Showing papers by "Jeffrey W. Milsom published in 1992"

Clinical conundrum of solitary rectal ulcer.

Abstract: A retrospective study of 80 patients with biopsy-proven solitary rectal ulcer (SRU) was conducted to review its clinical spectrum. The median follow-up was 25 months. The female-to-male ratio was 1.4∶1.0, and the mean age was 48.7 years (range, 14–76 years). Principal symptoms were bowel disturbances (74 percent) and rectal bleeding (56 percent). Twenty-one patients (26 percent) were asymptomatic and required no treatment. A previous “wrong” diagnosis was made in 25 percent. Rectal prolapse was identified in 28 percent (full-thickness, 15 percent; mucosal, 13 percent). The macroscopic appearance of the lesion seen in SRU varied widely and included polypoid lesions in 44 percent (the predominant finding in the asymptomatic group), ulcerated lesions in 29 percent (always symptomatic), and edematous, nonulcerated, hyperemic mucosa in 27 percent. Anorectal manometry provided little helpful information in the patients in whom it was performed. Management by bulk laxatives and bowel retraining led to symptomatic improvement in 19 percent of cases. In 29 percent of cases, symptoms persisted despite endoscopic healing of the lesion. Intractability of symptoms led to surgery in only 27 (34 percent) patients. Depending on the presence or absence of rectal prolapse, rectopexy or a conservative local procedure (such as local excision), respectively, appeared to be the optimal surgical treatment. The polypoid variety tended to respond to therapy more favorably than non-polypoid varieties. Thus, the macroscopic appearance of SRU has a significant bearing on the clinical course, and most cases do not require surgery.

Gastroduodenal polyps in patients with familial adenomatous polyposis.

Abstract: A review of the endoscopy reports and pathology results from esophagogastroduodenoscopy (EGD) of all patients with familial adenomatous polyposis (FAP) undergoing such an examination was performed Two hundred fortyseven patients were identified, with an overall prevalence of duodenal adenomas of 66 percent and of fundic gland polyps of 61 percent Analysis of our more recent experience (1986 to 1990) shows the prevalence to be 88 percent and 84 percent, respectively A normal-appearing papilla was adenomatous in 50 percent of cases No case of periampullary carcinoma developed in patients under surveillance Routine EGD is indicated for patients with FAP Duodenal adenomas and fundic gland polyps will occur in the majority of patients

Endoluminal ultrasound defines anatomy of the anal canal and pelvic floor.

Abstract: The aims of this study were to determine whether endoluminal ultrasound (ELUS) could identify various layers of the normal anal canal and to evaluate whether a 10-MHz probe provided better image resolution than a 7-MHz probe. Sonographic anatomy of the anal canal on ELUS was directly correlated with anatomic dissection of various layers (mucosa-submucosa, internal anal sphincter, and external anal sphincter) in cadavers. Sonographic appearance of the anal sphincters was further evaluated in patients by “tagging” various layers using sonodense needles. A higher frequency 10-MHz ultrasound probe (focal length, 1–4 cm) provides improved sonographic images of the anal canal, compared with the 7-MHz probe (focal length, 2–5 cm). ELUS can also successfully identify various structures of the pelvic floor including the puborectalis, urethral sphincter, vagina, and outlines of the pelvis and ischiorectal fossae. Its role in the evaluation of anorectal disorders appears promising.

Newly designed occluder pin for presacral hemorrhage.

Abstract: Conventional hemostatic measures are often unsatisfactory in presacral venous bleeding occurring during surgical mobilization of the rectum. We designed a new type of hemorrhage occluder pin, with a ridged shaft, which may be rapidly placed into the sacrum to control hemorrhage. The aims of this study were 1) to assess the best pin shaft length by measuring the thickness of human sacral vertebral bodies, 2) to measure the forces needed to pull the newly designed pin out of the human sacrum compared with conventionally shaped titanium thumb-tacks, and 3) to assess clinically the efficacy of the new device. Four fresh cadaveric pelves were isolated and cut on a sagittal plane, and the thickness of each vertebral body was measured. Titanium pins, both with ridged and with smooth shafts, were used. Twelve-millimeter-shaft pins were used for S1 and S2, and 7-mm pins were used for S3, S4, and S5. Pins were inserted into each sacral vertebra, and the forces needed to extract them from the bone were measured by computerized dynamometry. Significantly more force was required to extract ridgedvs.smooth pins, both with 12-mm and with 7-mm shafts. There was no significant difference between the forces needed to pull out 12-mmvs.7-mm pins. The new pin was successfully used to stop presacral hemorrhage in three patients with no complications one, three, and six months after surgery. This newly designed hemorrhage occluder pin may represent an improved method of controlling presacral venous hemorrhage.

Omeprazole-induced hypergastrinemia does not influence growth of colon carcinoma.

Abstract: Colonic mucosa and adenocarcinoma are known to possess gastrin receptors. Recent studies have suggested that some patients with large intestinal cancers and polyps have elevated serum gastrin levels and that gastrin may stimulate growth of colonic neoplasms. The aim of the present investigation was to determine whether endogenous hypergastrinemia--induced by the proton pump inhibitor omeprazole--would influence growth in a subcutaneously implanted murine colonic cancer. The results show that despite a fivefold increase in serum gastrin levels (193 pg/ml median value, range 186-252, in the omeprazole-treated group vs 36 pg/ml median value, range 28-37 in controls), there were no differences in tumor size or survival of tumor-bearing animals. Additionally, there were no differences in serum gastrin values between tumor- (29 pg/ml, range 25-38) and non-tumor- (34 pg/ml, range 25-30) bearing, untreated animals. Endogenous elevation of the serum gastrin hormone to five times the normal level does not demonstrate trophic effects on the murine colon tumor MC-26.

Direct comparison between Czerny-Lembert and circular-stapled anastomotic techniques in colorectal anastomosis: A similar pattern of healing for both

Abstract: There are scant experimental data directly comparing the healing of the circular-stapled (CS) anastomotic technique with the standard Czerny-Lembert two-layer handsewn (HS) anastomotic technique during the acute and chronic phases of healing. The purpose of this study, therefore, was toseriallyevaluate wound healing in CS and HS anastomoses in the normal porcine colorectum. Forty-two adult female mixed-breed pigs randomly under-went either HS or CS anastomosis at the sacral promontory. Laser Doppler velocimetry (LDV) was used to measure perianastomotic blood flow. Groups of animals under-went a second surgery at 3, 5, 11, 60, or 120 days postoperatively, and anastomoses were restudied using LDV, gross and microscopic grading of inflammation, bursting pressures, and hydroxyproline content. Additionally, the 60-day and 120-day groups of animals under-went preoperative biplanar barium enemas to identify leaks or stenoses. No significant differences in perianastomotic blood flow between the HS and CS techniques were obtained over the entire 120-day study period. Serial evaluation of wound healing revealed no significant differences between the two anastomotic techniques with respect to bursting pressures, gross or microscopic inflammatory scores, or hydroxyproline content. There were no leaks or stenoses with either technique. Despite earlier reports to the contrary, there appears to be no fundamental difference in the mode of healing in the porcine colorectum comparing the HS technique with the CS technique.

Does a proximal colostomy affect colorectal anastomotic healing

Abstract: Fecal diversion has been implicated as an etiologic factor in anastomotic stenosis following colorectal surgery, particularly following the use of circular anastomotic stapling devices. However, experimental confirmation of the effects of fecal diversion on anastomotic healing is virtually nonexistent. The purpose of this study was to serially evaluate colorectal anastomotic healing with proximal colostomy (COL) and without it (CON; control) using two anastomotic techniques in a porcine model. Fifty-two (28 CON; 24 COL) mixed-breed female pigs had colorectal anastomoses using either a two-layer handsewn (HS) or an EFA®(U.S. Surgical Corporation, Norwalk, CT) circular stapled (CS) technique. Anastomotic blood flow was measured using laser Doppler velocimetry (LDV). At second surgery (5, 11, 60, or 120 days post-operatively), the following data were collected: repeat LDV, gross and microscopic anastomotic inflammatory scores, anastomotic diameter, and bursting pressure. There were no significant differences in anastomotic blood flow (LDV), inflammatory scores, or incidence of leak or stenosis between the CON and COL groups or between anastomotic techniques. Bursting pressure was significantly lower for the COL group at day 11 but not any other postoperative day (POD). Proximal colostomy does not appear to exert adverse effects on colorectal anastomotic healing. The choice of colorectal anastomotic technique should not be influenced by the need for proximal colostomy.

Surgery of colorectal cancer and inflammatory bowel disease

Abstract: This review highlights the year's most important articles concerning surgical management of colorectal cancer and inflammatory bowel disease as well as examining the new and growing field of laparoscopic bowel surgery. As in the past, editorial comments pervade the text.

The Biological Response Modifiers Interleukin-2 and Tumor Necrosis Factor-α Modulate the Cytotoxic Activity of Tumor Infiltrating Lymphocytes Against Human Colon Cancer Cells

Abstract: Colorectal cancer is one of the most common malignancies in both men and women in the United States, and its incidence is still rising every year (1). At the time of initial diagnosis, less than 60% of the patients have localized disease which is amenable to surgical treatment, and the prognosis is even worse in the advanced stages of the disease. In addition to surgery, or when surgery is not indicated because of metastatic disease, alternate forms of therapy include chemotherapy and occasionally radiotherapy. Presently, 5-fluorouracil (5-FU) is the most effective chemotherapeutic agent, but response rate usually is not better than 20–30% (2). Other substances have been used in combination with 5-FU, such as leucovorin (folinic acid) and cis-platinum. These combinations only induce a modest increase in the response rates, but often result in severe drug-related toxicities, including 3–4% of drug related fatalities (3–5). Levamisole, an antihelmintic drug with immuno-enhancing properties, has been recently used in combination with 5-FU, and a moderate increase of survival rates has been reported (6).