Biomedical subjects
Publications and source records attributed to J J Stasik.
Retrorectal masses comprise a varied group of rarely encountered tumors. We present the case of a 42-year-old white woman with a retrorectal carcinoid tumor treated by abdominosacral resection. Diagnostic and therapeutic strategies are discussed.
PURPOSE: This study is designed to review a carcinoembryonic antigen (CEA)-driven postoperative protocol designed to identify patients suitable for curative reresection when recurrent colorectal cancer is identified. METHODS: A total of 285 patients who were operated on for colon or rectal carcinoma between 1981 and 1985 were evaluated (with CEA levels) every two months for the first two years, every three months for the third year, every six months for years 4 and 5, and annually thereafter. CEA levels above 5 microg were considered abnormal and were evaluated with diagnostic imaging and/or endoscopy. RESULTS: Follow-up was available for 280 patients (98.2 percent). Distribution of patients by Astler-Coller was: A, 14 percent; B1, 20 percent; B2, 39 percent; C1, 5 percent; C2, 21 percent. There were 62 of 280 patients (22 percent) who developed elevated CEA levels, with 44 patients who demonstrated clinical or radiographic evidence of recurrence. Eleven patients were selected for surgery with curative intent (4 hepatic resections, 1 pulmonary wedge resection, 2 abdominoperineal resections, 2 segmental bowel resections, and 2 cranial metastasectomies). Three of 11 patients (27 percent) benefited and have disease-free survivals greater than 60 months. Of the 223 patients without elevated CEA, 22 (9.9 percent) had recurrent cancer without any survivors. Overall, 3 of 285 patients (1.1 percent) were cured as a result of CEA follow-up. CONCLUSION: CEA-driven surgery is useful in selected patients and can produce long-term survivors.
BACKGROUND: Transanal repair of rectocele involving the suprasphincteric portion of the rectovaginal septum has been shown to provide excellent results in up to 90 per cent of cases. Selection of patients suitable for repair is important. Rectocele with concomitant cystocele is best repaired transvaginally. An alternative approach is recommended for enterocele. METHODS: With the patient in the prone position and using local anaesthesia, a mucomuscular endorectal flap is raised and the underlying tissues are plicated. The excessive flap is excised, and the cut edges are approximated. A retrospective review of 123 consecutive cases of transanal repair of rectocele was conducted. Patient satisfaction and complications were compared with those in a previously reported study. RESULTS: Overall patient satisfaction improved from 63 per cent of 59 patients in an earlier study to 82 per cent in this report. The overall complication rate decreased from 7 to 3 per cent. CONCLUSION: This study demonstrates the validity of a simple technique of transanal repair of rectocele in an ambulatory setting. Minimal morbidity and successful outcome can be achieved with this procedure.
PURPOSE: This study was designed to examine variations in operative mortality among surgical specialists who perform colorectal surgery. METHODS: Mortality rates were compared between six board-certified colorectal surgeons and 33 other institutional surgeons using comparable colorectal procedure codes and a validated database indicating patient severity of illness. Thirty-five ICD-9-CM procedure codes were used to identify 2,805 patients who underwent colorectal surgery as their principal procedure between July 1986 and April 1994. Atlas, a state-legislated outcome database, was used by the hospital's Quality Assurance Department to rank the Admission Severity Group (ASG) of 1,753 patients from January 1989 to April 1994 (higher ASG, 0 to 4, indicates increasing medical instability). RESULTS: Colorectal surgeons had an eight-year mean in-hospital mortality rate of 1.4 percent compared with 7.3 percent by other institutional surgeons (P = 0.0001). There was a significantly lower mortality rate for colorectal surgeons compared with other institutional surgeons in ASG 2 (0.8 and 3.8 percent, respectively; P = 0.026) and ASG 3 (5.7 and 16.4 percent, respectively; P = 0.001). CONCLUSIONS: Board-certified colorectal surgeons had a lower in-hospital mortality rate than other institutional surgeons as patients' severity of illness increased.
PURPOSE: A study of 523 fistulas of cryptoglandular origin operated on between January 1985 and December 1991 at the Lehigh Valley Hospital was undertaken for the purpose of establishing whether the "so-called" simple fistula-in-ano has a favorable outcome. High transsphincteric fistulas with or without high blind tract, suprasphincteric, extrasphincteric, and horseshoe fistulas as well as fistulas associated with inflammatory bowel disease were excluded. METHODS: Four-hundred sixty-one patients with anal fistulas classified as simple fistulas-in-ano (uncomplicated transsphincteric, low and high blind track intersphincteric) were studied retrospectively. There were 310 males and 151 females with an average age of 42 years and mean follow-up of 34 months. RESULTS: Thirty (6.5 percent) patients developed recurrent fistulas: 16 (53.3 percent) because of missed internal openings at initial surgery, six (20 percent) attributed to missed secondary tracks, five (16.7 percent) because of premature fistulotomy wound closure, and three (10 percent) because of miscellaneous factors. CONCLUSION: All so-called simple fistulas-in-ano may not have readily detectable primary openings and may possess secondary tracks which preclude their behavior as simple fistulas.
Delayed hemorrhage following surgical hemorrhoidectomy is a well-recognized complication. Emergency treatment may include suture ligation, anal packing, or other means of tamponade. At the Lehigh Valley Hospital, 27 patients were seen with the complication of delayed hemorrhage over an eight-year period from 1983 to 1990, for an incidence of 0.8 percent. Twenty-five patients (93 percent) underwent surgery primarily for hemorrhoidal disease; one patient had hemorrhoids removed in addition to a sphincterotomy for anal tissue, and the remaining patient had hemorrhoidectomy with fistulotomy. The mean interval from the operation to hemorrhage was six days. Treatment modalities included bedside anal packing in 20 patients (74 percent), observation alone in five patients (18 percent), and suture ligation in the operating room in two patients. Anal packing was successful in controlling postoperative hemorrhage in 20/20 patients, but late complications requiring reoperation developed in 15 percent.
Patients on chronic hemodialysis for end-stage renal disease (ESRD) may develop anorectal problems necessitating surgery. From January 1984 to December 1987, 18 ESRD patients underwent anorectal surgery. During this period, a mean of 215 patients underwent dialysis. Patients with ESRD present with characteristic problems: chronic constipation, need for dialysis pre- and postoperatively with heparin infusion, anemia, anticoagulation secondary to the consequences of uremia, and significant medical problems including coronary artery disease, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease (COPD). Two patients had concomitant anal fissure, two had fistula-in-ano, and one had an acute perianal abscess. In two patients, the postoperative course was complicated by hemorrhage and, in one patient, by abscess formation. There was no delay in wound healing compared with a cohort group. The essentials of perioperative management are discussed with respect to timing of dialysis, methods of anesthesia and pain management, coagulation screening, and complications. Patients on well-managed chronic dialysis will tolerate anorectal surgery without undue jeopardy.
Acute hemorrhoidal crisis can occur in the pregnant female. When medical therapy fails to relieve pain, operative intervention may be necessary. The surgeon, however, may be reluctant to operate due to potential complications to the mother and fetus. From July 1983 to July 1989, hemorrhoidectomy was performed in 25 of 12,455 pregnant women (0.2 percent) who delivered in our institution. Twenty-two women were in their third trimester, 80 percent were multiparous, and each had a remote history of hemorrhoidal symptoms, including intermittent pain, bleeding, and protrusion. Closed hemorrhoidectomy was performed under local anesthesia. The surgery was directed at removing only symptomatic disease, which included three quadrants in 14 patients, two quadrants in seven patients, and one quadrant in four patients. All patients experienced relief of intractable pain the day after surgery, except one patient who required a hemostatic packing during the immediate post-operative period. There were no other maternal or fetal complications. Subsequent follow-up for anorectal disease ranged from 6 months to 6 years. Six (24 percent) patients required additional hemorrhoid treatment. Hemorrhoidectomy in selected pregnant patients is safe in our experience.
A prospective, double-blind, randomized study was undertaken to compare perioperative parenteral metronidazole and erythromycin, One neomycin, and cefazolinhundred fifty-five patients were randomized into two groups by the pharmacy department. The resulting difference between the overall septic complication rate in patients receiving erythromycin, neomycin, and cefazolin (10.9 percent) and the rate in patients receiving metronidazole alone (31.9 percent) was significant. This indicates that an antibiotic to cover aerobic bacteria should be added to the regimen when metronidazole is used.
A voluntary community colorectal cancer screening project to detect occult blood in the stool of asymptomatic individuals was undertaken; 49,353 Hemoccult II kits were distributed. A total of 23,674 completed kits were returned to a central repository and processed (compliance rate, 48 percent); 851 participants had positive results (3.6 percent). Of the 640 who underwent further medical evaluation, 299 participants (46.7 percent) who had adequate follow-up had no evidence of disease. Diverse disease entities were detected in 341 participants, which was 1.4 percent of those enrolled. Forty-one patients (0.17 percent) showed significant findings that included 29 cancers (0.12 percent) and 12 (0.05 percent) noninvasive malignant polyps. Of the cancers, there were 27 colorectal, one non-Hodgkin's lymphoma, and one carcinoma of the vocal cord. In addition, 107 patients (0.45 percent) had benign polyps and 193 patients (0.82 percent) had various diseases of the gastrointestinal tract and other medical conditions. The cost of the program was modest and the results conformed to those found in previous screening surveys. The heightened public awareness of testing for colorectal disease and the detection of early lesions justifies the guaiac test screening program for mass survey.
Between September 1959 and December 1986, a total of 210 patients in a consecutive series were operated on for inflammatory bowel disease. One hundred ten (66 percent) had ileorectal anastomosis performed. There were no postoperative deaths. There were six failures in 53 ileorectal anastomoses for ulcerative colitis (11 percent), and five failures (8 percent) in 61 for Crohn's disease. The overall failure rate was 11 in 110 (10 percent). Ileorectal anastomosis, in suitable patients, is still a viable operation in the late 1980s.
Twenty-eight patients who underwent the Bacon pull-through procedure for carcinoma of the midrectum were reviewed retrospectively. The results were comparable to low anterior resection and abdominoperineal resection. Although the indications are limited, it is a viable option in a highly selected group of patients.
A technique is described and illustrated by case reports wherein removal of foreign bodies of the rectum is simplified by using the flexible sigmoidscope. Evidence from the literature indicates that delayed perforation is rare in this situation, and that outpatient management would suffice for most patients.
To evaluate the usefulness of serial postoperative carcinoembryonic antigen (CEA) assays, seven previously published decision rules for predicting tumor recurrence were compared retrospectively using CEA values from 214 patients followed 36 to 120 months after surgery for colorectal carcinoma. Decision rules employing cutoff values to predict tumor recurrence were found inadequate for the asymptomatic patient. This attenuation of prognostic usefulness appeared attributable to inadequacies of CEA assays for predicting late recurrences. From these analyses, elevated CEA results without other objective evidence might be insufficient to justify second-look surgery. In addition, late recurring tumors tended not to cause elevated CEA levels.
Continuous chemotherapy for hepatic metastases secondary to carcinoma of the colon and/or rectum was delivered via implantable pump in 20 patients. This is a follow-up to a preliminary report published in January 1985. Pumps were placed by a single surgeon in a community hospital; there was no mortality and minimal morbidity. Follow-up of these patients revealed a significant long-term complication rate secondary to effects of chemotherapy. Nine patients were alive at the cutoff date of this report; mean follow-up was 16 months. Eleven patients have died following implantation, with a mean survival of 14 months. Statistical analyses demonstrated increased survival rates for those patients whose tumors were poorly differentiated when compared with those with moderately differentiated or well-differentiated tumors. The objective response of liver metastases was overwhelmingly positive, as judged by CT scan and serial CEA levels. The significant rehospitalization rate for complications and the marginal increase in survival, however, have discouraged implantation of the pump at our institution.
A 55-year-old white man with an extensive retrorectal tumor died after transrectal needle biopsy. The indications and methods for biopsy of tumors in this location are controversial and are not well delineated in the literature. When resection seems unlikely or risky, or if a neoplasm is suspected which could be treated by nonsurgical means, biopsy is indicated. Antibiotics with aerobic and anaerobic coverage should be given prophylactically. When CT scan or sigmoidoscopic findings suggest a necrotic tumor, the transrectal approach should be avoided.
Anal incontinence can be attributed to anatomic and physiologic alterations in the external sphincter, internal sphincter and puborectalis muscle. Altered compliance or changes in the sensory threshold are contributing factors. In addition to history and physical examination, anal manometry and radiologic examination of the anorectal angle are helpful in determining the exact causative factors. Depending on the cause, either medical therapy or surgical repair can control anal incontinence.
The delivery of chemotherapy through the implantable hepatic infusion pump in the management of patients with hepatic metastases secondary to carcinoma of the colon and rectum is evaluated in this preliminary prospective study. Patients were selected according to hepatic lobar distribution and magnitude, age, and general systemic evaluation. Infusion pumps were implanted in a total of 14 patients who were judged to be unsuitable for hepatic resection. After pump implantation all patients were alive and well and receiving regional perfusion chemotherapy. For the nine patients in this study who have been monitored for a full six months, the median decrease in CEA levels was 49 percent. On computerized axial tomography (CT) and/or liver-spleen scan, five patients showed greater than 50 percent reduction in tumor size. All patients have demonstrated minimal systemic toxicity and have maintained a good quality of life. The results encourage further evaluation of perfusion chemotherapy.