Biomedical subjects
J B Gathright
Publications and source records attributed to J B Gathright.
Colonoscopic screening of asymptomatic patients with a family history of colon cancer.
The records of 201 asymptomatic patients who underwent colonoscopy based solely on a family history of colon cancer were reviewed. Eighty-five patients (42 percent) had a total of 166 lesions. Fifty-four (27 percent) patients of the screened population had neoplastic lesions, while 31 (15 percent) patients had nonneoplastic polyps. Four carcinomas were found. Twenty-five of the patients with polyps (29 percent) had no polyps distal to the splenic flexure; these proximal polyps (and two carcinomas) would have been missed on screening with fiberoptic sigmoidoscopy. Nineteen of these 25 patients had polyps smaller than 0.5 cm, which likely would have been missed with contrast enemas. Almost one half (47 percent) of all polyps discovered at screening colonoscopy were proximal to the descending colon. Only one patient younger than 40 years old had adenomas. The yield of polyps and cancer in patients with familial risk indicates screening colonoscopy should be considered after age 40.
Usefulness of performing colonoscopy one year after endoscopic polypectomy.
This retrospective study defines a population with neoplastic colonic polyps who have had colonoscopic polypectomy and, in follow-up within one year, a repeat colonoscopic evaluation. The population was broken down into two groups, one group that had polyps at the second examination and one group that did not. This study determined which factor(s) were significant among this population in distinguishing whether new polyps would be found at one year follow-up. The authors found that among the many variables studied, only polyp multiplicity was significant in predicting polyp recurrence. More than one polyp found at index colonoscopy led to a significant chance of having a new polyp after only one year. Also, it was demonstrated that these "new" polyps were unlikely to have been "missed" polyps from the initial colonoscopy. Because of the shifting location, smaller size, and fewer instances of histologic atypia in these polyps compared with those at index examination, the authors believe that polyps found after one year may be assumed to have arisen de novo. Finally, the authors show that a significant number of polyps occur beyond the reach of the flexible sigmoidoscope (approximately 60 cm). The authors recommend that patients who have polyps undergo a colonoscopic examination. When patients are re-evaluated after having colonoscopic neoplastic polypectomy, they should undergo repeat colonoscopy.
Surgical management of anorectal fistulas in Crohn's disease.
A retrospective review of patients with Crohn's disease treated at our institution from 1973 to 1986 revealed 35 patients operated upon for anorectal fistulas. Twenty-nine had low intermuscular fistulas (multiple in seven), and six had high intermuscular (supralevator) fistulas. Fistulotomy alone was performed in 19 patients, and eight underwent partial fistulotomy and seton insertion. Five additional patients had proximal fecal diversion before fistulotomy. Three patients with severe colonic and anorectal disease underwent proctocolectomy as the initial procedure. Of the 32 patients who had fistulotomy performed, complete healing occurred in 30. Seven patients who healed required more than one operation for fistula. One patient was left with an asymptomatic fistula, and one required proctectomy for persistent symptomatic fistula and proctitis. Success of operation correlated with absence of rectal disease and quiescent disease elsewhere in the gastrointestinal tract. Aggressive medical treatment is required to control bowel disease preoperatively. In the majority of patients, subsequent surgery is justified and healing can be anticipated.
Results of operation for rectovaginal fistula in Crohn's disease.
A retrospective review of patients with Crohn's disease treated at our institution from 1973 to 1986 revealed 12 patients operated on for rectovaginal fistula. Disease involved the large intestine in 10 patients. Primary fistula repair was performed in four patients and four others had staged repair with preliminary fecal diversion. Four patients with severe colonic and anorectal disease had proctocolectomy performed as the first procedure. Of eight patients who underwent fistula repair, complete healing occurred in six. One patient has a persistent fistula, which is minimally symptomatic, and the other required proctocolectomy after three unsuccessful repairs. Success of operation correlated with quiescent intestinal disease and absence of rectal involvement. In selected patients with symptomatic fistulas, surgical repair is indicated and healing can be anticipated.
The technique of intraoperative segmental artery arteriography to localize vascular ectasias.
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Ultrasonic characteristics of ileal tuberculosis.
Knowledge of the "pseudokidney sign" has proven beneficial in order to identify bowel lesions during ultrasound examinations. Numerous causes of the "pseudokidney sign" have been reported. Until now, however, there have been no published reports describing its association with tuberculosis. A description is given of a case of ileal tuberculosis identified by ultrasound, together with an explanation of its cause.
A potentially brighter prognosis for colon carcinoma in the third and fourth decades.
In contrast to earlier studies that suggested that colon carcinoma is unusually lethal in the young, 69 patients, ages 20 to 39 years, had a relatively good prognosis. Fifty-nine percent lived over 5 years after diagnosis, and 51% were cured. Furthermore, 67% were cured if they did not have distant spread of the carcinoma at the time of the initial operation. Neither age, sex, tumor size, location, mere presence of lymph node metastases, depth of tumor invasion, nor predisposing disease of the colon was a strong prognostic factor. Metastases to six or more lymph nodes and distant spread of the tumor at the time of initial surgery were ominous findings. Mucinous carcinoma was relatively frequent (28%) and was also an ominous feature (only 5 of 20 patients cured as opposed to 26 of 43 with classical adenocarcinoma).
Cholelithiasis in ileostomy patients.
A retrospective study of 152 ileostomates with inflammatory bowel disease (IBD) revealed that 16 patients (10.5 per cent) had diagnoses of cholelithiasis before, at the time of, or after having ileostomies. Of the remaining patients, 69 were followed for possible cholelithiasis, most of those with sonographic examination. Sixteen of this latter group of patients (23.2 per cent) were found to have cholelithiasis, usually in an asymptomatic stage. Among women over 50 years old, seven of 11 (63.6 per cent) had gallstones. Due to this high prevalence of cholelithiasis, gallbladder imaging is recommended as a part of the preoperative workup and follow-up of ileostomates. Prophylactic cholecystectomy may be carefully considered in female patients with IBD at the time of proctocolectomy.
Guidelines for use of the flexible fiberoptic sigmoidoscope in the management of the surgical patient.
Based on data from many clinical studies and programs, guidelines are presented for application of the flexible fiberoptic sigmoidoscope in the management of the surgical patient. The flexible fiberoptic sigmoidoscope has proved to be an instrument of extraordinary capability in detecting colorectal neoplasms with yields being two or three times greater than those of the rigid sigmoidoscope in the symptom-resolution, polyp and cancer surveillance patient categories. In addition, the practical advantages of the narrow diameter, flexibility, and length of the fiberoptic sigmoidoscope are readily appreciated when the surgeon finds that he can satisfactorily examine patients with rectal or sigmoid strictures, marked angulations, or contracted lumens in whom a rigid scope would be unsuitable. Data from the authors' comparative study of more than 3000 patients have permitted the development of not only guidelines for the application of the flexible fiberoptic sigmoidoscope but an appreciation of the modified role of the rigid sigmoidoscope and the proper relationship between the flexible fiberoptic sigmoidoscope and the flexible fiberoptic colonoscope. A most important consideration is based on data regarding the site distribution of 400 benign premalignant neoplasms detected in the comparative study. The even distribution of these lesions throughout the terminal 50 cm of colorectum underscores the need to examine as much of the colorectum as possible.
Management of rectal trauma.
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Colonic manifestations of collagen vascular diseases.
Upper gastrointestinal manifestations of collagen vascular diseases have been well described. Recently our attention has been focused on the colonic complications: fibrosis and stricture resulting in obstruction, severe obstipation and recurrent fecal impactions secondary to pseudo-obstruction, progressive colonic dilatation resulting in gangrene of the colon, and sigmoid volvulus and diverticulitis in the presence of both wide- and narrow-mouth pseudodiverticula. Patients with these colonic manifestations of collagen vascular disease are disabled, if not severely ill. Recognition of the problem enables the surgeon to plan definitive surgical intervention ranging from segmental resection to total colectomy and ileoproctostomy to restore satisfactory large bowel function.
Comparison of transient ischemic colitis with that requiring surgical treatment.
The records of 27 patients with colonic ischemia were reviewed. Twelve patients had typical reversible or transient ischemic colitis. Thirteen patients had an ischemic stricture or gangrene of the colon that required operation. Two of the patients have asymptomatic strictures of the splenic flexure and are under observation. The sigmoid colon in our series of patients was the most frequent area of symptomatic stricture formation. Any patient with ischemic colitis, especially that involving the sigmoid colon, should be observed closely for the development of a stricture. Surgical intervention is indicated only after colonoscopy and careful evaluation of symptoms and risk factors.
Sigmoidoscopic examinations with rigid and flexible fiberoptic sigmoidoscopes in the surgeon's office: a comparative prospective study of effectiveness in 1,012 cases.
The results obtained from 1,012 examinations in an on-going, cooperative study indicate that the overall yield provided by use of the flexible fiberoptic sigmoidoscope is 3.2 times greater than that of examinations with the rigid sigmoidoscope. More than twice (2.4 times) the number of polyps and more than three times the number of cancers were detected with the flexible fiberoptic sigmoidoscope. Experienced endoscopists can perform an examination with the flexible fiberoptic sigmoidoscope expeditiously in the office with minimal patient preparation, a high level of patient and physician acceptance, and relative safety when the usual mandatory colonoscopic precautions and guidelines are obeyed. The extraordinary advantages demonstrated by this study warrant wide clinical application of the flexible fiberoptic sigmoidoscope. We strongly recommend provision be made for appropriate training of physicians in the use of the instrument.
Vascular ectasias of the colon.
Vascular ectasias are an acquired type of arteriovenous malformation distinct from neoplastic and congenital lesions. They can be the source of occult, recurrent or massive colonic bleeding usually in elderly patients but, occasionally, in younger adults. The vascular lesions are usually small but can be quite diffuse. The majority occurs in the right colon, but in our group of patients, a substantial number occurred distal to the hepatic flexure. The diagnosis can be made preoperatively, with colonoscopy but, more consistently, with arteriography. Therefore, arteriography should be performed in any patient with bleeding of the colon before surgical intervention. We recommend resection of the involved segment of the intestine as the treatment of choice.
Repair of rectal prolapse: experience with the Ripstein sling.
Forty-eight patients with rectal prolapse were seen at Ochsner Clinic from 1955 to 1977. The charts of these patients were reviewed to assess the results of treatment and to evaluate a suggested association between rectal prolapse and solitary rectal ulcer syndrome. Since 1970 the Ripstein sling procedure has been used exclusively to treat those patients with rectal prolapse who are able to undergo a transabdominal procedure. We compared the results of this procedure with the ones formerly used: perineal (Altemeer), sigmoidectomy, and Thiersch procedures. Although the earlier operations for rectal prolapse were associated with either a high recurrence or a high complication rate, the Ripstein has both a low recurrence and a low morbidity rate: two patients had recurrence and two had the sling applied too tightly. The Ripstein procedure was shown to be an effective, safe procedure for repair of rectal prolapse, and the result was considered satisfactory by 20 of the 21 patients questioned. Regarding the association of rectal ulcer and rectal prolapse, we found that, although the symptoms of the solitary rectal ulcer syndrome and rectal prolapse are similar, they appear to represent a different response to the same stimulus, and the syndrome is relatively unabated by repair.
Selective arterial infusion of vasoconstrictors for massive diverticular bleeding.
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Colonoscopy. Inefficacy for early carcinoma detection in patients with ulcerative colitis.
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