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Biomedical subjects

I M Gelernt

Publications and source records attributed to I M Gelernt.

At least 19 recordsLinked to original sources
PubMed1999

Twelve-year experience with expanded polytetrafluoroethylene in the repair of abdominal wall defects.

BACKGROUND: A prosthetic device must be used to repair ventral hernias in patients with insufficient tissue for a tension-free primary closure. Several prosthetic materials have been employed for this purpose, with varying results. We here review a long experience with the use of expanded polytetrafluoroethylene (ePTFE) patches in the open repair of large abdominal wall defects. METHODS: Demographic, operative, follow-up, and histologic data were recorded and analyzed for all patients in a surgical practice who were treated for large abdominal wall defects with open repair using ePTFE patches between November 1983 and March 1996. RESULTS: Ventral hernia repairs using an ePTFE patch were performed in 98 patients. In 48 (49%), the patient had already undergone at least one previous ventral hernia repair. Of the 98 operations, 78 were full-thickness repairs, 11 were Rives-Stoppa procedures, and 9 were onlay operations. Complications included 5 seromas, 3 fistulas related to removal of a previously implanted prosthesis, and 9 infections. In addition, 10 patients developed recurrent hernias not related to explantation of the patch because of infection or fistula. In 3 patients, infections were treated successfully without removal of the patch. There were no complications related to adhesions, erosion of the patch into the viscera, or bowel obstruction. Histologic studies of longterm ePTFE implants showed excellent fibrous tissue ingrowth and minimal foreign body response. CONCLUSIONS: Our long-term clinical experience indicates that prosthetic patches of ePTFE are safe and effective when used in the repair of large abdominal wall defects that cannot be closed primarily. Operative complications were within acceptable limits, as was the reherniation rate.

Adult↗
PubMed1997

Restorative proctocolectomy in patients older than fifty years.

PURPOSE: This study was undertaken to compare functional results, complications, preoperative durations of disease, and rates of dysplasia and neoplasia between older and younger chronic ulcerative colitis patients undergoing restorative proctocolectomy (RPC) with mucosectomy. METHODS: A total of 392 patients with a preoperative diagnosis of chronic ulcerative colitis underwent elective RPC with mucosection and handsewn ileoanal anastomosis. Pathologic reports were reviewed, with specific reference to findings of dysplasia or cancer. Functional results concerning the number of bowel movements per 24 hour period and the incidence of fecal soilage were obtained by direct or telephone patient interview. FINDINGS: Group I consisted of 326 patients aged 5 to 49 (mean, 30.9) years and 160 women. Group II comprised 66 patients aged 50 to 74 (mean, 56.9) years and 29 women. Duration of disease was significantly longer in the older group (6.2 vs. 15.6 years; P < 0.001). The older group had significantly higher rates of dysplasia (29/326 vs. 19/66; P < 0.0001) and malignancy (14/326 vs. 9/66; P = 0.003). Rates of complication, hospital days following RPC, and total hospital days for all causes were comparable between groups. Perfect day-time continence was observed in 81.6 percent of Group I and 80 percent of Group II patients (213/261 vs. 40/50; P = 0.79). Perfect continence during sleep was observed in 65.1 percent of Group I and 62 percent of Group II patients (170/261 vs. 31/50; P = 0.67). Mean number of bowel movements per 24 hour period for Group I was 6.3 +/- 0.2 and for Group II was 7.4 +/- 0.5. Mean difference, one movement per 24 hours, was not significant (95 percent confidence interval, -0.02 to 2.1; t = 1.95, P = 0.055). CONCLUSIONS: We conclude that patients older than 50 years are suitable candidates for RPC with mucosectomy. Functional results and complication rates are similar to those observed among younger patients. Patients older than 50 years have a significantly higher rate of concurrent dysplasia and malignant degeneration than younger patients, most probably because of a longer duration of disease. RPC with mucosal excision potentially lowers this risk by elimination of all colorectal mucosa.

Age Factors↗
PubMed1995

Restorative proctocolectomy without diverting ileostomy.

PURPOSE: Restorative proctocolectomy (RPC) by abdominal colectomy and ileal pouch-anal anastomosis (IPAA) in the setting of chronic ulcerative colitis (CUC) and familial adenomatous polyposis (FAP) has gained widespread popularity among surgeons and patients. Traditionally, temporary loop ileostomy has been established proximal to the ileal pouch in an effort to mitigate the effects of any suture line complications that may occur. This study compares functional results and complications encountered after RPC with mucosectomy with and without temporary ileostomy. METHODS: One hundred forty-three consecutive patients with either CUC or FAP underwent RPC including mucosectomy and ileal "J" reservoir. Proximal loop ileostomy was performed in 69 patients, and ileostomy was omitted in 74. Ileostomy was omitted if the patient was taking no immunosuppressives and less than 20 mg of prednisone daily in the month preceding surgery, the anastomosis was absolutely tension-free, and blood supply to the pouch was excellent. RESULTS: There were no perioperative deaths. There were two instances of pelvic abscess, one in the diverted group and one in the nondiverted group. Occurrence of IPAA suture line dehiscence was not significantly different between the two groups (ileostomy, 4/69 (6 percent), vs. no ileostomy, 6/74 (8 percent); P > 0.05). Comparison of 129 patients with colitis with and without diversion also failed to demonstrate a significant difference with regard to IPAA suture line dehiscence (ileostomy, 4/69 (6 percent) vs. 4/60 (7 percent); P > 0.05). Frequency of bowel movements and continence were the same in both groups and were comparable with results obtained without mucosectomy. Mean hospital stay at time of RPC for the nondiverted group was significantly longer (12 days vs. 10 days; P = 0.0004). Significantly fewer patients without an ileostomy were hospitalized for partial intestinal obstruction (ileostomy, 13/69 (19 percent), vs. no ileostomy, 3/74 (4 percent); P = 0.02), and significantly fewer required enterolysis (ileostomy, 7/69 (10 percent), vs. no ileostomy, 1/74 (1 percent); P = 0.04). On average, patients without an ileostomy spent significantly fewer total days in the hospital (17 vs. 24; P = 0.002). CONCLUSION: Restorative proctocolectomy with mucosectomy and without ileostomy is the procedure of choice for selected patients with FAP and CUC. Septic complications and functional results are similar to those seen in patients managed with a stoma. Anastomotic leakage, when it occurs, can be safely managed in most cases without surgery. RPC without ileostomy results in significantly fewer episodes of intestinal obstruction, fewer instances of re-exploration, and fewer total days in the hospital.

Abscess↗
PubMed1995

Subtotal colectomy with Hartmann's pouch for inflammatory bowel disease.

PURPOSE: Fulminant or unremitting colitis caused by inflammatory bowel disease (IBD) is effectively managed by subtotal colectomy (STC) and standard ileostomy. However, controversy exists regarding the optimal management of the retained rectum. We reviewed our experience with intraperitoneal Hartmann's closure to determine whether this is an acceptable way to handle the rectal remnant. METHODS: We retrospectively reviewed hospital and office records of 114 consecutive patients with IBD colitis who underwent STC with Hartmann's pouch since 1988. Patient demographic data, operative details, and postoperative complications were recorded. In patients who underwent subsequent surgery, technical difficulty and complications related to rectal dissection were documented. RESULTS: There were three instances of pelvic sepsis secondary to leakage from the Hartmann's pouch, an overall incidence of 2.6 percent. Two of these patients required exploratory surgery. The third patient responded dramatically to antibiotics and transanal catheter decompression of the Hartmann's pouch. Subsequent to this experience, patients undergoing STC and Hartmann's closure for IBD colitis had transanal catheter drainage of the rectal remnant as a routine part of their postoperative care. There were no instances of leakage among the 41 patients who underwent rectal decompression. There were two reports (3 percent) of technical difficulty in locating or mobilizing the intraperitoneal rectal remnant at 60 subsequent surgical procedures. CONCLUSION: Intraperitoneal Hartmann's closure of the rectum is the preferred management in patients with intractable IBD colitis requiring STC.

Adolescent↗
PubMed1995

Perinuclear anti-neutrophil cytoplasmic antibody and refractory pouchitis. A case-control study.

Refractory pouchitis (RP) is a debilitating complication of ileal pouch reservoirs that affects approximately 2.5% of patients. Although the cause of RP is unknown, it is frequently hypothesized that it reflects underlying Crohn's disease. Since perinuclear anti-neutrophil cytoplasmic antibody (pANCA) is found in approximately 70% of ulcerative colitis patients but only rarely in Crohn's disease patients, it may help distinguish Crohn's disease from ulcerative colitis. Therefore, to test whether RP reflects "missed" Crohn's disease, we determined the ANCA status of 26 patients with RP. The pANCA was positive in 42% of cases [50% of Kock pouch cases and 33% of ileoanal pull-through (IAPT) cases] and 57% of matched control subjects without pouchitis (N = 42, P = NS). Moreover, 3/6 (50%) of IAPT RP subjects whose signs and symptoms most suggested Crohn's disease tested positive for pANCA. When compared to controls, IAPT cases exhibited significantly more preoperative extraintestinal manifestations (EIMs) of inflammatory bowel disease (P < 0.05). The presence of preoperative EIMs was 100% predictive of postoperative EIMs (P < 0.05). Review of pouch biopsies from cases of RP revealed no pathognomonic histologic features of Crohn's disease. These data confirm our previous suggestion that RP does not reflect underlying Crohn's disease but may be associated with the EIMs of inflammatory bowel disease.

Adult↗
PubMed1994

Adoptive cellular therapy of human breast and colorectal tumor targets using ex vivo activated memory T lymphocytes with potentiation by cis-diamminedichloroplatinum(II).

Autolymphocyte therapy (ALT) is adoptive cellular therapy of cancer using ex vivo activation of autologous peripheral blood lymphocytes (PBL). Memory T cells are the principal effector population in ALT, with in vivo activity in patients with metastatic renal cell carcinoma (RCC) and melanoma, and ex vivo cytotoxicity against autologous tumor targets. However, the noncytolytic lymphocyte portion of ex vivo-activated memory T cells (ALT cells) may also contribute as antitumor effectors. Pretreatment of murine and human tumor cells ex vivo with chemotherapeutic agents can enhance their susceptibility to antitumor lymphocytes ex vivo and in vivo. To determine whether cis-diamminedichloroplatinum(II) (DDP) could enhance ex vivo antitumor effects of ALT cells by immunomodulation, human breast and colorectal carcinoma target cells were derived from both primary and metastatic surgical specimens and incubated in complete medium (CM) with DDP or in CM alone (control group). Viability of each group was confirmed by trypan blue-dye exclusion test. ALT cells were prepared from autologous PBL at surgery. Primary and metastatic tumor cells from each group were used as targets for ALT cells and levels of interferon-gamma (IFN-gamma) release were measured as a determination of antitumor effect and recognition. Primary tumor target cells incubated in DDP showed enhanced antitumor effects and recognition by autologous ALT cells, as measured by the IFN-gamma assay compared to non-DDP-treated controls. Metastatic autologous tumor target cells demonstrated less IFN-gamma release than did the primary targets, although this was enhanced by pre-treating metastatic tumor targets with DDP. ALT cells demonstrated minimal IFN-gamma release when incubated with allogeneic tumor targets. These data suggest that autotumor recognition of metastatic tumor targets is comparable to that of primary lesions following ex vivo pretreatment of metastatic cells with nonlethal doses of certain chemotherapeutic agents. DDP may somehow alter the physical properties of target cells, rendering them susceptible to immune-mediated attack and the combination of ALT and DDP may lead to increased therapeutic efficacy in patients with metastatic breast and colon cancer.

Breast Neoplasms↗
PubMed1993

Refractory pouchitis: does it reflect underlying Crohn's disease?

Typical 'pouchitis' is a well recognised complication of ileal pouches in ulcerative colitis. Infrequently, a refractory pouchitis (RP) presents with certain clinical, endoscopic, and pathological features resembling Crohn's disease and is often ascribed to misdiagnosis of the initial colitis. To test that hypothesis and to identify risk factors for RP, this study reviewed cases of presumed ulcerative colitis with ileal pouches constructed at The Mount Sinai Hospital between 1973 and 1986. Twenty four cases with RP (16 Kock pouches and eight pelvic pouches) and 21 controls were compared for eight clinical variables. The original colectomy slides from 15 RP and 18 control cases were reviewed blindly, classified into five histological categories (corresponding to definite ulcerative colitis, definite Crohn's disease, and three indeterminate groups), and scored for 23 histological features. There were no significant clinical differences between RP and control cases except for more frequent extraintestinal manifestations (38% v 5%) and male preponderance (79% v 43%) in RP. There were also no significant differences between the distributions of RP cases and controls among the five histological categories or in the 23 histological features studied. Refractory pouchitis therefore does not seem to reflect underlying Crohn's disease, but may be linked to immunological mechanisms that are manifested clinically as extraintestinal complications.

Adult↗
PubMed1989

Mucosal proctectomy and ileoanal anastomosis.

The classical surgical therapy of ulcerative colitis and familial polyposis has been total proctocolectomy and ileostomy. In order to avoid a cutaneous stoma and to achieve continence without disruption of gastrointestinal continuity, responding to a demand particularly among younger patients, a mucosal proctectomy in association with an ileoanal anastomosis has been devised. The addition of an ileal reservoir proximal to the anastomosis results in fewer bowel movements and a greater degree of continence. In our series of 70 cases, we have analyzed the normal roentgen anatomy of the ileoanal anastomosis and the proximal ileal reservoir and present our findings on plain film and contrast examinations. To assess patients postoperatively, the radiologist should be aware of the basic surgery involved and the normal roentgen anatomy resulting from this procedure.

Adenomatous Polyposis Coli↗
PubMed1988

Medical decompression of toxic megacolon by "rolling". A new technique of decompression with favorable long-term follow-up.

We treated 19 consecutive patients with toxic megacolon complicating inflammatory bowel disease with the usual intensive medical regimen, but also added a new technique, namely, the frequent rolling of the patient to the prone position in order to redistribute colonic gas and thereby promote decompression. In all 19 patients (100%) the colon was decompressed within 1-13 days (mean 4.9 days). Two patients (10.5%) died. In long-term follow-up (mean 6.5 years), only 4 of the 17 survivors (21%) ultimately required colectomy; the remaining 13 (68%) were either completely well or only minimally symptomatic and did not require steroids. Most reports on the management of toxic megacolon stress the need for early surgical intervention, but our success in decompression with the addition of the "rolling technique" suggests an improvement in the nonoperative management of toxic megacolon.

Adult↗
PubMed1987

Repair of large abdominal wall defects with expanded polytetrafluoroethylene (PTFE).

Most abdominal wall incisional hernias can be repaired by primary closure. However, where the defect is large or there is tension on the closure, the use of a prosthetic material is indicated. Expanded polytetrafluoroethylene (PTFE) patches were used to repair incisional hernias in 28 patients between November 1983 and December 1986. Twelve of these patients (43%) had a prior failure of a primary repair. Reherniation occurred in three patients (10.7%). Wound infections developed in two patients (7.1%), both of whom had existing intestinal stomas, one with an intercurrent pelvic abscess. The prosthetic patch was removed in the patient with the abscess, but the infection was resolved in the other without sequelae. Septic complications did not occur after any operations performed in uncontaminated fields. None of the patients exhibited any undue discomfort, wound pain, erythema, or induration. Complications related to adhesions, erosion of the patch material into the viscera, bowel obstruction, or fistula formation did not occur. Based on this clinical experience, the authors believe that the PTFE patch appears to represent an advance in synthetic abdominal wall substitutes.

Adult↗
PubMed1986

Proctectomy for inflammatory bowel disease.

Between July 1973 and October 1984, we performed proctectomy either as part of a primary proctocolectomy or as a secondary staged procedure in 388 patients with ulcerative colitis and in 39 patients with Crohn's disease. The proctectomies were performed using a two-team synchronous approach. An intersphincteric or perimuscular technique was employed. All perineal wounds were closed and drained by suction drainage and the pelvic peritoneum was closed in all cases. Two patients died in the early postoperative period, one from a pulmonary embolus and one from sepsis. Three patients had to be reexplored for postoperative hemorrhage, in all cases from a branch of the superior hemorrhoidal artery. Postoperative perineal hematoma developed in two patients and perineal abscess developed in four patients which necessitated opening of the perineal skin wound. Nonhealing of the perineal wound occurred in 3 of 388 patients with ulcerative colitis and in 5 of 39 patients with Crohn's disease. No perineal dehiscence or hernias were seen. Postoperatively, one man was permanently impotent and two had prolonged but temporary impotence. Three patients had retrograde ejaculation at last follow-up.

Abscess↗
PubMed1985

Use of the long tube in the management of patients with small-intestinal obstruction due to adhesions.

A retrospective analysis was performed of all patients admitted to our hospital over a six-year period with a diagnosis of small-intestinal obstruction due to adhesions, to assess the efficacy of treatment with long-tube decompression. Of 127 episodes of obstruction, two thirds responded to nonoperative treatment. Factors that were associated with a greater likelihood of success with long-tube decompression included incomplete obstruction, recurrent obstruction, and passage of the tube beyond the pylorus. Clinical findings were relatively reliable as diagnostic indicators of strangulation. The overall mortality was 1.5%, with no deaths due to a delay in operative intervention. A trial of long-tube decompression is recommended in patients presenting with a diagnosis of small-intestinal obstruction due to adhesions in the absence of clinical evidence of strangulation.

Adolescent↗
PubMed1985

Is routine postoperative nasogastric decompression really necessary?

Controversy exists regarding the need for nasogastric tube decompression and the incidence of complications resulting from its use following major intra-abdominal surgery. To determine the value of such tubes, 100 patients were managed after surgery with a nasogastric tube in situ until the passage of flatus per rectum (Group I). In a second group of 100 patients, no nasogastric tube was placed after surgery unless vomiting, gross distention, or overt obstruction occurred (Group II). In Group I, the nasogastric tube remained in place an average of 6 days and five patients required replacement of the tube after its initial removal. In Group II, nasogastric intubation was required at some point after surgery in six patients. No aspiration pneumonia, nasal septum necrosis, anastomotic leak, or wound dehiscence was seen in either group. There were three wound infections in Group I and two in Group II. The most obvious difference was the increased comfort and mobility of the group of patients treated without routine nasogastric decompression (Group II). Routine use of the nasogastric tube adjunct to patient care following gastrointestinal tract surgery may be safely eliminated.

Cholecystectomy↗
PubMed1983

Sexual dysfunction following proctocolectomy for benign disease of the colon and rectum.

Standard surgical therapy for the treatment of chronic ulcerative colitis is total extirpation of the colon and rectum. Since ulcerative colitis is primarily a disease of young adults affecting many people at the inception or height of their sexually active years, postoperative sexual dysfunction is an extremely disconcerting complication. Between July 1973 and May 1981, 291 proctectomies for benign disease of the colon and rectum were performed by the authors. This included 135 men and 156 women. Resection of the rectum was performed using an intrasphincteric technique with dissection kept extremely close to the wall of the rectosigmoid, rectum, and anus. Proctectomy was performed in this manner to prevent significant disruption of the nerves carrying stimuli to the genital organs. Of the 135 males undergoing a proctectomy, four (3%) had a permanent deficit in sexual function. Two men, aged 32 and 30, could sustain an erection but had retrograde ejaculation. Two patients, age 19 and 44, have remained impotent for 1 1/2 and two years, respectively. One hundred fifty-two of the 156 females are sexually active and only two (1.3%) have complained of any physical sexual dysfunction. Each had temporary dyspareunia lasting between nine months and one year after operation.

Adult↗
PubMed1982

Granulomas do not affect postoperative recurrence rates in Crohn's disease.

Previous studies have reached disparate conclusions on the issue of whether or not granulomas confer any protection against recurrence of Crohn's disease after operation. In an attempt to resolve this controversy, we have examined postoperative recurrence rates in 102 patients with Crohn's disease. There were no differences in cumulative postoperative recurrence-free survival between the 53 patients with granulomas present in the resected specimens and the 49 patients without granulomas. It was concluded that the presence of granulomas in resected specimens of Crohn's disease exerts no independent influence on the rate of postoperative recurrence.

Crohn Disease↗
PubMed1982

Ruptured hepatic abscess: a rare cause of spontaneous pneumoperitoneum.

A 68-yr-old woman who developed an acute abdomen with clinical and radiological evidence of pneumoperitoneum is is described. At surgery, multiple left lobe hepatic abscesses were identified. Perforation of one abscess was apparent. Bacteriological studies revealed Streptococcus faecalis and gas-producing Klebsiella pneumoniae from the abscess cavities. Spontaneous pneumoperitoneum secondary to a ruptured hepatic abscess has to our knowledge never been reported.

Aged↗
PubMed1981

Experience with the flexible fiberoptic choledochoscope.

Despite significant effort on the part of surgeons, the incidence of retained calculi after common duct exploration still remains unacceptably high. It seems likely that the best way to reduce the incidence of retained calculi would be a more complete exploration of the common duct at the time of the initial operation. We report our experience with a flexible fiber optic endoscope used intraoperatively in 52 patients and postoperatively in one case to visualize the intrahepatic and extrahepatic bile ducts. In addition to visualization of stones, the choledochoscope has a channel through which various instruments can be passed to facilitate stone removal. Flexible choledochoscopy has been performed 53 times in 52 patients between July 1978 and November 1980. In one patient, the choledochoscope was used to explore the bile ducts via the T-tube tract after operation. In 52 patients, the scope was used intraoperatively: a) two patients demonstrated bile duct tumors, b) in 14, stones were not found on exploration. Of these, one had stenosis at the papilla of Vater and one had external compression of the duct by a pancreatic pseudocyst. All of these findings were confirmed by choledochoscopy, c) in 26 patients choledochoscopy confirmed complete surgical removal of all stones, d) in six patients, multiple stones were removed using routine common duct exploration but additional stones were seen with the choledochoscope, e) in three patients no stones were retrieved on routine duct exploration but were seen using the choledochoscope. In groups (d) and (e) the scope facilitated removal of the remaining stones. In eight cases stones were either grasped or crushed using the accessories of the choledochoscope. In one patient calculi were missed both by routine surgical exploration and choledochoscopy. No septic complications were seen in any of these patients.

Endoscopes↗