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Biomedical subjects

W H Isbister

Publications and source records attributed to W H Isbister.

At least 37 records · Page 2Linked to original sources
PubMed1998

Multiple laparotomies for severe intra-abdominal infection.

BACKGROUND: Mortality rates for patients with severe peritoneal infection are high. The present study was undertaken in order to examine mortality rates in patients with severe peritoneal infection who were managed by planned re-laparotomy. METHODS: Retrospective analysis of patients presenting at the King Faisal Specialist Hospital and Research Centre between 1992 and 1994 with severe peritoneal infection was undertaken. RESULTS: A total of 52 patients underwent either single (n = 30) or multiple (n = 22) peritoneal lavage, and Acute Physiology and Chronic Health Evaluation (APACHE II) scores and predicted mortality rates were calculated for these patients. The predicted mortality rate for patients undergoing a single washout was 42.4%, actual mortality: 23%. The predicted mortality for patients undergoing multiple washouts was 55.6%, actual mortality: 36.3%. No patient with a predicted mortality of < 30% who underwent multiple washouts died. Of nine patients with a predicted mortality between 31 and 60%, one died (11.1%). For a predicted mortality of 61-80%, five of six patients died (83.3%), and for patients with a predicted mortality of > 80%, two of three died (66.7%). CONCLUSIONS: The utilization of planned re-look laparotomy and peritoneal lavage in patients with severe peritonitis may result in a significant decrease in mortality as predicted by APACHE II scoring.

Adult↗
PubMed1998

Unplanned return to the operating room.

BACKGROUND: Unplanned return to the operating room (OR) has been suggested as one of the indicators that could be used to assess the quality of surgery in a hospital setting. The present study was undertaken in order to try to identify those factors that were important in determining the need for the return to the OR in patients undergoing a series of colorectal surgical procedures. METHODS: All patients who returned to the OR following an index colorectal procedure during a 15-year period on a colorectal service, were identified from the unit's database. The site of original disease, presentation, type of surgery performed, reason for re-operation and post-surgical morbidity and mortality were examined. RESULTS: Overall there were 2011 colorectal surgical admissions, and of these 19 males (61.2 years) and 18 females (67.4 years) underwent an unplanned return to the OR. In 34 patients the index operation was performed by a consultant surgeon. A total of 46% of index operations were performed in an emergency setting. The majority of patients had colorectal cancer. Most lesions were situated in the sigmoid colon or rectum. Postoperative adhesive obstruction was the commonest reason for return to the OR. No patient re-obstructed following re-operation. Overall eight wounds dehisced and five patients suffered anastomotic leakage. Intra-abdominal sepsis was found in 12 patients. Twenty-one patients developed urinary tract infections. Twenty-eight patients were discharged well, two patients were discharged dying with advanced malignancy and there were seven postoperative deaths (18.9%). CONCLUSIONS: Unplanned return to the OR is a function of both the patient's presenting problem and the surgical skill and judgement of the surgeon. It is thus in part determined by the patient casemix in a unit, service or institution.

Colectomy↗
PubMed1997

The surgical management of nonspecific inflammatory bowel disease: a small personal experience.

AIMS: To document the surgical management of patients with non specific inflammatory bowel disease managed in the colorectal service, University Department of Surgery, Wellington School of Medicine. METHODS: Retrospective analysis of patients managed between April 1975 and March 1990. RESULTS: Sixty five patients had inflammatory bowel disease. Twenty one (11 males) had ulcerative colitis and 44 (18 males) had Crohn's disease. There were no Maori. One hundred and twenty three operations were performed overall. Ten patients with ulcerative colitis were operated upon as emergencies. Five presented with fulminating disease. Six patients successfully underwent restorative proctocolectomy although one was subsequently thought to have had Crohn's disease. Overall there was one postoperative death. Crohn's disease patients underwent a total of 91 operations. Twenty nine operations were elective and 15 emergency during the first surgical admission. The commonest indication for surgery was stricture. The commonest operation performed was right hemicolectomy. Chest, wound and central line sepsis were the commonest postoperative problems. There were two postoperative deaths. Six patients favoured a series of relatively minor perineal operations to proctectomy. CONCLUSION: A cautious staged approach to the surgical management of inflammatory bowel disease patients resulted in only three deaths-an overall mortality rate of 4.6%. Accordingly we advocate a policy of expectant surgery to relieve symptoms or correct complications in patients with Crohn's disease. We believe that patients requiring surgery for ulcerative colitis should be offered the choice of either restorative proctocolectomy or panproctocolectomy and ileostomy.

Adult↗
PubMed1997

Emergency large bowel surgery: a 15-year audit.

OBJECT: To evaluate the management of patients presenting with colorectal emergencies. METHOD: Computerized audit of patients undergoing urgent/semi-urgent surgery in the Colorectal Service, University Department of Surgery, Wellington School of Medicine, NZ. RESULTS: 246 patients underwent major emergency or semi-emergency operations. Consultants performed 144 operations. The complications of cancer and diverticular disease were the commonest indications for surgery. Patients with inflammatory processes required significant perioperative nutrition. The disease site varied with the pathology. Overall the sigmoid colon was the commonest. Resection and anastomosis was generally performed for right-sided lesions whereas Hartmann's operation was the commonest procedure for more distally situated non neoplastic lesions. A loop diverting stoma was used most commonly in patients with obstructing cancer. The most frequent post-operative complication was urinary tract infection. Four patients developed pulmonary embolism, 2 ARDS, 4 myocardial infarction and 1 CVA. Persistent intra-abdominal sepsis requiring drainage occurred in five patients. There were 6 anastomotic leaks. 3 patients were re-operated upon to relieve post-operative small bowel obstruction. The overall post-operative mortality rate was 6.9%. CONCLUSION: A cautious policy of resecting right sided lesions and either diversion or resection without anastomosis for patients presenting acutely with left-sided colonic lesions resulted in a low overall mortality rate.

Adult↗
PubMed1997

Colorectal surgery in the elderly: an audit of surgery in octogenarians.

BACKGROUND: Morbidity and mortality rates are higher in elderly compared to younger patients undergoing colorectal cancer surgery. This study was undertaken to see whether this finding applied to all colorectal surgery in the elderly and if so to try to identify the determining factors. METHODS: All patients undergoing colorectal surgery between 1975 and 1990 were entered into a computerized database. Patients were divided into two groups, those less than 80 years (< 80) and those 80 years and more (80+), and compared with regard to the type of surgery performed, the patient's race, the seniority of the surgeon, the patient's disease, the operation performed and the postoperative morbidity and mortality. In addition, patients undergoing major resectional surgery and patients undergoing colorectal cancer surgery were compared separately. RESULTS: Of 2011 admissions, 88 were for patients of 80+. The male to female admission rate was 1:0.79 in the < 80 group and 1:1.25 in the 80+ group. More surgical procedures were performed by consultants in older patients. More emergency admissions were for 80+ patients. Rectal, sigmoid and right colonic pathology was more common in the elderly. Very few elderly patients were admitted with minor anorectal problems. Rectal prolapse and colorectal cancer were the commonest causes for admission in octogenarians. There were more pulmonary and cardiovascular postoperative complications in 80+ patients. Urinary tract infections were also more common. The postoperative mortality rate was higher in older patients (7.9 vs 1.4%). Four hundred and sixty-two patients underwent major resectional surgery and 45 were 80+. Surgery for diverticular disease was more frequent in younger patients (13.4 vs 2.2%) and cancer surgery in older patients (93.3 vs 70.5%). The postoperative mortality rate was higher in the elderly (11.1 vs 3.6%). Three hundred and thirty-six major resections were for cancer and 42 were 80+. Emergency surgery was performed more commonly in the older group (38.1 vs 14.9%). The rate of advanced disease seemed to be similar in both groups. The postoperative death rate was higher in the elderly (11.9 vs 3.4%). CONCLUSIONS: Elderly patients were more likely to die from cardiopulmonary problems after surgical interventions than either from their primary disease or from the surgery undertaken for it. Good postoperative cardiopulmonary support should thus be provided for all such patients.

Aged↗
PubMed1997

The management of colorectal perforation and peritonitis.

BACKGROUND: Surgical outcomes in patients presenting with colonic perforation or peritonitis tend to be poor. This study was undertaken to determine outcomes in such patients at a time before multiple re-laparotomies were performed. METHODS: Retrospective analysis of computer records of all patients presenting acutely to the University Surgical Unit (Wellington School of Medicine) with colonic perforation or peritonitis over a 15-year period. RESULTS: Seventy-three patients, 33 males and 40 females were admitted with either perforation or localized peritonitis of colorectal origin. Of these, 78% were managed as emergencies, but six were admitted electively and found incidentally. Consultant surgeons performed surgery slightly more frequently than registrars. Two patients were managed non-operatively. Forty-one per cent received peri-operative blood transfusion and 22% peri-operative total parenteral nutrition. The majority of patients presented with either peritonitis or free perforation in association with diverticular disease. The site of perforation was either ileocolic or sigmoid colonic in the majority of patients. Hartmann's operation was the most commonly performed resection. Respiratory, urinary and wound infections were the most commonly observed postoperative complications. Two patients developed anastomotic leaks (6.3%). The overall persistent intra-abdominal infection rate was 5.5%. Seven patients died following surgery. CONCLUSIONS: Resection of the perforated bowel is mandatory and this should be followed by anastomoses in the case of right-sided lesions and a Hartmann's operation or resection, colostomy and mucous fistula in distally situated lesions.

Colonic Diseases↗
PubMed1996

A comparison between colorectal surgical admissions in Maori and nonMaori.

AIMS: To compare Maori with nonMaori colorectal surgical admissions to a specialised colorectal unit in a teaching hospital. METHODS: All patients admitted to the colorectal service of the university department of surgery, Wellington, New Zealand between April 1975 and March 1990 have been entered into a computerised data base. Patients claiming to be Maori or of Maori descent were compared, in relation to colorectal diagnosis, type of admission and surgery and surgical complications, with those designated European or other. RESULTS: There were 90 Maori admissions (47 male, 43 female) and 1842 nonMaori admissions (1007 male, 835 female). The urgency of admission was similar in both groups. There were no significant differences in admission rates for obstruction, perforation, bleeding, diverticular disease, or anorectal abscess but more Maori seemed to have problems with haemorrhoids and perineal condylomata acuminata. More nonMaori were admitted with colorectal cancer. The frequencies of most major operations were similar in the two groups studied, although haemorrhoidectomy was more common in the Maori. A higher proportion of nonMaori patients had a consultant surgeon as the primary operator. The overall complication rates, with the exception of urinary tract infections were similar in both groups. One Maori patient died and there were 31 nonMaori deaths. CONCLUSION: There was no evidence that Maori had either less access to the public hospital system or that surgical colorectal diseases were more neglected. In general hospital admission rates for colorectal diseases in Maori and nonMaori were remarkably similar.

Adult↗
PubMed1996

Large bowel volvulus.

A retrospective analysis of all patients presenting with colorectal volvulus and managed on a colorectal service in the University Department of Surgery, Wellington School of Medicine, over a 15 year period was undertaken. There were 13 males (58.6 yr.) and 11 females (55.8 yr.). The Maori to non Maori ratio was 1:1.76. Overall 19 patients had sigmoid volvulus. Thirteen patients were admitted as emergencies and eight of these had a sigmoid volvulus that could not be deflated endoscopically, four had a caecal volvulus and one had a volvulus of the ascending colon. Five right hemicolectomies, three Hartmann's procedures, one laparotomy and tube splintage and four sigmoid colectomies were performed in these 14 patients. Two patients were admitted semi-acutely and deflated endoscopically and nine patients were admitted electively. Four patients developed post operative respiratory problems and four patients developed urinary tract infections. No patient developed an anastomotic leak. There were no post operative deaths. Endoscopic reduction was not found to be useful in this series. It is suggested that patients admitted acutely with compromised bowel should have a Hartmann's operation and that primary resection remains the treatment of choice in all other patients.

Colonic Diseases↗
PubMed1996

The management of left-sided large bowel obstruction: an audit.

BACKGROUND: The outcomes of patients admitted acutely to hospital with left-sided large bowel obstruction (LBO) were examined. METHODS: All patients admitted to the colorectal service (University Department of Surgery, Wellington School of Medicine) with LBO between 1975 and 1990 were reviewed. Sixty-four patients with left-sided LBO were identified. RESULTS: The most commonly found obstructing lesion was cancer. Two patients were not managed surgically. In 17.7% of patients there was development of postoperative respiratory complications and 16% developed wound problems following primary surgery. Fifty-nine patients survived their primary surgery and 45 had stomas. The stoma closure rate was 71.1% (32 of 45). The overall mortality rate for patients managed surgically was 6.5% (four of 62). The mortality rate for stoma formation was 4.3% (two of 47). The mortality rate for resection and then stoma closure was 3.2% (one of 32). CONCLUSIONS: This study has shown that a staged approach to the management of unselected patients with left-sided LBO is safe. Restoration of bowel continuity was achieved in 70% of patients.

Acute Disease↗
PubMed1996

The utility of pre-operative abdominal computerized tomography scanning in colorectal surgery.

To determine the utility of pre-operative abdominal computerized tomography (CT) scanning in patients with colorectal cancer, a prospective analysis was undertaken of all patients referred to a colorectal clinic for the primary treatment of colorectal cancer in a 5-year period. A clinical decision regarding the type of surgery to be performed was made prior to CT scanning, and this was then compared with the final surgery performed for each patient. The reason for any change in management was noted. Definitive management differed from proposed management in 14 of 116 patients studied. Surgery was avoided in one patient found to have multiple liver metastases on the CT scan. Operative findings changed the management in the remaining 13 patients. Seven patients had less aggressive surgery than proposed, one patient's surgery was abandoned because of extensive disease, and five patients had more radical surgery. Routine pre-operative CT scanning of the abdomen in patients with colorectal cancer does not seem to be justified from the results of this study.

Colonic Neoplasms↗
PubMed1995

Fistula in ano: a surgical audit.

OBJECTIVE: To document a 15 year experience of fistula in ano surgery. DESIGN: Retrospective audit of patients. SUBJECTS: All patients referred with fistula in ano between 1975 and 1990. SETTING: Colorectal Service, University Department of Surgery, Wellington School of Medicine. MAIN OUTCOME MEASURES: Resolution of symptoms and morbidity of surgery. RESULTS: 92 operations were performed in 88 patients. There were 65 males (39.6 year) and 23 females (25.9 year). Two patients were operated on two occasions and one patient with Crohn's disease (CD) had three fistulae laid open over a two year period. Three further patients with CD had one operation each. One patient had mucosal ulcerative colitis, one patient was found to have a carcinoma in situ close to the fistula tract and one had a carcinoma in the fistulous tract. There were no postoperative deaths. Over 50% of the patients were discharged within three days of surgery. No patient complained of anal incontinence at the time of discharge. Two patients returned with recurrence (a cryptogenic sepsis recurrence rate of 2.3%). CONCLUSION: Low fistulae in ano can be very satisfactorily managed by simple laying open. The recurrence rate following surgery is low, and there have been no complaints of problems with continence.

Adult↗
PubMed1995

Psoas abscess following ileo-anal pouch surgery.

An unusual case of psoas abscess complicating one of the earliest performed ileo-anal pouch anastomoses is reported. The authors have been unable to find a similar previously published case.

Adult↗
PubMed1995

Pilonidal disease.

All patients with pilonidal disease (abscess or sinus) managed surgically ('laying open') between 1975 and 1990 in the Colorectal Service, University Department of Surgery, Wellington School of Medicine were reviewed. A total of 323 operations (177 males, 146 females) were performed in 311 patients. Seven males and 5 females required two operations before satisfactory healing was achieved (recurrence rate 3.8%). Males were older than females (mean, 26.4 vs 21.5 years). One patient's wound bled following surgery and required immediate repacking. There were no other wound problems. One hundred and seventy-seven patients presented acutely with pilonidal abscess and 146 patients presented with pilonidal sinus. Patients with pilonidal abscess were younger than those with pilonidal sinus (male, 25.8 vs 26.9 years and female, 20.8 vs 23.5 years). There were proportionately more Maori patients who presented acutely. 'Laying open' under general anaesthesia seems to be a safe and successful method for managing pilonidal disease in all but the few patients in whom multiple operations have been performed previously or in those in whom healing has failed to occur. Based on our initial experience of 'day case' surgery the procedure could safely be done on an outpatient basis.

Abscess↗
PubMed1995

Rectal necrosis following anterior resection of the rectum.

Acute ischaemic colitis is a well recognized complication following abdominal surgery. It may occur spontaneously in older patients and is probably due to diffuse or localized obliterative arterial disease. In contrast, acute ischaemic proctitis is a rare clinical problem. It is caused by an acute surgical or thromboembolic interruption of the major blood supply and or collateral circulation of the rectum. Minor ischaemia may result in superficial mucosal ulceration whereas a major ischaemic episode will result in rectal necrosis with perforation. Acute rectal necrosis has not been reported as a complication following anterior resection of the rectum. This paper details a patient who developed necrosis of the rectum and the anal canal following anterior resection of the rectum for cancer of the recto-sigmoid junction.

Acute Disease↗
PubMed1995

Colonoscopy: how far is enough?

Total colonoscopy is arguably the best method available for examination of the colon and rectum. Colonoscopy costs are high and rising and it may be that in the future practitioners will be unable to afford to colonoscope all of the patients presently being examined. This retrospective study was undertaken in an attempt to examine the cost, in terms of lesions missed, of a limited endoscopy programme. During a 15 year period, 1426 colonoscopies were performed at Wellington Hospital, New Zealand. Total colonoscopy was possible in 79% of all patients. Three perforations occurred. Nine patients bled and two required blood transfusion after biopsy or 'snaring' of polyps. After exclusion of patients with continuous inflammatory bowel disease (IBD) 75% of all lesions were found in or distal to the descending colon. More cancers were found in patients colonoscoped because of bleeding. Thirty-two of 93 cancers diagnosed were proximal to the descending colon but 18 presented with bleeding. A further seven had a radiological abnormality. Only 7.5% of colorectal cancers would be missed by flexible sigmoidoscopy (65 cm) and 75% of the costs of total colonoscopy would be avoided if only patients presenting with bleeding and IBD were offered total colonoscopy and patients with radiological abnormalities were treated according to the abnormality. This compromise, based on the data presented, may represent a rational way to reduce colonoscopy costs.

Colonic Neoplasms↗
PubMed1995

Hartmann's operation: a personal experience.

This paper documents a 15 year experience with Hartmann's operation in the Colorectal Service at the Wellington School of Medicine, New Zealand. There were 31 male and 30 female patients. The majority had either complicated diverticular disease (27) or rectal cancer (27). Fifty-six patients were discharged home and five patients died within 30 days of surgery (8.2%). Of the 27 patients with complicated diverticular disease 19 proceeded to stoma closure with no mortality. Of the 27 patients who had complicated colorectal cancer only 2 had their stoma closed. There were 41 patients in whom bowel continuity was restored following construction of a Hartmann's stoma. Thirty-nine anastomoses were hand-sewn and two anastomoses were stapled. One patient developed a major anastomotic leak and one patient died postoperatively. Hartmann's operation has a definite place in the management of patients with complicated diverticular disease and recto-sigmoid cancer. The operation can be performed and the stoma closed safely in the former group but is less likely to be followed by restoration of continuity in the latter group.

Aged↗