Biomedical subjects
Publications and source records attributed to J J Stasik.
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.
Twenty-eight patients who underwent the Bacon pull-through operation were evaluated for continence by clinical and radiologic means. Six patients were available for anal manometry. Eighty-three percent of those patients followed for function did not have the sensation to defecate spontaneously. They had normal functioning of the external sphincter, failure of reflex inhibition of the internal sphincter, and decreased rectal compliance secondary to fibrosis of the presacral space. These factors created a distal high-pressure zone which, when combined with sensory loss due to transection of the levators, rendered the patient continent but without the ability to defecate spontaneously unless an enema was administered.
A modification of Sullivan's procedure for endorectal repair of "low" rectocele was completed in 59 patients with local anesthesia. Associated anorectal pathology was corrected in all patients. The technique is described. At follow-up, the results were as follows: 37 excellent (62.7 per cent), 10 good (16.9 per cent), eight fair (13.6 per cent), and four poor (6.7 per cent).
Evanescent colitis was first reported in 1971. This clinical entity is manifested by abrupt onset of colicky abdominal pain usually out of proportion to the physical findings, loose stools progressing to hematochezia, and segmental colonic involvement with spontaneous resolution in a matter of days. The diagnosis can be suggested by abdominal flat plate; confirmation depends upon barium-enema examination early in the course of the illness. The clinical presentation is identical to that of colonic ischemia with one remarkable exception: while colonic ischemia has come to be regarded as a disease of the elderly, usually with underlying vascular disease, evanescent colitis occurs in young people who are otherwise free of disease. In this report the authors present nine cases whose course is classic for colonic ischemia except that they are all less than 50 years of age and free of underlying vascular disease. Two of the patients were on oral contraceptive medication. A review of the literature revealed 15 additional cases. Five of these cases were associated with oral contraceptives. Conditions to be excluded in the differential diagnosis of this disease are the specific infectious colitides, idiopathic ulcerative colitis, granulomatous colitis and antibiotic-related pseudomembranous colitis.
Five patients with giant colonic diverticulum (GCD) are reported. Three of them had complications of the GCD including free perforation with pneumoperitoneum and peritonitis and an instance of carcinoma arising in a GCD. The preoperative diagnosis of GCD is made radiographically with findings of a large, smoothly marginated, round or oval, homogenous radiolucency in the abdomen that is in close apposition to the colon on barium enema examination. Barium enters the GCD in 60% of the cases. Most GCDs are considered to be pseudodiverticula; however, an occasional case may have all layers of bowel in the wall of the diverticulum and is believed to represent a true diverticulum or a communicating partial colonic duplication.
Except in the presence of severe perineal suppuration or sphincter damage by previous surgery for fistulas, the rectum was preserved in all patients considered candidates for surgery for inflammatory disease of the bowel. A primary anastomosis with a single-layer 5-0 monofilament stainless steel wire was carried out when a relatively healthy rectum with erythema and granularity presented. For patients with more severe disease of the rectum, a two-stage operation with intensive interval treatment of the rectum stump with topical corticosteroids was carried out. Of a total of eighty-six patients with involvement of the colon and rectum with either Crohn's disease or chronic ulcerative colitis, fifty-six patients were treated by local abdominal colectomy and ileorectal anastomosis. Twenty-four had primary anastomosis and thiry-two had a two-stage operation. One anastomotic dehiscence developed. A mean follow-up of 8.4 years (6 months to 20 years) has been satisfactory. Only three anastomoses have been taken down for unsatisfactory results. With the proper selection of patients and with appropriate treatment of the diseased rectal segment, a large majority of patients with inflammatory disease of the bowel can have long-term salutory results after colectomy and ileorectal anastomosis.
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A prospective study was designed to evaluate multiple rectal biopsy examinations for dysplasia in 34 patients who had ileorectal anastomosis performed, following colectomy for inflammatory bowel disease. Although all but eight patients had persistent inflammatory activity on histologic examination, only one patient who demonstrated villous transformation of the mucosa clinically, showed carcinoma in situ in the excised rectal specimen. A protocol for surveillance of preserved rectums in inflammatory bowel disease is offered.
A case in which a pheochromocytoma secreted vasoactive intestinal peptide, causing WDHA syndrome, is reported. The patient, a 43-year-old woman, was seen because of intractable watery diarrhea, hypokalemia and weight loss. She was found to have a mass in the right adrenal area. Preoperatively, vasoactive intestinal peptide levels were elevated, and the diagnosis of WDHA syndrome was entertained. Exploratory laparotomy revealed a tumor of the right adrenal gland, measuring 15 x 15 cm, which was resected. Histologic examination revealed it to be a pheochromocytoma. Postoperatively, vasoactive intestinal peptide returned to normal. The patient had complete remission of symptoms, and has remained well since.
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