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Biomedical subjects

I C Lavery

Publications and source records attributed to I C Lavery.

At least 91 records · Page 5Linked to original sources
PubMed1988

Internal fistulas in diverticular disease.

Internal fistulas in diverticular disease are uncommon and have a reputation of being difficult to treat. Eighty four patients treated from 1960 to April 1986, representing 20.4 percent (84 of 412) of the surgically treated diverticular disease patients, were reviewed. Eight patients had multiple fistulas. Sixty-five percent (60 to 92) of fistulas were colovesical, 25 percent (23 of 92) colovaginal, 6.5 percent (6 of 92) coloenteric, and 3 percent (3 of 92) colouterine fistulas. There were 66 percent (35 of 53) males and 34 percent (18 of 53) females with colovesical fistulas only. Hysterectomies had been performed in 50 percent (12 of 24) and 83 percent (19 of 23) of females with colovesical and colovaginal fistulas, respectively. Operative management included: resection anastomosis, resection with anastomosis and diversion, Hartmann procedure, and three-stage procedure. In the latter half of the series there was a significant decrease in staging procedures with no significant statistical difference in complications. There were three deaths (3.5 percent) in the series. Other complications included: wound infection, 21 percent (18 of 84), enterocutaneous fistula, 1 percent (4 of 84), and anastomotic dehiscence, 5 percent (4 of 84). Primary anastomosis can be performed with acceptable morbidity and mortality and today is the procedure of choice, leaving staging procedures to selected patients.

Colonic Diseases↗
PubMed1988

Catheter drainage of ischiorectal abscesses.

We retrospectively reviewed the charts of 55 patients with ischiorectal abscesses treated from 1980 to 1983 at the Cleveland Clinic Foundation. The patients were treated by placement of a 10F to 16F soft latex mushroom catheter into the abscess cavity under local anesthesia as an office procedure. The end of the catheter was shortened to leave 2 to 3 cm exiting the skin, and a bandage was applied. No sutures or irrigations were used, and the drains were removed an average of 12 days after placement. Antibiotics were not given. The patients ranged in age from 17 to 76 years (mean, 40 years) and 36% were female. Four patients had diabetes, and eight had a history of inflammatory bowel disease. Nine patients had been treated previously for anorectal abscesses. There were no complications. Adequate follow-up was obtainable in 31 patients (ten to 63 months; mean, 30 months). Eight of them (26%) were subsequently treated for fistulas found after resolution of the abscess, and an additional eight (26%) had a second abscess form during the follow-up period. The average time to this recurrence was 20 months. Catheter drainage of ischiorectal abscess in selected cases resulted in healing with low morbidity and significant cost savings.

Abscess↗
PubMed1988

Anal sphincter repair: a report of 60 cases and review of the literature.

This is a retrospective review of 58 patients undergoing surgery for anal incontinence at the Cleveland Clinic. Forty-four patients had overlapping sphincter repairs, nine had postanal repairs, three had a combination of overlapping repair and postanal repair and two had Silastic slings. An associated loop colostomy or ileostomy was performed in 19 patients (33%). Satisfactory continence was attained in 86% of patients with direct sphincter injury (overlapping sphincter repairs) and this is comparable with the experience of others. These results with the postanal repair for patients with neurogenic incontinence were poor, however, as four of the nine were complete failures. Poor results were directly related to the age of the patient (P less than 0.0001) and the duration of incontinence (P less than 0.02). It was concluded that direct sphincter injury (obstetric, operative or traumatic) is effectively treated by an overlapping sphincter repair. Incontinence secondary to a degenerative neuropathy affecting the anal sphincter mechanism, however, whether it occurs in conjunction with a pre-existing sphincter injury or alone, is often not cured by surgery, that is, by postanal repair.

Adult↗
PubMed1988

Colonoscopic diagnosis of an aorto-appendiceal fistula.

A case of an aorto-appendicular, aorto-enteric fistula diagnosed by colonoscopy after presentation with colonic haemorrhage is reported. The role of colonoscopy in such patients is discussed and reported experience is reviewed.

Aged↗
PubMed1987

The outcome of loop ileostomy closure in 293 cases.

Our experience with closure of loop ileostomies between the years 1975-1986 was reviewed. Ninety-three percent of stoma closures were done by simple transverse suture. The overall complication rate was 17%. Of the early postoperative complications (13%), the major complication was small bowel obstruction especially in patients where the stoma was protecting a pelvic ileal reservoir. Abdominal septic complications (postclosure) were rare (1%). These were generally caused by unrecognized enteric tears during the mobilization of the stoma rather than anastomotic leakage. A careful operative technique is required. The wound infection rate after healing by both secondary intention and primary skin closure was low (3%) and mainly superficial. Only one incisional hernia was observed in the late postoperative period. In three patients a posterior rectus sheath defect at the stoma site was found incidentally at laparotomy, without clinical evidence of an incisional hernia. Closure of a loop ileostomy is a safe operation with a low morbidity. In patients with a previous total colectomy there was a significant risk of small bowel obstruction after ileostomy closure.

Adolescent↗
PubMed1987

The long-term outcome in Crohn's disease.

The long-term outcome of Crohn's disease was reviewed in 139 patients who were treated at the Cleveland Clinic for a minimum of 15 years. At the time of diagnosis, 38 (27 percent), 39 (28 percent) and 62 (43 percent) patients had small-bowel, large-bowel, and ileocolic patterns of disease, respectively. The disease progressed with time and, eventually, 104 (75 percent) patients had ileocolic disease. One hundred twenty-two patients (88 percent) underwent at least one definitive operation for the disease. Forty-four (32 percent) patients had proctocolectomies and 65 (47 percent) have ileostomies. Associated manifestations of Crohn's disease occurred in a high proportion of patients; perianal disease in 78 (56 percent), intestinal fistulas in 45 (32 percent), extraintestinal disease in 49 (35 percent). Six patients died of causes directly related to the disease. Specific complications tend to occur at definite times in the course of the disease. Crohn's disease is not a benign condition. There is a relentless progression of the disease and a high incidence of complications when patients are followed over a long period.

Adult↗
PubMed1987

Surgery for ulcerative colitis in the pediatric population. Indications, treatment, and follow-up.

To evaluate the outcome of surgery for ulcerative colitis in pediatric and adolescent patients, the experience at the Cleveland Clinic Foundation was reviewed retrospectively. Fifty-nine percent of the patients presented with acute toxic colitis and sepsis; 94 percent underwent staged procedures with creation of a temporary or permanent ileostomy. Sepsis was the most frequent postoperative complication (38 percent), and accounted for all three deaths (5 percent). Long-term disability was minimal, and 90 percent of the patients were fully active at the time of follow-up.

Acute Disease↗
PubMed1987

Colocutaneous fistulas complicating diverticulitis.

The records of 93 patients with colocutaneous fistulas associated with diverticulitis treated at the Cleveland Clinic between 1965 and 1983 were reviewed. There were 56 males and 37 females with an age range of 19 to 80 years (median, 57 years). Eighty-eight fistulas followed surgery for diverticulitis while five developed spontaneously. The presence of a diverting stoma in 34 patients did not prevent fistula formation but did decrease morbidity (x2 = 12.75, P less than 0.001). Initial investigations showed a high incidence of recent weight loss (in 40 percent) and hypoalbuminemia (47 percent), although these factors did not influence outcome. Patients with high output (greater than 200 cc/day) fistulas (n = 9) fared significantly worse than those with low outputs. There were 28 patients with fistulas to other organs, 20 involving small bowel. Factors leading to persistence of the fistulas included sepsis (42 cases) and sigmoid colon distal to an intended colorectal anastomosis (38 cases). Ninety-two patients underwent surgery, 80 percent having a one- or two-stage resection and anastomosis. There was one postoperative death and complications occurred in 44 patients (48 percent). Surgery was successful in producing patients without stoma or fistula in 71 cases (77 percent). There were five recurrent fistulas, 14 new fistulas, and 13 patients retained their stomas. A diagnosis of Crohn's disease was made in ten patients who had a high rate of complicated fistulas, recurrent fistulas, and retained stomas. Patients with carcinomas (n = 5) also did poorly, but those on systemic steroids (n = 7) fared no worse than patients not receiving them. This study emphasizes the role of diversion of the fecal stream in reducing the morbidity of colonic fistulas. It is clearly important to carry out a true colorectal anastomosis after resection for diverticulitis, and in patients with unusually complicated clinical courses, the diagnosis of Crohn's disease should be entertained.

Adult↗
PubMed1987

Definitive management of rectal cancer by contact (endocavitary) irradiation.

In a retrospective review, 62 patients treated for rectal cancer by contact (endocavitary) irradiation at The Cleveland Clinic Foundation were analyzed. This treatment modality delivers high dose, low penetration irradiation to a rectal cancer by direct contact of a 50 KV x-ray source through a special proctoscope. Cancers selected for this treatment include small (3 cm or less), mobile tumors without presacral lymphadenopathy that are within reach of digital examination and are well- or moderately well-differentiated adenocarcinomas. Between 1973 and 1984, 62 patients (37 males, 25 females) were treated--46 by contact irradiation alone and 16 by contact irradiation after excisional biopsy. The median tumor dose was 12,000 rads administered in four fractions at monthly intervals. Mean follow-up was 31 months. Fifty-six patients (90 percent) were disease-free at the time of review or death (ten died from unrelated causes). Eleven patients (18 percent) developed local recurrence but eight of these without distant metastases were rendered disease-free by other treatment--six by surgical resection and two by further radiotherapy. Mean time since secondary treatment is 20 months. Three patients are alive with incurable disease and three have died from cancer--in three of these six patients there was no evidence of local disease. Ulcerated tumors developed local recurrence in five of 17 cases (29 percent) while polypoid tumors recurred locally in six cases (14 percent). Morbidity from the treatment was minor in nature. It is suggested that contact (endocavitary) irradiation is effective treatment for carefully selected cases of rectal cancer.

Adenocarcinoma↗
PubMed1987

Postoperative perineal hernia.

Eight patients (seven male and one female) with symptomatic postoperative perineal hernias treated at the Cleveland Clinic Foundation from 1975 to 1986 are reviewed. The patients ranged in age from 43 to 68 years (mean, 61 years). Seven had previous abdominoperineal resections of the rectum and one had a pelvic exenteration. The first two patients underwent repair via a perineal approach and both had recurrences of their hernias. These recurrences, as well as the presenting hernias in the six later patients, were repaired with mesh placed through an abdominal approach. Of these, there was one recurrence, which was repaired via an abdominal approach. There was no operative mortality. Based on experience, the authors believe that the best method of repair for this uncommon problem, involves placement of Marlex mesh across the pelvic inlet through an abdominal approach. This allows attachment of the mesh to the lateral musculature and posterior sacral periosteum under direct vision. The anterior borders of the mesh can be secured to the apex of the vaginal or prostatic tissue. The placement of metallic clips to the edges of the mesh allows for confirmation of the mesh position by radiographic examination during follow-up.

Aged↗
PubMed1987

Villous and tubulovillous adenomas of the colon and rectum. A retrospective review, 1964-1985.

The records of 1,040 patients with 1,440 villous and tubulovillous adenomas of the colon and rectum treated at the Cleveland Clinic over a 21 year period were reviewed. The incidence of invasive adenocarcinoma was higher in patients with multiple adenomas at the time of presentation, in patients with a family history of colorectal cancer, and in those with adenomas greater than 4 cm in diameter. Eighty percent of the adenocarcinomas were Dukes' A or B, 15 percent were Dukes' C, and 5 percent presented with distant metastases. Clinical impression on examination was more accurate than biopsy in assessing the presence of malignancy in these tumors. Recurrence after local treatment of both benign and malignant tumors was high. Recurrence was significantly related to the size of the adenoma (more common when the tumor was more than 4 cm in diameter), location (more common when it was located in the rectum), and the type of treatment. Only 4 percent of the patients had died from colorectal cancer at the time of follow-up. The overall 5 year actuarial survival rate was 85 percent.

Adenocarcinoma↗
PubMed1987

Single-dose piperacillin versus cefoxitin combined with 10 percent mannitol bowel preparation as prophylaxis in elective colorectal operations.

A prospective, randomized study was utilized to compare the effectiveness of a single dose of preoperative piperacillin versus triple-dose cefoxitin in prophylaxis for elective colorectal operations. All patients received a simple 1 day mechanical bowel preparation using 10 percent mannitol preparation administered orally. Ninety-four patients were entered into the study. Septic complications occurred in 9 percent of the piperacillin patients and in 12 percent of the cefoxitin patients.

Cathartics↗
PubMed1987

The role of fiberoptic endoscopy in the management of the continent ileostomy.

Between January 1982 and December 1985, 355 fiberoptic pouchoscopies were performed in 123 patients with a continent ileostomy. These examinations have been reviewed to determine the effectiveness of the technique as a diagnostic and therapeutic tool. The Olympus GIF-XP pediatric endoscope was used after pouch lavage, and the afferent loop of ileum, the pouch, and (by retroflexion) the nipple valve were examined on each occasion. There were 63 males and 60 females, with a median age of 35 years (range, 16 to 71 years). The median length of follow-up after pouch construction was 36 months (range, 6 to 120 months), and an average of three examinations were performed per patient (range, 1 to 12). Of 127 examinations performed in asymptomatic patients, the pouch was normal in 117 cases, and there was mesh erosion into the pouch in 10 cases. The remaining 228 examinations were for symptoms that included pouchitis (56), difficulty in intubation (47), incontinence (35), follow-up of treated pouchitis (18), parastomal sepsis (22), blood in the stool (13), anemia (8), excess mucus discharge (6), valve prolapse (4), and purulent discharge from the stoma (1). Eighty-four examinations were normal; 144 revealed a likely cause for the symptoms and led to appropriate treatment, which in 45 patients was surgical. Fiberoptic endoscopy was therapeutic in 6 patients in whom it was used on 10 occasions to intubate a pouch with a slipped valve. Radiographic studies were seldom used, with pouchograms being carried out in 16 patients and fistulograms in 5. Only the fistulograms contributed to the assessment of each patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1987

Colectomy with ileorectal anastomosis for familial adenomatous polyposis: the risk of rectal cancer.

One hundred thirty-three patients with familial adenomatous polyposis undergoing colectomy and ileorectal anastomosis have been reviewed for the occurrence of cancer in the rectal stump. Ten patients developed rectal cancer (Actuarial survivorship rate of 88% for those patients free of rectal cancer at 20 years). Potential risk factors for the development of rectal cancer, including age at colectomy, previous colon cancer, number of rectal polyps, and length of the rectal stump, were analyzed and no significant differences were found. A policy of total colectomy with ileorectal anastomosis at 12 to 15 cm with conscientious lifelong follow-up thereafter is advocated for persons affected by familial adenomatous polyposis.

Actuarial Analysis↗
PubMed1986

The results of surgical treatment of cancer of the colon at the Cleveland Clinic from 1965-1975: classification of the spread of colon cancer and long-term survival.

Between the years 1965-1975, 564 patients underwent surgical treatment for cancer of the colon. The primary tumour was removed in 502 patients (89%) in all cases with a "no touch isolation" technique. The 5-year survival rate corrected for age was 64% in 546 operative survivors, and 82% in 413 patients operated with intent to cure. Survival analyses are presented classifying the spread of the tumour by the clinico-pathological method of Turnbull, the TNM method, the Astler-Coller method, Dukes' method. The results suggest that the Astler-Coller classification offers no advantage over that of Dukes' when predicting survival for patients after operation for cure, and that separating those patients considered to have evidence of invasion of an adjacent organ at operation (Turnbull's classification) from those patients without evidence of contiguous growth, is only justified if invasion of cancer is confirmed by histological examination of the resected specimen.

Adult↗
PubMed1986

Desmoid tumors in familial polyposis coli.

Desmoid tumors are locally invasive, nonmetastasizing fibrous tumors most frequently seen in patients with familial polyposis coli (FPC). Of 325 patients with FPC treated at the Cleveland Clinic, 29 (8.9%) were found to have a total of 36 desmoid tumors. These tumors occur in young patients (mean age: 29.8 years), particularly women (ratio 3:1), and most appeared after previous colectomy (86%). The majority (72% of all desmoids, 90% of patients) were located within the abdomen, specifically within the mesentery of the small intestine. In most cases, attempts at surgical resection were followed by recurrence, and other previous treatments were similarly ineffective. Six of the 29 patients (21%) died from the desmoid and three died from other causes. The recent use of sulindac (Clinoril) has produced some early encouraging results in four patients with these tumors that have proven so difficult to treat in the past.

Abdominal Neoplasms↗
PubMed1985

Patient evaluation of the conventional ileostomy.

A survey of 322 ileostomates was undertaken to assess the impact of an ileostomy and determine problems that are encountered by patients. Most patients (72 percent) felt they led normal lives with the ileostomy and encountered fewer restrictions in life-style than with their disease. However, only 35 percent of patients felt their ileostomies functioned perfectly. Skin irritation (49 percent), offensive noise and odor (42 percent), detection of the appliance (17 percent), and difficulty in handling the appliance (29 percent) were some of the problems encountered. Psychologic problems were related to poor body image (22 percent) and sterility or impotence (12 percent). All of these problems, however, were less than had been anticipated. Various sources of information were available to the ileostomate. However, about 50 percent of patients felt they received inadequate preoperative information or counseling.

Adolescent↗