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Biomedical subjects

W P Mazier

Publications and source records attributed to W P Mazier.

At least 19 recordsLinked to original sources
PubMed1997

Adjuvant radiation therapy in resectable rectal cancer: should local recurrence rates affect the decision?

Adjuvant external beam pelvic radiotherapy (XRT) for resectable rectal cancer has been mandated by the National Cancer Institute because of reported 20 to 50 per cent reductions in local recurrence rates. However, these series' reported local recurrence rates are 18 to 39 per cent in the nonradiated patients, which seems extraordinarily high compared to the 3 to 5 per cent rates reported by surgeons advocating proctectomy with complete mesorectal excision. This fact, coupled with the high cost of XRT ($11,000-$14,000), the risk of radiation injury to small bowel and the neo-rectum, and the failure of XRT to provide any survival advantage, raises questions as to the precise role of XRT for rectal cancer. The purpose of this study was to perform a review of 212 consecutive patients undergoing curative resection via low anterior resection (LAR) or abdominoperineal resection (APR) for rectal cancer between 1989 and 1993, focusing on local and distant recurrence rates and survival. The choice of surgery alone (SUR), preoperative radiation (PRE) (45 Gy), or postoperative radiation (POST) (45-50 Gy) was at the surgeon's discretion. There were no significant differences in male:female ratio (SUR, 83:60; PRE, 14:8; POST, 34:13) or type of procedure (SUR-LAR, 112:APR, 31; PRE-LAR, 5:APR, 17; POST-LAR, 30:APR, 17) between the groups. There were no significant differences in age between the preoperative and postoperative radiation groups (PRE, 64.0 +/- 2.4; POST, 59.2 +/- 1.7); however, age was significantly different (P < 0.05) between the surgery-alone and the postoperative radiation groups (SUR, 68.5 +/- 0.8; POST, 59.2 +/- 1.7). With a median follow-up of 49 months, there were no significant differences in local recurrence (SUR, 4.2%; PRE, 4.5%; POST, 2.1%); however, there was a significantly longer survival for the SUR group compared to the other groups (SUR, 45.9 months; PRE, 36.4 months; POST, 39.3 months; P < 0.05 least significant difference). The PRE group also had shorter survival compared to the other groups when only Stage II and III lesions were studied (S, 40.0 months; PRE, 28.3 months; POST, 39.3 months). Local recurrences based on TNM stage were: T1N0 (S, 0 of 27; PRE, 0 of 3); T2N0 (S, 4 of 4S; PRE, 0 of 7); T2N1 (S, 0 of 9; POST, 1 of 5); T3,4N0 (S, 2 of 37; PRE, 1 of 9; POST, 0 of 10); and T3,4N1,2 (S, 0 of 21; PRE, 0 of 3; POST, 0 of 30). The results of this series support the contention that proctectomy with complete mesorectal excision yields a 4.2 per cent local recurrence rate without the need for adjuvant XRT. In this series, if all the patients had received adjuvant radiation, an additional $2.2 million would have been added to the costs of medical care. Therefore, the potential risks, costs, and benefits of adjuvant pelvic XRT for rectal cancer must be weighed against optimal benchmarks for local recurrence rate for surgery alone.

Adult↗
PubMed1997

Long-term outcome after ileocecal resection for Crohn's disease.

The decision to operate on ileocecal Crohn's disease is usually tempered by concern for early recurrence and the potential for multiple small bowel resections that will render the patients a gastroenterological cripple. However, delays in surgical management may unnecessarily prolong the patient's disease state and risk complications from both medications and unchecked disease. The aim of this study was to report the long-term clinical outcome of patients undergoing ileocecal resection for Crohn's disease between 1970 and 1993. One hundred eighty-one patients underwent ileocecal resection for Crohn's disease during the study period, with a median follow-up of 14.3 years. The mean age at the first resection was 32.7 +/- 0.9 years, and the male female ratio was 79:102. The indications for the initial resection were intractability in 119 (68.4%), obstruction in 45 (25.9%), enteric fistula in 27 (15.5%), perforation in 16 (9.2%), intra-abdominal abscess in 7 (4.0%), and hemorrhage in 5 (2.9%). Postoperative complications included prolonged ileus in 13 (7.5%), pneumonia/atelectasis in 15 (8.6%), wound infection in 11 (6.3%), urinary tract infection in 10 (5.7%), intra-abdominal abscess in 7 (4.0%), and wound dehiscence in 1 (0.6%). There were no operative mortalities. Fifty-six (30.9%) developed a recurrence requiring further surgery, with the mean time interval between initial ileocecal resection and operation for recurrence being 72.3 +/- 7.6 months. A second recurrence developed in 19 patients (10.5%) with a mean time interval of 52.3 +/- 8.3 months. The most frequent sites of first recurrence were the preanastomotic ileum in 49 (87.3%), the postanastomotic colon in 10 (17.9%), other colonic sites in 16 (28.6%), and other small bowel sites in 2 (3.6%) and other sites in 4 (7.1%). The types of resection for first recurrence were ileal resection in 28 (50%), right hemicolectomy in 17 (30.4%), segmental colectomy in 6 (10.7%), total proctocolectomy in 3 (5.4%), and proximal small bowel resection in 2 (3.6%). The long-term follow-up of this patient cohort indicated that 125 (69.1%) had only one resection, 37 (20.4%) required two resections, 15 (8.3%) required three resections, 4 (2.2%) required four resections. The results indicate that ileocecal resection of Crohn's disease had a high rate of disease control obtained with low morbidity, and a low frequency of three or more bowel resections (2.2%). Therefore, surgical resection of ileocecal Crohn's disease should not be unduly delayed for fear of risking short bowel syndrome. This approach should minimize overall disease-related patient morbidity by avoiding long periods of chronic illness.

Adult↗
PubMed1997

Outcome after incision and drainage with fistulotomy for ischiorectal abscess.

Concomitant anal fistulotomy (F) and incision and drainage (I&D) of ischiorectal abscesses (IA) are often avoided, for fear of irreversibly impairing anal continence. However, failure to identify and treat the frequently associated trans-sphincteric anal fistula dooms the patient to recurrent anal suppurative disease. We have employed an aggressive approach of performing I&D and F for IA at the time of initial presentation. Adequate drainage is assured by placement of counterincisions and Penrose drains to minimize the time for healing of the perianal wound. Drainage is followed by a careful examination of the anal canal for fistula localization followed by fistulotomy, or less frequently by cutting seton placement. We present our experience with this approach to IA, with special attention paid to the evaluation of recurrence rates and anal continence. This paper represents a retrospective review of 80 patients with IA managed from 1983 to 1996. Operative records and office records were reviewed, and follow-up data were obtained by telephone interview. Internal fistulous openings were identified in 55 (68.8%) patients. Surgeries included: 38 (47.5%) I&D and F, 8 (10%) I&D and seton, and 34 (42.5%) I&D alone. Follow-up data were available on 99 per cent of patients; mean, 44.3 months. Results showed a 44 per cent recurrence rate in those who underwent I&D as compared with 21.1 per cent following I&D and F. 11.8 per cent of patients treated with I&D experienced a change in their level of continence postoperatively as compared to 15.8 per cent treated with I&D and F. The results indicate that an aggressive approach to IA allows identification of a trans-sphincteric fistula in 57.5 per cent of patients with IA. Therefore, optimal surgical management for IA appears to be I&D and F, resulting in a lower recurrence rate and comparable morbidity as compared to I&D alone.

Abscess↗
PubMed1995

Operative repair of anovaginal and rectovaginal fistulas.

PURPOSE: Operative repair of low rectovaginal fistulas should be tailored to the specific anatomic defect. Endoanal flap repair frequently provides successful fistula closure; however, if substantial injury to the perineal body, anal sphincter, or rectovaginal septum exists, a more extensive repair is required. We present our experience with 95 consecutive patients, operated for rectovaginal fistulas via septal repair after conversion to a fourth degree perineal laceration, endoanal flap, or anoperineorrhaphy. METHODS: A retrospective chart review was performed. Data collected included etiology, location, size, repair type, and degree of anal continence. All patients received standard mechanical and antibiotic bowel preparation and parenteral antibiotics. No covering stomas were used. RESULTS: Fistula etiology included obstetric injury (N = 77), perianal cryptoglandular infection (N = 15), and other (N = 3). Thirty-one patients had previous unsuccessful repairs. Types of repairs were fourth degree perineal laceration (38), endoanal flap (19), and anoperineorrhaphy (38). Excellent or good functional results occurred in 92 patients (97 percent). Similar success occurred in patients with previous failed repairs (90 percent excellent or good). The recurrence rate was 3 percent. There were no outcome differences between techniques. CONCLUSION: We believe that all three types of repair for rectovaginal fistulas result in a high cure rate, thereby allowing operative technique to be tailored to the anatomic defects present. This approach should allow for optimal functional outcome.

Adult↗
PubMed1994

Hemorrhoids, fissures, and pruritus ani.

The diagnosis and management of hemorrhoids, fissures, and pruritus ani probably accounts for more than 81% of the complaints centered on this part of the human anatomy. This brief treatise offers a safe and practical approach to the management of these three diseases.

Fissure in Ano↗
PubMed1994

Can preoperative and postoperative CEA predict survival after colon cancer resection?

Although elevated preoperative carcinoembryonic antigen (CEA) levels are associated with a poor prognosis, little has been written regarding the correlation of CEA response following curative resection of colorectal cancer and its relationship to survival. The purpose of this study, therefore, was to retrospectively evaluate survival in three groups of patients undergoing curative resection (Dukes B and C) for colorectal carcinoma: 1) elevated preoperative CEA/elevated postoperative CEA (EL/EL); 2) elevated preoperative CEA/normal postoperative CEA (EL/NL); and 3) normal preoperative CEA/normal postoperative CEA (NL/NL). A normal CEA was defined as a value < 5.0 ng/mL. Levels were drawn the day before surgery and between 2 and 4 weeks postoperatively. Patients were evaluated for age, sex, histologic grade, CEA levels (pre and postoperative), nerve and venous invasion, tumor site, and survival. There were no significant differences with respect to age, sex, Dukes stage, tumor site, histologic grade, or incidence of nerve or vascular invasion among the three groups. Five-year survival was significantly worse for patients with elevated preoperative CEA levels compared to those with normal preoperative CEA (53% versus 64%, P < 0.05), and for the EL/EL group compared with either of the other two groups (EL/EL: 66.6 +/- 11.8; EL/NL: 87.7 +/- 10.2; Group 3: 93.4 +/- 9.5, P < 0.05 ANOVA). The results indicate that a preoperative elevated CEA, particularly one that fails to decrease to normal postoperatively following a curative resection for colorectal carcinoma, represents a poor prognostic factor. Use of the CEA response may be useful for identifying a subgroup of colorectal cancer patients who are candidates for adjuvant chemotherapy.

Adenocarcinoma↗
PubMed1993

Treatment of advanced hemorrhoidal disease: a prospective, randomized comparison of cold scalpel vs. contact Nd:YAG laser.

PURPOSE: Recently, laser technology has been advocated for the treatment of hemorrhoids. However, there has been little scientific evaluation of the use of the Nd:YAG laser for excisional treatment of hemorrhoidal disease. The purpose of this study was to perform a prospective randomized study of the Nd:YAG laser vs. scalpel excision, when performing a standard Ferguson-closed hemorrhoidectomy. METHODS: Patients presenting for internal-external hemorrhoidectomy were eligible for study. Hemorrhoidectomies were performed under epidural or caudal blocks. The standard Ferguson closed hemorrhoidectomy technique was used. Data evaluated included: age, sex, estimated blood loss, operative time, postoperative pain scores, postoperative analgesic use, wound healing, and time for return to work. Eighty-six patients were eligible for study (laser, N = 51; scalpel, N = 35). RESULTS: There were no significant differences between the groups, except for a greater degree of wound inflammation and dehiscence at the 10 day postoperative visit for the laser group (laser, 1.7 +/- .2; scalpel, 0.8 +/- .2; P < 0.05, t-test). The use of the Nd:YAG laser added $480 per case; as a result, the treatment cost for the laser group was $15,360 higher than that of the conventional group. CONCLUSION: The results indicate that there are no patient care advantages associated with the use of the Nd:YAG laser for excisional hemorrhoidectomy compared with scalpel excision. As new technology becomes available, surgeons must rigorously assess therapeutic efficacy and cost-benefit ratio before deciding to employ this technology for patient care.

Chronic Disease↗
PubMed1993

Open colectomy versus laparoscopic colectomy: are there differences?

Laparoscopic colectomy has been increasingly reported as an option for the treatment of colonic pathology. However, there is very little information regarding perioperative morbidity and the cost effectiveness of this technique. The purpose of this study is to review our first year of experience with laparoscopic colon resection. Data collected includes: age, technique (open laparotomy, laparoscopic, laparoscopic/converted open), Karnofsky score, complications, specimen size/nodes, OR time, hospital stay, and cost. This is a consecutive series of 140 elective colonic resections including 102 open laparotomies (O) and 38 laparoscopic (L) cases. The indications for surgery have included adenocarcinoma col/rect (O = 59, L = 9), diverticular disease (O = 10, L = 10), adenomatous polyp (O = 3, L = 7), IBD (Crohn's, CUC) (O = 15, L = 4), rectal prolapse (O = 3, L = 4), and other (O = 12, L = 4). There were no significant differences with respect to age (O = 60.7 +/- 1.5; L = 54.8 +/- 3.8; C = 66.1 +/- 3.1), perioperative morbidity (O = 11%; L = 15%; C = 17%). The laparoscopic and laparoscopic converted cases required significantly more time compared to the open laparotomy group (O = 2.1 +/- 0.2 hours; L = 2.9 +/- 0.2; C = 3.4 +/- 0.2). There were significantly less intraoperative blood loss associated with laparoscopic procedures compared with either open or converted groups of patients (O = 687 +/- 54 cc; L = 157 +/- 19; C = 491 +/- 50).(ABSTRACT TRUNCATED AT 250 WORDS)

Activities of Daily Living↗
PubMed1992

Epidural analgesia.

The most frequently used postoperative analgesia techniques are intramuscular injection (IM) and patient controlled analgesia (PCA). Recently, the use of epidural catheter injection (EPI) has been done with success. This study was done to prospectively compare these three techniques for postoperative analgesia after extensive operations upon the colon and rectum. Patients were randomized to one of three analgesia groups--IM, intramuscular morphine sulfate; PCA, patient controlled morphine sulfate, and EPI, epidural morphine sulfate. Data collected included age, time to first bowel movement, amount of narcotic, number achieving 75 per cent of preoperative forced vital capacity, postoperative pruritus, headache, nausea and vomiting, respiratory depression, atelectasis or pneumonitis. A visual analog pain scale was used to evaluate postoperative pain severity (0, no; 1, partial; 2, marked, and 3, total relief). Sixty-eight patients were eligible for study (IM, 19; PCA, 22; EPI, 23, and excluded, four). The EPI group required significantly less daily narcotic compared with either the IM or PCA groups (17.0 +/- 6.12 milligrams; 67.8 +/- 26.8 milligrams; 40.5 +/- 20.6 milligrams, respectively, less than 0.05 ANOVA) and total narcotic (81.3 +/- 31.3 milligrams; 355.4 +/- 147.7 milligrams; 215.3 +/- 105.4 milligrams, respectively, p less than 0.05 ANOVA). EPI achieves excellent pain control in more patients with a significantly lower dose of narcotics and significantly fewer pulmonary complications. Therefore, epidural analgesia is the optimal method of postoperative analgesia after extensive abdominal operations.

Adult↗
PubMed1991

The bottom end. Handling of the perineal wound after abdominoperineal resection.

There are a number of options for handling the perineal wound following abdominoperineal resection, including open packing or primary closure with suction drainage. Open packing has not been widely accepted, fearing that it may delay perineal wound healing. The purpose of this paper, therefore, was to retrospectively evaluate, the experience at Ferguson Hospital with abdominoperineal resection from 1977 through 1986. The study population consisted of 288 patients undergoing abdominoperineal resection for rectal adenocarcinoma. Forty-six patients had the perineal wound closed primarily and 242 had the perineal wound packed open. Ninety-four patients had the pelvic peritoneum left open and 194 underwent closure of the pelvic peritoneum. Overall operative mortality was 2.1 per cent, and there was no significant difference between primary closure and open packing of the perineal wound with respect to hospital stay, operating time, operative blood loss, perioperative mortality, incidence of postoperative bowel obstruction, incidence of postoperative complications, or average time for perineal wound healing. Therefore, it would appear that packing the perineal wound following abdominoperineal resection is a viable means of handling the bottom end.

Adenocarcinoma↗
PubMed1990

Intramural pH: a quantitative measurement for predicting colorectal anastomotic healing.

Leakage and stenosis are serious complications of gastrointestinal anastomotic surgery that may, in part, be related to local ischemia. The ability to accurately quantitate the degree of gastrointestinal anastomotic ischemia remains a challenging clinical problem. The purpose of this study was to: 1) develop a model of colorectal anastomotic stenosis following local ischemia; 2) compare the accuracy of laser Doppler velocimetry and intramural colonic pH in quantitating critical levels of intestinal anastomotic ischemia; and 3) compare the anastomotic healing process using either a standard two-layer Czerny-Lembert handsewn or EEATM stapled anastomotic technique under ischemic conditions. The studies reported here were performed in two phases. Phase I was the pilot study in which the authors developed a model of colorectal anastomotic ischemia and defined critical levels of ischemia using laser Doppler velocimetry and intramural pH (less than or equal to 200 mV; less than or equal to 7.0, respectively). These parameters were then tested prospectively in Phase II, assessing the effects of anastomotic ischemia on animals kept alive for 5, 11, 21, and 60 days after surgery. Overall there was a 70 percent incidence of anastomotic healing complications in the Phase II trial with laser Doppler velocimetry correctly predicting anastomotic outcome in 70 percent of cases and tissue pH in 93 percent of cases. The results indicate that, although laser Doppler velocimetry and intramural pH measurements provide safe, easy techniques for assessing the effects of ischemia on the colorectal anastomosis, measurement of intramural pH provides an optimal quantitative method for predicting subsequent anastomotic outcome and tissue viability.

Anastomosis, Surgical↗
PubMed1989

The use of anxiolytic and parasympathomimetic agents in the treatment of postoperative urinary retention following anorectal surgery. A prospective, randomized, double-blind study.

Approximately 30 percent of patients undergoing anorectal surgery will develop acute urinary retention. The cause of this complication is poorly understood. Anxiety, anal distention, bladder distention as a result of vigorous hydration during surgery, and reflex inhibition of the urinary bladder detrusor muscle secondary to pain have been postulated as contributing factors. A four-armed prospective, double-blind, randomized trial was carried out to determine whether an anxiolytic agent (midazolam, 5 mg intramuscularly) and/or a parasympathomimetic agent (bethanechol, 10 mg subcutaneously) reduce the incidence of postoperative urinary retention following anorectal surgery. One hundred thirty-two patients (ages, 18 to 50 years), in acute urinary retention 6 to 12 hours following anorectal surgery, were enrolled. Sixty-nine percent of patients responded to bethanechol. Side effects were minimal. Midazolam alone had no effect on retention. Bethanechol and midazolam in combination resulted in less retention than midazolam and a placebo (P less than 0.05). Bethanechol alone was better than a placebo (P less than 0.002). Mean intraoperative intravenous fluid volume for the entire study group was 900 cc. Initial postoperative urinary volumes of patients who failed the treatment protocol were significantly higher than in those responding to bethanechol (mean of 527 cc vs. 241 cc, P less than 0.001). The use of an anxiolytic agent was not effective in the treatment of postoperative urinary retention. Bladder distention may increase the incidence of urinary retention. Bethanechol, in a dose of 10 mg subcutaneously, significantly lowered the incidence of postoperative urinary catheterization and should be considered as initial treatment of postoperative urinary retention following anorectal surgery.

Acute Disease↗
PubMed1989

Safe resection for diverticular disease of the colon.

A retrospective study of 83 patients undergoing surgery for diverticular disease over two years at a colorectal specialty hospital was undertaken to assess the safety of resection. No patient had free perforation. Eighty-nine percent of 46 patients with neither abscess nor fistula underwent resection and primary anastomosis, the remainder undergoing other resectional therapy; there was no mortality in this group. Of the 37 patients with abscesses, fistulas, or both, all had resections with or without primary anastomoses and one of these 37 patients died (2.7 percent mortality). In the entire series of 83 patients, the operative mortality was 1.2 percent, although 69 percent had morbidity. Resection can be performed safely for diverticulitis, and primary anastomosis can be safely added in uncomplicated and selected complicated cases.

Abscess↗
PubMed1989

Colorectal anastomotic stenosis. Results of a survey of the ASCRS membership.

Anastomotic stenosis is a poorly understood and underexamined complication of gastrointestinal surgery, reportedly most frequent in the coloproctostomy. In order to better define this problem, a questionnaire was sent to members of the American Society of Colon and Rectal Surgeons regarding patients with gastrointestinal anastomotic stenosis. A total of 123 patients with intestinal anastomotic stenosis were analyzed. Eighty-two anastomoses were stapled and 41 were handsewn. Nearly all stenoses occurred in the distal bowel (70 rectal, 23 sigmoid colon). Preoperative risk factors identified were obesity (28 patients) and abscess (12 patients). Incomplete "doughnuts" were noted in 12 patients. Postoperative anastomotic leaks (15 patients), pelvic infection (13 patients), and postoperative radiation (7 patients) were believed to be contributing factors. Dilatation, using a variety of techniques, was the sole treatment for 65 patients, however, intra-abdominal surgery was necessary in 34 patients. Large intestinal anastomotic stenosis probably occurs most commonly following coloproctostomy (both with handsewn and stapled anastomoses). Dilatation alone resulted in adequate treatment in most patients in the study. Major surgery was required to correct this problem in a significant number of patients (28 percent) in this series. The true incidence of anastomotic stenosis in colorectal surgery is unknown and warrants further study.

Adult↗
PubMed1989

Surgical treatment of anorectal fistula in patients with Crohn's disease.

Forty-seven patients with Crohn's disease were operated upon for fistula in ano during a 22 year period with an average follow-up time of 82 months. In 29 of the patients, the fistulotomy or fistulectomy wound healed primarily; in 37, a state of complete healing or minimal disability, sometimes after multiple fistulotomies, was achieved. Five patients required proctectomy, but the need for removal of the anorectum was not caused by surgical treatment of the fistula in any instance. Of the 31 patients who had a classical internal opening at the dentate line, 23 healed primarily after surgical treatment of the fistula, compared with only seven of 16 patients without such an internal opening. The 21 patients in whom the rectum was not involved and in whom there was a classical internal opening at the dentate line were an especially favorable group: 18 of these healed primarily after surgical treatment of the fistula, and although ten of them had one or more recurrences of the fistulas, 18 ultimately achieved a state of complete healing or minimal disability. We conclude that operative treatment of fistula in ano is a safe and effective modality in a carefully selected group of patients with Crohn's disease.

Adolescent↗
PubMed1988

An assessment of colostomy irrigation.

One hundred patients with permanent sigmoid colostomies were surveyed to determine their satisfaction and success with the "irrigation" technique of colostomy management. Most patients who irrigate their colostomies achieve continence. Odors and skin irritation are minimized. The irrigation method is economical, time efficient, and allows a reasonably liberal diet. It avoids bulky appliances and is safe. In appropriately selected patients, the irrigation technique is the method of choice for management of an end-sigmoid colostomy.

Adult↗
PubMed1988

Diagnosis and management of endometriosis of the colon and rectum.

Colon and rectal endometriosis is a relatively rare entity that may have a wide array of clinical symptomatology and radiographic findings. Thirty-two patients with a diagnosis of colon or rectal endometriosis were seen and treated at the Ferguson Clinic between 1960 and 1986. Diagnostic, pathologic, and therapeutic findings were reviewed. All patients, except one, had large-bowel symptoms. Ten patients had previous histories of pelvic endometriosis. When endometriosis of the colon causes significant symptoms or a neoplasm cannot be ruled out, partial colectomy is recommended. If pelvic endometriosis is extensive, removal of the endometriomas and reproductive organs should be entertained concurrent with bowel resection. Hormonal manipulation may be attempted in certain select patients, with very close follow-up.

Colonic Neoplasms↗