Biomedical subjects

I C Lavery

Publications and source records attributed to I C Lavery.

At least 73 records · Page 4Linked to original sources

PubMed1991

Systemic cytotoxic chemotherapy and radiation therapy for desmoid in familial adenomatous polyposis.

Forty-two of 416 familial adenomatous polyposis (FAP) patients in the FAP registry at the Cleveland Clinic had desmoid tumors. The role of cytotoxic chemotherapy and radiation therapy in the management of these patients was investigated. Eight intra-abdominal desmoid tumors were treated by systemic cytotoxic chemotherapy. Two had complete remission, and one had partial remission. Five patients died as a result of the desmoid tumor or late complications of chemotherapy. Three intra-abdominal desmoids were treated by radiation therapy with no response. Neither cytotoxic chemotherapy nor radiation therapy is recommended as a first-choice treatment for intra-abdominal desmoid tumors in patients with FAP.

Adenomatous Polyposis Coli↗

PubMed1991

Consequences of ileal pouch-anal anastomosis for Crohn's colitis.

Patients with Crohn's colitis are generally not considered candidates for the ileal pouch-anal anastomosis (IPAA) procedure. We reviewed 362 consecutive patients undergoing IPAA and analyzed the outcome of this procedure on 25 patients with a preoperative diagnosis of mucosal ulcerative colitis who were subsequently proven to have Crohn's disease. The mean follow-up was 38.1 months. Sixteen patients have a functioning pouch, seven have required pouch excision, one is diverted, and one has died. Only one of nine patients in whom there was a preoperative clinical feature suggestive of Crohn's disease has a functioning pouch, with complications uniformly occurring within months of ileostomy closure. In contrast, 15 of 16 patients without preoperative features of Crohn's disease have maintained their pouch, generally with good results. These data suggest that patients in whom there is clinical and pathologic evidence of Crohn's disease do very poorly without meaningful symptom-free intervals. However, patients without any clinical features of Crohn's disease, despite a histopathologic diagnosis of Crohn's colitis, have had a good outcome with IPAA thus far.

Adult↗

PubMed1991

Psoas abscess: difficulties encountered.

From 1961 to 1989, 67 patients underwent various surgical procedures for psoas abscess. Retrospective analysis was undertaken in an effort to determine optimal surgical therapy. Forty patients were cured with one operation. Twenty-one patients required two operations, four patients required three operations, and two patients required more than three operations. The reason for failure of treatment was failure to resect the diseased bowel or to drain the psoas abscess adequately. A technique to recognize and treat the abscess definitively will be illustrated. The most common etiologies were Crohn's disease in 49 patients, postoperative sepsis in eight patients, and complications of renal disease in four patients. The length of hospital stay ranged from 5 to 392 days (mean, 26 days). There were two deaths. Failure to recognize and treat psoas abscess results in considerable morbidity.

Adolescent↗

PubMed1991

Impact of anal manipulation and pouch design on ileal pouch function.

The frequency of defecation, leakage, maximum resting pressure, and maximum squeeze pressure of the anal canal, maximum tolerated volume, and pouch compliance were evaluated in 116 consecutive patients following total proctocolectomy (TPC) with ileal pouch anal anastomosis (IPAA) and after temporary ileostomy closure. Sixty-nine patients had a double ileal loop pouch ("J") and 47 a triple ("S") design. Seventy patients had mucosal proctectomy and hand-sewn IPAA (mucosectomy) and 46 a stapled IPAA without mucosal proctectomy (stapled). Fifty percent of the S and 30% of the J pouch patients did not have nocturnal defecations. The avoidance of anal manipulation in the stapled group resulted in higher anal canal resting pressures and a lower incidence of leakage. The maximum tolerated volume and compliance was greater in the S pouch group than in the J group. Although the median frequency of defecation was equal in both pouch groups, fewer S pouch patients had nocturnal defecations. Anal canal resting tone may be the primary factor affecting continence following TPC and IPAA, but a compliant pouch may prevent leakage if sphincter function is compromised.

Anal Canal↗

PubMed1990

Spontaneous mutation in familial adenomatous polyposis.

A retrospective review of the familial adenomatous polyposis registry at the Cleveland Clinic Foundation revealed an incidence of spontaneous mutation in familial adenomatous polyposis (FAP) of 22 percent of family kindreds. These patients were reviewed retrospectively and compared with the total FAP population followed at The Cleveland Clinic Foundation with respect to the onset of disease, the incidence of carcinoma in the resected colon, and incidence of extracolonic manifestations. Review of the characteristics and presentations of these patients suggested that these individuals may harbor a more severe form of FAP. This may be due, in part, to the delay in diagnosis and, therefore, a higher rate of development of colorectal carcinoma and possibly duodenal adenomas. There is also a demonstrable higher rate of extracolonic manifestations of FAP present in this subset of patients. When selecting the initial type of prophylactic colonic resection the surgeon should bear in mind the increased incidence of extracolonic manifestations of the disease in this group of patients and their potential for complications.

Adenomatous Polyposis Coli↗

PubMed1990

Surgical treatment of enterovesical fistulas in Crohn's disease.

A review of the surgical treatment of enterovesical fistula in Crohn's disease was undertaken to evaluate its effectiveness and long-term results. Sixty-three patients, 39 men and 24 women, with a mean age of 34.4 years were identified with enterovesical fistula. They had documented Crohn's disease for a mean period of 7.0 years. Distribution of anatomic pattern was 34.9 percent ileal, 7.9 percent colonic, and 57.2 percent ileocolic. Nineteen (30.1 percent) had previous abdominal surgery for Crohn's disease. Presenting symptoms included frequency and dysuria in 93.6 percent, pneumaturia in 79.3 percent, and fecaluria in 63.4 percent; 60.3 percent of patients had all three features. Enterovesical fistula was confirmed preoperatively in 43 patients, suspected clinically in 15 patients, and diagnosed intraoperatively in 5 patients. Sixty-one of 63 patients underwent surgery with resection of the phlegmon or abscess with the diseased bowel and curettage or resection of the fistula. After curettage of the bladder defect, pelvic and bladder drainage was instituted. Coexistent fistulas, most commonly ileosigmoid, occurred in 31 patients. Intra-abdominal abscesses were found in 21 patients, of whom 15 required two-stage procedures. One patient died (mortality 1.6 percent), urine leak occurred in 3.2 percent, and wound infection occurred in 1.6 percent. Follow-up (mean, 106 months) has identified one recurrence of enterovesical fistula due to Crohn's disease, and a further recurrence from concomitant sigmoid diverticulitis. Enterocutaneous fistulas developed in 6.4 percent and 11 patients (17.4 percent) have required further resections for Crohn's disease. Surgical treatment of enterovesical fistula in Crohn's disease is a safe and effective treatment.

Adolescent↗

PubMed1990

Predictive value of congenital hypertrophy of the retinal pigment epithelium as a clinical marker for familial adenomatous polyposis.

One hundred forty-eight members of 53 kindreds with familial adenomatous polyposis (FAP) were examined for congenital hypertrophy of the retinal pigment epithelium (CHRPE) and extracolonic manifestations (ECM) to assess the value of CHRPE as a predictive marker for FAP. Based on eye examination results, the families were divided into 2 groups. In a first group of 34 families, all 61 members diagnosed as having polyps and 13 of the 33 patients at risk had 4 or more lesions distributed in both eyes. By contrast, in a second group of 18 families, all 32 polyposis patients and all 18 members at risk had less than 4 lesions. Extra-colonic manifestations were present in 26 of 34 families in the first group and in 11 of 18 families in the second group. Data on one family with ambiguous ancestry were reviewed separately. The existence of 4 or more CHRPE lesions distributed in both eyes seems to be a congenital marker for FAP, present in 65.4 percent of families. When present in a family: 1) it is found in all diagnosed patients in that family, 2) can therefore be considered predictive for the development of polyps in other family members who carry the trait, and 3) if confirmed by longer follow-up, may possibly preclude members without the trait from further evaluation and surveillance.

Adenomatous Polyposis Coli↗

PubMed1990

Mortality in patients with familial adenomatous polyposis.

The authors identified 132 patients who died with a documented diagnosis of familial adenomatous polyposis (FAP). A review of the medical records, autopsy reports, and in-depth discussion with local physicians and well-informed family members was performed. It was impossible, even after the review, to ascertain the exact cause of death in 22 patients. In the remaining patients, the cause of death was as follows: metastatic colorectal carcinoma, 64 patients (58.2 percent), (colon, 49 [44.5 percent], rectal, 15 [13.6 percent]); desmoid tumors, 12 (10.9 percent); periampullary carcinoma, 9 (8.2 percent); brain tumors, 8 (7.3 percent); perioperative mortalities, 5 (4.5 percent); adrenal carcinoma, 1 (0.9 percent); and abdominal carcinomatosis, 1 (0.9 percent). Ten patients died of causes not related to FAP. The major causes of death in 36 patients who underwent prophylactic colectomy were desmoid tumor and periampullary malignancy. This finding underscores the importance of lifelong surveillance and periodic endoscopic evaluation in patients with FAP.

Abdominal Neoplasms↗

PubMed1990

A technique for decompression of the obstructed Kock continent ileostomy.

A technique is described for intubation of the difficult, obstructed continent ileostomy. This procedure is safe and easily performed with commonly available materials. It initiates immediate primary treatment of the problem with decompression and catheter drainage, and also allows direct inspection of the pouch and valve to assist with planning of definitive treatment.

Humans↗

PubMed1989

Pouch ileitis.

Pouch ileitis is the most poorly understood complication of ileal reservoir surgery. Variability in definition of this syndrome may account for differences in incidence rate, associated symptoms, and response rate to therapy present in the literature. Outcomes of 19 episodes of pouch ileitis in patients having undergone prior colectomy and continent ileostomy construction for presumed ulcerative colitis were analyzed. An episode of pouch ileitis was characterized by: (1) abdominal pain, (2) increased ileal output, (3) mucosal inflammation within the continent ileostomy, and (4) absence of other recognized concurrent postoperative complications. The mean time of occurrence after construction of the continent ileostomy was 25 months (range 3-54 months). The mean length of follow-up of patients included in this analysis was 49 months from the time of continent ileostomy construction (range 22-101 months). Associated clinical symptoms included bloody effluent (53%), nausea or emesis (47%), and fever (42%). Endoscopic features were often nonspecific, with mucosal erythema (84%), edema (79%), friability (58%), and mucosal ulceration (53%) the most common. In those episodes of pouch ileitis where ileoscopy revealed no evidence of mucosal ulceration, complete resolution of the episode occurred 89% of the time, with 78% treated with antibiotics alone. In those episodes where mucosal ulceration was described on ileoscopy, 40% of episodes completely resolved after medical treatment, 20% with antibiotics alone. The varied clinical symptoms, endoscopic findings, and response to treatment raises the possibility that what has previously been described in the literature as pouch ileitis may be a heterogeneous group not of single etiology.(ABSTRACT TRUNCATED AT 250 WORDS)

Colectomy↗

PubMed1989

Internal anal sphincter function after total abdominal colectomy and stapled ileal pouch-anal anastomosis without mucosal proctectomy.

A comparison, based on results from anal manometry and continence, was made between eight patients after circular stapled ileal J-pouch-anal anastomosis without mucosectomy (Js) and seven patients after endoanal mucosal proctectomy and hand-sewn ileal pouch-anal anastomosis (Jm). The mean and range from ileostomy closure were 3.5 months (1.5 to 12) and 21.7 months (13 to 32), respectively. The mean maximum resting pressure (MRP) ( +/- SEM and range) was 81.3 mm Hg ( +/- 6.0 and 61 to 112.5) and 50.0 mm Hg ( +/- 6.2 and 17 to 62.5), respectively, for the Js and Jm groups (P less than .003). None of the Js patients experienced leakage or wore a pad, while in the Jm group 14 percent experienced minor leakage during the day and 28 percent at night. Seventy-one percent of the Jm group wore a pad at some point. Anal sphincter resting pressures and continence were better in the Js group. The improvement in MRP resulted from avoidance of injury to the internal and sphincter during dilatation and mucosectomy and the maintenance of a normal anal canal that allowed for proper closure.

Adult↗

PubMed1989

Perforating and nonperforating Crohn's disease. An unpredictable guide to recurrence after surgery.

Four hundred eighty-six patients who have had resections for Crohn's disease at the Cleveland Clinic were reviewed. The patients were categorized by indication for surgery into three groups: perforating (P) (135 patients), nonperforating (NP) (278 patients), and miscellaneous (M) (77) patients. One hundred ninety-four patients had two or more resections and 56 underwent a third resection. Patients were no more likely to have the same indication for surgery at the time of the second resection (P = 25 percent; NP = 44 percent; M = 57 percent) or the third resection (P = 11 percent; NP = 65 percent; M = 55 percent). There was also no difference in the interval between resections for the P and NP groups. The lack of agreement between resections suggests that the categorization of patients into P and NP groups does not facilitate prediction of the nature of recurrent disease. The concept of aggressive perforating and indolent nonperforating Crohn's is not substantiated by this study.

Adult↗

PubMed1989

En bloc resection for contiguous upper abdominal invasion by adenocarcinoma of the colon.

Although en bloc resection for contiguous invasion by adenocarcinoma of the colon is a well-recognized principle, it is difficult to assess the efficacy of this principle when upper abdominal viscera are involved. This study was undertaken to better define this subgroup. Seventeen patients were studied over a period of 20 years who underwent extended resections for colonic adenocarcinoma with upper abdominal organ invasion. The age range was 30 to 81 years (average, 61 years). There was a male-to-female ratio of greater than 2:1. The duration of presenting symptoms was as short as 4 days and as long as 18 months (average, 4.3 months). The most common complaint was weight loss (13/17). The next most common complaints were abdominal pain (10/17), bowel complaints (5/17), and septic symptoms (4/17). A single organ was involved in 7 instances, but multiple organs were involved in most cases. The frequency of involvement was the stomach, spleen, and duodenum (5 each), abdominal wall and diaphragm (4 each), pancreas and liver (3 each). There were 2 perioperative deaths and 9 other major complications. The most common cause of morbidity and mortality was septic in nature in 8 of the 11 instances. All 3 patients with pancreatic resections had postoperative complications; none were fatal. Five patients survived over 10 years, three were 5-year survivors, and two are living and free of disease at less than 5 years. Excluding the two perioperative deaths, four of the five patients who died in less than 5 years had documented recurrences.

Abdominal Neoplasms↗

PubMed1989

Strictureplasty in Crohn's disease.

Fifty patients with fibrotic small bowel strictures secondary to long-standing Crohn's disease underwent a total of 225 strictureplasties during the period from June 1984 to July 1988. Forty-two patients (84%) presented with obstructive symptoms. Patients had a 1- to 30-year history of Crohn's disease (mean, 14 years). Sixty-two per cent of patients were taking steroids at the time of admission, and 70% had had previous small bowel resections. All patients had one or more areas of small bowel affected with a fibrotic stricture and partial obstruction. Short strictures were treated by Heinecke-Mikulicz strictureplasties, and longer strictures by Finney side-to-side strictureplasties. In 30 patients (60%), 6- to 65-cm segments of small bowel were also resected due to acute inflammation with phlegmon or fistulae. Patients were discharged from the hospital 5 to 20 days after operation (mean, 10 days). After operation all patients with obstructive symptoms reported relief of symptoms and weight gain. Steroid doses could be tapered and nutritional parameters, such as total lymphocyte count, and serum albumin improved. Strictureplasty had 0% mortality and 16% morbidity rates. Complications included 3 enterocutaneous fistulae, 2 intra-abdominal abscesses, 2 hemorrhages requiring transfusion, 1 prolonged postoperative ileus that could be treated conservatively in 2 patients, and 1 restricture of a strictureplasty. Patients were followed for 1 to 40 months after operation (mean, 8 months). Resection of small bowel disease, especially that associated with perforation, is usually required in Crohn's disease. However, strictureplasty minimizes the need for bowel resection in patients with short fibrotic strictures resulting in recurrent small bowel obstruction.

Adolescent↗

PubMed1989

Surgical management of colonic inertia.

Fourteen patients with chronic constipation due to colonic inertia were treated with total abdominal colectomy and ileorectal anastomosis at the Cleveland Clinic Foundation from 1981 to 1986. All patients were white women ranging in age from 28 to 64 years (mean 41 years). The duration of symptoms averaged 21 years (range six to 47 years) and the average time between bowel movements was ten days. The preoperative evaluation included barium enema in 12 patients and colonoscopy in five (some patients had both studies). Anorectal dysfunction was excluded by manometry in ten patients and by rectal biopsy in six. Colonic transit studies were accomplished in only two patients. The hospital stay averaged 13 days, and there was no operative mortality. Postoperative morbidity included one case of small bowel obstruction, necessitating operative correction on postoperative day 9. Follow-up ranged from three months to five years. At their last clinic visit, the patients averaged two bowel movements per day. All patients had excellent bowel control and were happy with the procedure.

Adult↗

PubMed1988

Spontaneous resolution of rectal polyps in patients with familial polyposis following abdominal colectomy and ileorectal anastomosis.

One hundred sixteen patients were reviewed after abdominal colectomy and ileorectal anastomosis (IRA) for familial polyposis to determine the rate of postoperative spontaneous regression of rectal polyps. The failure of the IRA procedure was correlated with the preoperative number of rectal polyps and the degree of rectal polyp regression. Spontaneous resolution of rectal polyps occurred in 64 percent of the patients (complete 38 percent, partial 26 percent). In those patients initially having complete resolution, 55 percent redeveloped polyps during follow-up. With a mean follow-up of 9.3 years, seven patients have developed rectal cancer. Rectal cancer development was more common in those patients who had innumerable rectal polyps prior to IRA. Initial polyp regression did not preclude later development of rectal cancer. There were 11 deaths during the follow-up period, but only one of these was from rectal cancer. Abdominal colectomy and IRA is an effective treatment for familial polyposis. Spontaneous regression of polyps occurred in 64 percent of patients, but continuous and complete follow-up is necessary to fulgurate recurrent polyps and to screen for the development of cancer.

Adenomatous Polyposis Coli↗

PubMed1988

Perianal Bowen's disease.

Thirty-three patients with perianal Bowen's disease were treated at the Cleveland Clinic Foundation from 1954 to 1986. Twenty-one patients were women and 12 were men, ranging in age from 30 to 69 years (mean, 48 years). Twenty patients (61 percent) presented with symptomatic perianal disease, while 13 patients (39 percent) were noted as having perianal Bowen's disease upon pathologic examination of routine hemorrhoidectomy specimens. Ten of the patients (30 percent) had prior histories of unrelated cancer. Twenty-seven patients were managed by wide local excision, three patients by simple excision, three patients by fulguration, and one patient by an abdominoperineal resection. During a follow-up period averaging 3.7 years (range, 0.3 to 10 years), one patient developed a new invasive skin cancer while a second patient experienced a recurrence of perianal Bowen's disease. The characteristic gross appearance of this lesion and its failure to respond to conventional therapy should prompt the performance of a biopsy, which readily establishes the diagnosis. This experience confirms that wide local excision is adequate therapy for perianal Bowen's disease and that close clinical follow-up is necessary to identify disease recurrence or the development of a malignancy.

Adult↗

PubMed1988

Efficacy of pelvic packing in maintaining hemostasis after rectal excision for cancer.

In a retrospective study, the records of 95 patients who underwent rectal resection for carcinoma were reviewed to assess the efficacy and complications of pelvic packing for hemorrhage. Heavier blood loss was noted with fixed tumors, where preoperative radiation had been given, or there had been previous pelvic surgery, compared with situations where these factors were absent. Three patients died from myocardial infarction, pulmonary embolus, and renal failure, respectively. No patients required further hemostatic measures after pack removal. Perineal wound infection or delayed perineal wound healing occurred in 22 percent and abdominal wound infection in 6 percent of the patients. There were no instances of anastomotic leak, abdominal abscess, or pelvic abscess requiring laparotomy for treatment in this series. Pelvic packing is a safe, simple, and effective procedure for patients with problematic pelvic bleeding after rectal resection.

Carcinoma↗