Biomedical subjects

Tracy L Hull

Publications and source records attributed to Tracy L Hull.

11 recordsLinked to original sources

PubMed2004

Fertility is reduced after restorative proctocolectomy with ileal pouch anal anastomosis: a study of 300 patients.

BACKGROUND: Restorative proctocolectomy and ileal pouch anal anastomosis (RP/IPAA) has become the gold standard surgical therapy for the majority of patients with mucosal ulcerative colitis and familial adenomatous polyposis. The aims of this study were to evaluate the fertility rates before and after RP/IPAA, to compare them with the reproductive data of the general United States population, and to determine surgical parameters that might influence subsequent fertility. METHODS: Three hundred women of reproductive age who underwent RP/IPAA between 1983 and 2001 completed a mailed questionnaire regarding their reproductive function before and after the procedure. Additional information was obtained from the pelvic pouch database. The reproductive information was compared to age-matched historical control subjects from the United States general population. The associations between changes in fertility and surgical parameters were also investigated. RESULTS: The median (25th, 75th percentile) age at surgery was 28 (24, 33) years. Out of 300 women, 206 attempted to conceive. Before operation, 48 (38%) of 127 patients were unsuccessful after 1 year of unprotected intercourse, whereas after operation, 76 (56%) of 135 patients were unsuccessful. This infertility rate was higher after operation than before (P <.001). For the subgroup of 56 women who tried to get pregnant both before and after operation, the infertility rate was higher after operation than before (69% vs 46%; P=.005). Also, a higher percentage of these patients who had an intraoperative transfusion were infertile after operation compared to patients who did not have an intraoperative transfusion (54% vs 21%; P=.023). CONCLUSIONS: There was an increase in the infertility rate after RP/IPAA. Intraoperative blood transfusion had a negative impact on the fertility rate after operation in patients who tried to conceive both before and after RP/IPAA.

Adolescent↗

PubMed2003

What is the best surgical treatment for anorectal melanoma?

BACKGROUND AND AIMS: This study compared outcome following the two common surgical procedures for anorectal melanoma: wide local excision and abdominal perineal resection. We also examined the utility of endoluminal ultrasound to guide therapy. PATIENTS AND METHODS: Records of 19 patients surgically treated at our institution were studied. In addition to type of surgical procedure, we noted age, metastatic disease spread, sphincter involvement, tumor size and thickness, and mode of diagnosis. Survival after diagnosis and after recurrence of disease were also recorded. Ultrasound was used in seven, with the lesion delineated in six (all had therapy guided by the ultrasound). Regarding surgery ten had wide local excision, seven had abdominal perineal resection, and two had other procedures. RESULTS: The most common sites of recurrence were distant in 31.6% and regional lymph nodes in 26.3%. Mean survival after recurrence was 13 months (range 5-29). Two patients who had wide local excision are disease free and alive 135 and 29 months after diagnosis. Neither surgical treatment conferred obvious benefit on survival. CONCLUSION: Ultrasound can guide management by delineating lesions amendable to wide local excision. Since the mortality rate is high, wide local excision offers the advantage of avoiding a permanent colostomy and should be considered the procedure of choice when excision is feasible.

Adult↗

PubMed2003

Current indications for blow-hole colostomy:ileostomy procedure. A single center experience.

BACKGROUND AND AIMS: Because of improved medical care and surgical techniques blow-hole colostomy with loop ileostomy is now rarely performed to reduce operative risks in patients with toxic megacolon related to inflammatory bowel disease (IBD). We reviewed patient charts to identify continuing indications for this procedure. PATIENTS AND METHODS: Seventeen patients underwent blow-hole colostomy procedure with ( n=15) or without ( n=2) ileostomy (8 men, 9 women; median age 51 years, range 21-79) during the past 18 years (1983-2001). RESULTS: The indications for the procedure were: toxic megacolon related to IBD ( n=6), toxic megacolon related to IBD and associated with pregnancy ( n=2), Clostridium difficile colitis ( n=3), adult Hirschsprung's disease ( n=1), pancreatitis with obstructing pseudocyst ( n=1), and palliation for malignant bowel obstruction with metastases ( n=4). Patients were discharged home after a median stay of 10 days (range 4-32 days). The 4 patients who underwent a palliative blow-hole procedure had died secondary to their underlying disease by the time of follow-up. Of the remaining 13 patients 12 had their alimentary tract reconstituted, and one still awaits a definitive procedure. CONCLUSION: The blow-hole colostomy-ileostomy procedure is still indicated for select patients with toxic megacolon and large-bowel obstruction. The procedure acts as a bridge to definitive operation for toxic patients with benign disease and palliates those with malignant obstructions and metastasis.

Adult↗

PubMed2003

Quality of life improves within 30 days of surgery for Crohn's disease.

BACKGROUND: The effect of surgery on quality of life (QOL) in the early postoperative period is important in Crohn's disease because of the multiple surgical procedures that patients undergo and the acute QOL benefits that might occur as a result of modifications of medical treatment. Earlier studies of the effect of surgery on QOL have been retrospective and assessed changes 3 to 24 months after surgery. This study prospectively assesses the effect of surgery on QOL in the early postoperative period. STUDY DESIGN: Patients requiring surgical management of sequelae of Crohn's disease were obtained from a prospectively entered database including data on QOL. Preoperative and 30-day postoperative QOL were determined in 82 patients using Cleveland Global Quality of Life (CGQL) scores (range from 0 [worst] to 10 [best possible] QOL). Preoperative and postoperative scores were compared using a paired t-test to determine the significance of any change in QOL after surgery. The effect of other variables on change in QOL after surgery was assessed using the t-test or analysis of variance. Multifactor analysis of variance was used to assess the effect of several independent variables. RESULTS: Eighty-two patients (41 women) of 142 patients who had had surgery (58%) had complete preoperative and 30-day postoperative scores. The incidence of complications was 23% (11% were major). There was a significant improvement in QOL 30 days after surgery as measured by CGQL (0.6 +/- 0.2 preoperative to 0.7 +/- 0.2 postoperative; mean +/- SD; p < 0.001). The mean preoperative CGQL was 0.56 +/- 0.24 and the mean improvement was 0.11 +/- 0.20 toward a better QOL. Female patients (p < 0.05) and those who did not develop complications within 30 days of surgery (p < 0.05) had a significantly greater improvement in CGQL after surgery than other groups. No other factor was predictive of improved outcomes. CONCLUSIONS: QOL as measured by CGQL improves early after surgery (30 days postoperatively). Improvement in CGQL is greater in female patients and patients who do not develop complications in the postoperative period. It is not affected by other patient characteristics, nature of disease, indication, or procedure performed. Most patients who undergo surgery for Crohn's disease feel that surgery has helped them and would undergo surgery again.

Adult↗

PubMed2003

Prospective, age-related analysis of surgical results, functional outcome, and quality of life after ileal pouch-anal anastomosis.

OBJECTIVE To evaluate how age affects functional outcome and quality of life after ileal pouch anal anastomosis (IPAA). SUMMARY BACKGROUND DATA Because of the limited number of older patients undergoing IPAA, it has been difficult to assess functional outcome and quality of life stratified by age. METHODS IPAA was performed in 1895 patients. Patients were stratified by age into <45 (n = 1410), 46-55 (n = 289), 56-65 (n = 154), and more than 65 years (n = 42). Outcome was assessed prospectively. Results are presented at 1, 3, 5, and 10 years after surgery.RESULTS Patients were followed for 4.6 +/- 3.7 years (maximum, 17 years). Pouch failure occurred in 4.1% (pouch excision or permanent diversion). Incontinence and night time seepage were more common in older patients. There were minor differences in the quality of life, health, energy and happiness between age groups, with a slight benefit for those under 45 years. Fourteen percent or fewer patients experienced social, sexual or work restrictions. Overall, 96% of patients were happy to have undergone their surgery, and 98% recommended it to others. Although the respective figures were 89% and 96% in the over-65 age group, the difference was not significant. CONCLUSIONS These data provide a unique assessment of outcome after IPAA at multiple time points. Although functional outcome after IPAA is not as good in older patients, appropriate case selection confers acceptable function and quality of life to patients of all ages.

Adenomatous Polyposis Coli↗

PubMed2002

Long-term outcome of overlapping anal sphincter repair.

PURPOSE: This study reviews the long-term outcome of overlapping anal sphincteroplasty for acquired anal incontinence. METHODS: Seventy-one consecutive patients underwent overlapping sphincteroplasty from 1989 to 1996 Current degree of continence and associated quality of life were determined by telephone interview using the Fecal Incontinence Severity Index and Fecal Incontinence Quality of Life Scale, as validated by The American Society of Colon and Rectal Surgeons. Both the patient-rated and the surgeon-rated Fecal Incontinence Severity Index scores were recorded. Demographic and perioperative data were obtained from patient charts. RESULTS: Forty-nine (69 per cent) of the 71 patients, with a median age of 38.5 (range, 22-80) years, could be contacted at a median of 69 (range, 48-141) months after sphincter repair. Four patients were diverted at the time of follow-up. Twenty-four (54 percent) patients were incontinent to liquid or solid stool, and only six patients (14 percent) were totally continent. Fifteen patients (34 percent) had the best possible Fecal Incontinence Quality of Life score of 16. The median patient-rated and surgeon-rated Fecal Incontinence Severity Index scores were 20 (range, 0-61) and 20 (range, 0-57), respectively. The patient-rated score correlated to the surgeon-rated score (r = 0.98, P < 0.001) and the Fecal Incontinence Quality of Life score (r = 0.64, P < 0.001). CONCLUSION: Years after sphincter repair surgery more than half of the patients are incontinent to liquid or solid stool. The American Society of Colon and Rectal Surgeons-validated Fecal Incontinence Severity Index and Fecal Incontinence Quality of Life scores are useful and complementary tools for evaluation of fecal incontinence.

Adult↗

PubMed2002

Strictureplasty in diffuse Crohn's jejunoileitis: safe and durable.

PURPOSE: As an alternative to resection, strictureplasty may allow for preservation of intestinal length and avoidance of short-bowel syndrome in patients with diffuse Crohn's jejunoileitis. However, the long-term durability of the procedure and its safety have not been confirmed. The purpose of this study was to report our experience with strictureplasty for diffuse Crohn's jejunoileitis. METHODS: Between 1984 and 1999, 123 patients underwent a laparotomy that included an index strictureplasty for diffuse jejunoileitis. Patient history, operative details, and postoperative morbidities were obtained by chart review. Nineteen patients (15 percent) were receiving total parenteral nutrition for short-bowel syndrome, and 81 (66 percent) were taking chronic steroids. Total number of strictureplasties performed was 701 (median, 5/patient). Seventy percent of patients underwent a synchronous bowel resection. Follow-up information was determined by personal or phone interviews. Recurrence was defined as the need for reoperation, and risk was calculated by the Kaplan-Meier method. Patients with diffuse jejunoileitis were also compared with 219 patients with limited small-bowel Crohn's disease undergoing strictureplasty. RESULTS: The overall morbidity rate was 20 percent, with septic complications occurring in 6 percent. The surgical recurrence rate was 29 percent with a median follow-up period of 6.7 (range, 1-16) years. The recurrence rate in diffuse jejunoileitis patients did not differ from that seen in patients with limited small-bowel Crohn's disease (P = 0.38). Short duration of disease and short interval since last surgery were significant predictors of accelerated recurrence (P = 0.008 and 0.04, respectively). CONCLUSIONS: Strictureplasty is a safe and durable alternative to resection in diffuse Crohn's jejunoileitis. Patients with a short duration of disease and short interval since last surgery are at higher risk for accelerated recurrence. Patients with diffuse jejunoileitis do not appear to be at higher risk for recurrence than patients with more limited Crohn's disease.

Adolescent↗

PubMed2002

A study to determine the nitroglycerin ointment dose and dosing interval that best promote the healing of chronic anal fissures.

PURPOSE: The aim of this study was to determine the optimal dose and dosing interval of nitroglycerin ointment to heal chronic anal fissures. METHOD: A randomized, double-blind study of intra-anally applied nitroglycerin ointment (Anogesic) was conducted in 17 centers in 304 patients with chronic anal fissures. The patients were randomly assigned to one of eight treatment regimens (0.0, 0.1, 0.2, 0.4 percent nitroglycerin ointment applied twice or three times per day), for up to eight weeks. A dose-measuring device standardized the delivery of 374 mg ointment. Healing of fissures (complete reepithelialization) was assessed by physical examination using an observer unaware of treatment allocation. The subjects assessed pain intensity daily by completing a diary containing a visual analog scale for average pain intensity for the day, the worst pain intensity for the day, and pain intensity at the last defecation. RESULTS: There were no significant differences in fissure healing among any of the treatment groups; all groups, including placebo had a healing rate of approximately 50 percent. This rate of placebo response was inexplicably higher than previously reported in the literature. Treatment with 0.4 percent (1.5 mg) nitroglycerin ointment was associated with a significant (P < 0.0002) decrease in average pain intensity compared with vehicle as assessed by patients with a visual analog scale. The decreases were observed by Day 4 of treatment. At 8 weeks the magnitude of the difference between 0.4 percent nitroglycerin and control was a 21 percent reduction in average pain. Treatment was well tolerated, with only 3.29 percent of patients discontinuing treatment because of headache. Headaches were the primary adverse event and were dose related. CONCLUSION: Nitroglycerin ointment did not alter healing but significantly and rapidly reduced the pain associated with chronic anal fissures.

Adult↗

PubMed2002

Long-term survivor of anorectal melanoma: report of a case.

Anorectal melanoma is a rare malignant tumor with approximately 500 cases reported in the literature and has dismal long-term survival prospects. Its poor prognosis is attributable to a delay in diagnosis and its inherent biologic aggressiveness, with many patients presenting with metastatic disease. Endoluminal ultrasound is an established mode of evaluation. The mainstay of treatment is usually surgical with curative or palliative intent. The choice of abdominoperineal resection wide local excision of the tumor is controversial. This is an interesting report of a 76-year-old female who presented with an anal mass, eventually underwent a wide local excision of the lesion, which pathologically proved to be malignant melanoma, and was doing well without any evidence of disease ten years after surgery. This is the only known case in the literature of a lesion of this thickness to be "cured" by wide local excision.

Aged↗

PubMed2002

Pilonidal disease.

Pilonidal disease is a disease of young people, usually men, which can result in an abscess, draining sinus tracts, and moderate debility for some. It probably results from hair penetration beneath the skin, for reasons that are not totally clear. Therapy should be simple, inflict minimal pain, have a short hospitalization, have a low recurrence rate, require minimal wound care, and allow rapid return to normal activity. No treatment meets all these ideal goals. Therefore, starting with a simple treatment and progressing to other treatments if failure occurs despite meticulous wound care and hair shaving is the logical approach. Table 1 depicts treatments from simple to more complex.

Female↗

PubMedDate not supplied

Perioperative resting pressure predicts long-term postoperative function after ileal pouch-anal anastomosis.

The purpose of this study was to determine whether perioperative manometry is useful in predicting long-term functional status after ileal pouch-anal anastomosis (IPAA). Prospectively collected perioperative anal manometry data from 1439 patients undergoing IPAA from 1986 to 2000 were compared to postoperative functional status at various time intervals from 6 months to 8 years after IPAA. A validated questionnaire was used to obtain information regarding restrictions of diet, work, social and sexual activity, urgency, fecal seepage or incontinence, energy level, satisfaction with surgery, and quality of life. The presence of seepage and the degree of incontinence were compared to the patient's perceived quality of life, health, energy level, and satisfaction with surgery. Low (<40 mm Hg) pre- and postoperative resting pressures were associated with increased seepage, pad use, and incontinence. Patients with low resting pressures also reported diminished quality of life, health, energy level, and satisfaction with surgery. There was a significant association (P < 0.001) between seepage and degree of incontinence and quality of health, quality of life, energy level, and level of satisfaction with surgery. Perioperative resting anal sphincter pressures greater than 40 mm Hg are associated with significantly better function and quality of life after ileal IPAA. Improved functional outcome is associated with better quality-of-life outcomes. Low preoperative resting pressures do not preclude successful outcome after IPAA.

Anal Canal↗