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Biomedical subjects

W G Lewis

Publications and source records attributed to W G Lewis.

At least 19 recordsLinked to original sources
PubMed1996

Does eversion of the anorectum during restorative proctocolectomy influence functional outcome?

PURPOSE: The aim of this study was to determine the effect of eversion of the anorectum during restorative proctocolectomy (RP) for ulcerative colitis on functional outcome. METHODS: One hundred seventeen patients underwent RP with stapled end-to-end ileal pouch-anal anastomosis (EEA), without resection of the anal mucosa. Sixty-four underwent EEA with eversion of the anorectum, and 53 underwent EEA without eversion. Each patient underwent paired studies of anorectal function before and a median of 12 months after RP. RESULTS: One year after RP, median (interquartile range) maximum resting pressure was 69 (range, 51-88) cmH2O in those patients who underwent eversion vs. 80 (range, 64-90) cmH2O in patients without eversion (P < 0.04). Threshold sensation in the upper, middle, and lower thirds of the anal canal were 9.1, 7.4, and 6.8 mA after eversion vs. 6.9, 4.9, and 3.8 mA without eversion (P = 0.003, P < 0.001, P < 0.001, respectively). Before operation, all patients had a rectoanal inhibitory reflex; however, after RP, 54 of 64 patients in the eversion group and 50 of 53 patients with a stapled EEA without eversion had an inhibitory reflex (P = not significant). Leakage of mucus was experienced by 11 patients who underwent eversion, compared with 9 patients without eversion. Fifty-six of 64 patients with eversion could defer defecation for more than 30 min compared with 43 of 53 patients without eversion. Twenty-two of 64 patients in the eversion group retained perfect discrimination between flatus and feces compared with 38 of 54 without eversion (P < 0.001). Level of the anastomosis was 1 (range, 0.5-3) cm above dentate line after eversion compared with 1.5 (range, 0-6) cm without eversion. CONCLUSION: Clinical outcome after RP with eversion was not as good as outcome after stapled EEA without eversion. Such a conclusion requires confirmation in a prospective control trial.

Adult↗
PubMed1996

Prospective controlled trial of duplicated (J) versus quadruplicated (W) pelvic ileal reservoirs in restorative proctocolectomy for ulcerative colitis.

AIMS: A prospective randomised controlled trial was conducted to find out what influence the design of the pelvic reservoir had on the functional outcome. PATIENTS AND METHODS: Sixty patients received either a duplicated (J) or a quadruplicated (W) reservoir, constructed with either 30 or 40 cm of ileum. Each patient underwent laboratory tests of anorectal function before and one year after operation. RESULTS: One year after operation, 57 patients were available for assessment: each had good anal continence, though eight experienced minor leakage of mucus, and all were able to defer defecation for more than 15 minutes. Median bowel frequency in 24 hours (IQR) in patients with J reservoirs (5 (4-7)) did not differ significantly from that of patients with W reservoirs (5 (4-6)). Likewise, bowel frequency in patients with the smaller (30 cm) reservoirs did not differ significantly from bowel frequency in patients with the larger (40 cm) reservoirs. However, patients with large W40 reservoirs had the lowest bowel frequency of the four groups (median 4 per 24 hours, p = NS). The capacity and compliance of the W40 reservoirs were greater than those of the other types of reservoir, but the differences were not statistically significant. CONCLUSIONS: These findings provide support for the use of a relatively small (30 cm), duplicated (J) ileal reservoir, which is simple to construct with linear stapling instruments.

Adolescent↗
PubMed1996

Morbidity of varicose vein surgery: auditing the benefit of changing clinical practice.

During two consecutive study periods (24 months and 16 months), 997 patients (1322 legs) with varicose veins underwent surgical treatment in Huddersfield Royal Infirmary, using a variety of surgical techniques. The average length of stay was 1.5 days, and 95.5% of patients had a hospital stay of less than 2 days. Complications occurred in seven inpatients. A further 16 patients developed complications requiring readmission to hospital (10 minor and intermediate; 6 major). The complication rate appeared to be operator-dependent: an increased complication rate (particularly major complications) occurred after surgery by junior surgeons. Major complications included femoral vein injury (1 patient), postoperative deep venous thrombosis (4 patients), pulmonary embolism (1 patient) and groin lymphatic fistula requiring reoperation (1 patient). Between the first and second study period, a change in policy regarding the type of bandaging used and the use of postoperative antiembolic stockings occurred and appears to have reduced the incidence of thromboembolic complications from 0.7% to 0.2%. Varicose vein surgery is not without major complications though, fortunately, there was no mortality in this series. These complications can be minimised with good surgical technique and better supervision of surgical trainees. Modification of postoperative management can further enhance the safety of this procedure.

Adult↗
PubMed1995

Factors that influence functional outcome after coloanal anastomosis for carcinoma of the rectum.

Thirty consecutive patients had laboratory assessment of anorectal function after rectal excision and stapled coloanal anastomosis for rectal carcinoma. Eleven patients experienced perfect continence but 19 had faecal leakage with or without urgency of defaecation. Median (interquartile range) function was related to the pressures generated in the anal sphincter at rest (good versus poor function: 80 (63-91) versus 51 (23-60) cmH2O, P < 0.01), during maximum squeeze (160 (126-203) versus 102 (58-112) cmH2O, P < 0.01) and during reflex inhibition (58 (23-63) versus 36 (18-54) cmH2O, P < 0.05). Poor function was significantly commoner in women than in men (P < 0.01). These findings suggest that occult damage may have occurred to the anal sphincter before low anterior resection. Careful preoperative evaluation with manometry and endoanal ultrasonography may detect such damage and allow selection of patients for colopouch reconstruction.

Adult↗
PubMed1995

Clinical and physiological evaluation of anorectal eversion during restorative proctocolectomy.

Fifty patients had a restorative proctocolectomy with stapled end-to-end ileoanal anastomosis by the eversion technique. Median (interquartile range) maximum resting anal pressure was 90 (73-116) cmH2O before restorative proctocolectomy and 71 (51-88) cmH2O 1 year after surgery (P < 0.001). Median maximum squeeze pressure was 141 (110-185) cmH2O before surgery and 146 (118-186) cmH2O 1 year after surgery (P not significant). Median thresholds for sensation in the lower third of the anal canal before and 1 year after surgery were 5.3 and 7.1 mA, respectively (P = 0.006). One year after restorative proctocolectomy, all patients were continent, although two experienced leakage of mucus requiring a pad. Forty-two patients (84 per cent) could discriminate between faeces and flatus. Eversion of the anorectum during restorative proctocolectomy impairs the motor and sensory functions of the anal sphincter. Most patients achieved satisfactory anal continence, however, despite these physiological changes.

Adolescent↗
PubMed1995

Potential disadvantages of post-operative adjuvant radiotherapy after anterior resection for rectal cancer: a pilot study of sphincter function, rectal capacity and clinical outcome.

The aim of this study was to try to gauge the functional effect of post-operative adjuvant radiotherapy after potentially curative anterior resection for carcinoma of the rectum. Anorectal function was studied both in the laboratory and clinically in 59 patients, a median of 12 months (range 6-96) after operation. Nine patients received post-operative radiotherapy and 50 matched patients were treated by surgery alone. Though maximum resting anal pressures and maximum squeeze pressures were similar in the two groups of patients, the length and pressure profile of the anal sphincter were both markedly abnormal after radiotherapy. The capacity and compliance of the neorectum were diminished significantly after radiotherapy (maximum tolerated volume 53 ml vs 110 ml after surgery alone, P = 0.008, compliance 1.5 ml/cm H2O vs 3.7 ml/cm H2O after surgery alone, p = 0.018) and the amount of distension of the neorectum required to produced maximum inhibition of the anal sphincter during the rectoanal inhibitory reflex was also significantly diminished after radiotherapy (P = 0.005). Clinical anorectal function was worse among patients who had received radiotherapy, a greater proportion of whom experienced both urgency of defaecation and varying degrees of incontinence. Major faecal leakage necessitating the use of a pad was recorded in 3 of the 59 patients after radiotherapy (one of whom required a permanent colostomy), but in only 5 of 50 patients after surgery alone.

Adult↗
PubMed1995

Clinical results and manometric studies after rectal flap advancement for infra-levator trans-sphincteric fistula-in-ano.

Eleven patients with infra-levator trans-sphincteric fistula-in-ano underwent fistula excision with rectal flap advancement. The clinical results were assessed by interview and the physiological function determined by ano-rectal manometry. Nine patients underwent paired studies before and 5 (range 2 to 6) months after operation. Median maximum resting anal pressure was 84 (48-135) cm water before operation and 76 (29-139) cm water after operation (P = N.S.). Median maximum squeeze pressure was 112 (64-290) cm water before operation and 88 (44-316) cm water after operation (P = N.S.). The median sphincter length was preserved after operation. There was one clinical failure following the development of an abscess under the flap. All patients are continent and there have been no recurrences. We conclude that rectal flap advancement is an acceptable way to cure more complex fistula-in-ano. Good functional results are achieved by maintaining anal sphincter function together with preservation of the integrity of the anal margin.

Adult↗
PubMed1995

Recovery of physiologic and clinical function after low anterior resection of the rectum for carcinoma: myth or reality?

PURPOSE: The aim of this study was to examine the serial changes that take place in the first year after low anterior resection for rectal carcinoma, in terms both of anorectal physiology and clinical bowel function. Our hypothesis was that some patients never regain satisfactory anorectal function, because the operative procedure leads to permanent impairment of anorectal reflex and motor function. METHOD: Nineteen patients underwent serial tests of anorectal function, before and for one year after low anterior resection. The median level of the anastomosis above the anal high-pressure zone was 3 (range, 1-6) cm. RESULTS: Anal resting pressure (median (interquartile range)) was significantly decreased three months after operation (62 (46-72) cm H2O) and one year after operation was still significantly less (58 (48-73) cm H2O) than before operation (77 (58-93) cm H2O) (P < 0.01). Maximum tolerated volume in the neorectum decreased from 130 (88-193) ml before operation to 80 (51-89) ml three months after operation (P < 0.005) but returned to preoperative values by six months (125 (60-140) ml) (P = not significant) and remained at these values one year after operation. The volume in the "neorectal" balloon required to elicit a maximum rectoanal inhibitory reflex was significantly less three months after operation than before operation (50 (43-60) ml compared with 100 (73-100) ml; P < 0.005); one year after operation, the volume required was still significantly less than before operation (50 ml vs. 100 ml) (P < 0.015). Bowel frequency increased from 1 (1-2) in 24 hours before operation to 4 (2-5) times in 24 hours after operation and remained at 4 times in 24 hours throughout the first year after operation. Three months after operation, 53 percent of patients experienced some degree of fecal leakage and 24 percent experienced urgency of defecation. These aspects of bowel function improved with time, but even one year after operation, 29 percent of patients continued to experience fecal leakage and 18 percent wore a protective pad. CONCLUSIONS: Anal resting pressure decreased significantly after low anterior resection and did not recover in the course of the first year after operation. Moreover, the volume of an air-filled balloon in the neorectum that was required to elicit maximum inhibition of the anal sphincter was significantly less after anterior resection that before operation. These long-term and presumably permanent changes in physiologic behavior of the anoneorectum after low anterior resection provide an explanation for the failure of some patients to regain satisfactory bowel function following that procedure.

Aged↗
PubMed1995

Why do some patients experience poor functional results after anterior resection of the rectum for carcinoma?

PURPOSE: The aim of this study was to examine the dynamic inter-relationship of the anal sphincter, residual rectum, and neorectum after low anterior resection for rectal carcinoma. METHODS: Seventy-three patients underwent laboratory tests of anorectal function a median of ten (range 1-100) months after operation. All patients completed quality of life questionnaires and had the level of their anastomoses determined by rigid sigmoidoscopy. Forty-four patients (60 percent) had some form of disturbance of bowel function, which was classified as "poor" function if bowel frequency was four or more in 24 hours and if there was also either fecal leakage or urgency of defecation. Manometric data were analyzed using stepwise logistic regression analysis. RESULTS: Only two factors were found to be significantly and independently associated with poor bowel function, namely, the pressure recorded in the upper part of the anal sphincter in response to distention of the neorectum (15 (7-24) cm of water in patients with poor function vs. 29 (15-58) cm in patients with good function; P < 0.005) and the level of the anastomosis above the anal sphincteric high pressure zone (2.5 (2-3.5) cm in patients with poor function vs. 6 (4-12) cm in patients with good function; P < 0.005). CONCLUSION: Continence after anterior resection is related to an appropriate "sampling" response in the anal sphincter to activity within the neorectum. This in turn, is directly related to length of the residual rectum, which is, therefore, of crucial importance to function.

Aged↗
PubMed1995

Intra-arterial chemotherapy in patients with breast cancer: a feasibility study.

The aim of this study was to assess the practicality of treating patients with various stages of breast cancer by means of regional (intra-arterial) chemotherapy. Three groups of patients received a median of four (range 2-4) cycles of combination chemotherapy: group I operable primary (n = 10); group II, locally advanced disease (n = 20); group III, recurrent locoregional disease (n = 22). The response rates (complete response, partial response and mixed response) in these groups of patients were 100% in groups I and II and 86% in group III. Morbidity included drug streaming and dysaesthesia in the hand. Patients in groups I and II had their tumours downstaged, allowing surgery to be performed. Local control was also achieved in group III when other treatment modalities had failed.

Adult↗
PubMed1995

Preservation of complete anal sphincteric proprioception in restorative proctocolectomy: the inhibitory reflex and fine control of continence need not be impaired.

This study evaluates whether reflux function of the anal sphincter remains unchanged after restorative proctocolectomy, provided that the sphincter remaining is kept intact, without mucosal stripping or endo-anal anastomosis. Paired tests of anorectal function were performed before, and a median of 6 (range 2-12) months after restorative proctocolectomy with stapled, end to end pouch-anal anastomosis. Beforehand, distension of the rectum with 50 ml of air produced a median (interquartile range) increase in pressure within the rectum of 22 (15-29) cm H2O and reflex inhibition of the anal sphincter from a pressure of 76 (62-106) cm H2O to a pressure of 34 (15-52) cm H2O. After the procedure, distension of the ileal pouch with 50 ml of air produced an increase in pressure within the pouch of only 5 (4-8) cm H2O (p < 0.001 compared with beforehand) and reflex inhibition of the anal sphincter from a pressure of 62 (25-79) cm H2O to 37 (17-68) cm H2O. Maximal reflex inhibition of the upper third if the anal sphincter to a pressure of 26 (15-48) cm H2O was observed when pressure within the pouch increased by 16 (11-22) cm H2O. After restorative proctocolectomy, all patients were continent (two experienced minor nocturnal leakage of mucus) and 25 could discriminate between flatus and faeces. Thus, reflux function was preserved in response to changes in pressure, ensuring that the subtler aspects of anal continence were preserved.

Adolescent↗
PubMed1995

The perfect pelvic pouch--what makes the difference?

The aim of this study was to determine what factors are important for the achievement of perfect anal continence after restorative proctocolectomy. One hundred patients underwent paired studies of anorectal physiology before and one year after restorative proctocolectomy with pelvic ileal reservoir (11 S, 25 J, 64 W) with stapled ileoanal anastomosis, without mucosectomy. Fifty seven patients attained perfect anal continence and were able to discriminate flatus from faeces with such confidence that they were able to release flatus safely without fear of faecal soiling. The remaining 43 patients experienced minor problems in this regard. Four factors were found to correlate significantly with a perfect functional result (median, perfect v imperfect): maximum resting anal pressure (72 v 57 cm H2O, p < 0.02), the sensory threshold in the upper and mid-anal canal (7.3 v 8.6 and 5.3 v 7.0 mA, p < 0.05 and p < 0.02), compliance of the ileal reservoir (12.4 v 7.6 ml/cm H2O, p < 0.01), and the presence of a pouch-anal inhibitory reflex (56 of 57 patients v 29 of 43 patients, p < 0.01). The quality of anal continence depends on several factors: a complaint ileal reservoir, a strong sensitive anal sphincter, and normal reflex coordination of the activities of the reservoir and the sphincter. Excellent pouch-anal coordination is obtainable irrespective of the design of the reservoir, provided that these criteria are satisfied.

Adolescent↗
PubMed1994

Internal anal sphincter activity after restorative proctocolectomy for ulcerative colitis: a study using continuous ambulatory manometry.

PURPOSE: The aim of this study was to further investigate continuous ambulatory anal manometry which has recently been introduced as a method for studying anorectal activity in ambulant patients, thereby avoiding many of the potential drawbacks of static techniques. METHOD: In this study continuous ambulatory manometry was used to assess the activity of the internal anal sphincter in patients who had undergone restorative proctocolectomy, and, in particular, to compare patients who had undergone conventional mucosal proctectomy with sutured endoanal, ileoanal anastomosis with patients who had undergone restorative proctocolectomy with preservation of the entire anal canal by means of stapled, end-to-end, ileoanal anastomosis without mucosectomy. RESULTS: Evidence of basal internal sphincter activity was found in only 38 percent of patients after mucosal proctectomy with sutured endoanal anastomosis, whereas all patients after restorative proctocolectomy with stapled end-to-end anastomosis and all control individuals showed such activity of the internal sphincter. Similarly, the number of sampling episodes seen in patients after mucosal proctectomy with endoanal anastomosis was significantly less (median, 0.0/hours (0-30/hours)) than the number of sampling episodes observed in patients after end-to-end anastomosis (median, 4.5/hours (1-48/hours)) or in control individuals (median, 5.6/hours (0-31/hours)) (P < 0.001). CONCLUSIONS: These results suggest that the internal anal sphincter is damaged in the course of mucosal proctectomy and endoanal anastomosis. In contrast, after restorative proctocolectomy with stapled, end-to-end anastomosis normal function of the internal sphincter is preserved.

Adult↗
PubMed1994

Stricture at the pouch-anal anastomosis after restorative proctocolectomy.

PURPOSE: The aim of this study was to determine what factors may be responsible for the development of a stricture at the pouch-anal anastomosis after restorative proctocolectomy. METHODS: A consecutive series of 115 patients was studied retrospectively a median of 34 months (range, 4-100 months) after operation or ileostomy closure. The procedure failed in 11 patients (9.6 percent) who subsequently had to have a permanent ileostomy. Another two patients were excluded from the analysis, one of whom was awaiting ileostomy closure, whereas the other had a stricture due to a desmoid tumor. Of the remaining 102 patients, 39 (38 percent) developed an ileoanal anastomotic stricture, which was severe and persistent in 16 percent. RESULTS: The results were analyzed with the aid of multivariate logistic regression analysis. Factors which predisposed significantly to the development of an ileoanal anastomotic stricture were 1) use of the 25-mm (small) diameter stapling gun (P = 0.05), 3) use of a defunctioning ileostomy (P = 0.03), and 4) anastomotic dehiscence and pelvic sepsis (P = 0.03). The single patient whose operation failed because of a stricture had also developed pelvic sepsis associated with an anastomotic dehiscence. CONCLUSIONS: The eventual clinical, functional outcome after dilation of a stricture in the 39 patients who developed a stricture was as good as the outcome in the 63 patients who did not a develop stricture.

Adolescent↗
PubMed1994

Coordinated activity of the new "rectum" and anal sphincter after sphincter-saving resection of the rectum for colitis or carcinoma.

PURPOSE: The aim of this study was to determine whether coordinated activity exists across a stapled enteroanal anastomosis. METHODS: Twenty-nine patients were studied for a median of one year after complete excision of the rectum and stapled enteroanal anastomosis; 12 patients underwent low anterior resection with coloanal anastomosis for carcinoma, and 17 patients underwent restorative proctocolectomy with ileoanal anastomosis. RESULTS: Maximum anal resting pressures were slightly lower after coloanal anastomosis than after ileoanal anastomosis [median range, 56 (11-60) cm H2O, cf 69 (40-107) cm H2O, P = NS]. During distention of the neorectum, anal sphincter pressures at 2.5, 1.5, and 0.5 cm from the anal verge were significantly lower after coloanal anastomosis compared with after ileoanal anastomosis (P < 0.01 at each station). The volume of neorectal distention required to produce maximal inhibition of the anal sphincter was significantly less after coloanal anastomosis at 50 (range, 20-60) ml of air than after ileoanal anastomosis at 240 (range, 100-420) ml of air (P < 0.01). Minor fecal leakage and urgency of bowel action were significantly more common after coloanal anastomosis (P < 0.01). CONCLUSION: Alterations in the dynamic response of the anal sphincter to distention of the neorectum may explain why the clinical results were better after ileal pouch-anal anastomosis than after coloanal anastomosis.

Adult↗
PubMed1994

Decrease in the anorectal pressure gradient after low anterior resection of the rectum. A study using continuous ambulatory manometry.

PURPOSE: Changes in anorectal function after low anterior resection of the rectum (LAR) often lead to symptoms of urgency and frequency of defecation, the anterior resection syndrome. It has been reported that preservation of part of the rectum improves clinical results, but why this should be remains unclear. METHODS: We have carried out continuous ambulatory manometric studies in two groups of patients: 11 patients, a median of 11 (range, 5-96) months after LAR, in whom the median anastomotic level above the anal high-pressure zone was 0 (range, 0-2) cm; 9 patients, a median of 6 (range, 3-12) months after sigmoid colectomy, in whom the rectum remained in situ and who acted as controls. RESULTS: Comparing the LAR group with controls, resting anal pressures were lower, median 68 (range 27-102) cm H2O vs. 95 (45-116) cm H2O (P < 0.05), and neorectal pressures were higher, 25 (0-48) cm H2O vs. 10 (0-10) cm H2O (P < 0.01). Thus the anorectal pressure gradients were less, 34 (0-74) cm H2O vs. 81 (35-113) cm H2O (P < 0.01). Slow-wave activity in the anal sphincter was present in six patients (55 percent) after coloanal anastomosis and eight patients (89 percent) after sigmoid colectomy. Sampling episodes were seen in only two patients (18 percent) after coloanal anastomosis and five patients (56 percent) after sigmoid colectomy. When clinical endpoints were compared (LAR vs. controls), bowel frequency in 24 hours was higher, 5 (3-8) vs. 2 (1-3) (P < 0.01); fecal leakage was more common, affecting seven patients (64 percent) vs. one patient (11 percent) (P < 0.05), and urgency of defecation was also more common. CONCLUSIONS: The inferior clinical results observed after LAR compared with the results after sigmoid colectomy are thus in part because of higher neorectal pressure acting on a weakened sphincter mechanism. These observations lend support to the idea that neorectal capacity should be increased in patients who undergo low anterior resection.

Aged↗
PubMed1993

Effect of anorectal eversion during restorative proctocolectomy on anal sphincter function.

Twenty-six patients underwent restorative proctocolectomy with end-to-end ileal pouch-anal anastomosis, without resection of the anal mucosa, by the eversion technique. Before surgery patients underwent tests of anorectal function. These were repeated a median of 8 (range 3-21) months after operation. The median (range) maximum resting anal pressure was 93 (36-149) cmH2O before and 71 (40-131) cmH2O after operation (P = 0.002). The median (range) maximum squeeze pressure before operation was 136 (73-280) cmH2O; it was 149 (69-290) cmH2O afterwards (P not significant). The median (range) length of the anal sphincter was 3.5 (2.5-4.5) cm before and 3.5 (2.0-4.5) cm after operation (P not significant). Thresholds for sensation in the upper, middle and lower thirds of the anal canal before and after operation were, respectively, 8.7 versus 8.7, 6.8 versus 7.4 and 4.2 versus 6.2 mA (P not significant). All 26 patients were continent, although one experienced minor leakage. Function of the anal sphincter is not significantly impaired by eversion of the rectum and anus during restorative proctocolectomy.

Adolescent↗