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Biomedical subjects

R J Heald

Publications and source records attributed to R J Heald.

At least 37 records · Page 2Linked to original sources
PubMed2001

Risk factors for, and management of anastomotic leakage in rectal surgery.

Anastomotic leakage is one of the most serious early complications of any rectal anastomosis. Proximal defunctioning mitigates the consequences of leakage but does not abolish the risk. The lower the anastomosis the higher the risks of leakage. There is evidence that a short colon pouch reduces the risks of leakage. A high index of suspicion is required to detect the early non-specific signs of anastomotic leakage. Urgent surgical intervention is usually required to avert a life threatening situation. Reports of the demise of temporary defunctioning of the low anastomosis are premature, and judicious use of faecal diversion should never be regarded as surgical temerity.

Journal Article↗
PubMed2001

Surgical decisions in the elderly: the importance of biological age.

Surgeons will sometimes advise against an operation because the patient is 'old and frail'. A simple starring system (one to five), based on performance and lifestyle, has been devised to assess the biological age of elderly patients. 10 consultant surgeons and 10 trainees answered questions about their treatment recommendations for hypothetical patients of standard age and medical history but with various star ratings and surgical conditions. 1000 decisions were available for analysis. The four and five star patients (those leading an independent existence) were recommended 266 interventions, the one and two star patients 55. Trainees were more inclined to intervene than consultants, recommending operations in half the patients rather than one-third. These results indicate that decisions on surgical management are strongly influenced by the patient's star rating or biological age. If the starring method proves reproducible in other patient groups and settings, it could allow better communication on an important factor in clinical decisions.

Age Factors↗
PubMed2001

Cadaveric dissection for the rectal surgeon.

The benefits of total mesorectal excision are due to the complete excision of the mesorectum with preservation of the pelvic autonomic nerve plexuses, the hypogastric nerves and nervi erigentes. Several important structures are incompletely seen at operation, and cadaveric dissection of an intact lower trunk and a sagittally hemisected pelvis is a valuable exercise in demonstrating them. A method for dissection is described which illustrates the key anatomical points.

Autonomic Nervous System↗
PubMed2000

Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm. Stockholm Colorectal Cancer Study Group, Basingstoke Bowel Cancer Research Project.

BACKGROUND: The Stockholm I and II randomised trials demonstrated the value of preoperative radiotherapy in preventing local recurrence in rectal cancer. This, study investigated the potential for further improvement by introduction of the concept of total mesorectal excision (TME) to surgeons in Stockholm, Sweden. METHODS: Workshops started in 1994 and included 11 television-based demonstrations and two histopathology sessions. The study population consisted of all patients who underwent abdominal operations for rectal cancer in Stockholm County during 1995-96 (TME project; n=447). Outcomes at 2 years were compared with those from the Stockholm I (n=790) and II (n=542) trials as historical controls. FINDINGS: For patients with curative abdominal resections, there were no differences between the Stockholm I (n=686), Stockholm II (n=481), and TME project (n=381) groups in 30-day mortality (30 [4%], six [1%], and 12 [3%]), anastomotic leakage (27 [10%], 18 [9%], and 23 [9%]), or all complications (204 [30%], 169 [35%], and 134 [35%]). This similarity was achieved despite a decrease in the proportion of abdominoperineal procedures from 55-60% to 27%. Local recurrence occurred in significantly fewer of the TME group than of the Stockholm I and II groups (21 [6%] vs 103 [15%] and 66 [14%], p<0.001) as did cancer-related death (35 [9%] vs 104 [15%] and 77 [16%], p<0.002). INTERPRETATION: A surgical teaching initiative had a major effect on cancer outcomes. The proportion of abdominoperineal procedures and the local recurrence rate decreased by more than 50% and there is already evidence of a decline in rectal-cancer mortality.

Adult↗
PubMed2000

Total mesorectal exsicion (TME).

For almost twenty years the concept of total mesorectal excision (TME) has featured in the medical literature. It remains however the object of ongoing controversy and sometimes of downright antagonism. At the present time there are at least four other names for exactly the same technique being championed by different authorities. 1. Circumferential Mesorectal Excision (Enker); 2. Sharp Mesorectal Excision (Cohen); 3. Extrafascial Excision of the Rectum (Hill); 4. Total Anatomical Dissection (Boley). As Shakespeare said "A rose by any other name would smell as sweet".

Digestive System Surgical Procedures↗
PubMed1999

Improved survival and local control after total mesorectal excision or D3 lymphadenectomy in the treatment of primary rectal cancer: an international analysis of 1411 patients.

AIMS: Improved local control and survival in the treatment of rectal cancer have been reported after total mesorectal excision and after extended lymphadenectomy. Comparison of published results is difficult because of differences in patient populations and definitions. We compared three series of patients who underwent standardized surgery [i.e. total mesorectal excision (TME) or D3 lymphadenectomy] with patients who underwent conventional surgery, using actual patient data and uniform definitions. METHODS: TME was performed at Memorial Sloan-Kettering Cancer Center, New York, USA (n=254) and the North Hampshire Hospital, Basingstoke, UK (n=204). D3 lymphadenectomy was performed at the National Cancer Center, Tokyo (n=233). Conventional surgery was used in hospitals in Norway (n=366) and in hospitals of the Comprehensive Cancer Center West, The Netherlands (n=354). Only patients with a curatively resected primary TNM Stage II or Stage III rectal cancer within 12 cm from the anal verge were included. RESULTS: Five-year overall survival and cancer-specific survival were 62-75% and 75-80%, respectively, in the standardized surgery groups and 42-44% and 52%, respectively, in the conventional surgery groups. Local recurrence rates ranged from 4 to 9% in the standardized surgery groups and 32-35% in the conventional surgery groups. CONCLUSIONS: A 30% survival difference and 25% local recurrence difference is not likely to be caused by the shortcomings which are inherent in a non-randomized study: selection bias, assessment variability or stage migration. This study suggests that standardized surgery gives superior survival and local control when compared to conventional surgery.

Aged↗
PubMed1998

Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978-1997.

OBJECTIVE: To examine the role of total mesorectal excision in the management of rectal cancer. DESIGN: A prospective consecutive case series. SETTING: A district hospital and referral center in Basingstoke, England. PATIENTS: Five hundred nineteen surgical patients with adenocarcinoma of the rectum treated for cure or palliation. INTERVENTIONS: Anterior resections (n = 465) with low stapled anastomoses (407 total mesorectal excisions), abdominoperineal resections (n = 37), Hartmann resections (n = 10), local excisions (n = 4), and laparotomy only (n = 3). Preoperative radiotherapy was used in 49 patients (7 with abdominoperineal resections, 38 with anterior resections, 3 with Hartmann resections, and 1 with laparotomy). MAIN OUTCOME MEASURES: Local recurrence and cancer-specific survival. RESULTS: Cancer-specific survival of all surgically treated patients was 68% at 5 years and 66% at 10 years. The local recurrence rate was 6% (95% confidence interval, 2%-10%) at 5 years and 8% (95% confidence interval, 2%-14%) at 10 years. In 405 "curative" resections, the local recurrence rate was 3% (95% confidence interval, 0%-5%) at 5 years and 4% (95% confidence interval, 0%-8%) at 10 years. Disease-free survival in this group was 80% at 5 years and 78% at 10 years. An analysis of histopathological risk factors for recurrence indicates only the Dukes stage, extramural vascular invasion, and tumor differentiation as variables in these results. CONCLUSIONS: Rectal cancer can be cured by surgical therapy alone in 2 of 3 patients undergoing surgical excision in all stages and in 4 of 5 patients having curative resections. In future clinical trials of adjuvant chemotherapy and radiotherapy, strategies should incorporate total mesorectal excision as the surgical procedure of choice.

Adenocarcinoma↗
PubMed1998

Embryology and anatomy of the rectum.

Rectal cancer surgery is difficult due to the rectum's relatively inaccessible pelvic position and its direct relation to many vital structures. The surgeon is challenged to restore intestinal continuity while working in a confined space. Despite the importance of these issues, the embryology and surgical anatomy of the rectum have been poorly understood. In recent years, cadaver dissections and operative resection under direct vision have provided a clearer picture of the structure of the rectum and mesorectum, their innervation, blood supply, and surrounding structures. New imaging techniques will shed further light on the anatomy of these structures and their anatomic variations.

Anastomosis, Surgical↗
PubMed1998

Effect of the introduction of total mesorectal excision for the treatment of rectal cancer.

BACKGROUND: Total mesorectal excision (TME) has been reported to reduce local recurrence and improve survival rates in patients with rectal carcinoma. This paper reports the problems that have arisen with the introduction of this new surgical technique. METHODS: This was a prospective study of two consecutive groups of patients: one who underwent TME (n = 76) and one who did not (non-TME, n = 76). RESULTS: Postoperative mortality rate in the non-TME and TME group was 5 and 7 per cent respectively, and the rate of anastomotic failure was 8 and 16 per cent respectively. Anastomotic leaks in TME patients were located in the mid and lower rectum. TME patients with anastomotic failure had lower anastomoses and a longer duration of operation than non-TME patients. Intraoperative problems were encountered in 71 per cent of the failures. All TME patients who had a leak required reoperation compared with 25 per cent of non-TME patients. TME patients without postoperative complications stayed significantly longer in hospital than non-TME patients. CONCLUSION: Anastomotic dehiscence increased after introduction of the TME technique but this improved with experience.

Adult↗
PubMed1997

Abdominoperineal excision of the rectum--an endangered operation. Norman Nigro Lectureship.

PURPOSE: This study was undertaken to test the efficacy of an extreme policy of sphincter conservation by combining precise total mesorectal excision with low stapling techniques and endoluminal lavage to guard against implantation. METHODS: A total of 136 consecutive operations for cancer below 5 cm from the anal verge has been prospectively documented and followed for a mean of 7.7 (range, 1-18) years. A total of 105 of the operations were anterior resections (77 percent), and 31 were abdominoperineal excisions (23 percent). RESULTS: The oncologic results in the 105 patients who underwent anterior resections appear greatly superior to those of the patients who underwent abdominoperineal excisions, although the number of abdominoperineal excisions was small (31). Actuarial local recurrence at six years for anterior resection and total mesorectal excision was 1 percent for 85 curative procedures and 4 percent for all cases (n = 100), compared with 33 and 47 percent for abdominoperineal excisions (n = 15 and 31). Only four recurrences were observed below the level of the levators, three in the wound of an abdominoperineal excision and one in a stapled anastomosis after a palliative excision. No cases of nodal metastasis in the ischiorectal fossa were observed. CONCLUSION: In a unit specializing in sphincter conservation, precise total mesorectal excision from above appears oncologically superior to abdominoperineal excision. Three-fourths of patients with carcinoma of the lower one-third of the rectum can be offered sphincter-conserving surgery, although temporary defunctioning is probably prudent in such cases. The wound of an abdominoperineal excision may be a prerequisite for perineal recurrence, which may often be caused by implantation.

Abdomen↗
PubMed1996

Family based colorectal cancer screening in a district hospital.

Colorectal cancer (CRC) screening using family history to define a group at increased risk is gaining support. Three hundred and ninety six subjects aged over 25 with at least one first degree affected relative have been screened using a single slide, immunological faecal occult blood test (FOBT), and family history data to select the highest risk group. Compliance was 64.9% but was significantly better if contact was made within one year of diagnosis of the index relative (75% v 62.1%, chi 2 = 5.7, p < 0.05). Twelve subjects (13.2%) of those who had a colonoscopy) bearing adenomas have been detected, three of which were at high risk of malignant transformation. No cancers have been diagnosed. Most subjects undergoing screening were less than 55 years of age (67.8%). These accounted for most colonoscopies (68.1%) but only one large adenoma was diagnosed in this group. The FOBT was particularly useful, enabling the detection of five large adenomas. Family based CRC screening is practical in a district hospital setting. Although labour intensive, it meets a population demand and can detect significant numbers of adenomas. Screening, even in those at moderately increased risk, could be focused on the older age groups, probably those aged over 40.

Adenoma↗