and fourteen patients (76%) had benign villous adenomas, 23 patients (15%) had superficial carcinomas, and 14 patients (9%) had invasive carcinomas. Hence the accuracy of detecting a clinically benign villous tumor of the rectum was 91%. This is high enough to avoid a more radical procedure when the clinical impression is that of a benign villous tumor of the rectum.
Twelve patients sustained sixteen pelvic fracture-related iliac and femoral arterial (5) and venous (11) injuries. Death was due in large part to delays in recognition and direct operative control of the major vascular disruption. Prompt operative exploration of all pedestrians admitted in hemorrhagic shock will open pelvic fractures characterized by a double break in the pelvic ring should reduce the 83 per cent mortality currently associated with this combination of injuries.
Although elbow dislocation occurs frequently, associated brachial artery injury is rare. Adequate treatment of this injury includes prompt arteriography, reduction of the dislocation, vascular repair, and transarticular fixation of the reduction. A case report and review of the literature are presented.
The mortality among 604 patients with pelvic fractures was 12%. Pedestrian accidents were the etiologic agent in 27% of the patients, but accounted for 49% of the deaths and for 73% of the deaths primarily due to pelvic fractures. Although 71 of the 72 patients who died sustained concomitant major injuries (mean, 3.1), 60% of the deaths (43 patients) were attributed entirely or in part to pelvic fractures. Of particular interest were the 26 patients in whom the pelvic fracture was the primary cause of death. Ninety-three percent were in shock or had clinical evidence of hypovolemia at the time of admission. Eighteen patients (69%) exsanguinated from their pelvic fractures shortly after hospital admission (mean, 9 hours). They were more elderly than the eight patients who survived their initial resuscitation, but subsequently died of sepsis or of renal failure (mean, 62 vs. 38 years). Sepsis arising in the pelvic hematoma and acute renal failure induced by pelvic hemorrhage and/or pelvic sepsis each accounted for 15% of the deaths. Ninety-one percent of the patients who died primarily of their pelvic fracture had a single or double break in the pelvic ring. Thirty-one precent had open pelvic fractures, and injury associated with a 50% mortality. Twenty-three percent had pelvic fracture related iliac or femoral vessel disruptions, an injury associated with a 75% mortality. Mortality in these patients clearly resulted from ineffective control of pelvic hemorrhage and from the inability to prevent sepsis in the pelvic hematoma.
Twelve pregnant women underwent diagnostic peritoneal lavage for suspected blunt abdominal trauma. Peritoneal lavage was both safe and accurate. The lavage was negative in four patients. Two of these patients survived without clinical evidence of abdominal injuries. The absence of abdominal injuries was confirmed at autopsy in the two patients who subsequently died. Peritoneal lavage was positive for hemoperitoneum in eight patients. All eight had significant abdominal injuries.