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R J Heald

Publications and source records attributed to R J Heald.

At least 55 records · Page 3Linked to original sources
PubMed1995

Two cases of colo-ovarian cyst fistula.

Fistula between the large bowel and an ovarian cyst is a recognised but rare pathological entity. We present two cases of colo-ovarian cyst fistula, the first occurring as a result of diverticular disease of the sigmoid colon and the second complicating a cystadenocarcinoma of the ovary. The aetiology of colo-ovarian cyst fistula is reviewed and the differential diagnosis is discussed.

Aged↗
PubMed1994

Leakage from stapled low anastomosis after total mesorectal excision for carcinoma of the rectum.

Over 14 years 276 patients with rectal cancer underwent surgery; 219 who underwent low anterior resection of the rectum with total mesorectal excision were studied. There were 24 (11.0 per cent) major anastomotic leaks associated with peritonitis or a pelvic collection and 14 (6.4 per cent) minor leaks that were asymptomatic and detected by contrast enema. All major leaks occurred at an anastomotic height of less than 6 cm (P = 0.08). The abdominoperineal excision rate was 9.1 per cent. Major leaks were associated with failure to defunction in 11 of 62 patients and with a defunctioning colostomy in 13 of 157 (P = 0.03). Of the 24 patients with major leaks seven developed peritonitis, one with a defunctioned anastomosis (P = 0.002), and three died (P = 0.02). Use of the sigmoid colon led to major leakage in seven of 32 patients compared with 17 of 187 when the splenic flexure was employed (P = 0.05). There was no increase in the local recurrence rate but only nine patients with major leakage and a temporary stoma have had these closed. Key technical factors include: a clean dry pelvic cavity, pulsatile colonic blood supply, suction drainage started during closure and mobilization of ample tissue to fill the pelvic space.

Adult↗
PubMed1993

Mesorectal excision for rectal cancer.

Concern about world wide local recurrence rates for rectal cancer of 20-45%, together with anxiety at the recent proliferation of adjuvant therapies, led us to review the efficacy of total mesorectal excision (TME) with which no adjuvant therapy had been combined. Precise, sharp dissection is undertaken around the integral mesentery of the hind gut, which envelopes the entire mid rectum. This procedure adds to operative time and complications but has been claimed to eliminate virtually all locally recurrent disease after "curative" surgery. Independent analysis (J. K. M.) of prospective follow-up data extended over a 13-year interval (1978-91; mean 7.5 years). The actuarial local recurrence rate after curative anterior resection at 5 years is 4% (95% Cl 0-7.5%) and the overall recurrence rate is 18% (10-25%). 10-year figures are 4% (0-11%) and 19% (7-32%). In view of the high-risk classification used for the North Central Cancer Treatment Group (NCCTG), which has led to a trend to chemoradiotherapy, a similar group of high-risk Basingstoke cases was constructed for comparison purposes. This group included 135 consecutive Dukes' B (B2) and Dukes' C cancer operations, both anterior resection and abdominal-perineal excision, for tumours below 12 cm from the anal verge. Results from TME alone are substantially superior to the best reported (NCCTG) from conventional surgery plus radiotherapy or combination chemoradiotherapy: 5% local recurrence at 5 years compared with 25% and 13.5%, respectively; and 22% overall recurrence compared with 62.7% and 41.5%, respectively (Dukes' B cases [B2], 15%; Dukes' C cases, 32%). Meticulous TME, which encompasses the whole field of tumour spread, can improve cure rates and reduce the variability of outcomes between surgeons. Far more genuine "cures" of rectal cancer are possible by surgery alone than have generally been believed or are currently accepted. Better surgical results are an essential background for the more selective use of adjuvant therapy in the future.

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PubMed1993

Lymph node metastases in early rectal cancer.

Local excision of early rectal tumours is an attractive proposition, avoiding the morbidity and mortality of major resection and possible permanent stoma. This study was designed to investigate the incidence of lymph node metastases associated with tumours that are locally confined to the bowel wall. A total of 454 rectal excision specimens were reviewed. Twenty-two (20 per cent) of 109 patients with tumours locally confined to the bowel wall had metastases in local lymph nodes, although 14 of these had only one or two involved nodes. Three of 27 patients with tumours that did not penetrate through the submucosa had lymph node metastases. Less well differentiated tumours were more likely to have metastasized but there was no significant difference in the height or size of tumours or in the depth of invasion between patients with or without lymph node metastases.

Humans↗
PubMed1993

Abdominal wall abscess--an unusual primary presentation of a transverse colonic carcinoma.

Carcinoma of the transverse colon presenting as an abscess of the anterior abdominal wall is a rare occurrence. Such a case is presented, where all investigations failed to show the nature of the lesion. The literature has been reviewed and the pathology that characterizes such lesions, and their management in the light of their favourable prognosis, is discussed. Occult colonic carcinoma should be considered in the differential diagnosis of such abscesses.

Abdominal Muscles↗
PubMed1992

Function of the distal rectum after low anterior resection for carcinoma.

From a personal series of 232 anterior resections performed over 10 years, functional results have been analysed in two specific groups of patients: those with anastomoses 3 cm (n = 26) and 6 cm (n = 42) from the anal verge. In both groups low anterior resection had been performed with total mesorectal excision. Function was assessed in four categories: bowel frequency, ability to distinguish flatus from faeces, ability to defer defaecation, and frequency of soiling. Independent analysis of the 3 cm group showed a significant deterioration in function in each category after operation. The ability to defer defaecation and the frequency of soiling were unchanged after operation in the 6 cm group, and these functions were significantly better than in the 3 cm group. On the basis of these results, patients undergoing low anterior resection with total mesorectal excision should benefit from the preservation of a short segment of distal rectum, provided that the distal resection margin is not compromised.

Adult↗
PubMed1992

Flush aortic tie versus selective preservation of the ascending left colic artery in low anterior resection for rectal carcinoma.

The effects of two methods of colonic vascular ligation were studied in 143 consecutive patients who underwent low anterior resection with total mesorectal excision and full mobilization of the splenic flexure. Either the ascending left colic artery (ALCA) was selectively preserved (n = 52) or a flush aortic ligation was performed (n = 91). In those with a protective colostomy, the radiological leak rate was 12 per cent when the ALCA was preserved (n = 41) and 10 per cent when a flush aortic tie was performed (n = 60) (P greater than 0.95; 95 per cent confidence interval (c.i.) for difference -10 to +15 per cent). In those without a colostomy, the clinical leak rates of 9 per cent when the ALCA was preserved (n = 11) and 19 per cent when a flush aortic tie was performed (n = 31) were not significantly different (P greater than 0.10; 95 per cent c.i. for difference -12 to +32 per cent). Proportional hazards analysis showed no association between the method of vascular ligation and the risk of tumour recurrence and death. Anastomotic leak rates, tumour recurrence and survival were not related to the method of vascular ligation.

Anastomosis, Surgical↗
PubMed1991

Risk of peritonitis and fatal septicaemia and the need to defunction the low anastomosis.

The aim of this study was to investigate the need to defunction the low anastomosis after anterior resection of the rectum with total mesorectal excision for rectal cancer. Two hundred consecutive patients (125 defunctioned, 75 non-defunctioned) undergoing low anterior resection for carcinoma were included in the study. Peritonitis requiring emergency laparotomy occurred in 8 per cent of the patients who did not have a defunctioning stoma compared with less than 1 per cent of those patients who had a defunctioning stoma (P less than 0.01). There was no mortality related to closure of the stoma but seven patients developed a faecal fistula and ten developed an incisional hernia. Despite current trends to avoid the defunctioning stoma, these results suggest that after total mesorectal excision the faecal stream should be temporarily diverted away from the anastomosis that is 6 cm or less from the anal verge to protect against potentially life-threatening anastomotic leakage.

Anastomosis, Surgical↗
PubMed1991

Prospective audit of an extramucosal technique for intestinal anastomosis.

A computerized prospective audit was conducted of 500 intestinal anastomoses constructed in 470 operations on 461 consecutive patients between 1 January 1986 and 16 November 1990. All anastomoses were constructed by an open extramucosal method, emphasizing the avoidance of sutures through mucosa and avoiding the use of intestinal clamps. There were 214 men and 247 women, with a median age of 66 years. Clinical anastomotic leakage was detected from 11 (2.2 per cent) of 500 anastomoses. There were 18 (3.8 per cent) deaths resulting from the 470 operations, but only two (0.4 per cent) were associated with anastomotic leakage, which was not the direct cause of death in either. Peritonitis occurred as a consequence of leakage in two (8 per cent) of 26 resections for Crohn's disease, but the patients survived after reoperation. The single-layer extramucosal technique is probably the safest method available for intestinal suture.

Aged↗