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Biomedical subjects

T L Hull

Publications and source records attributed to T L Hull.

At least 19 recordsLinked to original sources
PubMed2002

Factors affecting local recurrence of colonic adenocarcinoma.

PURPOSE: The aim of this retrospective study was to determine which aspects of tumor morphology and histology influenced the incidence of local recurrence after curative resection of colonic adenocarcinoma. METHODS: Patients who had a curative resection for a primary colonic adenocarcinoma between 1980 and 1993 (inclusive) were identified from the colorectal cancer database in the Department of Colorectal Surgery. The charts of patients diagnosed with a local recurrence were then reviewed and their findings at operation and histologic assessment analyzed. Patients were followed up for at least five years or until death. RESULTS: Over the period of study, 1,031 patients had a curative resection for colonic adenocarcinoma. Local recurrences were detected in 32 patients (3.1 percent). The gender distribution of patients with local recurrence was 18 males (56.3 percent) and 14 females (43.7 percent) with a mean age of 63.4 years. The median time to local recurrence was 13 (range, 2-71) months. The distribution of primary tumors that recurred locally favored the cecum (n = 9; 28.1 percent) and sigmoid colon (n = 14; 43.7 percent) over other locations; these were, however, the most common sites of primary lesions. Less common sites included the ascending colon (n = 0; 0 percent), hepatic flexure (n = 2; 6.3 percent), transverse colon (n = 1; 3.1 percent), splenic flexure (n = 3; 9.4 percent), and descending colon (n = 3; 9.4 percent). Of the total number of tumors, 101 were found to be adherent to at least 1 other intra-abdominal viscus, and 12 (11.9 percent) recurred locally. Other factors associated with local recurrence were tumor perforation and fistulation. Overall, 30 tumors (2.9 percent) were perforated, and 6 (20 percent) recurred locally. Four tumors (0.4 percent) were fistulating; of these, 2 (50 percent) recurred locally. Advanced tumor stage was also associated with an increased rate of local recurrence (Stage I, 0 percent; Stage II, 2.05 percent; Stage III, 7.0 percent; and Stage IV, 6.1 percent). Similarly, tumor differentiation was related to local recurrence, with no instances in well-differentiated tumors, 2.8 percent in moderately differentiated tumors, and 6.8 percent in poorly differentiated tumors. CONCLUSIONS: The location of the primary tumor is not a factor in producing local recurrence. Fixity to another viscus, perforation or fistulation, advanced stage of disease, and differentiation of tumor appear to increase the chances of recurrence of curatively resected colonic carcinoma. Although the recurrence rate is higher in these groups than for tumors overall, definitive oncologic surgery prevents recurrence in the majority of cases. No colonic tumor that was T1 or T2 (N0, N1, or N2) or that was well differentiated recurred locally.

Adenocarcinoma↗
PubMed2002

Pan-colonic decrease in interstitial cells of Cajal in patients with slow transit constipation.

BACKGROUND: Interstitial cells of Cajal (ICC) are required for normal intestinal motility. ICC are found throughout the human colon and are decreased in the sigmoid colon of patients with slow transit constipation. AIMS: The aims of this study were to determine the normal distribution of ICC within the human colon and to determine if ICC are decreased throughout the colon in slow transit constipation. PATIENTS: The caecum, ascending, transverse, and sigmoid colons from six patients with slow transit constipation and colonic tissue from patients with resected colon cancer were used for this study. METHODS: ICC cells were identified with a polyclonal antibody to c-Kit, serial 0.5 microm sections were obtained by confocal microscopy, and three dimensional software was employed to reconstruct the entire thickness of the colonic muscularis propria and submucosa. RESULTS: ICC were located within both the longitudinal and circular muscle layers. Two networks of ICC were identified, one in the myenteric plexus region and another, less defined network, in the submucosal border. Caecum, ascending colon, transverse colon, and sigmoid colon displayed similar ICC volumes. ICC volume was significantly lower in the slow transit constipation patients across all colonic regions. CONCLUSIONS: The data suggest that ICC distribution is relatively uniform throughout the human colon and that decreased ICC volume is pan-colonic in idiopathic slow transit constipation.

Adolescent↗
PubMed2001

Mucosectomy vs. stapled ileal pouch-anal anastomosis in patients with familial adenomatous polyposis: functional outcome and neoplasia control.

PURPOSE: The tradeoff of neoplasia control for better function represented by a stapled ileal pouch-anal anastomosis is still controversial in patients with familial adenomatous polyposis. We compared outcomes after mucosectomy and hand-sewn ileal pouch-anal anastomosis with those after stapled ileal pouch-anal anastomosis in 119 patients with familial adenomatous polyposis who underwent surgery since 1983. METHODS: Age, gender, length of follow-up, complications, quality of life, incontinence, urgency, nighttime and daytime seepage, pad usage, necessity of ileostomy, and incidence of adenomas developing in pouch and anal transitional zone were recorded. RESULTS: There were 42 mucosectomy and 77 stapled patients who were followed up for an average of 5.8 and 3.6 years, respectively, with endoscopic surveillance. There was one postoperative death in the stapled group that prohibited long-term follow-up. Nine of 42 mucosectomy patients developed pouch adenomas vs. 8 of 76 in the stapled group. Six of 42 patients developed adenomas in the mucosectomized anal transitional zone in the mucosectomy group. Twenty-one of 76 patients developed adenomas in the anal transitional zone in the stapled group. All were managed with local procedures or further surveillance. One of 76 patients developed cancer in the residual low rectum; this required further resection. Patients with stapled anastomosis had better outcomes in every category. Differences in incontinence, daytime and nighttime seepage, pad usage, and avoidance of ileostomy were statistically significant. All patients with mucosectomy required ileostomy vs. only 40 of 77 patients with stapled anastomosis. CONCLUSION: Familial adenomatous polyposis patients with stapled ileal pouch-anal anastomosis have better functional outcome and can avoid temporary diversion. This should be balanced against a 28 percent incidence of adenomas in the anal transitional zone.

Adenoma↗
PubMed2001

Outcome of sphincteroplasty combined with surgery for urinary incontinence and pelvic organ prolapse.

PURPOSE: This is the first reported prospective study comparing outcome and cost in patients undergoing sphincteroplasty for anal incontinence vs. sphincteroplasty performed in combination with one or more procedures for urinary incontinence and/or pelvic organ prolapse. METHODS: We analyzed 44 patients with fecal incontinence who underwent anal sphincter repair alone (20 patients) or in combination with procedures for urinary incontinence or pelvic organ prolapse (24 patients). Information regarding risk factors for fecal incontinence, the degree of incontinence, and the extent that incontinence limited social, physical, and sexual activity was prospectively obtained from questionnaires. Clinic chart reviews and follow-up telephone interviews provided additional data. A cohort of case-matched patients who underwent only urogynecologic procedures was compared retrospectively for operative time, hospital cost, length of stay, and postoperative complications. RESULTS: There were no major complications in any group. The functional outcomes, physical, social, and sexual activity were similar in all three groups. Twenty-two of 24 patients who underwent the combined procedures were glad that they had both procedures concomitantly. CONCLUSION: Combination pelvic floor surgery provides good outcomes and is cost effective. This approach should be offered to women with concurrent problems of fecal and urinary incontinence and/or pelvic organ prolapse.

Anal Canal↗
PubMed2001

Preliminary results of an outcome tool used for evaluation of surgical treatment for fecal incontinence.

PURPOSE: The lack of an outcome tool to evaluate the outcome of surgical and medical treatment for fecal incontinence makes interpretation of success difficult. The purpose of this study was to evaluate a preliminary outcome tool for fecal incontinence. METHOD: Since 1994 an extensive database has prospectively been collected on all females undergoing an overlapping sphincter repair for fecal incontinence by a single surgeon. A simple incontinence form designed to examine outcome, developed by colon and rectal surgeons, was filled out preoperatively and postoperatively. RESULTS: Of 206 females evaluated for surgical treatment of their fecal incontinence, 65 underwent surgical treatment from January 1994 until July 1999. The mean age was 49 (range, 23-80) years, and the mean follow-up was 10 (range, 1-50) months. When comparing each variable (problems holding gas, staining of undergarments, accidental bowel movements, and need to wear pads) and lifestyle issue (physical, social, and sexual activities) preoperatively and postoperatively, there was significant improvement in all areas. Three parameters were chosen (change in accidental bowel movements, improvement in two of three lifestyle areas, and improvement in one of three lifestyle areas) to examine individual items from the database and to determine if they affected outcome. No single variable has a significant effect on the outcome. A scoring system was devised from the questionnaire. From preoperatively to postoperatively, there was a median 14-point improvement that was statistically significant. CONCLUSIONS: This preliminary tool to examine outcome for fecal incontinence measures parameters that are significantly improved by overlapping sphincteroplasty. More work is needed to refine and validate this tool because a standard outcome tool is needed for reporting the results of surgical treatment of fecal incontinence.

Adult↗
PubMed2001

Coloplasty in low colorectal anastomosis: manometric and functional comparison with straight and colonic J-pouch anastomosis.

PURPOSE: After resection of the distal rectum with a straight reanastomosis, poor bowel function can occur. This is felt to be because of the loss of the rectal reservoir. To overcome this, a neoreservoir using a colonic J-pouch has been advocated in low colorectal and coloanal anastomosis. However, difficulties in reach, inability to fit the pouch into a narrow pelvis, and postoperative evacuation problems can make the colonic J-pouch problematic. Coloplasty is a new technique that may overcome the poor bowel function seen in the straight anastomosis and the problems of the colonic J-pouch. The purpose of this study was to compare the functional results after a low colorectal anastomosis among patients receiving a coloplasty, colonic J-pouch, or straight anastomosis. METHODS: Twenty patients underwent construction of a coloplasty with a low colorectal anastomosis. Postoperative manometry and functional outcome of these patients was compared with a matched group of 16 patients who had a colonic J-pouch and low colorectal anastomosis and 17 patients who had a straight low colorectal anastomosis. RESULTS: Maximum tolerated volume was significantly favorable in the coloplasty (mean, 116.9 ml) and colonic J-pouch group (mean, 150 ml) vs. the straight anastomosis group (mean, 83.3; P < 0.05) The compliance was also significantly favorable for the coloplasty (mean, 4.9 ml/mmHg) and the colonic J-pouch group (mean, 6.1 ml/mmHg) vs. the straight anastomosis group (mean, 3.2 ml/mmHg; P < 0.05) The coloplasty (mean, 2.6; range, 1-5) and colonic J-pouch (mean, 3.1; range, 2-6) had significantly fewer bowel movements per day than the straight anastomosis group (mean, 4.5; range, 1-8; P < 0.05). Similar complication rates were noted in the three groups. CONCLUSIONS: Patients with a coloplasty and low colorectal anastomosis seem to have similar functional outcome along with similar pouch compliance compared with patients with colonic J-pouch and low colorectal anastomosis. However, the coloplasty may provide an alternative method to the colonic J-pouch for a neorectal reservoir construction when reach or a narrow pelvis prohibits its formation. Technically it also may be easier to construct.

Anastomosis, Surgical↗
PubMed2001

Safety and longterm efficacy of strictureplasty in 314 patients with obstructing small bowel Crohn's disease.

BACKGROUND: Since its introduction in the early 1980s, strictureplasty (SXP) has become a viable option in the surgical management of obstructing small bowel Crohn's disease. Questions still remain regarding its safety and longterm durability in comparison to resection. Precise indications and contraindications to the procedure are also not well defined. STUDY DESIGN: A retrospective review of all patients undergoing SXP for obstructing small bowel Crohn's disease at the Cleveland Clinic between 1984 and 1999 was conducted. A total of 314 patients underwent a laparotomy that included the index SXP The total number of SXPs performed was 1,124, with a median of two (range 1 to 19) per patient. Sixty-six percent of patients underwent a synchronous bowel resection. Recurrence was defined as the need for reoperation. Followup information was determined by personal interviews, phone interviews, or both. RESULTS: The overall morbidity rate was 18%, with septic complications occurring in 5% of patients. Preoperative weight loss (p = 0.004) and older age (p = 0.008) were found to be significant predictors of morbidity. The surgical recurrence rate was 34%, with a median followup period of 7.5 years (range 1 to 16 years). Age was found to be a significant predictor of recurrence (p = 0.02), with younger patients having a shorter time to reoperation. CONCLUSIONS: This large series of patients with longterm followup confirms the safety and efficacy of strictureplasty in patients with obstructing small bowel Crohn's disease. The 18% morbidity and 34% operative recurrence rates compare favorably with reported results of resective surgery. Caution should be used in patients with preoperative weight loss, because they experienced higher complication rates. Although young patients seem to follow an accelerated course, SXP remains indicated as part of an overall strategy to conserve intestinal length.

Adolescent↗
PubMed2001

Repair of recurrent rectovaginal fistulas.

BACKGROUND: Recurrent rectovaginal fistulas (RRVFs) pose a challenging problem, which can be treated by different surgical procedures. We performed this study to determine the ultimate success rate of various repair techniques. METHODS: Using a standard data collection form, we retrospectively reviewed charts of patients treated for RRVF. RESULTS: Between 1991 and 2000, 57 procedures were performed in 35 women who presented with RRVF. Median follow-up was 4 months (interquartile range, 1,25). The causes of RRVF included obstetrical injury (n = 15), Crohn's disease (n = 12), fistula occurring after proctocolectomy with ileal pouch-anal anastomosis (for ulcerative colitis, n = 3; indeterminate colitis, n = 1; familial polyposis, n = 1), cryptoglandular disease (n = 2), and fistula occurring immediately after low anterior resection for rectal cancer (n = 1). The methods of repair used included mucosal advancement flap (n = 30), fistulotomy with overlapping sphincter repair (n = 14), rectal sleeve advancement (n = 3), fibrin glue (n = 1), proctectomy with colonic pull-through (n = 2), and ileal pouch revision (n = 6). Twenty-seven of 34 (79%) patients with adequate follow-up eventually healed after a median of 2 operations. Logistic regression was used to analyze outcome according to etiology of fistula, patient age, number of prior repairs, time interval between last repair and current repair, and presence of fecal diversion. Crohn's disease, the presence of a diverting stoma, and decreased time interval since prior repair were associated with a poorer outcome. CONCLUSIONS: Most RRVFs can be successfully repaired, although repeated operations may be necessary. Delaying repair may improve outcome.

Adult↗
PubMed1999

Familial desmoids in association with adrenal and ovarian masses and leiomyomas: report of three cases.

PURPOSE: Desmoid tumors are rare occurrences. However, they are more commonly seen in patients with familial adenomatous polyposis. The purpose of this article is to review three cases of abdominal desmoids in association with adrenal, ovarian masses, leiomyoma, and neurologic involvement in three sisters with familial adenomatous polyposis. METHOD: A case study was done of these sisters, their siblings, and their parents. RESULTS: All three sisters had desmoid tumors and no evidence of familial adenomatous polyposis. All three sisters had ovarian pathology, two had adrenal masses, one had a fibroadenoma of the breast, one had a leiomyoma of the stomach, and two had neurologic involvement. Additionally, male siblings, parents, and grandparents had no evidence of desmoids or familial adenomatous polyposis. CONCLUSION: This constellation of symptoms in the affected sisters may reflect a separate gene defect predisposing to desmoid tumors or a varying expression of the adenomatous polyposis coli gene.

Adenomatous Polyposis Coli↗
PubMed1999

Ileoanal procedures: acute and long-term management issues.

The pelvic pouch procedure has become the preferred surgical treatment for patients with ulcerative colitis and familial adenomatous polyposis. Even though this operation removes the diseased colon and allows defecation through the anus, the outcome is not "perfect." Rather, ongoing management issues occur that require attention. This article reviews acute and chronic management issues related to the creation and management of the pelvic pouch.

Chronic Disease↗
PubMed1998

Advancement sleeve flaps for treatment of severe perianal Crohn's disease.

BACKGROUND: Traditionally proctectomy has been the treatment for severe, complex fistula in ano from Crohn's disease. However, based on the success of rectal advancement flaps in Crohn's disease, circumferential transanal sleeve advancement flaps (TSAFs) were proposed for this subgroup of patients with severe fistula. METHODS: From 1991 to 1995, 13 patients (12 women) with severe perianal Crohn's disease and multiple fistula tracts underwent a TSAF procedure. Data were collected retrospectively using a standard data sheet. RESULTS: There were no postoperative deaths or major morbidity. One year after surgery, the fistula had healed in eight of 13 patients (with three requiring additional surgery before healing). Of patients in whom the procedure failed, three underwent proctectomy for progression of disease and the other two had recurrence of a rectovaginal fistula 6 and 8 months after surgery. Of six variables evaluated (previous procedure, steroid use, steroid dosage, associated Crohn's disease, associated procedures and diverting stoma), only associated procedures were significantly related to a successful outcome (P=0.008). CONCLUSION: Some patients with severe perianal Crohn's fistula and a relatively normal rectum can be offered TSAFs. Even with successful outcome in eight of 13 patients, this may still be a viable option if the only alternative would be total proctocolectomy and a permanent stoma.

Adult↗
PubMed1998

Fecal incontinence in women.

Pelvic floor disorders are common in women. Most gynecologists are well versed in the management of urinary incontinence and uterovaginal prolapse; however, knowledge of disorders involving the anorectum is often lacking. This review will discuss the issue of anorectal incontinence in women, attempt to provide a logical outline for evaluation and treatment, and offer potential methods of prevention.

Episiotomy↗
PubMed1997

Surgical treatment of recurrent complete rectal prolapse: a thirty-year experience.

PURPOSE: Complete recurrent rectal prolapse (RRP) after initial prolapse surgery is well described. Our aim was to examine the possible causes for RRP, to learn of the operations performed most frequently, and to examine the outcome following recurrence surgery. METHODS: Patients with RRP were reviewed retrospectively from 1963 to 1993. RESULTS: A total of 24 patients (19 females) had RRP. Of these, 29 operations were performed; three patients had 2 RRP operations, and one patient had 3 RRP operations. Median age was 56 (range, 18-88) years. Median follow-up and median duration to recurrence were 6.75 (range, 0.08-17) years and 2 (range, 0.1-29) years. One patient had RRP at the end of the follow-up period. RRP occurred after 15 abdominal and 9 perineal operations. Treatment for RRP included 25 abdominal and 4 perineal operations. Causes for RRP were identified in 41 percent of cases and was most often attributable to problems with the mesh following the Ripstein procedure. Preoperative incontinence and constipation were largely unchanged by RRP operation. CONCLUSION: RRP occurred most commonly because of problems with the mesh, but no etiologic factor was found in the majority of patients. Abdominal operations were performed more frequently than perineal approaches for RRP. Elimination of prolapse can be obtained, but bowel dysfunction still remains in 60 percent of patients.

Adolescent↗
PubMed1997

Vaginal fistula following restorative proctocolectomy.

UNLABELLED: Vaginal fistula (VF) is a devastating complication following restorative proctocolectomy. PURPOSE: This study was designed to examine the perioperative factors influencing the outcome and management of vaginal fistula. METHOD: Between October 1983 and September 1994, 526 women underwent restorative proctocolectomy. Nineteen develop VF (3.6 percent), and six were referred from other institutions with this complication. These 25 women were followed for a minimum of nine months. RESULTS: Preoperative diagnosis of ulcerative colitis was made in 23 of the patients with VF (92 percent), and indeterminate colitis and familial adenomatous polyposis was determined in the rest of the patients. Postoperatively, 12 of the 23 women (52 percent) with a preoperative diagnosis of ulcerative colitis had clinical/pathologic findings of Crohn's disease, and 1 woman was reclassified as having indeterminate colitis. Postoperative pelvic sepsis was significantly higher in women with VF than in those without VF (26.3 vs. 6.3 percent; P = 0.003). Median time until occurrence of VF following loop ileostomy closure was later for women with delayed findings of Crohn's disease at 16.5 (range, <1-72) months, compared with women without Crohn's disease at 0.5 (range, <1-67) months (P < 0.05). Of the 163 women with handsewn anastomosis performed at our institution, 12 developed VF (7.4 percent). In contrast, 7 of the 363 patients with stapled anastomosis had VF (1.9 percent; P = 0.003). Site of VF was found at the anastomosis in 12 patients, below in 12 patients, and above in 1 patient. Presence of Crohn's disease and anastomotic technique did not influence the site of VF. Initial management of VF consisted of transanal repair in 20 patients (advancement flap, 12; direct repair, 6; and neoileoanal anastomosis, 2), seton in 1 patient, transabdominal approach in 1 patient, transvaginal in 1 patient, observation in 1 patient, and pouch excision in 1 patient. Of the 13 women without Crohn's disease, 12 had transanal repair (10 healed, 1 had recurrence, and 1 had pouch excision), and 1 had successfully repair with transabdominal technique, for an overall success rate of 84.6 percent. Of the 12 women with VF and delayed findings of Crohn's disease, transanal repair was performed on 9, 1 had pouch excision without repair, 1 had seton placement and pouch excision, and 1 underwent observation. Transanal technique of repair in women with Crohn's disease successfully healed three women (33.3 percent). Overall, of the 12 women with delayed findings of Crohn's disease, 6 had pouch excision, 3 had recurrences, and 3 healed. CONCLUSION: VF is an uncommon complication following restorative proctocolectomy and is associated with a high incidence of pelvic sepsis and handsewn anastomosis. Late presentation of VF is more common with Crohn's disease and is associated with a poor prognosis and pouch salvage rate. Transanal techniques are an effective means of VF repair.

Adenomatous Polyposis Coli↗
PubMed1997

Surgical approaches to low anovaginal fistula in Crohn's disease.

BACKGROUND: Anovaginal fistula due to Crohn's disease can be surgically repaired in some women. The purpose of this study was to analyze the types of fistula along with the features that point to success or failure in treating these patients. METHODS: Women with anovaginal fistula and Crohn's disease treated surgically by one surgeon from 1988 to 1992 were retrospectively studied. RESULTS: Forty-eight women underwent treatment for anovaginal fistula caused by Crohn's disease. This represented 55% of the total patients seen for anovaginal fistula from all causes. Nine patients had severe anorectal and/or colonic disease and underwent total proctocolectomy with ileostomy. Four other patients had seton placement only. The remaining 35 patients underwent transanal repair of their fistula and are the basis of this study. Three types of flap repairs were performed: curvilinear advancement rectal flap (n = 24), linear advancement rectal flap (n = 6), and advancement sleeve flap (n = 5). The type of surgery selected depended on the associated anal and colorectal disease. Diverting ileostomies were used in nine patients with a successful outcome in eight. Healing occurred with the initial repair in 19/35 (54%). An additional five patients underwent successful repeat procedures for an overall success rate of 24/35 (68%). CONCLUSION: Surgical closure of anovaginal can be offered to selected women with Crohn's disease, thus avoiding a permanent stoma in this group. The type of flap chosen for repair depends on the characteristics of the fistula.

Adult↗
PubMed1997

Fecal incontinence in women with urinary incontinence and pelvic organ prolapse.

OBJECTIVE: To determine the prevalence of and factors associated with fecal incontinence in women with urinary incontinence or pelvic organ prolapse. METHODS: Study subjects were recruited prospectively, and all participants received questionnaires regarding bowel function and underwent a standardized history and physical examination. Fecal incontinence was defined as the involuntary loss of feces sufficient to be considered a problem by the patient. RESULTS: Forty-two subjects had fecal incontinence, an overall prevalence of 17%. One hundred seventy women had urinary incontinence, pelvic organ prolapse, or both, and 36 of these (21%) had fecal incontinence. One hundred (40%) women had urinary incontinence, of whom 31 also had fecal incontinence. Seventy women had isolated pelvic organ prolapse and five (7%) were incontinent of feces. Univariate analysis revealed that any degree of pelvic organ prolapse, increasing degrees of prolapse within each vaginal segment, urinary incontinence, advanced age, postmenopausal status, increased vaginal parity, prior hysterectomy, history of irritable bowel syndrome, and abnormal sphincter tone were associated significantly with fecal incontinence. Multiple logistic regression analysis indicated that only urinary incontinence (odds ratio [OR] 4.6, P < .001, 95% confidence interval [CI] 1.9, 11.2), abnormal anal sphincter tone (OR 2.3, P = .04, 95% CI 1.1, 5.1), and irritable bowel syndrome (OR 8.3, P = .002, 95% CI 2.1, 32.8) were associated with fecal incontinence. CONCLUSIONS: There is a high rate of fecal incontinence in women with urinary incontinence and pelvic organ prolapse. Clinicians providing health care to a similar group of women should inquire routinely and specifically about fecal incontinence.

Adult↗