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Biomedical subjects

J A Coller

Publications and source records attributed to J A Coller.

At least 73 records · Page 4Linked to original sources
PubMed1990

Bleeding stomal varices. The role of local treatment.

The authors reviewed their experience with 12 patients (median age, 38 years; range, 24 to 66 years) who had bleeding stomal varices. Stomal variceal bleeding occurred between 1 and 11 years (median, 5.5 years) after creation of the stoma. Control of bleeding initially consisted of direct pressure; recurrent bleeding occurred in one patient who died before definitive therapy could be performed. The remaining 11 patients underwent a total of 18 additional procedures for control of bleeding stomal varices, including 9 local procedures, 8 portosystemic shunts, and 1 liver transplantation. Seven patients were dead of hepatic failure a median of 4 years (range, 1 to 9 years) after treatment. Recurrent bleeding occurred in three patients after local treatment and in one patient after a portosystemic shunt. Bleeding stomal varices are a manifestation of severe liver disease and portal hypertension. Although local procedures may be effective for initial control of bleeding, recurrent bleeding often occurs. Mortality is high because of the severity of the underlying liver disease.

Adult↗
PubMed1990

Perianal hidradenitis suppurativa. The Lahey Clinic experience.

Perianal hidradenitis suppurativa, a chronic recurrent inflammatory disease of apocrine glands, adjacent anal canal skin, and soft tissues, is characteristically ignored and misdiagnosed. A retrospective analysis of 43 patients with perianal hidradenitis suppurativa was performed; 40 patients (93 percent) were male and 3 (7 percent) were female, with a median age at presentation of 29 years. Symptoms, including pain, swelling, purulent discharge, and pruritus, had been present for a median of six years. Diagnoses at the time of presentation included pilonidal disease (28 percent), anal fistula (37 percent), and perirectal abscess (16 percent). Associated medical conditions included diabetes (12 percent) and obesity (12 percent), and 70 percent of the patients were smokers. Once the correct diagnosis was established, 72 percent of patients had wide local excision with healing by secondary intention, and 28 percent of patients had incision and drainage or limited local excision. Although 67 percent of the patients had recurrence of disease after initial treatment, wide excision was more successful in preventing recurrence. Skin grafting failed uniformly, and colostomy was rarely necessary. Despite its relatively common occurrence, perianal hidradenitis suppurativa is infrequently diagnosed correctly and recurs in many patients despite appropriate surgical treatment, making the disease a source of frustration for surgeon and patient alike.

Adolescent↗
PubMed1990

Manometric assessment of patients with obstetric injuries and fecal incontinence.

Anorectal manometry was performed with a multilumen continuously perfused catheter in nine women with fecal incontinence after vaginal delivery. All patients had a third-degree or fourth-degree perineal laceration. The median age was 30 (range, 24 to 38) years. Anal manometry revealed low resting and squeeze pressures with a mean pressure of 28.7 +/- 5.3 mm Hg (normal, 60 to 80 mm Hg) and 42.5 +/- 5.9 mm Hg (normal, 100 to 150 mm Hg), respectively. Seven of nine patients had specific anterior quadrant defects demonstrated by cross-sectional analysis of the sphincter. In addition, five patients had evidence of global defects of the sphincter or relatively low pressures in other portions of the sphincter. Follow-up manometric data were obtained in four patients after reconstruction of the sphincter and demonstrated a mean improvement of resting and squeeze pressures of 5.1 mm Hg and 16.0 mm Hg, respectively. Although specific anterior defects may be expected with the history of obstetric trauma, the presence of global defects of the sphincter was unexpected and may support the role of injury to the innervation of the musculature of the pelvic floor as a contributing cause of fecal incontinence after childbirth. Anal manometry provides a quantitative assessment of sphincter function and dysfunction and is an important part of the preoperative assessment of patients with fecal incontinence from obstetric injuries.

Adult↗
PubMed1990

Perirectal abscess in Crohn's disease. Drainage and outcome.

The role of surgical intervention in the treatment of patients with anorectal Crohn's disease is controversial. To clarify the success of aggressive drainage and the subsequent clinical course of patients with Crohn's disease and perirectal abscesses, the authors reviewed the records of 38 patients who presented with this condition during an eight-year period. Twenty-two male and 16 female patients (median age, 32 years; range, 17 to 61 years) with clinically or pathologically confirmed Crohn's disease of the bowel underwent operation for perirectal abscesses. Thirty-two percent of patients had no previous history of anorectal Crohn's disease. Thirty simple abscesses and 8 complex horseshoe abscesses were treated. At operation, 53 percent of patients underwent incision and drainage whereas 26 percent received loop indwelling drains and 21 percent had mushroom catheters placed. After resolution of the index abscess, recurrent abscesses occurred in 45 percent of the patients who underwent catheter drainage and 56 percent of the patients who underwent incision and drainage. More importantly, 44 percent of the incision and drainage group and only 31 percent of the catheter drainage group required subsequent proctectomy to control perineal sepsis. The healing time of the perineal wound was longer than six months in 83 percent of patients requiring rectal excision. We concluded that long-term catheter drainage may offer substantial benefit in the overall outcome of the treatment of patients with Crohn's disease and perirectal abscess.

Abscess↗
PubMed1990

Addition of parenteral cefoxitin to regimen of oral antibiotics for elective colorectal operations. A randomized prospective study.

The efficacy of cefoxitin, a perioperative parenteral antibiotic, combined with mechanical bowel preparation and oral antibiotics to prevent wound infections and other septic complications in patients undergoing elective colorectal operations, was examined in a prospective randomized study. All 197 patients who completed the study received mechanical bowel preparation and oral neomycin/erythromycin base. In addition a perioperative parenteral antibiotic was given in three divided doses to 101 patients. The other 96 patients received no parenteral antibiotics. The overall incidence of intra-abdominal septic complications was 7.3% (7 of 96) in the control group (no cefoxitin) and 5% (5 of 101) in the treatment group (cefoxitin). This difference was not statistically significant. The incidence of abdominal wound infection was 14.6% in the control group and 5% in the treatment group, a statistically significant difference (p = 0.02). The addition of perioperative parenteral cefoxitin greatly reduced the incidence of wound infections in patients undergoing elective colorectal operations who had been prepared with mechanical bowel cleansing and oral antimicrobial agents.

Abscess↗
PubMed1989

Malignant duodenocolic fistula diagnosed by endoscopy.

A case of duodenocolic fistula secondary to carcinoma of the hepatic flexure is reported that was diagnosed by gastroduodenoscopy. The clinical, endoscopic, and radiographic features of this entity are discussed. Treatment options are reviewed.

Adenocarcinoma↗
PubMed1989

Rectovaginal fistula in Crohn's disease.

Rectovaginal fistulas in the setting of Crohn's disease present a difficult management dilemma. Some patients with this problem require proctocolectomy, yet other patients with minimal symptoms never require an operation for treatment of the rectovaginal fistula. For a small percentage of patients, local surgical repair of the fistula may be warranted. Since 1980, this study has attempted local repair in seven patients with symptomatic rectovaginal fistulas from Crohn's disease. Five patients underwent staged repair of the fistula. Closure of the colostomy was eventually possible in three of these patients. Two of the three patients have had no evidence of recurrence at followup in excess of two years. The third patient required an ileostomy for intestinal disease and had no recurrence of the fistula. Two patients underwent primary repair of the rectovaginal fistula without fecal diversion; in one of these patients, the fistula recurred ten days after operation, necessitating a diverting ileostomy. The other patient remains cured 26 months after repair. The results of this review indicate that in the setting of quiescent rectal disease, an attempt to repair the fistula can be expected to have a reasonable chance of success. The presence of a rectovaginal fistula in a patient with Crohn's disease does not mandate removal of the rectum.

Adult↗
PubMed1989

Fluoroscopy in colonoscopy. Who is using it and why?

Use of fluoroscopy during colonoscopy has never been broadly assessed. A survey of 1,864 members of the Society of American Gastrointestinal Endoscopic Surgeons and the American Society of Colon and Rectal Surgeons was carried out to quantify the use of fluoroscopy and to elicit impressions regarding its capabilities, indications, and usefulness. After the establishment of the responding colonoscopist's training, experience, and other background data, impressions of fluoroscopy's role in many issues were obtained using a graded response system. Concluding the two-page survey were open-ended questions addressing the respondent's indications, contraindications, and rationale for using or not using fluoroscopy. Six hundred thirty-one colonoscopists responded. Seventy-five per cent never use fluoroscopy; the most frequently cited reasons were lack of need and inaccessibility of fluoroscopy. For many colonoscopists, fluoroscopy is unavailable (22%) or available outside of the usual endoscopy setting (44%). Fluoroscopy is used by 25 per cent of colonoscopists. Almost three quarters of this group have the capability of performing fluoroscopy in their colonoscopy unit. The indications for fluoroscopy varied with the frequency of its use; frequent users employ fluoroscopy to treat loops, to confirm cecal intubation, and to locate the instrument tip precisely. Infrequent users employ fluoroscopy to apply the sigmoid straightening overtube or because of prior failed colonoscopy. Impressions regarding the impact of fluoroscopy on learning, completing, and safeguarding colonoscopy were obtained. Most colonoscopists are satisfied without using fluoroscopy, although 65 per cent of nonusers believe it would improve colonoscopy performance if it were used. Ninety-two per cent of frequent users of fluoroscopy reported that they would feel significantly impaired without having the capability to perform fluoroscopy.(ABSTRACT TRUNCATED AT 250 WORDS)

Colonoscopy↗
PubMed1988

Closure of abdominal wounds with polydioxanone. A prospective study.

Polydioxanone, an absorbable synthetic monofilament suture, was used to close abdominal wounds in 200 consecutive operative procedures. All patients were followed up for one year. Despite a high incidence of risk factors for impaired wound healing, the incidence of dehiscence and evisceration was zero; incisional hernia occurred in 2.9% of vertical midline wounds and in 3.6% of transverse incisions. This new suture material is safe and effective for closure of abdominal wounds.

Abdominal Muscles↗
PubMed1988

Ripstein procedure. Lahey Clinic experience: 1963-1985.

We reviewed our 22-year experience with 135 Ripstein procedures for rectal prolapse in 118 women and 17 men. Follow-up ranged from one to 256 months (median, 41 months). Five patients were unavailable for follow-up. There was one perioperative death (0.7%). Complications included hemorrhage from presacral veins in 11 patients (8.1%), recurrent prolapse in 13 patients (9.6%), and stricture at the site of the sling in three patients (2.2%). Specific intraoperative technical factors could be related to recurrent prolapse in four patients (30.8%). Attention to technical details is mandatory to minimize immediate and long-term complications. Patients should be prepared for anterior resection, since a sling procedure may be inadvisable at the time of exploration. Resection may be the preferred operation for men, who have a high rate of recurrent prolapse with the Ripstein procedure.

Adult↗
PubMed1988

Can the pouch be saved?

From 1980 to 1986, 165 patients underwent ileal reservoir procedures at the Lahey Clinic Medical Center; 142 (86 percent) had J-shaped pouches constructed, and 23 (14 percent) had S-shaped pouches constructed. In this series, 42 complications specifically related to the pouch occurred in 36 patients. Stricture was most common, followed by separation of the ileoanal anastomosis, pelvic sepsis, complex fistula, and a leaking pouch. Through judicious application of remedial operations and either delay in closure of the ileostomy or establishment of proximal loop ileostomy, only seven patients required reestablishment of fecal diversion. The authors urge aggressive diagnostic and therapeutic efforts to save the pouch and maintain satisfactory function in most patients.

Adenomatous Polyposis Coli↗
PubMed1988

Surgical correction of anal incontinence.

Seventy-six operative procedures for anal incontinence performed at the Lahey Clinic Medical Center between 1964 and 1985 were reviewed. Etiologic factors, findings on preoperative physical examination, and functional results are reported for 61 procedures in the four categories of simple anterior reefing, anterior reefing with perineal body reconstruction and anoplasty skin closure, posterior proctopexy, and Dacron Silastic sling insertion. In women with anterior sphincter defects, combining anoplasty skin closure and deep external sphincter plication gives superior functional results over superficial reefing, especially when there is attenuation of the rectovaginal septum and perineal body. The posterior proctopexy is most useful in patients with intact external sphincters and incontinence without recognizable cause or after abdominal repair of rectal prolapse.

Adolescent↗
PubMed1988

Vascular ectasia. Diagnosis and treatment by colonoscopy.

Vascular ectasia is an increasingly recognized cause of gastrointestinal tract bleeding in the elderly. Colonoscopy is assuming an important role in diagnosis and treatment of these lesions. The records of 30 patients who had a diagnosis of vascular ectasia made by colonoscopy have been retrospectively reviewed. The 30 patients included 14 men and 16 women whose median age was 70 years (range, 54 to 89 years). All patients had vascular ectasia of the cecum or ascending colon or both, five patients (16.7%) had multiple lesions, and 18 patients (60%) had associated cardiac, vascular, pulmonary, or renal disease. Of the 27 patients who presented with gastrointestinal tract bleeding, 13 (48.1%) underwent endoscopic fulguration, nine (33.3%) underwent resection, and seven (25.9%) were treated conservatively. Endoscopic fulguration was definitive treatment in 11 of the 27 patients (40.7%). A positive histologic diagnosis of vascular ectasia was made in nine of 15 patients (60%) in whom endoscopic biopsy was performed. In the hands of an experienced endoscopist, colonoscopy is a safe and effective way of diagnosing vascular ectasia and is potentially therapeutic. Endoscopic coagulation should be attempted before operation in patients with chronic anemia, limited bleeding, or concomitant severe medical disease.

Aged↗
PubMed1987

Technique of mesenteric lengthening in ileal reservoir-anal anastomosis.

Construction of a satisfactory ileal reservoir-anal anastomosis is dependent on the ability of the reservoir to reach the anus without tension. A technique has been developed for the generation of satisfactory mesenteric length in 159 consecutive J-reservoir procedures. By careful attention to technical details with particular reliance on the division of branches between the primary and secondary arcade vessels within the mesentery, sufficient length can be achieved in each case with an acceptable complication rate. When combined with the ease of construction of the J-reservoir, this technique of mesenteric lengthening has made the double-loop reservoir the procedure of choice.

Anal Canal↗
PubMed1987

Colorectal cancer: Lahey Clinic experience, 1972-1976. An analysis of prognostic indicators.

The records of 344 consecutive patients with colorectal cancer treated operatively at the Lahey Clinic from 1972 through 1976 were reviewed, and the effects of 41 clinical and pathologic variables on survival were analyzed. The variables associated with poorer five-year survival rates were advanced Dukes' stage, four or more positive nodes, blood vessel invasion, lymphatic invasion, circumferential involvement, and obstruction at initial presentation. As a group, patients with right colon cancers (cecum and ascending colon) had the best survival rates. When fistula formation or localized perforation had occurred, en bloc resection of locally involved adjacent viscera improved survival rates. These prognostic indicators aid in the selection of patients for wider colonic and mesenteric resections.

Actuarial Analysis↗
PubMed1987

Clinical application of anorectal manometry.

Anal sphincter manometry provides an objective assessment of one aspect of the anorectal sphincter mechanism. It provides a far more reliable indicator of anal sphincter tone than can be achieved by digital examination. The relative contribution of the voluntary and involuntary components can be assessed, and the integrity of reflex inhibition to rectal distention can be evaluated. Anal sphincter manometry may provide direct evidence of the underlying problem as in Hirschsprung's disease or anal sphincter hypertonia. Radial cross-sectional analysis can provide identification of surgically repairable segmental defects as in the case of traumatic injury. On the other hand, the finding of a normal anal sphincter profile may serve to redirect one's investigational efforts to other components of the sphincter apparatus.

Anal Canal↗
PubMed1986

Ileoanal reservoir for ulcerative colitis and familial polyposis.

Although total proctocolectomy with permanent ileostomy is regarded as the definitive therapy for ulcerative colitis and familial polyposis, psychologic and physical complications with this operation have stimulated the development of the operation of total abdominal colectomy, mucosal proctectomy, ileal reservoir, and ileoanal anastomosis as an alternative surgical procedure. Since 1980, 104 of these operative procedures have been completed with no operative mortality; experience has been gained with both the J- and S-type reservoirs. Despite an appreciable number of postoperative complications, satisfactory function of the reservoir has been achieved in 86 of 91 patients followed up for at least three months after closure of the ileostomy. The remaining five patients have required reinstitution of fecal diversion. Functional results have not differed between two-limbed and three-limbed reservoirs. This operation must be considered a viable alternative in patients with ulcerative colitis and familial polyposis.

Abscess↗