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Biomedical subjects

R D Madoff

Publications and source records attributed to R D Madoff.

51 records · Page 3Linked to original sources
PubMed1996

Preoperative adjuvant radiation with chemotherapy for rectal cancer: its impact on stage of disease and the role of endorectal ultrasound.

BACKGROUND: Preoperative adjuvant radiation combined with chemotherapy is a recent development in the management of patients with rectal cancer invading perirectal tissue and regional lymph nodes. This study was performed to assess the impact of preoperative adjuvant therapy in patients judged by endorectal ultrasound to have extramural invasion of rectal cancer and/or regional lymph node involvement on tumor regression in bowel wall and lymph nodes. The predictive value of ultrasound in staging wall penetration and lymph node involvement after preoperative adjuvant therapy was also assessed. METHODS: Patients (n = 43) were selected by ultrasound to have preoperative irradiation (4,500-5,040 cGy over 5-6 weeks). In 30 patients this was combined with 5-fluorouracil, 370 mg/m(2), for 5 days in the first and last weeks of irradiation. Pretreatment ultrasound was compared with pathologic findings in the resected specimen in all patients. Twenty-one were assessed by ultrasound after adjuvant therapy and findings compared with histology. RESULTS: Downstaging was seen in 23 (53%) patients with wall invasion and in 23 (72%) of 32 patients with lymph node involvement. Overall, downstaging was achieved in 30 (70%). Positive predictive values of ultrasound after irradiation were 72% and 56% for wall penetration and lymph node status, respectively. Negative predictive values of ultrasound after irradiation were 100% and 82%, respectively. CONCLUSION: In the majority of patients with rectal cancer invading perirectal tissues or lymph nodes, lesions may be downstaged by preoperative adjuvant therapy. Endorectal ultrasound after adjuvant therapy for rectal cancer is of a lesser predictive value chiefly because of overstaging.

Adult↗
PubMed1995

Current therapy for recurrent and extensive anal warts.

PURPOSE: This study was undertaken to review the literature regarding the current therapy for recurrent and extensive anal warts. METHODS: The available treatments for condyloma acuminatum are reviewed with particular regard to their efficacy for recurrent or extensive anal lesions. Topical agents, surgical methods, and the use of interferon are discussed. Treatment of anal warts in the immunocompromised patient is also addressed. CONCLUSIONS: Although small lesions may be responsive to repeated applications of topical agents, more extensive lesions require surgical or combination treatment. Intralesional interferon may be a useful adjunct to surgical methods to decrease recurrence.

Anus Diseases↗
PubMed1995

Functional assessment of ileal pouch-anal anastomotic techniques.

BACKGROUND: Recent advances in ileal pouch-anal anastomotic (IPAA) technique include the substitution of a double stapled anastomosis for a mucosectomy and hand-sewn pouch-anal anastomosis, and the use of staples to construct a "J" shaped pouch rather than a hand-sewn "S" pouch in most cases. METHOD: To determine the impact these technical changes have had on pouch function, 235 IPAA patients with 15 to 155 months of follow-up (mean 70 months) were interviewed by telephone concerning pouch function and quality of life. Categorical responses were then evaluated by contingency table analysis to detect differences between mucosectomy (n = 157) and nonmucosectomy (n = 80) groups, and between J pouch (n = 50), S pouch with mucosectomy (n = 137), and S pouch nonmucosectomy (n = 30) subgroups. An index encompassing nine functional measures was used to quantify the overall impact of technique changes (optimal score 100). RESULTS: Stool frequency for mucosectomy patients was 7.2 movements/24 hours, compared to 7.1 for nonmucosectomy patients. Elimination of a mucosectomy dramatically reduced nocturnal major incontinence (P < 0.001), nocturnal minor incontinence (P < 0.001), daytime minor incontinence (P = 0.03), and day-time pad use (P = 0.002). Nonmucosectomy patients had a better functional index score than had patients with an S pouch, even when only data from nonmucosectomy patients were analyzed (J = 95.5, S = 91.8, P = 0.009). CONCLUSIONS: Avoidance of a mucosectomy in the performance of an ileal pouch-anal anastomosis does not influence stool frequency but does significantly improve fecal continence and introduces no detectable morbidity associated with the retained rectal mucosa.

Adult↗
PubMed1993

Colon and rectal cancer in pregnancy.

Colorectal carcinoma presenting in pregnancy is an uncommon disease that is reported to be associated with an extremely poor prognosis. To better characterize this disease, we surveyed the membership of the American Society of Colon and Rectal Surgeons by mailed questionnaire and reviewed the literature. Forty-one new cases of women with large bowel cancer who presented during pregnancy or the immediate postpartum period were identified. The mean age at presentation was 31 years (range, 16-41 years). Tumor distribution was as follows: right colon-3, transverse colon-2, left colon-2, sigmoid colon-8, and rectum-26. Dukes stage at presentation was A = 0, B = 16, C = 17, and D = 6 (two patients were unstaged). Average follow-up was 41 months. Stage for stage, survival was found to be similar to patients with colorectal tumors in the general population. Large bowel cancer coexistent with pregnancy presents in a distal distribution (64 percent of tumors in the current series and 86 percent of those reported in the literature were located in the rectum) and presents at an advanced stage (60 percent were Stage C or more advanced at the time of diagnosis). While patient survival is poor, it is no different stage for stage from the general population with colorectal tumors.

Adolescent↗
PubMed1993

Protective effect of RibCys following high-dose irradiation of the rectosigmoid.

UNLABELLED: Ribose-cysteine (RibCys) is a prodrug of L-cysteine that stimulates glutathione biosynthesis. Increased glutathione levels have been shown to have a protective effect against radiation-induced injury and oxidative stress. Surface oximetry has previously been used successfully to predict anastomotic leakage. PURPOSE: The following study was done to evaluate the protective effect of RibCys and the predictive value of PtO2 determinations in a swine model. METHODS: Domestic swine were divided into three groups: Group A served as a nonradiated control; Group B received 6,000 to 6,500 rad to the rectosigmoid; and Group C received RibCys (1 g/kg) prior to receiving 6,000 to 6,500 rad. Radiated animals and controls underwent rectosigmoid resection after a three-week rest period. Intraoperative anastomotic PtO2 was checked with a modified Clark electrode. Anastomoses were evaluated radiographically at three and seven days; animals were sacrificed, and bursting strength was recorded at 10 days. RESULTS: Mean bursting pressures were 243.8 +/- 59.4, 199.5 +/- 37.8, and 209.5 +/- 54.9 mmHg (NS) for Groups A, B, and C, respectively. Anastomotic PtO2 ranged from 19 to 98 mmHg and could not be correlated with anastomotic leaks or bursting pressure. There were 11/15 radiation-related deaths and leaks (eight deaths and three leaks) in the radiated group and 4/12 radiation-related deaths and leaks (three deaths and one leak) in the group receiving radiation and RibCys (P < 0.04). CONCLUSIONS: 1) RibCys protected animals against radiation-related deaths and anastomotic leaks following high doses of pelvic irradiation; 2) anastomotic PtO2 levels did not correlate with anastomotic healing in this model.

Anastomosis, Surgical↗
PubMed1992

Treatment of rectal prolapse in the elderly by perineal rectosigmoidectomy.

The results and complications of perineal rectosigmoidectomy for complete rectal prolapse in 114 patients have been reviewed. Most patients were elderly and high risk by virtue of other concurrent medical conditions. Fourteen patients (12 percent) developed significant postoperative complications. Hospital stay was short (median, four days). Ten patients were lost to follow-up. The remaining 104 patients were followed for 3 to 90 months. Eleven patients (10 percent) developed recurrent full-thickness rectal prolapse, six of them underwent repeat perineal rectosigmoidectomy. Sixty-seven patients had fecal incontinence prior to surgery. Eleven patients underwent concomitant levatoroplasty; 10 of them either improved or regained full continence of feces postoperatively. Twenty-six of the 56 patients who underwent perineal rectosigmoidectomy alone improved or regained full continence. Rectal prolapse can be successfully treated by perineal rectosigmoidectomy in elderly, high-risk patients with minimal morbidity. Levatoroplasty dramatically improves fecal incontinence occurring in association with rectal prolapse.

Adult↗
PubMed1992

Long-term functional results of colon resection and rectopexy for overt rectal prolapse.

We reviewed the long-term functional results of colon resection and suture rectopexy for complete rectal prolapse in 47 patients followed for more than 3 yr (mean 65 months). Thirty-three patients underwent sigmoidectomy, eight patients underwent subtotal colectomy, and four patients underwent sigmoidectomy with subsequent subtotal colectomy. Three patients (6.3%) developed recurrent full-thickness prolapse, and four patients (8.5%) developed rectal mucosal prolapse. Twenty patients presented with constipation, 10 (50%) of whom improved after surgery. Constipation improved in seven (70%) patients who underwent subtotal colectomy. Twenty-one patients presented with incontinence, eight (38%) of whom improved. Continence worsened in six patients, and four patients developed significant diarrhea. These complications did not correlate with the extent of bowel resection. Three patients required subsequent stomas. Colon resection and rectopexy provides long-term control of rectal prolapse with an acceptable recurrence rate. Subtotal colon resection is frequently helpful in patients with associated constipation. However, colon resection of any magnitude entails a small risk of chronic diarrhea and/or diminished continence.

Colectomy↗
PubMed1991

Comparative intrinsic and extrinsic compliance characteristics of S, J, and W ileoanal pouches.

Although compliance of the ileoanal reservoir pouch has been shown to affect function, previous compliance studies may have been influenced by the compliance of the small bowel proximal to the pouch and by supporting pelvic structures. The following study was designed to isolate the pouch and to compare intrinsic and extrinsic factors influencing pouch compliance. Thirty-three mongrel dogs underwent rectal mucosectomy and proctocolectomy with S-pouch (S) in nine, stapled J-pouch (SJ) in nine, handsewn J-pouch (HJ) in nine and handsewn W-pouch (SW) in six. At 2 weeks, each dog underwent laparotomy, the small bowel 2 cm proximal to the pouch was clamped, and in vivo pouch compliance was measured using anal balloon occlusion and continuous saline infusion manometry. The pouch was then removed and ex vivo measurements were repeated. Mean compliance slopes between 0 and 40 cm H2O were compared by ANOVA and paired t-tests. In vivo and ex vivo compliance in ml/cm H2O was 3.1 +/- 1.2 and 3.8 +/- 1.6 (P = 0.25) for the S-pouch, 3.1 +/- 0.6 and 5.2 +/- 1.7 (P less than 0.01) for the SJ-pouch, 2.3 +/- 0.5 and 4.8 +/- 0.7 (P less than 0.001) for the HJ-pouch, 3.6 +/- 0.6 and 6.0 +/- 0.7 (P less than 0.001) for the W-pouch. Pearson's correlation coefficient for in vivo and ex vivo measurements of the S, SJ, HJ, and W pouches were r2 = 0.066, 0.001, 0.039, and 0.379, respectively. It is concluded that: 1) Isolated pouch compliance can be accurately measured in experimental animals with proximal and distal occlusion and inflow manometry. 2) In vivo compliance is significantly less in the HJ compared with S, SJ, and W pouches. 3) Differences between in vivo and ex vivo compliance of SJ, HJ, and SW pouches are significant. 4) In vivo and ex vivo compliance determinations correlate poorly. 5) Extrinsic factors contribute significantly to pouch compliance.

Anal Canal↗
PubMed1990

Rectal compliance: a critical reappraisal.

Compliance is a widely measured parameter of rectal function. Its value is determined clinically by recording pressure changes associated with volume infusion into a rectal balloon. This paper examines the inherent assumptions of the rectal balloon technique and discusses several of its shortcomings. A stricter definition of rectal compliance is needed, and in vivo compliance should be correlated with the directly measured mechanical properties of the rectal wall.

Catheterization↗
PubMed1987

Left ventricular function in malnutrition.

Twenty-one dogs were chronically instrumented with ultrasonic left ventricular dimension transducers and micromanometers to elucidate the effects of acute protein-calorie malnutrition on cardiac function. Ten dogs received a regular diet for 3 wk, whereas 11 dogs received a protein-calorie-deficient diet designed to achieve a mean weight loss of 20-25% over a 3-wk period. Studies of cardiac function were performed in awake intact animals at base line (1 wk postoperatively) and after 3 wk. In the malnourished dogs, cardiac mass was lost in proportion to total body mass loss. Mean cardiac mass fell from 115 to 91 g. This was largely due to wall thinning in this group. Heart rate dropped from 125 to 79 beats/min with malnutrition and ejection fraction increased from 29.8 to 34.6%. Cardiac output fell from 2.98 to 2.38 l/min, but cardiac index normalized to body surface area was unchanged. No significant changes in hemodynamics were observed in the control group. In the malnutrition group, global ventricular contractility, as measured by the load-independent index of systolic function or the slope of linear relationship between end-systolic pressure and end-systolic volume (EmaxPV), decreased slightly from 3.56 to 2.81 mmHg/ml (P = 0.07). However, Emax calculated from circumferential stress and strain data was unchanged. This indicates that depressed contractility was due to loss of cardiac muscle mass rather than any change in the myocardium per se. Response to beta-adrenergic stimulation was unchanged with starvation. Acute protein-calorie malnutrition causes significant cardiac atrophy that is reflected in decreased cardiac output and slightly reduced contractility but not in intrinsic properties of the myocardium.

Animals↗
PubMed1985

Prolonged surgical intensive care. A useful allocation of medical resources.

To determine factors related to outcome following prolonged stays in the surgical intensive care unit (ICU), we reviewed the charts of all 59 patients who required surgical ICU stays of one week or longer during 1982 (63 admissions). Overall ICU survival was 58.7% and varied inversely with acute illness severity, length of ICU stay, and hospital cost. The need for renal dialysis and prolonged mechanical ventilatory support were associated with bad outcomes. Age did not affect ICU survival. Follow-up survival was 33% of the original group or 56.8% of ICU survivors. Poor chronic health was associated with a high late mortality. The functional status of surviving patients was satisfactory, with 18 of 21 patients living independently. We conclude that there is significant survival following prolonged ICU therapy, and that, although identifiable factors related to outcome exist, none alone permit the discontinuation of therapy on an individual basis.

Adult↗
PubMedDate not supplied

Prognostic significance of tumor markers in colorectal cancer patients: DNA index, S-phase fraction, p53 expression, and Ki-67 index.

Risk of colorectal cancer recurrence has traditionally been determined by use of pathologic staging. However, it is apparent that subgroups of patients exist within tumor stages whose clinical behavior differs. This study was undertaken to identify tumor-associated factors that might be predictive of outcome in patients with intermediate stages who will benefit the most from postsurgical adjuvant therapy. Seventy patients with stage II and III colorectal cancer were assessed for DNA index, S-phase fraction, p53 expression, and Ki-67 index. Tumor recurrence was analyzed by means of nonparametric tests and Cox proportional hazard models incorporating standard clinical and pathologic criteria. Of the four prognostic markers evaluated, Ki-67 index was significantly associated with disease recurrence (P = 0.02), whereas DNA index, S-phase fraction, and p53 expression were not. After stratification by tumor stage, significant associations between Ki-67 index and disease recurrence were retained in stage II tumors (P = 0.01) but not in stage III tumors (P = 0.23). Cox proportional hazard regression analysis indicated that among stage II patients, those with a Ki-67 index >45% were associated with 6.5 times greater risk for disease recurrence than those with a Ki-67 index >/=45%. It was concluded that an elevated Ki- 67 index is associated with an increased risk of tumor recurrence in stage II colorectal cancer.

Aged↗
PubMedDate not supplied

Cardiac beta-adrenergic responsiveness is well preserved in moderate protein calorie malnutrition from semistarvation.

Twenty-one dogs underwent instrumentation of the left ventricle with ultrasonic dimension to study the effects of acute protein-calorie malnutrition on the adrenergic responsiveness of the heart. This study allowed a chronic and dynamic measurement of the major cardiac axes and the ventricular wall thickness, which in turn can be used to derive sophisticated measurements of global and intrinsic left ventricular function. Of the 21 dogs, 11 received a protein- and calorie-deficient diet designed to achieve a mean weight loss from a baseline of 20-25% over a 4-week period. The other 10 dogs received a normal diet. Dogs were also randomized to receive either acute propranolol beta-receptor blockade (n = 9) or acute isoproterenol beta-receptor stimulation (n = 12) during their baseline studies. Of the nine dogs given propranolol, five were subsequently malnourished and four served as controls. Of the 12 given isoproterenol, six were rendered malnourished and six were controls. All dogs were studied at both baseline and 4 weeks and received drugs in an identical fashion during both studies. The significant changes with malnutrition consisted of decreases in heart rate, cardiac mass, and left ventricular wall thickness. The degree of change in stroke volume, ejection fraction, cardiac output, dp/dt, and Emax (index of left ventricular contractility), with the administration of propranolol or isoproterenol was unaltered by malnutrition. These data support the contention that moderate protein-calorie malnutrition is well tolerated in instrumented, unstessed dogs and that the left ventricle's capacity to respond to beta-stimulation and to tolerate beta-blockade is largely unimpaired.

Animals↗