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J W Milsom

Publications and source records attributed to J W Milsom.

At least 19 recordsLinked to original sources
PubMed2005

Intraoperative carbon dioxide colonoscopy: a safe insufflation alternative for locating colonic lesions during laparoscopic surgery.

BACKGROUND: Intraoperative colonoscopy (IOC) is useful for locating colonic pathologies during laparoscopy, but bowel distention compromises the subsequent visualization and procedure. Carbon dioxide (CO2), with its rapid absorption, has been proved effective for alleviating bowel distention in ambulatory settings. Its intraoperative role, however, has never been studied. This study aimed to assess the feasibility, safety, and advantages of CO2-insufflated IOC during laparoscopy. METHODS: For this study, CO2-insufflated IOC was performed for 20 patients under CO2 pneumoperitoneum. Parameters, including end-tidal CO2 (ETCO2) and minute volume, were prospectively registered. Time until resolution of bowel distention was determined by laparoscopic evaluation. RESULTS: All lesions were located by CO2-insufflated IOC in 15 min. During IOC, ETCO2 increased, but remained within normal values, and was quickly compensated with minimal hyperventilation. Bowel distention totally disappeared in 21 min, allowing immediate initiation of laparoscopic procedures under adequate visualization. CONCLUSIONS: The findings show that CO2-insufflated IOC during laparoscopy is feasible, safe, and of practical value for minimizing bowel distention without impeding the subsequent visualization and procedure.

Adult↗
PubMed2005

Three cases of adenocarcinoma following restorative proctocolectomy with hand-sewn anastomosis for ulcerative colitis: a review of reported cases in the literature.

Restorative proctocolectomy (RPC) has been accepted as optimal surgical therapy for most patients with ulcerative colitis. The occurrence of adenocarcinoma adjacent to the ileoanal anastomotic site for ulcerative colitis is a serious but rare outcome. There are 16 reported cases. We report three additional cases and review previous cases in the literature.

Adenocarcinoma↗
PubMed2004

Laparoscopic total colectomy: hand-assisted vs standard technique.

BACKGROUND: Although hand-assisted laparoscopic surgery (HALS) has been proposed as an alternative to laparoscopically assisted surgery (LAP), little is known about its role in total colectomy. The objectives of the study were to compare the outcomes in patients undergoing total colectomy via either HALS or LAP and to determine what benefits HALS might have in extensive colorectal procedures. METHODS: We reviewed the data for 23 patients who underwent total proctocolectomy (TPC) or total abdominal colectomy (TAC) using either a HALS or LAP technique. RESULTS: There were 12 HALS (five TPC, seven TAC) and 11 LAP (seven TPC, four TAC) for ulcerative colitis (n = 17), familial polyposis (n = 5), and colonic inertia (n = 1). One LAP was converted (9.1%). The operative time was shorter for HALS than for LAP (210 vs 273 min; p = 0.03). Blood loss and incision length were similar. Postoperative recovery and morbidity rates were comparable. CONCLUSION: HALS reduces the operative time but patient morbidity rates and recovery are similar to LAP. HALS may be preferable for extensive colorectal procedures such as TPC and TAC.

Adolescent↗
PubMed2004

Use of the surgical towel in colorectal hand-assisted laparoscopic surgery (HALS).

The use of laparotomy pads or towels to displace the small intestine away from the operative site is a well-established technique in open surgery; however, its application is unfeasible or extremely challenging in standard laparoscopic surgery. We describe the use of standard surgical towels in hand-assisted laparoscopic surgery (HALS). A Pfannenstiel incision is made and a Gelport hand-access device is assembled. A sterilized surgical towel, 65 x 44 cm in size, is inserted via the Gelport, unfolded, and placed over the bowel loops laparoscopically with the assistance of the hand. The bowel loops are then housed gently in the towel and displaced away from of the operative site. HALS enables the easy insertion and handling of a large surgical towel inside the peritoneal cavity. The towel successfully retracts the small intestine, enabling the surgeon to concentrate the use of his or her hand on the targeted structures. This practical and inexpensive tip adds another advantageous component to the practice of colorectal HALS.

Bedding and Linens↗
PubMed2003

Hand-assisted laparoscopic colorectal surgery using GelPort.

BACKGROUND: An easily usable hand access device will optimize success in hand-assisted laparoscopic surgery (HALS). The authors describe their initial series of HALS colorectal resections using GelPort to evaluate their current technique and results with this new device. METHODS: A retrospective study investigated 33 HALS colorectal procedures including total colectomy ( n = 16) and low anterior resection ( n = 10). All operative data, including intraoperative GelPort performance, were prospectively recorded and retrospectively analyzed. RESULTS: In this study, 3 (9.1%) of 33 HALS procedures were converted to open surgery, and 4 (13.3%) of 30 HALS procedures required minimal enlargement of incisions to facilitate extracorporeal procedures. The operative time was 263 +/- 85 min, and the blood loss was 282 +/- 148 ml. There were no device malfunctions. Three major complications (9.1%) and 7 minor wound infections (21%) were noted postoperatively. The mean hospital stay was 7.9 +/- 3.8 days. CONCLUSION: When performed with GelPort, HALS is safely and reliably applicable for various colorectal procedures.

Adult↗
PubMed2001

Laparoscopic total colectomy for acute colitis: a case-control study.

INTRODUCTION: There are no previous comparative studies of total abdominal colectomy by laparoscopic methods in ulcerative colitis and Crohn's disease patients requiring urgent colectomy. This study aimed to determine the safety and efficacy of laparoscopic colectomy in these patients compared with those undergoing conventional urgent colectomy. METHODS: Patients undergoing laparoscopic total colectomy for acute colitis were identified in a prospective registry. All patients underwent a total colectomy with creation of an end ileostomy and buried mucous fistula. No patient had fulminant disease (tachycardia, fever, marked leukocytosis, peritonitis), but all were failing to respond to medical treatment. Patients undergoing conventional total colectomy were matched for age, gender, body mass index, diagnosis, disease severity, and operative period. Median values (range) are listed. RESULTS: From 1997 to 1999, there were 19 laparoscopic and 29 matched conventional patients. There were no inadvertent colotomies or conversions in the laparoscopic group. Although there was no difference in operative blood loss in the laparoscopic group (100 (range, 50-700) ml) when compared with the conventional group (150 (range, 50-500) ml), the operative times were significantly longer in the laparoscopic group (210 (range, 150-270) vs. 120 (range, 60-180) minutes, P < 0.001). Bowel function returned more quickly in the laparoscopic group (1 (range, 1-3) vs. 2 (range, 1-4) days; P = 0.003) and the length of stay was shorter (4 (range, 3-13) vs. 6 (range, 4-24) days; P = 0.04). Complications occurred in three (16 percent) laparoscopic patients (2 wound infection and 1 ileus) and in seven (24 percent) conventional patients (3 wound infection, 3 deep venous thrombosis, 1 upper gastrointestinal bleed). CONCLUSIONS: Laparoscopic total colectomy is feasible and safe in patients with acute nonfulminant colitis and may lead to a faster recovery than conventional resection.

Acute Disease↗
PubMed2001

CO2 pneumoperitoneum does not enhance tumor growth and metastasis: study of a rat cecal wall inoculation model.

INTRODUCTION: Although many studies have evaluated the effects of carbon dioxide pneumoperitoneum on port site recurrence, little is known about its outcome on tumor growth and metastasis. The effect of pneumoperitoneum with carbon dioxide on cecal tumor growth and metastasis was compared with laparotomy using a rat colon cancer cell line. METHODS: Time Course Study: Fifty WF/BN F1 hybrid rats were inoculated with 2,000,000 WB2054M5 tumor cells into the cecal wall and explored two to ten weeks after injection. Main Study: 152 rats were randomly assigned either to 6-mmHg CO2 pneumoperitoneum (30 minutes) or 4-cm laparotomy (30 minutes) two weeks after tumor inoculation and were explored four weeks after treatment. RESULTS: Time Course Study: Thirty-seven (95 percent) of the surviving rats developed a cecal wall tumor, and there was progressive tumor growth and metastasis over the ten-week period. At six weeks, metastasis occurred to the liver in 25 percent, to the lung in 38 percent, and to the lymph node in 63 percent, and peritoneal seeding occurred in 38 percent; this time period was chosen for the main study. Main Study: At the time of treatment (2 weeks), 124 rats were eligible for randomization. One hundred two rats survived the six-week period (50 pneumoperitoneum, 52 laparotomy) and were killed. There were no differences between the CO2 pneumoperitoneum and laparotomy groups regarding cecal tumor growth (1.043 vs. 0.894 g) and metastases to the liver (32 vs. 37 percent), lung (34 vs. 17 percent), lymph node (84 vs. 77 percent), and wound or port (20 vs. 23 percent). CONCLUSIONS: A cecal wall inoculation model mimics the natural cascade of colon cancer growth and metastasis. CO2 pneumoperitoneum did not affect the tumor growth and metastasis to the liver and other organs when compared with laparotomy in this model.

Animals↗
PubMed2001

Prospective, randomized trial comparing laparoscopic vs. conventional surgery for refractory ileocolic Crohn's disease.

INTRODUCTION: Surgeons have been reluctant to apply laparoscopic techniques to Crohn's disease surgery because of concerns with evaluating and excising inflamed tissue using laparoscopic methods. Additionally in Crohn's disease surgery, laparoscopic techniques have not been demonstrated to have clear advantages over conventional ones. METHOD: We conducted a prospective, randomized trial in one surgical department comparing laparoscopic vs. conventional techniques in 60 patients (25 males), median age 34.4 (range, 10-60.1) years, undergoing elective ileocolic resection for refractory Crohn's disease. Postoperatively, all patients underwent measurement of pulmonary function tests every 12 hours, and were treated identically on a highly controlled protocol with regard to analgesic administration, feeding, and postoperative care. RESULTS: Of the 31 patients assigned to laparoscopic and 29 to the conventional group, all had isolated Crohn's disease of the terminal ileum plus or minus the cecum. Median length of the incision was 5 cm in the laparoscopic group and 12 cm in the conventional group. Overall recovery of 80 percent of forced expiratory volume (one second) and forced vital capacity was a median of 2.5 days for laparoscopic and 3.5 days for conventional (P = 0.03). There was no difference in the amount of morphine equivalents used between groups postoperatively. Flatus and first bowel movement returned a median of 3 and 4 days, respectively, after laparoscopic vs. 3.3 and 4 days, respectively, after conventional surgery (P = 0.21). Median length of stay was five (range, 4-30) days for laparoscopic, and six (range, 4-18) days for conventional surgery. Major complications occurred in one patient in each group. Minor complications occurred in four laparoscopic and eight conventional patients (P < 0.05). There were no deaths. Two laparoscopic patients were converted to conventional as a result of adhesions or inflammation. All patients recovered well and there were no clinical recurrences in the follow-up period (median, 20; range, 12-45 months). CONCLUSIONS: Within a single institution, single surgical team, prospective, randomized trial, laparoscopic techniques offered a faster recovery of pulmonary function, fewer complications, and shorter length of stay compared with conventional surgery for selected patients undergoing ileocolic resection for Crohn's disease.

Adolescent↗
PubMed2001

Laparoscopic surgery in Crohn's disease.

Laparoscopic surgeons attempting to treat Crohn's disease must have experience working with inflammatory bowel disease and advanced laparoscopic skills. Nonetheless, laparoscopy is dramatically changing all aspects of gastrointestinal surgery and inflammatory bowel disease, including Crohn's disease, is likely to benefit, as well. This article defines the role of laparoscopy in treating Crohn's disease and outlines surgical therapy.

Colectomy↗
PubMed2001

[Laparoscopic restorative proctocolectomy in ulcerative colitis and colonic polyps].

With increasing experience, laparoscopic techniques have been applied even to extended colorectal operations as restorative proctocolectomy in ulcerative colitis and familial adenomatous polyposis. After initial medial transection of the three main vascular pedicles, the colon is dissected free laterally, from the sigmoid orally towards the ileum. The rectum is mobilized down to the pelvic floor. Over a Pfannenstiel incision, the bowel is extracted and the pouch is created. The anastomosis is completed in double-stapling technique. At two departments, 27 patients have been operated on. The median time of operation was 320 min (180-540). The median length of hospital stay was 8.1 days. There was no postoperative mortality. The complication rate was similar to conventional surgery at the same institutions. Three patients had to be re-operated on, two for ileal obstruction close to the pouch, one patient for bleeding from the pouch. In restorative proctocolectomy, laparoscopic techniques prove to be safely feasible. They have the potential to become an appealing alternative to open surgery.

Adenomatous Polyposis Coli↗
PubMed2000

Laparoscopic total mesorectal excision with autonomic nerve preservation.

Laparoscopy has greatly influenced abdominal surgery. We hypothesize that the benefits of minimally invasive surgery are applicable to rectal cancer. A cadaver model of laparoscopic rectal resection with total mesorectal excision (TME) and autonomic nerve preservation was utilized to explore this hypothesis. The principles of TME were followed, including high vascular ligation, sharp mesorectal dissection, and identification and preservation of the autonomic pelvic nerves. After proving feasibility in the cadaver model, a clinical study was performed on patients with mid to low rectal cancers. We observed acceptable morbidity with this minimally invasive technique of rectal resection and TME. We conclude that there is growing evidence that laparoscopic methods can be applied to patients with rectal cancer.

Adenocarcinoma↗
PubMed2000

Laparoscopic restorative proctocolectomy: case-matched comparative study with open restorative proctocolectomy.

PURPOSE: A laparoscopic approach to restorative proctocolectomy is new and has not been compared recently with the traditional open procedure. By using prospectively gathered data, laparoscopic and open restorative proctocolectomy procedures in mucosal ulcerative colitis and familial adenomatous polyposis patients were compared by using a case-matched design. METHODS: Forty patients, composing 20 consecutive laparoscopic cases (13 mucosal ulcerative colitis, 7 familial adenomatous polyposis), were matched for age, gender, and body mass index with 20 open cases (13 mucosal ulcerative colitis, 7 familial adenomatous polyposis) performed during the same time period. Mucosal ulcerative colitis patients were also matched for severity of disease by using hemoglobin and albumin levels, whole blood count, and steroid dependency. A loop ileostomy was made in 12 of 13 laparoscopic mucosal ulcerative colitis patients, all open mucosal ulcerative colitis patients, and no familial adenomatous polyposis patients. RESULTS: The median age was 25 (range, 9-61) years. There were no intraoperative complications in either group and no conversions in the laparoscopic group. The operative times (median, range) were significantly longer in laparoscopic cases (330, 180-480 minutes) vs. open cases (230, 180-300 minutes), P < 0.001. Bowel function returned more quickly in laparoscopic cases (2, 1-8 days) vs. open cases (4, 1-13 days), P = 0.03; and the length of stay was shorter in laparoscopic cases (7, 4-14 days) vs. open cases (8, 6-17 days), P = 0.02. For diverted patients, the median length of stay was reduced by two days in laparoscopic cases (6, 4-14 days) vs. open cases (8, 6-17 days), P = 0.01. Complications occurred in 4 of 20 laparoscopic patients (3 obstruction/ileus and 1 pelvic abscess) and 5 of 20 open patients (2 obstruction and ileus, 1 each anastomotic leak and abscess, peptic ulceration, and episode of dehydration). CONCLUSIONS: Return of intestinal function and length of stay are reduced in the laparoscopic group compared with open group. A laparoscopic approach to restorative proctocolectomy has the potential of becoming an appealing alternative to conventional restorative proctocolectomy surgery.

Adenomatous Polyposis Coli↗
PubMed2000

Laparoscopic colorectal cancer surgery for palliation.

PURPOSE: The aim of this study was to review our experience with laparoscopic colorectal cancer surgery for palliative purposes and to assess its safety and efficacy. METHODS: This was a prospective analysis of 30 patients with incurable colorectal cancer considered for laparoscopic surgery for palliative purposes. RESULTS: Resection of a single segment of the bowel was performed in 15 patients (6 right and 1 left colectomies and 8 proctosigmoidectomies). One patient underwent both right colectomy and sigmoidectomy because of double lesions. Stoma creation only was performed in 11 patients (5 colostomies and 6 ileostomies). Three patients were converted to an open procedure. For resection, median operative time was 170 minutes, and median estimated blood loss was 150 ml. For stoma creation, median operative time was 60 minutes, and median blood loss was 50 ml. There were no intraoperative complications. Postoperative death occurred in two severely debilitated patients after stoma creation. One patient developed a pulmonary embolism eight days postoperatively, later dying of pulmonary failure. Another patient died six hours after loop colostomy. Autopsy was refused. There were no other postoperative complications. Median time to passage of flatus was two days and of stool five days after resection and two days for both flatus and stool after stoma creation. Median time to discharge was eight days after resection and seven days after stoma creation. All patients were able to eat and recover normal bowel function. Among the resection group, six patients died (median time to death, 12 months) during a median follow-up period of 13 months. Among the stoma creation group, five patients died (median time to death, 8 months) during median follow-up period of ten months. There were no port-site recurrences. CONCLUSION: The laparoscopic approach for patients with incurable colorectal cancer can provide effective palliation with avoidance of a major laparotomy in the majority of cases.

Aged↗
PubMed2000

Prospective, blinded comparison of laparoscopic ultrasonography vs. contrast-enhanced computerized tomography for liver assessment in patients undergoing colorectal carcinoma surgery.

PURPOSE: To prospectively and blindly compare intraoperative laparoscopic ultrasonography to preoperative contrast-enhanced computerized tomography in detecting liver lesions in colorectal cancer patients. Additionally, we compared conventional (open) intraoperative ultrasonography with bimanual liver palpation to contrast-enhanced computerized tomography in a subset of patients. METHODS: From December 1995 to March 1998, 77 consecutive patients underwent curative (n = 63) or palliative (n = 14) resections for colorectal cancer. All patients undergoing curative resections were randomized to either laparoscopic (n = 34) or conventional (n = 29) surgery after informed consent. All patients underwent contrast-enhanced computerized tomography, diagnostic laparoscopy, and laparoscopic ultrasonography before resection. In those patients who had conventional procedures, intraoperative ultrasonography with bimanual liver palpation was also done. All laparoscopic ultrasonography and intraoperative ultrasonography evaluations were performed by one of two radiologists who were blinded to the CT results. All hepatic segments were scanned using a standardized method. The yield of each modality was calculated using the number of lesions identified by each imaging modality divided by the total number of lesions identified. RESULTS: In 43 of the 77 patients, both the laparoscopic ultrasonography and CT scan were negative for any liver lesions. In 34 patients, a total of 130 lesions were detected by laparoscopic ultrasonography, CT, or both. When compared with laparoscopic ultrasonography, intraoperative ultrasonography with bimanual liver palpation identified one additional metastatic lesion and no additional benign lesions. laparoscopic ultrasonography identified two patients with mets who had negative preoperative contrast-enhanced computerized tomography. CONCLUSIONS: Laparoscopic ultrasonography of the liver at the time of primary resection of colorectal cancer yields more lesions than preoperative contrast-enhanced computerized tomography and should be considered for routine use during laparoscopic oncologic colorectal surgery.

Adenocarcinoma↗
PubMed2000

Comparison of intravenous/oral ciprofloxacin plus metronidazole versus piperacillin/tazobactam in the treatment of complicated intraabdominal infections.

OBJECTIVE: To compare the safety and efficacy of intravenous (IV) ciprofloxacin plus IV metronidazole (CIP+MET) with that of IV piperacillin/tazobactam (PIP/TAZO) in adults with complicated intraabdominal infections, and to compare the efficacy of sequential IV-to-oral CIP+MET therapy with that of the IV CIP-only regimen. SUMMARY BACKGROUND DATA: Treatment of intraabdominal infections remains a challenge, mainly because of their polymicrobial etiology and attendant death and complications. Antimicrobial regimens using sequential IV-to-oral therapy may reduce the length of hospital stay. METHODS: In this multicenter, randomized, double-blind trial involving 459 patients, clinically improved IV-treated patients were switched to oral therapy after 48 hours. Overall clinical response was the primary efficacy measurement. RESULTS: A total of 282 patients (151 CIP+MET, 131 PIP/TAZO) were valid for efficacy. Of these patients, 64% CIP+MET and 57% PIP/TAZO patients were considered candidates for oral therapy. Patients had a mean APACHE II score of 9.6. The most common diagnoses were appendicitis (33%), other intraabdominal infection (29%), and abscess (25%). Overall clinical resolution rates were statistically superior for CIP+MET (74%) compared with PIP/TAZO (63%). Corresponding rates in the subgroup suitable for oral therapy were 85% for CIP+MET and 70% for PIP/TAZO. Postsurgical wound infection rates were significantly lower in CIP+MET (11%) versus PIP/TAZO patients (19%). Mean length of stay was 14 days for CIP+MET and 17 days for PIP/TAZO patients. CONCLUSION: CIP+MET, initially administered IV and followed by CIP+MET oral therapy, was clinically more effective than IV PIP/TAZO for the treatment of patients with complicated intraabdominal infections.

Abdomen↗
PubMed2000

Laparoscopic colectomy for malignancy.

It is clear from published series that laparoscopic colectomy for cancer can be performed safely by experienced surgeons, but there is a considerable learning curve for the procedure. Although surgeons have shown that an equivalent resection can be performed, it is not clear yet that this translates into equivalent recurrence and survival rates. Most of the expected benefits of minimal access surgery are being provided by laparoscopic colectomy, although these benefits have not been as readily achievable as those seen with other procedures. Even the early results of laparoscopic colectomy for cancer are encouraging, although the fate of this procedure rests with the long-term analysis of a number of trials currently underway. Laparoscopic techniques are continuing to evolve and improve secondary not only to technological breakthroughs but also advances in basic science and clinical research. This article provides technical descriptions to illustrate key concepts in laparoscopic resection of the right colon and rectosigmoid for cancer and reviews the results of recent prospective randomized trials.

Colectomy↗
PubMed1999

Laparoscopic surgery of the colon and rectum.

The use of laparoscopic techniques in benign colorectal surgery has expanded over the past several years, but controversy continues to surround the use of laparoscopic resection in cases of colorectal carcinoma. Diagnostic laparoscopy, the creation of stomas, and limited resections are becoming reasonable indications for benign diseases. In cases of malignancy, resection through a conventional incision or a laparoscope must adhere to the same defined surgical oncologic principles. Current randomized trials comparing open resection to laparoscopic resection should address these concerns. Port-site recurrence remains a leading concern regarding the widespread acceptance of laparoscopic resection for colorectal carcinoma. This article focuses on the applications of laparoscopic colorectal surgery for malignant diseases. Further research in this area combined with advances in laparoscopic technology will be critical to the future successful application of laparoscopic surgery to colorectal carcinoma.

Colon↗