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Biomedical subjects

J M MacKeigan

Publications and source records attributed to J M MacKeigan.

At least 19 recordsLinked to original sources
PubMed1997

Adjuvant radiation therapy in resectable rectal cancer: should local recurrence rates affect the decision?

Adjuvant external beam pelvic radiotherapy (XRT) for resectable rectal cancer has been mandated by the National Cancer Institute because of reported 20 to 50 per cent reductions in local recurrence rates. However, these series' reported local recurrence rates are 18 to 39 per cent in the nonradiated patients, which seems extraordinarily high compared to the 3 to 5 per cent rates reported by surgeons advocating proctectomy with complete mesorectal excision. This fact, coupled with the high cost of XRT ($11,000-$14,000), the risk of radiation injury to small bowel and the neo-rectum, and the failure of XRT to provide any survival advantage, raises questions as to the precise role of XRT for rectal cancer. The purpose of this study was to perform a review of 212 consecutive patients undergoing curative resection via low anterior resection (LAR) or abdominoperineal resection (APR) for rectal cancer between 1989 and 1993, focusing on local and distant recurrence rates and survival. The choice of surgery alone (SUR), preoperative radiation (PRE) (45 Gy), or postoperative radiation (POST) (45-50 Gy) was at the surgeon's discretion. There were no significant differences in male:female ratio (SUR, 83:60; PRE, 14:8; POST, 34:13) or type of procedure (SUR-LAR, 112:APR, 31; PRE-LAR, 5:APR, 17; POST-LAR, 30:APR, 17) between the groups. There were no significant differences in age between the preoperative and postoperative radiation groups (PRE, 64.0 +/- 2.4; POST, 59.2 +/- 1.7); however, age was significantly different (P < 0.05) between the surgery-alone and the postoperative radiation groups (SUR, 68.5 +/- 0.8; POST, 59.2 +/- 1.7). With a median follow-up of 49 months, there were no significant differences in local recurrence (SUR, 4.2%; PRE, 4.5%; POST, 2.1%); however, there was a significantly longer survival for the SUR group compared to the other groups (SUR, 45.9 months; PRE, 36.4 months; POST, 39.3 months; P < 0.05 least significant difference). The PRE group also had shorter survival compared to the other groups when only Stage II and III lesions were studied (S, 40.0 months; PRE, 28.3 months; POST, 39.3 months). Local recurrences based on TNM stage were: T1N0 (S, 0 of 27; PRE, 0 of 3); T2N0 (S, 4 of 4S; PRE, 0 of 7); T2N1 (S, 0 of 9; POST, 1 of 5); T3,4N0 (S, 2 of 37; PRE, 1 of 9; POST, 0 of 10); and T3,4N1,2 (S, 0 of 21; PRE, 0 of 3; POST, 0 of 30). The results of this series support the contention that proctectomy with complete mesorectal excision yields a 4.2 per cent local recurrence rate without the need for adjuvant XRT. In this series, if all the patients had received adjuvant radiation, an additional $2.2 million would have been added to the costs of medical care. Therefore, the potential risks, costs, and benefits of adjuvant pelvic XRT for rectal cancer must be weighed against optimal benchmarks for local recurrence rate for surgery alone.

Adult↗
PubMed1997

Long-term outcome after ileocecal resection for Crohn's disease.

The decision to operate on ileocecal Crohn's disease is usually tempered by concern for early recurrence and the potential for multiple small bowel resections that will render the patients a gastroenterological cripple. However, delays in surgical management may unnecessarily prolong the patient's disease state and risk complications from both medications and unchecked disease. The aim of this study was to report the long-term clinical outcome of patients undergoing ileocecal resection for Crohn's disease between 1970 and 1993. One hundred eighty-one patients underwent ileocecal resection for Crohn's disease during the study period, with a median follow-up of 14.3 years. The mean age at the first resection was 32.7 +/- 0.9 years, and the male female ratio was 79:102. The indications for the initial resection were intractability in 119 (68.4%), obstruction in 45 (25.9%), enteric fistula in 27 (15.5%), perforation in 16 (9.2%), intra-abdominal abscess in 7 (4.0%), and hemorrhage in 5 (2.9%). Postoperative complications included prolonged ileus in 13 (7.5%), pneumonia/atelectasis in 15 (8.6%), wound infection in 11 (6.3%), urinary tract infection in 10 (5.7%), intra-abdominal abscess in 7 (4.0%), and wound dehiscence in 1 (0.6%). There were no operative mortalities. Fifty-six (30.9%) developed a recurrence requiring further surgery, with the mean time interval between initial ileocecal resection and operation for recurrence being 72.3 +/- 7.6 months. A second recurrence developed in 19 patients (10.5%) with a mean time interval of 52.3 +/- 8.3 months. The most frequent sites of first recurrence were the preanastomotic ileum in 49 (87.3%), the postanastomotic colon in 10 (17.9%), other colonic sites in 16 (28.6%), and other small bowel sites in 2 (3.6%) and other sites in 4 (7.1%). The types of resection for first recurrence were ileal resection in 28 (50%), right hemicolectomy in 17 (30.4%), segmental colectomy in 6 (10.7%), total proctocolectomy in 3 (5.4%), and proximal small bowel resection in 2 (3.6%). The long-term follow-up of this patient cohort indicated that 125 (69.1%) had only one resection, 37 (20.4%) required two resections, 15 (8.3%) required three resections, 4 (2.2%) required four resections. The results indicate that ileocecal resection of Crohn's disease had a high rate of disease control obtained with low morbidity, and a low frequency of three or more bowel resections (2.2%). Therefore, surgical resection of ileocecal Crohn's disease should not be unduly delayed for fear of risking short bowel syndrome. This approach should minimize overall disease-related patient morbidity by avoiding long periods of chronic illness.

Adult↗
PubMed1995

Superior nitrogen balance after laparoscopic-assisted colectomy.

BACKGROUND: Although early resumption of enteral feeding after gastrointestinal surgery results in improved nitrogen balance and lower infectious complications, no postoperative nutritional data after laparoscopic-assisted colectomy exists. OBJECTIVE: The authors prospectively compared nitrogen balance after laparoscopic-assisted colectomy versus open colectomy. METHODS: This is a series of colon resections (open, N = 10; laparoscopic-assisted, N = 9) at the Ferguson-Blodgett Hospital, Grand Rapids, Michigan, between January and March 1993. Nitrogen intake and 24-hour urine collections were performed on postoperative days 1, 3, and 7 for the analysis of total urinary nitrogen and urinary 3 methylhistidine-(3mH). RESULTS: The time to passage of flatus (4.7 +/- 0.6; 2.0 +/- 0.2), resumption of oral intake (6.1 +/- 0.7; 1.4 +/- 0.2; p < 0.05, Student's test), first bowel movement (5.2 +/- 1.0; 3.0 +/- 0.3; p < 0.05, Student;s t test), and discharge (10.3 +/- 1.3; 4.1 +/- 1.8; p < 0.05, Student's t test) occurred significantly earlier in the laparoscopic-assisted colectomy group. Overall hospital charges were lower in the laparoscopic-assisted colectomy group ($11,572 +/- $823 vs. $13,961 +/- $1050). The operative time was higher in the laparoscopic-assisted colectomy group (176 +/- 12 hours vs. 105 +/- 17 hours, p < 0.05,Student's test). Blood loss was higher in the open group (805 +/- 264 mL vs 217 +/- 32 mL, p < 0.05, Student's test). Urinary nitrogen losses were similar between the two groups; however, significantly more patients in the laparoscopic-assisted colectomy group achieved net positive nitrogen on day 3 (6/9; 0/10; p < 0.05, Fisher's exact test), and day 7 (9/9; 4/10; p < 0.05, Fisher's exact test). Infectious complications occurred less frequently in the laparoscopic-assisted colectomy group (0/9 vs. 4/10; p < 0.05, Fisher's exact test). CONCLUSIONS: Patients undergoing laparoscopic-assisted colectomy can achieve early resumption of enteral nutrition with earlier return to positive nitrogen balance compared with open colectomy. This may offer benefits of fewer infectious complications and lower cost of care.

Colectomy↗
PubMed1993

Treatment of advanced hemorrhoidal disease: a prospective, randomized comparison of cold scalpel vs. contact Nd:YAG laser.

PURPOSE: Recently, laser technology has been advocated for the treatment of hemorrhoids. However, there has been little scientific evaluation of the use of the Nd:YAG laser for excisional treatment of hemorrhoidal disease. The purpose of this study was to perform a prospective randomized study of the Nd:YAG laser vs. scalpel excision, when performing a standard Ferguson-closed hemorrhoidectomy. METHODS: Patients presenting for internal-external hemorrhoidectomy were eligible for study. Hemorrhoidectomies were performed under epidural or caudal blocks. The standard Ferguson closed hemorrhoidectomy technique was used. Data evaluated included: age, sex, estimated blood loss, operative time, postoperative pain scores, postoperative analgesic use, wound healing, and time for return to work. Eighty-six patients were eligible for study (laser, N = 51; scalpel, N = 35). RESULTS: There were no significant differences between the groups, except for a greater degree of wound inflammation and dehiscence at the 10 day postoperative visit for the laser group (laser, 1.7 +/- .2; scalpel, 0.8 +/- .2; P < 0.05, t-test). The use of the Nd:YAG laser added $480 per case; as a result, the treatment cost for the laser group was $15,360 higher than that of the conventional group. CONCLUSION: The results indicate that there are no patient care advantages associated with the use of the Nd:YAG laser for excisional hemorrhoidectomy compared with scalpel excision. As new technology becomes available, surgeons must rigorously assess therapeutic efficacy and cost-benefit ratio before deciding to employ this technology for patient care.

Chronic Disease↗
PubMed1993

Rectopexy.

Many surgical procedures have been described for the management of full-thickness rectal prolapse. Currently, the three procedures most frequently used are anterior resection with or without suture rectopexy, transabdominal mesh fixation without resection, and perineal proctosigmoidectomy. Only the latter procedure avoids a laparotomy, and the mesh fixation technique has a high incidence of severe constipation postoperatively. Recently, there have been two reports of laparoscopic mesh fixation for rectal prolapse which were successful. However, the long-term concerns are probably very similar. Therefore, the purpose of this paper is to report a series of 6 laparoscopic-assisted anterior resections performed for rectal prolapse at Ferguson-Blodgett Hospital from January 1, 1992 through October 30, 1992. There were no perioperative mortalities and the only complication was a port site bleed which required re-exploration. The mean time for resumption of oral intake was 2.75 +/- 1.5 days and the length of hospital stay was 4.0 +/- 0.8 days. No early recurrences (< 1 yr) have been noted in this series. The authors feel that laparoscopic-assisted anterior resection is a safe and effective method of treating full-thickness rectal prolapse, thereby avoiding a laparotomy and reducing hospital stay.

Adult↗
PubMed1992

Short-chain fatty acid enemas: a cost-effective alternative in the treatment of nonspecific proctosigmoiditis.

The purpose of this study was to perform a randomized, prospective comparison of corticosteroid enemas (CS--100 mg of hydrocortisone/60 cc P.R. q.h.s.; n = 12), mesalamine enemas (5-ASA--4 g/60 cc P.R. q.h.s.; n = 19), and short-chain fatty acid enemas (SCFA--60 cc P.R. b.i.d.; n = 14) for the treatment of proctosigmoiditis. Patients presenting to the Ferguson Clinic with the diagnosis of idiopathic proctosigmoiditis were evaluated for age, sex, prior history of proctitis, duration of symptoms prior to presentation, endoscopic scoring, and mucosal biopsies. Clinical evaluation was performed at two-week intervals for six weeks, with repeat biopsies taken at six weeks. There was no significant difference with respect to age, male/female ratio, past history of proctosigmoiditis, length of colorectum involved at the time of initial presentation, symptom resolution, and endoscopic and histologic improvement among the three treatment groups. Recovery occurred in a similar proportion in each of the three groups: CS, 10/12; 5-ASA, 17/19; and SCFA, 12/14. The cost of six weeks of treatment was: CS, $71.82; 5-ASA, $347.28; and SCFA, $31.50. This study indicates that SCFA enemas are equally efficacious to CS or 5-ASA enemas for the treatment of proctosigmoiditis at a significant cost savings.

Adult↗
PubMed1992

The necessity of routine pathologic evaluation of hemorrhoidectomy specimens.

Unsuspected carcinoma of the anus found on routine pathologic analysis of specimens taken at hemorrhoidectomy is a rare occurrence. Rates of 1 to 2 per cent are quoted, but without the support of objective data. During the past 20 years, 21,257 hemorrhoidectomies have been performed at Ferguson Hospital. During that time period, only one instance of unsuspected carcinoma of the anus was diagnosed solely by microscopic analysis of a specimen that was taken at hemorrhoidectomy. Based on this information, we recommend selective rather than routine pathologic evaluation of hemorrhoidectomy specimens. All patients should undergo careful anorectal examination prior to hemorrhoidectomy. Repeat examination should be performed with the patient under anesthesia and all excised tissue should be visually and manually inspected by the operating surgeon. Any suspicious areas as based on preoperative evaluation, examination under anesthesia or inspection of excised tissue should be sent for gross and microscopic evaluation.

Adenocarcinoma↗
PubMed1991

Transanal excision of large, rectal villous adenomas.

The purpose of this study is to demonstrate that a transanal excisional approach can be successfully used in most cases of large, benign, rectal villous adenomas with acceptable rates of recurrence and complications in comparison with historic controls. A retrospective review of all cases of benign, large, rectal villous adenomas at this institution from 1975 to 1985 was performed. A total of 122 patients had large, benign, rectal villous adenomas excised. All except five were treated by transanal excision. Thirty-eight percent of lesions were more proximal than 8 cm from the anal verge. The average follow-up was 55 months. Twenty-seven percent of patients were treated for residual disease after a known incomplete initial treatment or an adenoma at the same location within 6 months of the original treatment. Thirty percent of patients were treated for recurrent adenoma 6 months after complete initial treatment. Two patients (1.7 percent) with recurrences were found to have invasive carcinoma. Both patients had excisional therapy, and one had additional radiation therapy for these carcinomas. Ten postoperative hemorrhages and two perforations occurred as symptomatic or serious complications. This renders a 10 percent complication rate for the study group, which is lower than reported by others using the Kraske or trans-sphincteric approach to the rectum. Because of the expected higher recurrence rate, regular follow-up is necessary for this type of therapy. In conclusion, this study demonstrated that transanal excision of large, benign, rectal villous adenomas can be a safe and effective method of treatment.

Adenoma↗
PubMed1991

Is colonoscopic screening appropriate in asymptomatic patients with family history of colon cancer?

Colonoscopy has been advocated by some investigators as the most appropriate means of screening asymptomatic patients with a positive family history of colorectal cancer. However, results of such screening have been widely disparate. The purpose of this study was to evaluate the yield of colonoscopy in a cohort of completely asymptomatic individuals with one or two first-degree relatives with a history of colorectal cancer and to compare this yield with that of colonoscopy in a group of patients with apparent anal bleeding. Patients with possible genetic disorders, such as familial polyposis, were excluded. A total of 160 asymptomatic patients and a comparison group of 137 patients with nonacute anorectal bleeding underwent colonoscopy. Colonoscopy was completed in 143 of the 160 study patients (89 percent) and in all of the comparison patients and did not result in any complications. Twenty-two adenomas were found in 17 study patients (10.6 percent); 16 of the 22 adenomas were less than 1 cm in size. In the comparison group, eight adenomas were identified (5.8 percent of patients). No cancers were identified. The difference in polyp frequency between groups was not significant. The relatively low yield of colorectal neoplasms discovered at colonoscopy in this study may in part be due to the small sample size or to the strict criteria used to define these asymptomatic patients but does not lend strong support to the notion that colonoscopy is an appropriate first step in screening the asymptomatic patient with one or two first-degree relatives with colon cancer.

Adult↗
PubMed1988

Anorectal and colonic disease and the immunocompromised host.

The immunocompromised host is becoming increasingly ubiquitous in the authors' patient population. There are growing numbers of long-term transplant recipients, and combination chemotherapy is producing many long-term survivors. Of greatest concern is that the number of patients with human immunodeficiency virus (HIV) causing immunosuppression is increasing. The literature is reviewed to produce a current summary of conditions affecting the anorectum and colon and arising as a direct consequence of the immunocompromised host. Pathophysiology and theoretic considerations are mentioned where applicable and current therapy is discussed. The conditions are classified under infectious, neoplastic, iatrogenic, and congenital. Although the colorectal surgeon will encounter most of these conditions sometime during a career, many are infrequent, and a current review is provided herein to provide categorization and updated information.

Colonic Diseases↗
PubMed1984

Surgical treatment of chronic anal fissure. A retrospective study of 1753 cases.

This is a retrospective study of 1753 cases of chronic anal fissures treated by five varying methods over a five-year period from January 1976 to December 1980. Results showed that the incidence of recurrent fissures was higher in those treated by anal fissurectomy with sphincterotomy. There was also a significant difference in operative time, length of hospital stay, patient discomfort, and incidence of urinary retention among these operative methods. Generally, lateral anal sphincterotomy and multiple anal sphincterotomies showed a lesser incidence of these factors. A simpler procedure, such as lateral anal sphincterotomy or multiple anal sphincterotomies, is the treatment of choice for chronic anal fissure. However, a chronic anal fissure associated with symptomatic enlarged hemorrhoids may have a similar result when treated with hemorrhoidectomy and fissurectomy as a combined procedure.

Adult↗
PubMed1982

Juvenile polyps of the colon and rectum.

Two hundred and fifty-eight patients with juvenile polyps were reviewed. Ten patients less than 20 years of age were found to have adenomas. The points to be presented can, therefore, be emphasized. Juvenile polyps are a distinct pathologic entity and can occur at any age and in either sex. Adenomas do exist in pediatric patients. We should not assume that every polyp in patients less than 20 years of age is automatically a juvenile polyp and, therefore, benign. Barium enema is recommended for any child or adolescent in whom one or more polyps are found. In multiple polyposis, the finding that one polyp is of the juvenile type does not necessarily rule out the presence of adenoma. Any patient with a solitary adenoma who has multiple polyps, whether adenoma or juvenile polyps, should be observed at appropriate intervals by sigmoidoscopic, roentgenographic and, possibly, colonoscopic examination. Finally, we hope that this study will inspire others to investigate further this interesting pathologic condition.

Adenoma↗
PubMed1978

Colonic endoscopy in perspective.

Sigmoidoscopy is an easy procedure and should be utilized more frequently. Barium enema examination is incomplete without sigmoidoscopy. Flexible fiberoptic sigmoidoscopy may have a role in the detection of disease of the descending, sigmoid, and rectosigmoid colon. The necessity for its routine usage remains to be determined. The control of colonic polyps by colonoscopy has been the greatest contribution to date by the fiberoptic instrument. Colonoscopy has improved the accuracy of diagnosis of colonic disease and, in certain instances, is helpful in the early detection of cancer of the colon. Colonoscopy complements the use of barium enema examination. Colonoscopy only for the purpose of confirmation of clinical or radiological diagnosis is often unnecessary. While the benefits of endoscopy are obvious, there are definite practical and technological limitations to its use. Complications, although infrequent, are major. Indications for colonoscopy must be clear and findings interpreted with knowledge of the limitations.

Colonic Diseases↗
PubMed1978

Hemorrhoids, fistulae and fissures: office and hospital management--a critical review.

We have tried to present a comprehensive survey of present-day management of hemorrhoids, fistulae and fissures, be it in the office or in the hospital. There is great socioeconomic pressure lately for cost-containment, which is apt to effect better medical judgment in the selection of type and place of management. Minor operations can and should be done, as always, on an outpatient basis. General anesthesia is not a minor matter and hemorrhoidectomy is not a minor operation. The major function of outpatient service in the management of anal disease is that of accurate and comprehensive diagnosis. Hundreds of patients come to us only because they fear cancer and it is not enough for us to hunt for and treat the vague little disorders of which they complain. The incidence of cancer of the colon rectum in this country just recently has slightly surpassed that of lung cancer. Adjuvant treatments (e.g., chemotherapy, radiotherapy, immunotherapy and their combinations) are promising but still in the investigational stage. Early diagnosis is our finest weapon with subsequent surgical management. The challenge and responsibility for early diagnosis of colorectal cancer is ours alone. We must first recognize it and then meet it firmly and squarely. We must feel for (digital rectal), look for (sigmoidoscopy), and search for (barium enema x-ray examination) colorectal cancer in all of our patients regardless of the insignificance of anal symptoms and anal findings. Our countrymen fear cancer. We have the devices to allay their fears or to cure their cancers if they are found early enough. We have a straightforward moral commitment and a national trust.

Ambulatory Care↗
PubMed1977

Lymphocyte blastogenic responses to allogeneic leukocytes and autochthonous tumor cells in colorectal carcinoma.

The blastogenic reactivity of peripheral blood lymphocytes (PBL) and mesenteric lymph node lymphocytes (LNL) against normal allogeneic leukocytes and autochthonous colorectal carcinoma cells is evaluated in 36 patients, and correlated with the patient's Dukes classification. Mesenteric LNL react significantly better than PBL to allogeneic leukocytes in both Dukes B and C (p less than 0.05). There are too few patients in Dukes A and D to permit statistical evaluation but the trend is the same. By contrast, LNL fail to react to autochthonous tumor cells in all classes, except in a few Dukes B patients. The proportion of PBL reactivity to autochthonous tumor cells seems to increase for Dukes C and D. It is possible that specific lymphocyte reactivity in colorectal carcinoma may be related to the antigenicity and immunogenicity of the tumor.

Antigens, Neoplasm↗