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Biomedical subjects

I C Lavery

Publications and source records attributed to I C Lavery.

At least 19 recordsLinked to original sources
PubMed2004

Analysis of the outcome of ileal pouch-anal anastomosis in patients with Crohn's disease.

PURPOSE: Ileal pouch-anal anastomosis has come to represent the procedure of choice for patients requiring surgery for mucosal ulcerative colitis. In contrast, a proven diagnosis of Crohn's disease is generally held to preclude ileal pouch-anal anastomosis. However, patients with ileal pouch-anal anastomosis for apparent mucosal ulcerative colitis who are subsequently found to have Crohn's disease have a variable course. We reviewed our experience in this scenario to determine whether selected patients with Crohn's disease may be candidates for ileal pouch-anal anastomosis. METHODS: A retrospective review of the prospectively maintained ileal pouch-anal anastomosis database was undertaken to identify patients with a diagnosis of Crohn's disease after ileal pouch-anal anastomosis. Clinical outcome and quality-of-life data were obtained from the database and chart review. End points were the development of recrudescent Crohn's disease, pouch failure, and quality of life and functional outcome at the time of data collection. Differences between groups were calculated using the chi-squared test. Cumulative incidence of recrudescent Crohn's disease and pouch loss were calculated by the Kaplan-Meier method. Factors predictive of development of recrudescent Crohn's disease and pouch loss were examined by univariate analysis. RESULTS: Sixty patients (32 females; median age, 33 (range, 15-74) years) who underwent ileal pouch-anal anastomosis for mucosal ulcerative colitis subsequently had that diagnosis revised to Crohn's disease. Median follow-up of all patients was 46 (range, 4-158) months at time of data collection by which time 21 patients (35 percent) had developed recrudescent Crohn's disease. No pre-ileal pouch-anal anastomosis factors examined were predictors of the development of recrudescent Crohn's disease on univariate analysis. Median follow-up of the latter group was 63 (range, 0-132) months from time of diagnosis, by which time six patients underwent pouch excision and another patient was permanently defunctioned. The overall pouch loss rate for the entire cohort was 12 percent and 33 percent for those with recrudescent Crohn's disease. Median daily bowel movements in those with ileal pouch-anal anastomosis in situ at the time of data collection was 7 (range, 3-20), with 50 percent of patients rarely or never experiencing urgency and 59 percent reporting perfect or near perfect continence. Median quality of life, health, and happiness scores were 9.9 and 10 of 10. CONCLUSIONS: The secondary diagnosis of Crohn's disease after ileal pouch-anal anastomosis is associated with protracted freedom from clinically evident Crohn's disease, low pouch loss rate, and good functional outcome. Such results only can be improved by the continued development of medical strategies for the long-term suppression of Crohn's disease. These data support a prospective evaluation of ileal pouch-anal anastomosis in selected patients with Crohn's disease.

Adolescent↗
PubMed2002

Factors affecting local recurrence of colonic adenocarcinoma.

PURPOSE: The aim of this retrospective study was to determine which aspects of tumor morphology and histology influenced the incidence of local recurrence after curative resection of colonic adenocarcinoma. METHODS: Patients who had a curative resection for a primary colonic adenocarcinoma between 1980 and 1993 (inclusive) were identified from the colorectal cancer database in the Department of Colorectal Surgery. The charts of patients diagnosed with a local recurrence were then reviewed and their findings at operation and histologic assessment analyzed. Patients were followed up for at least five years or until death. RESULTS: Over the period of study, 1,031 patients had a curative resection for colonic adenocarcinoma. Local recurrences were detected in 32 patients (3.1 percent). The gender distribution of patients with local recurrence was 18 males (56.3 percent) and 14 females (43.7 percent) with a mean age of 63.4 years. The median time to local recurrence was 13 (range, 2-71) months. The distribution of primary tumors that recurred locally favored the cecum (n = 9; 28.1 percent) and sigmoid colon (n = 14; 43.7 percent) over other locations; these were, however, the most common sites of primary lesions. Less common sites included the ascending colon (n = 0; 0 percent), hepatic flexure (n = 2; 6.3 percent), transverse colon (n = 1; 3.1 percent), splenic flexure (n = 3; 9.4 percent), and descending colon (n = 3; 9.4 percent). Of the total number of tumors, 101 were found to be adherent to at least 1 other intra-abdominal viscus, and 12 (11.9 percent) recurred locally. Other factors associated with local recurrence were tumor perforation and fistulation. Overall, 30 tumors (2.9 percent) were perforated, and 6 (20 percent) recurred locally. Four tumors (0.4 percent) were fistulating; of these, 2 (50 percent) recurred locally. Advanced tumor stage was also associated with an increased rate of local recurrence (Stage I, 0 percent; Stage II, 2.05 percent; Stage III, 7.0 percent; and Stage IV, 6.1 percent). Similarly, tumor differentiation was related to local recurrence, with no instances in well-differentiated tumors, 2.8 percent in moderately differentiated tumors, and 6.8 percent in poorly differentiated tumors. CONCLUSIONS: The location of the primary tumor is not a factor in producing local recurrence. Fixity to another viscus, perforation or fistulation, advanced stage of disease, and differentiation of tumor appear to increase the chances of recurrence of curatively resected colonic carcinoma. Although the recurrence rate is higher in these groups than for tumors overall, definitive oncologic surgery prevents recurrence in the majority of cases. No colonic tumor that was T1 or T2 (N0, N1, or N2) or that was well differentiated recurred locally.

Adenocarcinoma↗
PubMed2001

Locally recurrent rectal cancer: predictors and success of salvage surgery.

PURPOSE: After curative surgery for rectal cancer, patients with pelvic recurrence may undergo curative surgical resection. We determined whether salvage surgery in appropriately selected patients could significantly lengthen disease-free survival time and if so what factors predicted this outcome. METHOD: We reviewed the records of all patients treated for rectal cancer at our institution between 1980 and 1993. Of 937 patients who underwent surgery with curative intent after proctectomy or transanal local excision, 81 (8.6 percent) experienced local recurrence. During the same period 36 patients with locally recurrent rectal cancer were referred from other institutions. Logistic regression analysis was used to identify predictors of salvage surgery. The Kaplan-Meier method was used to estimate cancer-specific and disease-free survival times in 43 patients who underwent salvage surgery. The Cox proportional hazard model was used to identify factors associated with these outcomes. RESULTS: Of 117 patients with locally recurrent rectal cancer, 43 (36.7 percent) underwent salvage surgery. Factors associated with higher chance of receiving salvage surgery were female gender, the first operation performed at outside institutions, and transanal local excision as the initial operation. For 43 patients who underwent salvage surgery, five-year cancer-specific and disease-free survival rates were 49.7 and 32.2 percent, respectively. No factors were significantly associated with death caused by cancer. However, a trend for poor prognosis was observed in patients with recurrence diameter >3 cm and tumor fixation Degree 2. CONCLUSION: Salvage surgery for properly selected patients with locally recurrent rectal cancer allows long-term palliation and significantly lengthens disease-free survival.

Disease-Free Survival↗
PubMed2001

Mucosectomy vs. stapled ileal pouch-anal anastomosis in patients with familial adenomatous polyposis: functional outcome and neoplasia control.

PURPOSE: The tradeoff of neoplasia control for better function represented by a stapled ileal pouch-anal anastomosis is still controversial in patients with familial adenomatous polyposis. We compared outcomes after mucosectomy and hand-sewn ileal pouch-anal anastomosis with those after stapled ileal pouch-anal anastomosis in 119 patients with familial adenomatous polyposis who underwent surgery since 1983. METHODS: Age, gender, length of follow-up, complications, quality of life, incontinence, urgency, nighttime and daytime seepage, pad usage, necessity of ileostomy, and incidence of adenomas developing in pouch and anal transitional zone were recorded. RESULTS: There were 42 mucosectomy and 77 stapled patients who were followed up for an average of 5.8 and 3.6 years, respectively, with endoscopic surveillance. There was one postoperative death in the stapled group that prohibited long-term follow-up. Nine of 42 mucosectomy patients developed pouch adenomas vs. 8 of 76 in the stapled group. Six of 42 patients developed adenomas in the mucosectomized anal transitional zone in the mucosectomy group. Twenty-one of 76 patients developed adenomas in the anal transitional zone in the stapled group. All were managed with local procedures or further surveillance. One of 76 patients developed cancer in the residual low rectum; this required further resection. Patients with stapled anastomosis had better outcomes in every category. Differences in incontinence, daytime and nighttime seepage, pad usage, and avoidance of ileostomy were statistically significant. All patients with mucosectomy required ileostomy vs. only 40 of 77 patients with stapled anastomosis. CONCLUSION: Familial adenomatous polyposis patients with stapled ileal pouch-anal anastomosis have better functional outcome and can avoid temporary diversion. This should be balanced against a 28 percent incidence of adenomas in the anal transitional zone.

Adenoma↗
PubMed2001

The management of neoplastic colorectal obstruction with colonic endolumenal stenting devices.

BACKGROUND: Colonic endolumenal stenting (CELS) to treat obstructing colorectal neoplasms was first described in 1991. The aim of this study was to review the published world literature and make recommendations for its use in current clinical practice. METHODS: Suitable English language reports were identified using a Medline search. RESULTS: CELS can been successfully accomplished in 64% to 100% of obstructing malignant colonic lesions. Distal lesions are more common and theoretically more easy to stent although lesions within the ascending colon have been successfully managed. Minor complications include transient anorectal pain and rectal bleeding, however, significant complications of stent dislocation and colonic perforation are also well recognized. CONCLUSION: CELS can aid the palliative management of malignant colorectal obstruction. Its role in relieving obstruction prior to resection remains to be defined. Increasing experience has allowed the safe placement of stents and relief of obstruction of virtually any lesion throughout the large bowel.

Colorectal Neoplasms↗
PubMed2001

Safety and longterm efficacy of strictureplasty in 314 patients with obstructing small bowel Crohn's disease.

BACKGROUND: Since its introduction in the early 1980s, strictureplasty (SXP) has become a viable option in the surgical management of obstructing small bowel Crohn's disease. Questions still remain regarding its safety and longterm durability in comparison to resection. Precise indications and contraindications to the procedure are also not well defined. STUDY DESIGN: A retrospective review of all patients undergoing SXP for obstructing small bowel Crohn's disease at the Cleveland Clinic between 1984 and 1999 was conducted. A total of 314 patients underwent a laparotomy that included the index SXP The total number of SXPs performed was 1,124, with a median of two (range 1 to 19) per patient. Sixty-six percent of patients underwent a synchronous bowel resection. Recurrence was defined as the need for reoperation. Followup information was determined by personal interviews, phone interviews, or both. RESULTS: The overall morbidity rate was 18%, with septic complications occurring in 5% of patients. Preoperative weight loss (p = 0.004) and older age (p = 0.008) were found to be significant predictors of morbidity. The surgical recurrence rate was 34%, with a median followup period of 7.5 years (range 1 to 16 years). Age was found to be a significant predictor of recurrence (p = 0.02), with younger patients having a shorter time to reoperation. CONCLUSIONS: This large series of patients with longterm followup confirms the safety and efficacy of strictureplasty in patients with obstructing small bowel Crohn's disease. The 18% morbidity and 34% operative recurrence rates compare favorably with reported results of resective surgery. Caution should be used in patients with preoperative weight loss, because they experienced higher complication rates. Although young patients seem to follow an accelerated course, SXP remains indicated as part of an overall strategy to conserve intestinal length.

Adolescent↗
PubMed2001

Function of a colonic J pouch continues to improve with time.

BACKGROUND: J pouch-anal anastomosis is thought to give superior functional results to straight coloanal anastomosis after rectal resection. Follow-up studies have suggested that this improvement is not maintained and that evacuatory difficulties may increase. METHODS: Some 119 consecutive patients had a coloanal anastomosis after resection for rectal carcinoma over 113 months, 62 with a J pouch and 57 with a straight coloanal anastomosis. Functional results were determined by patient questionnaire. The two groups were compared for the first and second 5-year intervals of study. RESULTS: Patients who had a J pouch had significantly better median Kirwan continence scores for the duration of the study and 5-9 years after surgery: 1 versus 2 (P = 0.05) and 1 versus 2 (P < 0.01), respectively. Some 5-9 years after surgery the median number of nocturnal bowel movements was significantly lower in patients who had a J pouch than in those with a straight coloanal anastomosis (0 versus 1; P = 0.02). Similarly, significantly better results were seen with regard to evacuation difficulties and urgency of defaecation. CONCLUSION: The function of the J pouch was superior to that of the straight coloanal anastomosis and appeared to improve with time.

Adenocarcinoma↗
PubMed2000

Incidence and natural history of dysplasia of the anal transitional zone after ileal pouch-anal anastomosis: results of a five-year to ten-year follow-up.

PURPOSE: Preservation of the anal transitional zone during ileal pouch-anal anastomosis is still controversial because of the risk of dysplasia and the theoretical risk of associated cancer. Without long-term follow-up data, the natural history and optimal treatment of anal transitional zone dysplasia are unknown. The aim of this study was to determine the long-term risk of dysplasia in the anal transitional zone and to evaluate the outcome of a conservative management policy for anal transitional zone dysplasia. METHODS: Two hundred ten patients undergoing anal transitional zone-sparing ileal pouch-anal anastomosis for ulcerative or indeterminate colitis between 1987 and 1992 and who were studied with serial anal transitional zone biopsies for at least five years postoperatively were included. Median follow up was 77 (range, 60-124) months. RESULTS: Anal transitional zone dysplasia developed in seven patients 4 to 51 (median, 11) months postoperatively. There was no association with gender, age, preoperative disease duration or extent of colitis, but the risk of anal transitional zone dysplasia was significantly increased in patients with prior cancer or dysplasia in the colon or rectum. Dysplasia was high grade in one and low grade in six. Two patients each with low-grade dysplasia detected on three separate occasions underwent mucosectomy 29 and 38 months after detection of low-grade dysplasia, but no cancer was found. The five other patients with dysplasia on one or two occasions were treated expectantly and were apparently dysplasia-free for a median of 72 (range, 48-100) months. CONCLUSIONS: Anal transitional zone dysplasia after ileal pouch-anal anastomosis is infrequent, is most common in the first two to three years postoperatively and may apparently disappear on repeated biopsy. Anal transitional zone preservation did not lead to the development of cancer in the anal transitional zone after five to ten years of follow-up. Long-term surveillance is recommended to monitor dysplasia. If repeat biopsy confirms persistent dysplasia, anal transitional zone excision with neoileal pouch-anal anastomosis is recommended.

Adolescent↗
PubMed2000

Treatment of colon and rectal cancer.

This article discusses multimodal treatment of noncomplicated colon and rectal cancer, considerations for specific types of colon cancer, considerations that may modify the extent and technique of surgery, the role of adjuvant chemotherapy for colon adenocarcinoma and rectal cancer, and surgical treatment of complicated colorectal cancer.

Adenocarcinoma↗
PubMed1999

Long-term functional outcome and quality of life after stapled restorative proctocolectomy.

OBJECTIVE: To evaluate prospectively long-term quality of life and functional outcome after restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis, and to evaluate and validate a novel quality-of-life indicator in this group of patients. SUMMARY BACKGROUND DATA: Restorative proctocolectomy with ileal pouch-anal anastomosis is now the preferred option when total proctocolectomy is required for ulcerative colitis or familial adenomatous polyposis, but long-term data on functional outcome and quality of life after the procedure are lacking. METHODS: Patients (n = 977) who underwent RPC with stapled anastomosis for colitis or polyposis coli and who were followed for > or =12 months were included. Quality of life, fecal incontinence, and satisfaction with surgery were prospectively evaluated by structured interview or questionnaire for 1 to 12 years after surgery (median 5.0). Quality of life was scored using the Cleveland Global Quality of Life (CGQL) instrument (Fazio Score). This is a novel score developed over the past 15 years by the senior author. Quality of life was also evaluated in a subgroup of patients with the Short Form 36 (SF-36). The CGQL was validated by determining its reliability, responsiveness, and validity as well as its correlation with the SF-36 score. RESULTS: Postoperative quality of life as measured by SF-36 was excellent and compared well with published norms for the general U.S. population. The CGQL was found to be reliable, responsive, and valid, and there was a high correlation with the SF-36 scores. Using the CGQL, quality of life was shown to increase after the first 2 years after surgery, and there was no deterioration thereafter. The prevalence of perfect continence increased from 75.5% before surgery to 82.4% after surgery, and although this deteriorated somewhat >2 years after surgery, it was no worse than preoperative values. Ninety-eight percent of patients would recommend the surgery to others. CONCLUSIONS: Long-term quality of life after ileal pouch surgery is excellent and the level of continence is satisfactory. This surgery is an excellent long-term option in patients requiring total proctocolectomy. The CGQL is a simple, valid, and reliable measure of quality of life after pelvic pouch surgery and may well be applicable in many other clinical conditions.

Aged↗
PubMed1998

Total mesorectal excision is not necessary for cancers of the upper rectum.

BACKGROUND: The technical aspects of surgery of the upper rectum (10 to 15 cm from the anal verge) and sigmoid colon are similar, but a change in technique is required for surgery of the lower rectum (< 10 cm). The aim of this study was to compare the outcomes of the treatment of upper rectal cancer (UR), in which total mesorectal excision (TME) was not performed, with outcomes of sigmoid colon cancers (S) and lower rectal cancers (LR). METHODS: Between 1980 and 1990, 891 patients were treated with curative intent for sigmoid (n = 225) and rectal cancer (UR = 229; LR = 437). The Kaplan-Meier and Cox proportional hazards analyses were used to compare outcomes. RESULTS: The risk of local recurrence alone, local and distant recurrence, death as a result of cancer, or any recurrence or death as a result of cancer was 3.5, 2.7, 2.1, and 1.9 times higher for patients with LR than for patients with UR, but the risk was not increased for UR relative to S. CONCLUSIONS: The outcome of treatment for UR is the same as for S and differs favorably from that for LR. UR should be treated by the same technique as S.

Adenocarcinoma↗
PubMed1998

Repeat ileal pouch-anal anastomosis to salvage septic complications of pelvic pouches: clinical outcome and quality of life assessment.

OBJECTIVE: To evaluate the outcome of repeat ileal pouch-anal anastomosis (IPAA) for septic complications of pelvic pouch surgery; to assess the relationship between diagnosis and outcome; to assess quality of life after surgery. SUMMARY BACKGROUND DATA: Pelvic and perineal sepsis due to ileal pouch-anal anastomotic leaks frequently results in pouch loss. Many surgeons believe that pelvic sepsis and/or dense pelvic fibrosis makes salvage surgery unsafe or that pouches salvaged under these circumstances may not function well. As a result, there are few studies of pouch salvage procedures for septic indications. METHODS: The authors reviewed records of Cleveland Clinic Foundation patients who had undergone repeat IPAA surgery after septic complications from previous pelvic pouch surgery and who had completed at least 6 months of follow-up. Final diagnoses included ulcerative colitis (n = 22), Crohn's disease (n = 10), indeterminate colitis (n = 1), and familial polyposis (n = 2). Patients with functioning pouches were interviewed about functional problems and quality of life using an in-house questionnaire and the validated SF-36 Health Survey. RESULTS: Of 35 patients, 30 (86%) had a functioning pouch 6 months after repeat IPAA. In 4 patients, complications led to pouch removal or fecal diversion. One patient declined stoma closure. Of the patients with mucosal ulcerative colitis (MUC), 95% (21/22) had a functioning pouch 6 months after surgery. For patients with Crohn's disease (CD) 60% (6/10) have maintained a functioning pouch. Of the 30 patients with functioning pouches, 17 (57%) rated their quality of life as either "good" or "excellent," the remaining 13 (43%) selected "fair" or "poor." All said they would choose repeat IPAA surgery again. An SF-36 Health Survey completed by all patients with a functioning pouch at follow-up showed a mean physical component scale of 46.4 and a mean mental component scale of 47.6, scores well within the normal limit. CONCLUSIONS: Repeat IPAA can often salvage pelvic pouches in patients with MUC who suffer major chronic perianastomotic and pelvic sepsis. Patients who had successful repeat IPAA surgery often report functional problems but would still choose to have the surgery again. For patients with CD, ultimate pouch excision or fecal diversion have been required in 40% indicating a guarded prognosis for these patients. Data on the success of the procedure for patients with indeterminate colitis and familial adenomatous polyposis were inconclusive because of small sample sizes.

Adult↗
PubMed1997

Perianal Bowen's disease: a clinicopathologic study of 47 patients.

PURPOSE: Perianal Bowen's disease is an uncommon squamous-cell carcinoma in situ usually treated by surgical excision. There are controversies concerning surgical margin extent, because the disease is likely to recur in nonexcised skin areas of the anal and perianal skin. The aims of this study were 1) to determine the recurrence rate after different surgical treatments and 2) to determine if molecular markers might have a prognostic role in perianal Bowen's disease. METHOD: Retrospective chart review from 1972 to 1993 of 47 patients with perianal Bowen's disease was undertaken. Follow-up was obtained by office visits and/or phone questionnaire. Immunohistochemical analysis for p53 protein and Ki-67 nuclear antigen was conducted on fixed tissue specimens. RESULTS: Twenty-six patients were treated by wide local excision with microscopic clearance of resection margins, 15 by local excision with only macroscopic clearance of resection margins, 5 by CO2 laser vaporization, and 1 by abdominoperineal resection because of fecal incontinence. Median follow-up for the entire population was 104 (range, 16-273) months. The incidence of local recurrence was 23.1 percent (6/26) after wide local excision, 53.3 percent (8/15) after local excision, and 80 percent (4/5) after CO2-laser vaporization. Recurrence rate estimated by Kaplan-Meier analysis is statistically different (P = 0.002) between radically treated patients (wide local excision/abdominoperineal resection; n = 27) and patients undergoing conservative treatment (local excision/laser vaporization; n = 20). Among patients with recurrence, the median time until recurrence was 38.5 (range, 3-89) months and 41.5 (range, 4-111) months after conservative and radical treatment, respectively. Nine of 20 (45 percent) patients in the conservative group and none of the 27 patients in the radical group had multiple episodes of recurrence (P < 0.001). In addition, 3 of 20 and 0 of 27 patients in the respective groups developed an invasive cancer (P = 0.034). Positive staining for p53 protein was observed in 12 (33.3 percent) of the 36 tissue specimens available for immunohistochemical analysis. Recurrence occurred in 9 of 24 (37.5 percent) patients negative for p53 and in 6 of 12 (50 percent) patients with positive p53 expression (P = not significant). Ki-67 antigen-graded expression from 1+ to 4+ did not reveal any correlation with incidence of recurrence. Recurrence rate did not differ by p53 and Ki-67 results, either in the overall group of 36 patients or stratified by surgical treatment groups. CONCLUSION: Wide local excision for perianal Bowen's disease leads to a significantly lower recurrence rate than local excision or laser therapy. Follow-up longer than five years is recommended because of the risk of late recurrence. p53 protein and Ki-67 antigen immunohistologic expression may not have a prognostic role in perianal Bowen's disease.

Aged↗
PubMed1997

Vaginal fistula following restorative proctocolectomy.

UNLABELLED: Vaginal fistula (VF) is a devastating complication following restorative proctocolectomy. PURPOSE: This study was designed to examine the perioperative factors influencing the outcome and management of vaginal fistula. METHOD: Between October 1983 and September 1994, 526 women underwent restorative proctocolectomy. Nineteen develop VF (3.6 percent), and six were referred from other institutions with this complication. These 25 women were followed for a minimum of nine months. RESULTS: Preoperative diagnosis of ulcerative colitis was made in 23 of the patients with VF (92 percent), and indeterminate colitis and familial adenomatous polyposis was determined in the rest of the patients. Postoperatively, 12 of the 23 women (52 percent) with a preoperative diagnosis of ulcerative colitis had clinical/pathologic findings of Crohn's disease, and 1 woman was reclassified as having indeterminate colitis. Postoperative pelvic sepsis was significantly higher in women with VF than in those without VF (26.3 vs. 6.3 percent; P = 0.003). Median time until occurrence of VF following loop ileostomy closure was later for women with delayed findings of Crohn's disease at 16.5 (range, <1-72) months, compared with women without Crohn's disease at 0.5 (range, <1-67) months (P < 0.05). Of the 163 women with handsewn anastomosis performed at our institution, 12 developed VF (7.4 percent). In contrast, 7 of the 363 patients with stapled anastomosis had VF (1.9 percent; P = 0.003). Site of VF was found at the anastomosis in 12 patients, below in 12 patients, and above in 1 patient. Presence of Crohn's disease and anastomotic technique did not influence the site of VF. Initial management of VF consisted of transanal repair in 20 patients (advancement flap, 12; direct repair, 6; and neoileoanal anastomosis, 2), seton in 1 patient, transabdominal approach in 1 patient, transvaginal in 1 patient, observation in 1 patient, and pouch excision in 1 patient. Of the 13 women without Crohn's disease, 12 had transanal repair (10 healed, 1 had recurrence, and 1 had pouch excision), and 1 had successfully repair with transabdominal technique, for an overall success rate of 84.6 percent. Of the 12 women with VF and delayed findings of Crohn's disease, transanal repair was performed on 9, 1 had pouch excision without repair, 1 had seton placement and pouch excision, and 1 underwent observation. Transanal technique of repair in women with Crohn's disease successfully healed three women (33.3 percent). Overall, of the 12 women with delayed findings of Crohn's disease, 6 had pouch excision, 3 had recurrences, and 3 healed. CONCLUSION: VF is an uncommon complication following restorative proctocolectomy and is associated with a high incidence of pelvic sepsis and handsewn anastomosis. Late presentation of VF is more common with Crohn's disease and is associated with a poor prognosis and pouch salvage rate. Transanal techniques are an effective means of VF repair.

Adenomatous Polyposis Coli↗
PubMed1997

Operation in patients with incurable colon cancer--is it worthwhile?

PURPOSE: This study was designed to identify objective criteria that might help surgeons decide which patients with incurable colon cancer will benefit from palliative surgery and which will not. METHODS: Charts of 68 patients with incurable colon cancer were reviewed. Fifty-seven patients underwent resection, six had a bypass of a nonresectable cancer, and five had no surgery at all. Time to death was the major end point of the study. Minor end points were postoperative morbidity and mortality. Independent variables analyzed were comorbidity, preoperative carcinoembryonic antigen, liver function tests, extent of liver metastases, stage and site of tumor, and tumor cell differentiation. RESULTS: There were six postoperative deaths, and six patients had complications. Mean survival after palliative resection was 10.6 months, after bypass was 3.4 months, and after diagnosis in patients not operated on was 2 months. Patients with > 50 percent of their liver replaced by cancer had significantly worse survival than those with < 50 percent involvement (mean, 4.2 +/- 4 standard deviation (SD) vs. 14.4 +/- 10.6 SD; P < 0.003, Wilcoxon's rank-sum test). Tumor differentiation also influenced survival (poor, mean 8.4 +/- 8.2 SD; well/moderate, 12.5 +/- 9.2 SD; P < 0.02). No other variable had a significant effect on survival. CONCLUSION: Resection of primary colon cancer in patients with incurable disease has a relatively high postoperative mortality but is worthwhile as long as hepatic metastases occupy less than 50 percent of liver volume.

Aged↗
PubMed1997

Long-term outcome of patients with perianal Paget's disease.

BACKGROUND: Perianal Paget's disease (PPD) is a rare intraepithelial adenocarcinoma with a significant rate of recurrence after treatment and high risk of progression to an invasive cancer. PATIENTS AND METHODS: Fourteen patients with a mean follow-up longer than 5 years were studied to determine the outcome after surgical treatment. The immunohistochemical accumulation of p53 protein also was assessed in tissue specimens to evaluate its prognostic role in patients with PPD. RESULTS: Four patients were excluded because of progression to invasive malignancy at the time of diagnosis. Two patients underwent local excision (LE) with macroscopic clearance of the surgical margins; the remaining eight patients underwent wide local excision (WLE), i.e., > 1 cm microscopic clearance of the surgical margins. The actuarial 8-year recurrence rate for patients treated with LE and WLE was 100% and 50% (SE = 17.7), respectively. Progression to invasive carcinoma occurred after a median time of 56 months (range 23-72) in two patients treated with LE and in one of eight patients treated with WLE. All four patients with recurrence after WLE were successfully treated (no further recurrence) with a second WLE. Actuarial 8-year survival was 0% in the LE group and 40% (SE = 21.9) in the WLE group. There was no p53 protein accumulation in any of the ten patients with PPD. CONCLUSIONS: Survival of patients with PPD treated by WLE was higher than that for those treated with LE. Thus, wide local excision is recommended over limited local excision as a preferred treatment for PPD. Follow-up longer than 5 years seems to be indicated because of the risk of late progression to invasive cancer. When PPD does recur, a second WLE may be curative. The absence of accumulated p53 protein suggests that this marker may not have a prognostic role in PPD.

Adult↗