Biomedical subjects

T L Hull

Publications and source records attributed to T L Hull.

35 records · Page 2Linked to original sources

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↗

PubMed1997

Factors associated with the occurrence of leaks in stapled rectal anastomoses: a review of 1,014 patients.

BACKGROUND: Despite improvement in surgical techniques and stapling devices during the last 10 years, colorectal anastomoses are still prone to leakage. The purpose of this study was to assess the performance and safety of stapled anastomoses in rectal surgery and to identify factors that influence the occurrence of anastomotic leaks. STUDY DESIGN: A review was undertaken of 1,014 patients who underwent stapled anastomoses to the rectum or anal canal for colorectal cancer or benign disease between 1989 and 1995 in a tertiary care institution. Indications for operations, comorbidities at admission, preoperative bowel preparation, stapler size, intraoperative events, associated surgical procedures, and clinical outcomes were tested for any association with anastomotic leak. RESULTS: A double stapled technique was used in 154 patients and a conventional single stapler technique was used in 860. Postoperative mortality was 1.6%, and the overall morbidity was 18.4%. Clinically apparent anastomotic leak developed in 29 patients (2.9%). Anastomotic dehiscence occurred in 22 of 284 patients (7.7%) after low stapling (within 7 cm from the anal verge) and in 7 of 730 patients (1%) after high stapling (p < 0.001). Diabetes mellitus, use of pelvic drainage, and duration of surgery were significantly related to the occurrence of anastomotic leak by the univariate analysis. Multivariate regression analysis identified an anastomotic distance from the anal verge within 7 cm as the only variable related to the occurrence of postoperative leak (p < 0.001). CONCLUSION: Low anastomoses were associated with a leak rate greater than with high colorectal anastomoses. We conclude that anastomoses to the rectum using the circular stapler can be done with low mortality and morbidity.

Adolescent↗

PubMed1997

The risk of cancer and dysplasia among ulcerative colitis patients with primary sclerosing cholangitis.

BACKGROUND: Ulcerative colitis (UC) patients with primary sclerosing cholangitis (PSC) may have an increased risk for colonic dysplasia or cancer. They also may have higher levels of carcinogenic secondary bile acids and, thus, be more likely to develop cancer in the right side of the colon, where secondary bile acid concentrations are highest. METHODS: Since 1983, 1212 UC patients have undergone total proctocolectomy with ileal pouch-anal anastomosis at the Cleveland Clinic. All 27 patients with PSC were compared with the remaining 1185 patients in a historical cohort study. RESULTS: Dysplasia detected during cancer surveillance was the indication for surgery in 16 (59.5%) PSC patients and 136 (11.5%) controls [adjusted relative risk (RR), 6.9; 95% confidence interval (CI), 3.0-16.0]. Dysplasia or cancer was found in the resected specimen in 18 (66.7%) PSC patients and 145 (12.2%) controls (RR 10.4, CI 4.1-26.1). Right-sided cancers (proximal to the splenic flexure) were found in all four PSC patients with cancer and in 20 of 49 controls with cancer (RR 2.5, CI 1.3-5.4). CONCLUSIONS: UC patients with PSC are at a significantly increased risk for dysplasia or cancer. The high proportion of right-sided cancers supports the contention that secondary bile acids are carcinogenic and increase the likelihood of cancer in the proximal colon.

Adolescent↗

PubMed1996

Long-term analysis of the use of transanal rectal advancement flaps for complicated anorectal/vaginal fistulas.

UNLABELLED: Transanal rectal advancement flap (TRAF) is a surgical option in the management of rectovaginal and other complicated fistulas involving the anorectum. Most reported series have a short follow-up. PURPOSE: This study was undertaken to determine the long-term success, safety, applicability, and factors affecting recurrence in patients managed with TRAF, including patients with Crohn's disease. METHODS/MATERIALS: Retrospective analysis of all patients undergoing endorectal advancement flaps at a single institution between 1988 and 1993 was performed. One hundred one patients were identified (70 percent female; 30 percent male). Included were 52 patients with rectovaginal, 46 with anal perineal, and 3 with rectourethral fistulas. Causes were obstetric injury in 13 patients, Crohn's disease in 47, cryptoglandular in 19, mucosal ulcerative colitis in 7, and surgical trauma or undefined causes in 15 patients. RESULTS: No mortality occurred. Median follow-up was 31 (range, 1-79 months). Immediate failure (within one week of the repair) was seen in 6 percent of patients. Statistically (P<0.001) higher recurrence rates were observed in patients who had undergone previous repairs. Mean hospital stay was four days. Overall recurrence was seen in 29 patients (29 percent). Seventy-five percent of all recurrences occurred within the first 15 months; however, recurrence was noted for up to 55 months after repair. Etiology of fistula, use of constipating medications, antibiotic use, and most importantly associated Crohn's disease did not statistically affect recurrence rates. Failure rate was only influenced by previous number of repairs. CONCLUSION: TRAF is a safe technique for managing complicated anorectal and rectovaginal fistulas, including patients with Crohn's disease. Long-term follow-up is essential to accurately report recurrence rates.

Adolescent↗

PubMed1996

Sexual function following restorative proctocolectomy in women.

PURPOSE: This study was undertaken to identify the incidence and type of sexual dysfunction experienced by women after undergoing restorative proctocolectomy. METHODS: A questionnaire was sent to 262 females who underwent restorative proctocolectomy by a single surgeon from 1984 to 1993. The response rate was 35 percent (92/262). Additional information was gained from our pelvic pouch data base. Mean follow-up was 43 (6-130) months. RESULTS: Following surgery, a significant increase was found in vaginal dryness, dyspareunia, pain interfering with sexual pleasure, and limiting of sexual activity because of concerns of stool leakage. There was no significant change in sexual desire, arousal, sensitivity, frequency of intercourse, or satisfaction with sexual relationship. CONCLUSION: Potential sexual dysfunction following restorative proctocolectomy in women merits discussion in preoperative counseling with the patient.

Adult↗

PubMed1996

Comparison of handsewn with stapled loop ileostomy closures.

PURPOSE: The aim of this study was to determine if a stapled side-to-side closure of an ileostomy results in decreased length of hospital stay compared with a handsewn closure. METHODS: From March 1993 to August 1994, patients who had previously undergone total proctocolectomy with pelvic pouch formation and loop ileostomy were studied. At the time of ileostomy closure, patients were randomized to have their stoma closed by a handsewn technique or stapled closure. Data were prospectively gathered. RESULTS: During 17 months, 61 consecutive patients (38 male, 23 female) with a mean age of 37.8 (range, 16-69) years had their ileostomy closed and were entered into this study. There were 31 patients in the stapled group and 30 in the handsewn group. Mean operative time was 55 (range, 32-97) minutes in the stapled group and 67 (range, 42-128) minutes in the handsewn group (P = 0.01 Wilcoxon's test). Average length of stay was three (range, 2-5) days in the stapled group and 2.5 (range, 1-19) days in the handsewn group. One patient from the stapled group and two patients from the handsewn group were readmitted because of small-bowel obstruction. One patient from the stapled group underwent additional surgery for a leaking enterotomy with no defect in staple closure. Two patients from the handsewn group underwent additional surgery for small-bowel obstruction. There was no significant difference in day of first stool or day of solid diet for the two groups. CONCLUSION: Handsewn and stapled closures of loop ileostomy are not significantly different with respect to day of first stool, day until solid diet, or discharge day. Complications were similar in the two groups. Stapled closure is significantly quicker than handsewn closure.

Adolescent↗

PubMed1996

How safe is strictureplasty in the management of Crohn's disease?

BACKGROUND: Strictureplasty is a well-accepted technique in the management of selected patients with Crohn's disease. To determine the safety and optimal clinical setting for performing strictureplasty, perioperative complications and long-term outcomes need to be analyzed. PATIENTS AND MATERIALS: We retrospectively reviewed the charts of 162 patients (87 men, 75 women) with Crohn's disease who underwent strictureplasty between June 1984 and July 1994. Medical and surgical history, including medications and laboratory data, intraoperative findings, perioperative complications, and long-term follow-up data were recorded. RESULTS: These patients underwent 698 strictureplasties (Heineke-Mikulicz procedures, 617; Finney procedures, 81). Median hospital stay was 8 days. Perioperative septic complications were noted in 8 patients (5%); however, reoperation for sepsis was needed only in 5 patients. Five percent of patients developed prolonged ileus after strictureplasty. Symptomatic improvement after strictureplasty was achieved in 98% of patients. Restricture or new stricture or perforative disease was seen in 5% and 17% of patients, respectively, during a 42-month median follow-up period. CONCLUSIONS: Our findings show that strictureplasty is a good surgical option for stenosing small-bowel Crohn's disease, particularly in patients with multiple obstruction and in those vulnerable to short-bowel syndrome. Perioperative complications are few, and long-term results are gratifying.

Crohn Disease↗

PubMed1996

The pelvic pouch procedure and continent ostomies: overview and controversies.

The pelvic pouch and the continent ostomy provide reservoirs for fecal contents and avoid the need for traditional pouches. Patients with ulcerative colitis or familial polyposis coli now have the option of undergoing one of these procedures rather than a traditional ostomy. This article describes both procedures and covers preoperative and postoperative management, with emphasis on coordinated management by the ET nurse and surgeon.

Bandages↗

PubMed1996

Effect of resection margins on the recurrence of Crohn's disease in the small bowel. A randomized controlled trial.

OBJECTIVE: The authors assess the effect of surgical margin width on recurrence rates after intestinal resection of Crohn's Disease (CD). BACKGROUND: The optimal width of margins when resecting DC of the small bowel is controversial. Most studies have been retrospective and have had conflicting results. METHODS: Patients undergoing ileocolic resection for CD (N = 152) were randomly assigned to two groups in which the proximal line of resection was 2 cm (limited resection) or 12 cm (extended resection) from the macroscopically involved area. Patients also were classified by whether the margin of resection was microscopically normal (category 1), contained nonspecific changes (category 2), were suggestive but not diagnostic for CD (category 3), or were diagnostic for CD (category 4). Recurrence was defined as reoperation for recurrent preanastomotic disease. RESULTS: Data were collected on 131 patients. Median follow-up time was 55.7 months. Disease recurred in 29 patients: 25% of patients in the limited resection group and 18% of patients in the extended resection group. In the 90 patients in category 1 with normal tissue, recurrence occurred in 16, whereas in the 41 patients with some degree of microscopic involvement, recurrence occurred in 13. Recurrence rates were 36% in category 2, 39% in category 3, and 21% in category 4. No group differences were statistically at the 0.01 level. CONCLUSION: Recurrence of CD is unaffected by the width of the margin of resection from macroscopically involved bowel. Recurrence rates also do not increase when microscopic CD is present at the resection margins. Therefore, extensive resection margins are unnecessary.

Adult↗

PubMed1995

Paradoxical puborectalis contraction in patients after pelvic pouch construction.

UNLABELLED: Normal defecation is associated with relaxation of sphincters during the evacuation process. However, obstructive defecation is sometimes seen clinically manifested by abnormal contraction of the puborectalis during defecation rather than relaxing. This condition has not previously been described after pelvic pouch construction. PURPOSE: This study was done to evaluate patients for defecation difficulties caused by paradoxical puborectalis contraction after pelvic pouch procedures. METHODS: Prospectively, patients with defecation difficulties were questioned. They then underwent electromyography if they met particular criteria. Biofeedback was offered to all patients demonstrating paradox on electromyography. Follow-up was by clinic visits and interviews. RESULTS: After pelvic pouch construction, 13 patients were found to have paradoxical puborectalis contraction. Twelve of 13 patients elected to have biofeedback therapy. Eleven of these 12 were available for follow-up an average of eight (1-15) months after biofeedback. Nine improved, and two had no change in their defecation difficulty. Of the initial 13, 10 had an event, either pouchitis or abdominal trauma, directly before their defecation problems. CONCLUSION: Paradoxical puborectalis contraction can occur in patients after pelvic pouch surgery. It should be suspected in patients with defecation difficulties in the absence of an anatomic abnormality. Biofeedback is effective treatment.

Biofeedback, Psychology↗

PubMed1994

Preoperative biopsy of pararectal lymph nodes in rectal cancer using endoluminal ultrasonography.

PURPOSE: Because definitive information regarding lymph node status in rectal cancer would be valuable preoperatively, we evaluated the safety, feasibility, and accuracy of performing endoluminal ultrasound-guided biopsies of pararectal lymph nodes in 26 rectal cancer patients. Biopsies were compared with the pararectal tissues removed at surgery. METHODS: Using a longitudinally oriented 7.0-MHz ultrasound probe and an 18-gauge spring-loaded core biopsy needle, patients underwent biopsies of lymph nodes detected ultrasonographically without complications. RESULTS: A biopsy of adenocarcinoma was obtained in 13 patients, lymphoid material in 5 patients, and irrelevant material in 8 patients. Accuracy rate (true positives divided by number of procedures) was 77 percent, with a sensitivity of 71 percent, a specificity of 89 percent, a positive predictive value of 92 percent, and a negative predictive value of 62 percent. When adenocarcinoma or lymphoid material was obtained, there was only one false positive and one false negative. CONCLUSION: Endoluminal ultrasonography-guided lymph node biopsy is simple and safe, and when adenocarcinoma or lymphoid material is obtained on biopsy, clinical decision making can be based on this information.

Adenocarcinoma↗

PubMed1994

Endocavitary irradiation. An option in select patients with rectal cancer.

PURPOSE: Endocavitary irradiation delivers high-dose irradiation with limited penetration and is an established modality for the curative treatment of select tumors. The purpose of this study was to review the experience from our institution with endocavitary irradiation. METHODS: All patients with rectal cancer treated with endocavitary irradiation between 1973 and 1992 were studied. Collected data included: tumor size, tumor differentiation, distance from the anal verge, mean follow-up, recurrence, and other treatments used. RESULTS: One hundred ninety-nine patients received endocavitary irradiation, with 126 treated with curative intent. No significant differences were found between groups with recurrence and no recurrence when examining tumor size, differentiation, distance from the anal verge, or follow-up. With a mean time to recurrence of 16.1 (range, 1-56) months, 37/126 patients had a recurrence, and 89/126 had no recurrence. Ten recurrences were distant, and all patients died of the disease. Twenty-seven patients had local recurrence. Following additional treatments, 14 additional patients were rendered free of disease. CONCLUSION: Endocavitary irradiation initially rendered 71 percent (89/126) free of disease. With additional treatment 11 percent (14/126) were rendered free of disease. In the subgroup of patients followed more than five years, 68 percent had no evidence of disease at follow-up after endocavitary irradiation, and 91 percent had no evidence of disease with additional treatment. Tumor size, differentiation, morphology, and distance from the anal verge did not influence recurrence. Debulking or surgical excision before endocavitary irradiation did not increase recurrence. Diligent long-term follow-up and a liberal policy to biopsy suspicious areas may increase the salvage rate.

Adult↗

PubMed1994

Pelvic floor disorders.

The pelvic floor conditions form a diverse array of primarily functional conditions that are rarely life-threatening but may be severely debilitating. Reassurance combined with initial medical and dietary management of most of these conditions greatly ameliorates the suffering of most patients. Surgical intervention is most successful in patients with demonstrable defects such as mechanical sphincter disruption or obvious complete rectal prolapse. Surgery should be offered only to patients with other functional pelvic floor disorders who manifest intractable symptoms.

Humans↗

PubMed1993

Electrogalvanic stimulation for levator syndrome: how effective is it in the long-term?

Levator syndrome is a symptom complex of severe pain and pressure in the anorectal area. Electrogalvanic stimulation (EGS) has been proposed as a treatment for this condition. Several reports have described EGS as up to 90 percent "effective" in treating levator syndrome, but the length of follow-up was uncertain or short-term in these studies. The purpose of this study was to examine the long-term benefits of EGS in levator syndrome patients treated at one institution. All patients undergoing EGS for levator syndrome between 1985 and 1991 were studied. Initial complaints, physical examination, number of treatments, procedure tolerance, and long-term benefit were determined through personal interviews and chart reviews. There were 52 patients (63 percent females and 37 percent males) with a median age of 54 years (range, 24-84 years). All patients presented with anorectal pain. Tenderness was localized by examination to the left in 43 percent, to the right in 23 percent, and bilateral in 8.6 percent and was not localized in 2.6 percent. Fifty percent received fewer than four one-hour treatments, 33 percent received four to six treatments, and 17 percent received more than six treatments. Seventy-seven percent felt that the treatment was painless. Follow-up results were as follow: number, 52; percent follow-up, 88; mean follow-up, 28 months (range, 0-71 months); symptoms relieved, 19 percent; partial relief, 24 percent; no relief, 57 percent. Of four patients with a wrong diagnosis, three were ultimately diagnosed with recurrent pelvic cancer and one had an anal fissure. At our institution, EGS was a tolerable treatment, but a substantial number of patients received no benefit. An organic etiology of anorectal pain must always be excluded.

Adult↗