1
|
Kemeny MM, Zhao F, Forastiere AA, Catalano P, Hamilton SR, Miedema BW, Dawson NA, Weiner LM, Smith BD, Mason BA, Graziano SL, Gilman PB, Venook AP, Pinto HA, Whitehead RP, O’Dwyer PJ, Benson AB. Phase III Prospectively Randomized Trial of Perioperative 5-FU After Curative Resection for Colon Cancer: An Intergroup Trial of the ECOG-ACRIN Cancer Research Group (E1292). Ann Surg Oncol 2023; 30:1099-1109. [PMID: 36305992 PMCID: PMC9807536 DOI: 10.1245/s10434-022-12705-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 10/04/2022] [Indexed: 01/16/2023]
Abstract
BACKGROUND Studies suggest that adjuvant chemotherapy should be initiated at the earliest possible time. The Eastern Cooperative Oncology Group (ECOG) and Intergroup evaluated the effect of perioperative fluorouracil (5-FU) on overall survival (OS) for colon cancer. PATIENTS AND METHODS This phase III trial randomized patients to receive continuous infusional 5-FU for 7 days starting within 24 h after curative resection (arm A) or no perioperative 5-FU (arm B). Patients with Dukes' B3 and C disease received adjuvant chemotherapy per standard of care. The primary endpoint of the trial was overall survival in patients with Dukes' B3 and C disease. The secondary objective was to determine whether a week of perioperative infusion would affect survival in patients with Dukes' B2 colon cancer with no additional chemotherapy. RESULTS From August 1993 to May 2000, 859 patients were enrolled and 855 randomized (arm A: 427; arm B: 428). The trial was terminated early due to slow accrual. The median follow-up is 15.4 years (0.03-20.3 years). Among patients with Dukes' B3 and C disease, there was no statistically significant difference in OS [median 10.3 years (95% CI 8.4, 13.2) for perioperative chemotherapy and 9.3 years (95% CI 5.7, 12.3) for no perioperative therapy, one-sided log-rank p = 0.178, HR = 0.88 (95% CI 0.66, 1.16)] or disease-free survival (DFS). For patients with Dukes' B2 disease, there was also no significant difference in OS (median 16.1 versus 12.9 years) or DFS. There was no difference between treatment arms in operative complications. One week of continuous infusion of 5-FU was tolerable; 18% of arm A patients experienced grade 3 or greater toxicity.
Collapse
Affiliation(s)
- M. Margaret Kemeny
- Icahn School of Medicine at Mount Sinai, Queens Cancer Center of NYC Health + Hospitals/Queens, Jamaica, NY USA
| | - Fengmin Zhao
- Dana Farber Cancer Institute - ECOG-ACRIN Biostatistics Center, Boston, MA USA
| | - Arlene A. Forastiere
- John Hopkins University and Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD USA
| | - Paul Catalano
- Dana Farber Cancer Institute - ECOG-ACRIN Biostatistics Center, Boston, MA USA
| | | | | | | | | | | | | | | | | | - Alan P. Venook
- Helen Diller Family Comprehensive Cancer Center, USCF, San Francisco, CA USA
| | | | | | - Peter J. O’Dwyer
- University of Pennsylvania and Abramson Cancer Center, Philadelphia, PA USA
| | | |
Collapse
|
2
|
Wei W, Ramaswamy A, de la Torre R, Miedema BW. Partially covered esophageal stents cause bowel injury when used to treat complications of bariatric surgery. Surg Endosc 2012. [PMID: 22736286 DOI: 10.1007/s00464-012-2406-1.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND We hypothesized that an esophageal nitinol stent that is mainly silicone-covered but partially uncovered may allow tissue ingrowth and decrease the migration rate seen with fully covered stents and still allow safe stent removal. The aim of this study was to evaluate the first human results of using partially covered stents for anastomotic complications of bariatric surgery. METHODS This was a retrospective evaluation of all patients with staple-line complications after bariatric surgery who received a partly covered stent at a single tertiary-care bariatric center. The stents varied in length from 10 to 15 cm and in diameter from 18 to 23 mm. RESULTS From April 2009 to April 2010, eight patients received partially covered stents on 14 separate occasions. The indications were gastrojejunal stricture in four, acute leak in two, acute leak followed by a later stricture in one, and a perforated anastomotic ulcer in one patient. Single stents were placed in 12 sessions and two overlapping stents in two sessions. At the time of stent deployment, one patient had the uncovered proximal end of the stent in the stomach, with all others in the distal esophagus. Immediate symptom improvement occurred in 12/14 stent placements. Oral nutrition was initiated for 10/14 stent treatments within 48 h. Stents were removed after 25 ± 10 days. Minor stent displacement occurred with 9/13 stents, with the proximal end of the stent moving into the stomach, though the site of pathology remained covered. The stents were difficult to remove when tissue ingrowth was present. One patient required laparoscopic removal and one required two endoscopy sessions for removal. At the time of removal of ten stents, where the proximal end was found in the stomach, four had gastric ulceration, three had gastric mucosa replaced by granulation tissue, and three had normal gastric mucosa. In four cases where the proximal portion of the stent stayed in the esophagus, the esophageal deployment zone had abnormalities: three with granulation tissue and one with denuding of the esophageal mucosa. The distal uncovered portion of the stent in the Roux limb never became embedded in the mucosa and caused minimal injury. CONCLUSIONS A partially covered stent was successful in keeping the site of the pathology covered and provided rapid symptom improvement and oral nutrition in most patients. The proximal end of the stent generally moved from the esophagus to the stomach, probably due to esophageal peristalsis. The proximal uncovered portion of the stent causes significant bowel mucosal injury and sometimes becomes embedded in the esophagus or the stomach, making removal difficult. We no longer use partially covered stents.
Collapse
Affiliation(s)
- Wei Wei
- Department of General Surgery, University of Missouri School of Medicine, Columbia, MO 65212, USA.
| | | | | | | |
Collapse
|
3
|
Wei W, Ramaswamy A, de la Torre R, Miedema BW. Partially covered esophageal stents cause bowel injury when used to treat complications of bariatric surgery. Surg Endosc 2012; 27:56-60. [PMID: 22736286 DOI: 10.1007/s00464-012-2406-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 05/17/2012] [Indexed: 02/01/2023]
Affiliation(s)
- Wei Wei
- Department of General Surgery, University of Missouri School of Medicine, Columbia, MO 65212, USA.
| | | | | | | |
Collapse
|
4
|
Abstract
Postsurgical leaks after bariatric procedures are a significant cause of morbidity and mortality. They usually arise from anastomotic and staple line failures that are attributed to surgical technique, ischemia, and patient comorbid conditions. Timely diagnosis from subtle clinical clues is the key to appropriate management. Traditional treatment consists of adequate control of the intra-abdominal infection via surgical or percutaneous drainage maneuvers, antibiotics, and nutrition support via parenteral or feeding tube routes. Recently, endoscopically placed covered esophageal stents have been used to exclude the leak site, allowing oral nutrition and speeding healing.
Collapse
Affiliation(s)
- Mario P Morales
- SSM Weight-Loss Institute, DePaul Health Center, SSM Health Care, 12266 DePaul Drive Suite 310, St Louis, MO 63044, USA.
| | | | | | | |
Collapse
|
5
|
Powell B, Whang SH, Bachman SL, Astudillo JA, Sporn E, Miedema BW, Thaler K. Transvaginal repair of a large chronic porcine ventral hernia with synthetic mesh using NOTES. JSLS 2010; 14:234-9. [PMID: 20932375 PMCID: PMC3043574 DOI: 10.4293/108680810x12785289144313] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Transvaginal placement of synthetic mesh to repair large porcine hernia using NOTES technology appears to be a feasible alternative to traditional techniques. Background: Ventral incisional hernias still remain a common surgical problem. We tested the feasibility of transvaginal placement of a large synthetic mesh to repair a porcine hernia. Methods: Seven pigs were used in this survival model. Each animal had creation of a 5-cm hernia defect and underwent a transvaginal repair of the defect with synthetic mesh. A single colpotomy was made using a 12-cm trocar for an overtube. The mesh was cut to size and placed through the trocar. A single-channel gastroscope with an endoscopic atraumatic grasper was used for grasping sutures. Further fascial sutures were placed every 5cm. Results: Mesh repair was feasible in all 7 animals. Mean operative time was 133 minutes. Technical difficulties were encountered. No gross contamination was seen at the time of necropsy. However, 5 animals had positive mesh cultures; 7 had positive cultures in the rectouterine space in enrichment broth or on direct culture. Conclusion: Transvaginal placement of synthetic mesh to repair a large porcine hernia using NOTES is challenging but feasible. Future studies need to be conducted to develop better techniques and determine the significance of mesh contamination.
Collapse
Affiliation(s)
- Ben Powell
- University of Missouri, Columbia, Missouri, USA
| | | | | | | | | | | | | |
Collapse
|
6
|
Whang SH, Satgunam S, Miedema BW, Thaler K. Transvaginal cholecystectomy by using a prototype flexible clip applier. Gastrointest Endosc 2010; 72:351-7. [PMID: 20674623 DOI: 10.1016/j.gie.2010.02.050] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Accepted: 02/23/2010] [Indexed: 12/10/2022]
Abstract
BACKGROUND Currently, no endoscopic clips have been proven to be effective in ligating the cystic duct in natural orifice transluminal endoscopic surgery (NOTES) hybrid cholecystectomy. OBJECTIVE To determine the safety and feasibility of a prototype endoscopic flexible clip applier, which is the only flexible device that deploys a zero-gap clip. DESIGN Pilot study in a survival porcine model. Necropsy was performed at 2 weeks postprocedure. SETTING University of Missouri animal laboratory, Columbia, Missouri. INTERVENTION Transvaginal cholecystectomy was performed on 6 survival pigs using the NOTES Toolbox 1.0. MAIN OUTCOME MEASUREMENTS Safety and feasibility of the described instrument. Investigators were asked to fill out a standardized, blinded questionnaire on the ease of use and functionality of the flexible clip applier. RESULTS Clipping of the cystic duct was achieved with the flexible clip applier in all 6 pigs. The mean time for completion of clipping of the cystic duct was 9 minutes. Multiple attempts were required to successfully fire the clip in 2 of 6 pigs. We were unable to visualize the tip of the clip before deployment. Difficulty releasing the clip from the applier once fired and challenges in clip loading were encountered. The clips were visualized in place at necropsy, with no bile leakage, evidence of infection, or injury to surrounding structures seen in any cases. LIMITATIONS Preclinical animal model. CONCLUSION The prototype flexible clip applier showed adequate safety and was feasible in clipping the cystic duct in all animals. Design efforts to improve clip visualization, loading, and release are underway.
Collapse
Affiliation(s)
- Susan H Whang
- Department of General Surgery, University of Missouri, Columbia, Missouri 65212, USA
| | | | | | | |
Collapse
|
7
|
Sporn E, Astudillo JA, Bachman SL, Mayfield TP, Thaler K, Miedema BW. Transgastric biologic mesh delivery and abdominal wall hernia repair in a porcine model. Endoscopy 2009; 41:1062-8. [PMID: 19967621 DOI: 10.1055/s-0029-1215331] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND STUDY AIMS Incisional abdominal wall hernias currently require repair with open or laparoscopic surgery, which is associated with wound complications and recurrent hernia formation. Natural orifice transluminal endoscopic surgery (NOTES) techniques may have the potential to decrease the morbidity associated with hernia repair. The aim of this study was to repair a chronic ventral hernia with a biologic mesh placed transgastrically in a porcine model. MATERIALS AND METHODS Six pigs underwent creation of an incisional abdominal wall hernia. At least 4 weeks later, transgastric repair was done using an underlay biologic mesh with at least 5 cm of overlap from the hernia fascial edge. The mesh was secured with transfascial sutures and the stomach was closed with a sutured gastropexy. Pigs were evaluated 2 weeks later by laparoscopy. Pigs were sacrificed and necropsy wa s performed 4 weeks after the repair. RESULTS Six pigs underwent hernia repair lasting a mean (+/- SD) of 204 +/- 123 minutes, with one perioperative death. At 2 weeks after hernia repair, laparoscopy showed significant adhesions in all pigs; one pig had extensive mesh infection and was sacrificed. Necropsy on one pig at 2 weeks and four pigs at 4 weeks showed complete coverage of the hernia defect in all pigs. All pigs had mesh abscesses or a positive mesh culture. CONCLUSION Transgastric repair of a chronic ventral hernia is technically feasible. Difficulties with mesh delivery and infection need to be overcome before this approach can be used in humans.
Collapse
Affiliation(s)
- E Sporn
- Department of Surgery, University of Missouri, Columbia, Missouri 65212, USA
| | | | | | | | | | | |
Collapse
|
8
|
Whang SH, Astudillo JA, Sporn E, Bachman SL, Miedema BW, Davis W, Thaler K. In search of the best peritoneal adhesion model: comparison of different techniques in a rat model. J Surg Res 2009; 167:245-50. [PMID: 20304431 DOI: 10.1016/j.jss.2009.06.020] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2009] [Revised: 05/21/2009] [Accepted: 06/12/2009] [Indexed: 11/26/2022]
Abstract
BACKGROUND Adhesion-related complications after abdominal surgery result in significant morbidity and costs. Results from animal studies investigating prevention or treatment of adhesions are limited due to lack of consistency in existing animal models. The aim of this study was to compare quality and quantity of adhesions in four different models and to find the best model. MATERIALS AND METHODS This study was approved by the University of Missouri Animal Care and Use Committee (ACUC). Forty female rats were randomly assigned to four different groups of 10 animals each. Adhesion created was performed utilizing the four techniques: Group 1 - parietal peritoneum excision (PPE), Group 2 - parietal peritoneum abrasion (PPA), Group 3 - peritoneal button creation (PBC), and Group 4 - cecal abrasion (CA). Rats were allowed to recover and necropsy was performed on postoperative d 14. Adhesions were scored by an established quantitative and qualitative scoring systems. The midline incision served as the control in each animal. RESULTS The four groups were not equal with respect to both quantity score (P<0.001) and quality score (P=0.042). The PBC group had the highest quantity of adhesions. The highest quality of adhesion was seen in the PPE group. A multivariate analysis carried out to quantify the performance of each model clearly demonstrated that PBC exhibited the best results in terms of both quantity and quality. CONCLUSIONS The button technique (PBC) is most consistent and reproducible technique for an intra-abdominal adhesion model. This model can help in the study and development of substances to prevent adhesion formation in the future.
Collapse
Affiliation(s)
- Susan H Whang
- Department of General Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | | | | | | | | | | | | |
Collapse
|
9
|
Miedema BW, Thaler K. Flexible transgastric peritoneoscopy and liver biopsy. Gastrointest Endosc 2009; 69:1195; author reply 1196. [PMID: 19410055 DOI: 10.1016/j.gie.2008.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2008] [Accepted: 09/15/2008] [Indexed: 02/08/2023]
|
10
|
Sporn E, Petroski GF, Mancini GJ, Astudillo JA, Miedema BW, Thaler K. Laparoscopic appendectomy--is it worth the cost? Trend analysis in the US from 2000 to 2005. J Am Coll Surg 2009; 208:179-85.e2. [PMID: 19228528 DOI: 10.1016/j.jamcollsurg.2008.10.026] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2008] [Revised: 10/25/2008] [Accepted: 10/29/2008] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although laparoscopic appendectomy is widely used for treatment of appendicitis, it is still unclear if it is superior to the open approach. STUDY DESIGN From the Nationwide Inpatient Sample 2000 to 2005, hospitalizations with the primary ICD-9 procedure code of laparoscopic (LA) and open appendectomy (OA) were included in this study. Outcomes of length of stay, costs, and complications were assessed by stratified analysis for uncomplicated and complicated appendicitis (perforation or abscess). Regression methods were used to adjust for covariates and to detect trends. Costs were rescaled using the hospital and related services portion of the Medical Consumer Price Index. RESULTS Between 2000 and 2005, 132,663 (56.3%) patients underwent OA and 102,810 (43.7%) had LA. Frequency of LA increased from 32.2% to 58.0% (p < 0.001); conversion rates decreased from 9.9% to 6.9% (p < 0.001). Covariate adjusted length of stay for LA was approximately 15% shorter than for OA in both uncomplicated and complicated cases (p < 0.001). Adjusted costs for LA were 22% higher in uncomplicated appendicitis and 9% higher in patients with complicated appendicitis (p < 0.001). Costs and length of stay decreased over time in OA and LA. The risk for a complication was higher in the LA group (p < 0.05, odds ratio=1.07, 95% CI 1.00 to 1.14) with uncomplicated appendicitis. CONCLUSIONS LA results in higher costs and increased morbidity for patients with uncomplicated appendicitis. Nevertheless, LA is increasingly used. Patients undergoing LA benefit from a slightly shorter hospital stay. In general, open appendectomy may be the preferred approach for patients with acute appendicitis, with indication for LA in selected subgroups of patients.
Collapse
Affiliation(s)
- Emanuel Sporn
- Department of Surgery, School of Medicine, University of Missouri-Columbia, Columbia, MO, USA
| | | | | | | | | | | |
Collapse
|
11
|
Bachman SL, Sporn E, Furrer JL, Astudillo JA, Calaluce R, McIntosh MA, Miedema BW, Thaler K. Colonic sterilization for natural orifice translumenal endoscopic surgery (NOTES) procedures: a comparison of two decontamination protocols. Surg Endosc 2009; 23:1854-9. [PMID: 19118416 DOI: 10.1007/s00464-008-0295-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2008] [Revised: 05/24/2008] [Accepted: 06/09/2008] [Indexed: 12/21/2022]
Abstract
BACKGROUND This study aimed to evaluate the effect of two different sterilization protocols on the bacterial counts in the swine colon as preparation for natural orifice translumenal endoscopic surgery (NOTES) surgery. METHODS In this study, 16 swine were randomized to two different colonic sterilization protocols: low colonic irrigation using 300 ml of a 1:1 dilution of 10% povidone-iodine (Betadine) with sterile saline, followed by 1 g of cefoxitin dissolved in 300 ml of saline or two consecutive 300-ml irrigations using a quaternary ammonium antimicrobial agent (Onamer M). Colonic cultures were taken before colonic cleansing after a decontamination protocol and after completion of the NOTES procedure. The Invitrogen live/dead bacterial viability kit was used to assess for change in the bacterial load. A qualitative culture of peritoneal fluid was obtained at the end of the NOTES procedure. Colon mucosal biopsies obtained immediately after the sterilization procedure and at the 2-week necropsy point were evaluated for mucosal changes. RESULTS Protocol 1 resulted in an average 93% decrease in live colonic bacteria versus 90% with protocol 2 (nonsignificant difference). After a NOTES procedure, group 1 had a 62% increase in live bacteria and group 2 had a 31% increase (nonsignificant difference). Peritoneal cultures also were obtained. Bacteria were isolated from the peritoneal fluid of all the animals, and two or more species were isolated from 75% of the animals. There was no evidence of peritoneal infection at necropsy. Reactive epithelial changes and mild inflammation were the only pathologic abnormalities. No changes were noted at histologic evaluation of colonic mucosa after 2 weeks, demonstrating that these were temporary changes. CONCLUSION Colonic irrigation with Betadine and antibiotics are as effective for bacterial decontamination of the swine colon as a quaternary ammonium compound. The results of this study support the use of either protocol. Despite thorough decontamination, peritoneal contamination occurs. The significance of this for humans is unknown.
Collapse
Affiliation(s)
- Sharon L Bachman
- Department of Surgery, University of Missouri, One Hospital Drive, Columbia, MO 65212, USA.
| | | | | | | | | | | | | | | |
Collapse
|
12
|
Sporn E, Miedema BW, Astudillo JA, Bachman SL, Loy TS, Davis JW, Calaluce R, Thaler K. Gastrotomy creation and closure for NOTES using a gastropexy technique (with video). Gastrointest Endosc 2008; 68:948-53. [PMID: 18599054 DOI: 10.1016/j.gie.2008.03.1094] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Accepted: 03/17/2008] [Indexed: 12/10/2022]
Abstract
BACKGROUND Safe and efficient gastrotomy creation and closure is pivotal for natural orifice transluminal endoscopic surgery (NOTES). OBJECTIVE To test a method of transgastric access and closure with commercially available devices. DESIGN An animal survival study. SETTING University hospital. PATIENTS Fifteen pigs. INTERVENTIONS By using a surgical suture passer, under endoscopic guidance, 3 percutaneous stay sutures were placed, in a triangular fashion, through the gastric wall. A gastrotomy was created with a dilation balloon, which was introduced over a guidewire through the gastric wall in the center of the 3 sutures. After performing a NOTES procedure, the gastrotomy was closed by tying the sutures. Necropsies were performed after 2 to 4 weeks. MAIN OUTCOME MEASUREMENTS Success and time of gastrotomy creation and closure, and intraoperative and postoperative complications. RESULTS Gastrotomies were successfully created and closed in all the animals. The median time to create a gastrotomy was 19 minutes (range 11-85 minutes), and the median closure time was 1 minute (range 1-45 minutes). One pig died on postoperative day 1 because of peritonitis caused by a leaking gastrotomy site that extended beyond the stay sutures. There were no other gastrotomy-related complications. All gastrotomies were well healed at the necropsy. LIMITATION No control group. CONCLUSIONS We evaluated a simple method by using the principles of the PEG technique combined with a gastropexy, which is familiar to the majority of endoscopists. Strict attention to the gastrotomy site is needed, because one leak was from the gastrotomy site that extended beyond the stay sutures.
Collapse
Affiliation(s)
- Emanuel Sporn
- Department of Surgery, School of Medicine, University of Missouri-Columbia, Columbia, Missouri 65212, USA
| | | | | | | | | | | | | | | |
Collapse
|
13
|
Sporn E, Bachman SL, Miedema BW, Loy TS, Calaluce R, Thaler K. Endoscopic colotomy closure for natural orifice transluminal endoscopic surgery using a T-fastener prototype in comparison to conventional laparoscopic suture closure. Gastrointest Endosc 2008; 68:724-30. [PMID: 18534584 DOI: 10.1016/j.gie.2008.02.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2007] [Accepted: 02/05/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Safe and efficient endoscopic closure of a colotomy is essential for transcolonic peritoneal access or endoscopic full-thickness resection of the colon, if open or laparoscopic surgery is to be avoided. OBJECTIVE To compare the feasibility and safety of colotomy closure with the newly developed Tissue Approximation System (TAS, Ethicon Endo-Surgery, Inc.) to conventional laparoscopic suture closure. DESIGN Prospective randomized survival animal study involving 16 pigs. SETTING University hospital. INTERVENTIONS Pigs were randomized for closure of a 2- to 3-cm full-thickness colotomy with the TAS or with a conventional laparoscopic running suture. MAIN OUTCOME MEASUREMENTS Success of colotomy closure, time of colotomy closure, postoperative infection, and complication rates. RESULTS Colotomies were successfully closed in all animals. Median closure time (range) was 39.5 minutes (25-95 min) in the TAS group and 23 minutes (16-40 min) in the laparoscopic group (P = .0134). There were no postoperative infections or complications. LIMITATIONS Closure with the TAS was performed under laparoscopic vision. There was no control group without closure of the colotomy site. CONCLUSIONS Colotomies are safely closed with the TAS with comparable results to laparoscopic closure. The TAS may serve as a useful tool to close full-thickness colon defects or colotomy sites made for transluminal endoscopic procedures.
Collapse
Affiliation(s)
- Emanuel Sporn
- Department of Surgery, University of Missouri-Columbia, Columbia, Missouri 65212, USA
| | | | | | | | | | | |
Collapse
|
14
|
Geiger TM, Miedema BW, Tsereteli Z, Sporn E, Thaler K. Stent placement for benign colonic stenosis: case report, review of the literature, and animal pilot data. Int J Colorectal Dis 2008; 23:1007-12. [PMID: 18594837 DOI: 10.1007/s00384-008-0518-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2008] [Indexed: 02/04/2023]
Abstract
BACKGROUND Permanent metal stent placement for malignant intestinal obstruction has been proven to be efficient. Temporary stents for benign conditions of the colon and rectum are less studied. This is a case study, review of the literature, and observation from an animal model on placement of stents in the colorectum for benign disease. MATERIALS AND METHODS A 55-year-old man presented with recurrent obstructions from a benign stricture of the distal sigmoid colon. After failed balloon dilations, a polyester coated stent was placed. The purpose of the stent was to improve symptoms and avoid surgery. The stent was expelled after 5 days. We conducted a literature review of stents placed for benign colorectal strictures and an animal study to evaluate stent migration. RESULTS In the literature, there were 53 reports of uncovered metal stents, four covered metal stents, and six polyester stents. Patency rates were 71%, and migration rate was 43%. Migration occurred earlier with polyester stents (mean=8 days) versus covered (32 days) or uncovered metal stents (112 days). Severe complications were seen in 23% of patients. Four 45-kg pigs underwent rectosigmoid transection with a 21-mm anastomosis and endoscopic placement of a Polyflex stent. Two stents were secured with suture. Stents without fixation were expelled within 24 h of surgery. Stents with fixation were expelled between postoperative days 2 and 14. CONCLUSION Stents for the treatment of benign colorectal strictures are safe, with comparable patency rates between stent types. Metal stents can cause severe complications. In a pig model, covered polyester stents tend to migrate early even with fixation. Further investigation needs to focus on new stent designs and/or better fixation.
Collapse
Affiliation(s)
- Timothy M Geiger
- Division of General Surgery, University of Missouri-Columbia, Columbia, MO 65212, USA
| | | | | | | | | |
Collapse
|
15
|
Sporn E, Miedema BW, Astudillo JA, Siddiqi SH, Marshall JB, Calaluce R, Cleveland DS, Loy TS, Thaler K. Evaluation of a novel endoluminal stapling procedure to restrict the lower esophageal sphincter and reduce reflux. Endoscopy 2008; 40:752-8. [PMID: 18773342 DOI: 10.1055/s-2008-1077511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND STUDY AIMS An effective, safe, and long-lasting endoluminal treatment for gastroesophageal reflux disease (GERD) would be an attractive prospect. We developed an endoluminal technique to restrict and tighten the lower esophageal sphincter (LES), by using a transoral endoscopic stapling device in a porcine model. PATIENTS AND METHODS Pre-interventional evaluation comprised endoscopy, manometry, and 48-hour pH measurement of the distal esophagus using the catheterless BRAVO pH capsule. By placing the endoluminal stapling device at the LES and firing a 2.5-cm staple line, a vertical plication was created. In five pilot pigs (phase 1), plications were placed in various locations at the LES. In another five pigs (phase 2), plications were placed uniformly at the mid level of the LES on the lesser curvature side. Measurements were repeated 2 weeks after the procedure. Necropsy and histological analysis were performed. RESULTS Endoluminal stapling was successfully completed in all animals. In phase 2, the median procedure time was 15 minutes (range 10-55 minutes). LES pressure increased from 10.5 mmHg (+/- 2.5 mmHg) to 14.3 mmHg (+/- 3.8 mmHg) (P = 0.038). Median percentage of time with pH below 4 decreased from 6.6% (range 2.9%-48.8%) to 2.2% (range 0%-10.4%) (P = 0.043). Histology showed the staple line involving the muscular layer in all pigs. A gap was present in the central part of the staple line in three pigs resulting in a mucosa-muscular bridge of tissue. This bridge did not influence the results. CONCLUSION This novel endoluminal technique is feasible and safe in a porcine model over 2 weeks. It is appealing due to its simplicity and ease of application. Further studies aimed at eliminating the gap in the staple line and investigating more animals over longer survival periods are needed.
Collapse
Affiliation(s)
- E Sporn
- Department of Surgery, University of Missouri, Columbia 65212, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Christian J, Barrier BF, Schust D, Miedema BW, Thaler K. Culdoscopy: A Foundation for Natural Orifice Surgery—Past, Present, and Future. J Am Coll Surg 2008; 207:417-22. [DOI: 10.1016/j.jamcollsurg.2008.01.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2008] [Revised: 01/29/2008] [Accepted: 01/30/2008] [Indexed: 10/22/2022]
|
17
|
Edwards CA, Bui TP, Astudillo JA, de la Torre RA, Miedema BW, Ramaswamy A, Fearing NM, Ramshaw BJ, Thaler K, Scott JS. Management of anastomotic leaks after Roux-en-Y bypass using self-expanding polyester stents. Surg Obes Relat Dis 2008; 4:594-9; discussion 599-600. [PMID: 18722820 DOI: 10.1016/j.soard.2008.05.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2007] [Revised: 02/27/2008] [Accepted: 05/01/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUND To analyze the outcomes of a series of endoscopically placed polyester self-expanding polyflex stents (SEPSs) for the management of anastomotic leaks after Roux-en-Y bypass. Anastomotic leaks after gastric bypass cause significant morbidity and mortality. Covered polyester SEPSs might have a role in the treatment of these leaks. METHODS A retrospective chart review was performed from January 2006 to November 2006 that included all acute and chronic leaks treated with SEPSs. RESULTS A total of 6 patients were treated with stents, with a mean procedure time of 22 minutes. Of these 6 patients, 5 had acute postoperative leaks and 1 had a chronic fistula. Five patients started oral intake 1-6 days after their procedure. All acute leaks had complete healing at a median of 44 days. The patient with a chronic gastrocutaneous fistula required revisional surgery for fistula closure. In addition, 5 patients had stent migration, and 3 required stent replacement. CONCLUSION An endoscopically placed SEPS provides a less-invasive alternative to treat acute anastomotic leaks after Roux-en-Y bypass while simultaneously allowing oral intake. The results of this case series have demonstrated this treatment to be safe and effective.
Collapse
Affiliation(s)
- Christopher A Edwards
- Department of Surgery, University of Missouri-Columbia, Columbia, Missouri 65212, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Tsereteli Z, Sporn E, Geiger TM, Cleveland D, Frazier S, Rawlings A, Bachman SL, Miedema BW, Thaler K. Placement of a covered polyester stent prevents complications from a colorectal anastomotic leak and supports healing: randomized controlled trial in a large animal model. Surgery 2008; 144:786-92. [PMID: 19081022 DOI: 10.1016/j.surg.2008.05.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2007] [Accepted: 05/29/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anastomotic leaks after colorectal operation continue to be a significant cause of morbidity. A covered endoluminal stent could seal a leak and eliminate the need for diversion. The aim of this study was to test the efficacy of a temporary covered stent to prevent leak related complications. METHODS Sixteen adult pigs (80-120 lbs) underwent open transection of the rectosigmoid followed by anastomosis with a circular stapler. Eight animals (study group) underwent endoscopic placement of a 21-mm covered polyester stent. Eight control group animals were left without stents. In all animals, a 2-cm leak was created along the anterior portion of the anastomosis. The animals were killed after 2 weeks and evaluated for abdominal infection, fistulae, and adhesions. The anastomosis was excised and the following parameters were assessed by a pathologist blinded to treatment: mucosal interruption (mm), inflammatory response, collagen type I and III, granulation, and fibrosis (grade 0-4). RESULTS Stents were spontaneously expelled between postoperative days 6 and 9. At necropsy, none of the animals in the study group had leak related complications, whereas in the control group, 5 (63%) developed intraabdominal infection (4 abscesses, 1 fistula) at the anastomosis (P = .002). Dense adhesions to the anastomosis were found in 7 (88%) control animals. On histology, anastomotic sites in the study group had significantly less mucosal interruption and granulation. Two pigs in the study group died on postoperative day 7, one due to evisceration and one from bladder necrosis. The mortality result is not different from controls (P = .47), both events seem to be unrelated to stent placement. CONCLUSION Temporary placement of a covered polyester stent across a colorectal anastomosis prevents leak-related complications and supports the healing of anastomotic leaks.
Collapse
Affiliation(s)
- Zurab Tsereteli
- Department of General Surgery, University of Missouri, Columbia, MO 65212, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Sporn E, Miedema BW, Bachman SL, Astudillo JA, Loy TS, Calaluce R, Thaler K. Endoscopic colotomy closure after full thickness excision: comparison of T fastener with multiclip applier. Endoscopy 2008; 40:589-94. [PMID: 18609453 DOI: 10.1055/s-2008-1077377] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND STUDY AIMS Safe, reliable, and efficient endoscopic closure of a colotomy is paramount for endoscopic full thickness excision of the colon. Two newly developed devices, the Tissue Apposition System (TAS) and the InScope Multi-Clip Applier (IMCA), may help to achieve this. The aim of this study was to determine the feasibility of using each device to close colotomies after full thickness wall excisions. MATERIAL AND METHODS 12 pigs were used in the study. After laparoscopic full thickness excision of the colonic wall, the defect was closed using either the TAS or the IMCA. Closure was performed under laparoscopic vision. Success of colotomy closure, time taken for colotomy closure, postoperative infections, and complication rates were recorded. RESULTS Complete closure was achieved in 6/6 pigs in the TAS group. In 5/6 pigs in the IMCA group closure was successful; in one pig laparoscopic assistance was used. Median closure time (range) was significantly lower in the TAS group at 48 minutes (15 - 51) vs. 76 minutes (43 - 145) in the IMCA group. There were no postoperative infections or complications. CONCLUSIONS Endoscopic closure after full thickness colonic wall excision is feasible with both the TAS and the IMCA. Closure times are significantly shorter and handling is easier with the TAS. Combined use of both systems might be beneficial.
Collapse
Affiliation(s)
- E Sporn
- Department of Surgery, University of Missouri, Columbia, Missouri 65212, USA
| | | | | | | | | | | | | |
Collapse
|
20
|
Sporn E, Davis JW, Thaler K, Miedema BW. Sentinel node mapping during laparoscopic distal gastrectomy for gastric cancer. Surg Endosc 2008; 22:2097. [PMID: 18553200 DOI: 10.1007/s00464-008-9991-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2008] [Accepted: 03/25/2008] [Indexed: 11/27/2022]
|
21
|
Eubanks S, Edwards CA, Fearing NM, Ramaswamy A, de la Torre RA, Thaler KJ, Miedema BW, Scott JS. Use of endoscopic stents to treat anastomotic complications after bariatric surgery. J Am Coll Surg 2008; 206:935-8; discussion 938-9. [PMID: 18471727 DOI: 10.1016/j.jamcollsurg.2008.02.016] [Citation(s) in RCA: 156] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2008] [Accepted: 02/19/2008] [Indexed: 12/27/2022]
Abstract
BACKGROUND Complications after bariatric surgery often require longterm parenteral nutrition to achieve healing. Recently, endoscopic treatments have become available that provide healing while allowing for oral nutrition. The purpose of this study was to present outcomes of the largest series to date treating staple line complications after bariatric surgery with endoscopic covered stents. STUDY DESIGN A retrospective evaluation was performed of all patients treated for staple line complications after bariatric surgery at a single tertiary care bariatric center. Acute postoperative leaks, chronic gastrocutaneous fistulas, and anastomotic strictures refractory to endoscopic dilation after both gastric bypass and sleeve gastrectomy were included. RESULTS From January 2006 to June 2007, 19 patients (11 with acute leaks, 2 with chronic fistulas, and 6 with strictures) were treated with a total of 34 endoscopic silicone covered stents (23 polyester, 11 metal). Mean followup was 3.6 months. Immediate symptomatic improvement occurred in 90% (91% of acute leaks, 100% of fistulas, and 84% of strictures). Oral feeding was started in 79% of patients immediately after stenting. Resolution of leak or stricture after stent treatment occurred in 16 of 19 patients (84%). Healing of leak, fistula, and stricture occurred at means of 33 days, 46 days, and 7 days, respectively. Three patients (1 with leak, 1 with fistula, and 1 with stricture) had unsuccessful stent treatment. Migration of the stent occurred in 58% of 34 stents placed. Most migration was minimal, but three stents were removed surgically after distal small bowel migration. There was no mortality. CONCLUSIONS Treatment of anastomotic complications after bariatric surgery with endoscopic covered stents allows rapid healing while simultaneously allowing for oral nutrition. The primary morbidity is stent migration.
Collapse
Affiliation(s)
- Steve Eubanks
- Department of Surgery, University of Missouri, Columbia, MO 65212, USA
| | | | | | | | | | | | | | | |
Collapse
|
22
|
Geiger TM, Awad ZT, Burgard M, Singh A, Davis W, Thaler K, Miedema BW. Prognostic indicators of quality of life after cholecystectomy for biliary dyskinesia. Am Surg 2008; 74:400-404. [PMID: 18481495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Approximately 30 per cent of patients who undergo cholecystectomy for biliary dyskinesia will continue to have symptoms after surgery. Quality of life has not been evaluated but may be decreased in these patients. The purpose of this study was to measure quality of life after laparoscopic cholecystectomy in these patients to better define optimal treatment of biliary dyskinesia. All patients with biliary dyskinesia (defined as the absence of gallstones, and a gallbladder ejection fraction of <35%) who underwent cholecystectomy at our institution from January 31, 2000 to January 31, 2005 were identified. Preoperative data including ultrasound, biochemical data, and pathology were retrieved by chart review. Postoperative assessment included the Gastrointestinal Quality of Life Index and a symptom survey. The postoperative quality of life was compared with historic standards. The quality of life was also compared with preoperative variables to determine if any variables predicted outcome. A total of 66 patients were identified as fitting the inclusion criteria. Forty-three patients were reached by phone and 30 agreed to participate. Patients were noted to have good recall as to preoperative symptoms when the retrospective survey of symptoms was compared with the medical record. The mean +/- SD postoperative quality of life in the study population was 113 +/- 20. This is higher than in historic patients with gallbladder disease before (84 +/- 19) and after (102 +/- 13) cholecystectomy. Quality of life in the study group was lower than the healthy control (125 +/- 13). Patients having both postprandial nausea and vomiting before surgery had a lower quality of life (P < 0.029) after surgery as compared with those without these preoperative symptoms. When adjusted for nausea and vomiting, the quality of life in study patients (119 +/- 14) was similar to normal controls. No other symptom, laboratory, pathologic, or sonographic data were predictive of a lower quality of life. Cholecystectomy is beneficial for most patients with biliary dyskinesia. Nausea and vomiting were negative predictors of quality of life after cholecystectomy. These patients with nausea and vomiting may have a global gastrointestinal motility disorder and are less likely to benefit from cholecystectomy.
Collapse
Affiliation(s)
- Timothy M Geiger
- Department of General Surgery, University of Missouri-Columbia,Columbia, Missouri 65212, USA
| | | | | | | | | | | | | |
Collapse
|
23
|
Geiger TM, Awad ZT, Burgard M, Singh A, Davis W, Thaler K, Miedema BW. Prognostic Indicators of Quality of Life after Cholecystectomy for Biliary Dyskinesia. Am Surg 2008. [DOI: 10.1177/000313480807400507] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Approximately 30 per cent of patients who undergo cholecystectomy for biliary dyskinesia will continue to have symptoms after surgery. Quality of life has not been evaluated but may be decreased in these patients. The purpose of this study was to measure quality of life after laparoscopic cholecystectomy in these patients to better define optimal treatment of biliary dyskinesia. All patients with biliary dyskinesia (defined as the absence of gallstones, and a gallbladder ejection fraction of <35%) who underwent cholecystectomy at our institution from January 31, 2000 to January 31, 2005 were identified. Preoperative data including ultrasound, biochemical data, and pathology were retrieved by chart review. Postoperative assessment included the Gastrointestinal Quality of Life Index and a symptom survey. The postoperative quality of life was compared with historic standards. The quality of life was also compared with preoperative variables to determine if any variables predicted outcome. A total of 66 patients were identified as fitting the inclusion criteria. Forty-three patients were reached by phone and 30 agreed to participate. Patients were noted to have good recall as to preoperative symptoms when the retrospective survey of symptoms was compared with the medical record. The mean ± SD postoperative quality of life in the study population was 113 ± 20. This is higher than in historic patients with gallbladder disease before (84 ± 19) and after (102 ± 13) cholecystectomy. Quality of life in the study group was lower than the healthy control (125 ± 13). Patients having both postprandial nausea and vomiting before surgery had a lower quality of life ( P < 0.029) after surgery as compared with those without these preoperative symptoms. When adjusted for nausea and vomiting, the quality of life in study patients (119 ± 14) was similar to normal controls. No other symptom, laboratory, pathologic, or sonographic data were predictive of a lower quality of life. Cholecystectomy is beneficial for most patients with biliary dyskinesia. Nausea and vomiting were negative predictors of quality of life after cholecystectomy. These patients with nausea and vomiting may have a global gastrointestinal motility disorder and are less likely to benefit from cholecystectomy.
Collapse
Affiliation(s)
- Timothy M. Geiger
- From the Department of General Surgery, University of Missouri-Columbia, Columbia, Missouri; the
| | - Ziad T. Awad
- Department of Surgery, University of Florida-Shands Jacksonville, Jacksonville, Florida
| | - Michael Burgard
- From the Department of General Surgery, University of Missouri-Columbia, Columbia, Missouri; the
| | - Amolak Singh
- From the Department of General Surgery, University of Missouri-Columbia, Columbia, Missouri; the
| | - Wade Davis
- Department of Health Management and Informatics, University of Missouri-Columbia, Columbia, Missouri
- Department of Statistics, University of Missouri-Columbia, Columbia, Missouri
| | - Klaus Thaler
- From the Department of General Surgery, University of Missouri-Columbia, Columbia, Missouri; the
| | - Brent W. Miedema
- From the Department of General Surgery, University of Missouri-Columbia, Columbia, Missouri; the
| |
Collapse
|
24
|
Morales MP, Mancini GJ, Miedema BW, Rangnekar NJ, Koivunen DG, Ramshaw BJ, Eubanks WS, Stephenson HE. Integrated flexible endoscopy training during surgical residency. Surg Endosc 2008; 22:2013-7. [PMID: 18297358 DOI: 10.1007/s00464-008-9760-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2008] [Accepted: 01/03/2008] [Indexed: 11/30/2022]
Abstract
BACKGROUND New advances in endoscopic surgery make it imperative that future gastrointestinal surgeons obtain adequate endoscopy skills. An evaluation of the 2001-02 general surgery residency endoscopy experience at the University of Missouri revealed that chief residents were graduating with an average of 43 endoscopic cases. This met American Board of Surgery (ABS) and Accreditation Council for Graduate Medical Education (ACGME) requirements but is inadequate preparation for carrying out advanced endoscopic surgery. Our aim was to determine if endoscopy volume could be improved by dedicating specific staff surgeon time to a gastrointestinal diagnostic center at an affiliated Veterans Administration Hospital. METHODS During the academic years 2002-05, two general surgeons who routinely perform endoscopy staffed the gastrointestinal endoscopy center at the Harry S. Truman Hospital two days per week. A minimum of one categorical surgical resident participated during these endoscopy training days while on the Veterans Hospital surgical service. A retrospective observational review of ACGME surgery resident case logs from 2001 to 2005 was conducted to document the changes in resident endoscopy experience. The cases were compiled by postgraduate year (PGY). RESULTS Resident endoscopy case volume increased 850% from 2001 to 2005. Graduating residents completed an average of 161 endoscopies. Endoscopic experience was attained at all levels of training: 26, 21, 34, 23, and 26 mean endoscopies/year for PGY-1 to PGY-5, respectively. CONCLUSIONS Having specific endoscopy training days at a VA Hospital under the guidance of a dedicated staff surgeon is a successful method to improve surgical resident endoscopy case volume. An integrated endoscopy training curriculum results in early skills acquisition, continued proficiency throughout residency, and is an efficient way to obtain endoscopic skills. In addition, the foundation of flexible endoscopic skill and experience has allowed early integration of surgery residents into research efforts in natural orifice transluminal endoscopic surgery.
Collapse
Affiliation(s)
- Mario P Morales
- Department of Surgery, Division of General Surgery, University of Missouri-School of Medicine, One Hospital Drive, Columbia, Missouri 65203, USA
| | | | | | | | | | | | | | | |
Collapse
|
25
|
Geiger TM, Miedema BW, Geana MV, Thaler K, Rangnekar NJ, Cameron GT. Improving rates for screening colonoscopy: Analysis of the health information national trends survey (HINTS I) data. Surg Endosc 2007; 22:527-33. [DOI: 10.1007/s00464-007-9673-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2007] [Revised: 07/08/2007] [Accepted: 08/07/2007] [Indexed: 01/10/2023]
|
26
|
Geiger TM, Tebb ZD, Sato E, Miedema BW, Awad ZT. Laparoscopic resection of colon cancer and synchronous liver metastasis. J Laparoendosc Adv Surg Tech A 2006; 16:51-3. [PMID: 16494549 DOI: 10.1089/lap.2006.16.51] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The recommended surgical approach to synchronous colorectal metastasis has not been clarified. Simultaneous open liver and colon resection for synchronous colorectal carcinoma has been shown beneficial when compared to staged resections. A review of the literature has shown the benefits of both laparoscopic colon resection for colorectal cancer and laparoscopic left lateral segmentectomy in liver disease. We present the case of a 60-year-old male with sigmoid colon carcinoma and a synchronous solitary liver metastasis localized to the left lateral segment. Using laparoscopic techniques, we were able to achieve simultaneous resection of the sigmoid colon and left lateral liver segment.
Collapse
Affiliation(s)
- Timothy M Geiger
- Department of Surgery, University of Missouri-Columbia, McHaney Hall 4th Floor, 1 Hospital Drive, Columbia, MO 65212. USA.
| | | | | | | | | |
Collapse
|
27
|
Redston M, Compton CC, Miedema BW, Niedzwiecki D, Dowell JM, Jewell SD, Fleshman JM, Bem J, Mayer RJ, Bertagnolli MM. Analysis of micrometastatic disease in sentinel lymph nodes from resectable colon cancer: results of Cancer and Leukemia Group B Trial 80001. J Clin Oncol 2006; 24:878-83. [PMID: 16418493 DOI: 10.1200/jco.2005.03.6038] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
PURPOSE To determine whether sentinel lymph node (LN) sampling (SLNS) could reduce the number of nodes required to characterize micrometastatic disease (MMD) in patients with potentially curable colon cancer. PATIENTS AND METHODS Cancer and Leukemia Group B 80001 was a study to determine whether SLNS could identify a subset of LNs that predicted the status of the nodal basin for resectable colon cancer and, therefore, could be extensively evaluated for the presence of micrometastases. Patients enrolled onto this study underwent SLNS after injection of 1% isosulfan blue, and both sentinel nodes (SNs) and non-SNs obtained during primary tumor resection were sectioned at multiple levels and stained using anti-carcinoembryonic antigen and anticytokeratin antibodies. RESULTS Using standard histopathology, SNs failed to predict the presence of nodal disease in 13 (54%) of 24 node-positive patients. Immunostains were performed for patients whose LNs were negative by standard histopathology. Depending on the immunohistochemical criteria used to assign LN positivity, SN examination resulted in either an unacceptably high false-positive rate (20%) or a low sensitivity for detection of MMD (40%). CONCLUSION By examining both SNs and non-SNs, this multi-institutional study showed that SNs did not accurately predict the presence of either conventionally defined nodal metastases or MMD. As a result, SLNS is not a useful technique for the study of MMD in patients with colon cancer.
Collapse
Affiliation(s)
- Mark Redston
- Brigham and Women's Hospital, Boston, MA 02115, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Miedema BW. A new repair for midline ventral hernias using a Kugel mesh. Am J Surg 2005; 189:252. [PMID: 15721003 DOI: 10.1016/j.amjsurg.2004.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
29
|
Miedema BW. Comparison of repair techniques for major incisional hernias. Am J Surg 2005; 189:127. [PMID: 15701507 DOI: 10.1016/j.amjsurg.2004.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
30
|
Miedema BW, Ibrahim SM, Davis BD, Koivunen DG. A prospective trial of primary inguinal hernia repair by surgical trainees. Hernia 2004; 8:28-32. [PMID: 12898290 DOI: 10.1007/s10029-003-0151-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2002] [Accepted: 05/28/2003] [Indexed: 12/26/2022]
Abstract
The main hypotheses were that the Lichtenstein inguinal hernia repair has a lower recurrence rate and similar incidence of chronic groin pain compared to sutured repairs when performed by surgical trainees. In a U.S. Veterans Administration Hospital, 150 primary hernia repairs were randomized to a Lichtenstein, McVay, or Shouldice repair. The Shouldice repair included a routine relaxing incision. First- and second-year residents, under the supervision of an experienced general surgeon, performed the procedure. Long-term follow-up was obtained in 81% of patients. Hernia recurrence rate was Lichtenstein 8%, McVay 10%, Shouldice 5% ( P>0.1) at 6-9 years follow-up. More patients had chronic groin pain following Lichtenstein repair (38%) than after Shouldice repair (7%) ( P<0.05). More information is needed on long-term groin pain following anterior mesh repair. The Shouldice inguinal hernia repair may have a role in open primary herniorrhaphy to decrease the risk of chronic groin pain.
Collapse
Affiliation(s)
- B W Miedema
- Department of Surgery, Harry S Truman Veterans Administration Hospital and the University of Missouri Health Center, Columbia, Missouri, USA.
| | | | | | | |
Collapse
|
31
|
Miedema BW. Laparoscopic ventral hernia repair. Surg Endosc 2004; 17:1684; author reply 1685. [PMID: 14702978 DOI: 10.1007/s00464-003-8152-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
32
|
|
33
|
Abstract
OBJECTIVE The inability to tolerate feedings after aortic surgery prolongs hospitalization. The aim of this study was to define jejunal manometric and small bowel transit characteristics associated with the ileus that follows transperitoneal aortic surgery. METHODS Five male patients who underwent transperitoneal infrarenal aortobifemoral bypass had intraoperative placement of a jejunal multilumen catheter. The open abdomen allowed precise placement of pressure recording ports at 20, 22, 24, 26, 28, and 38 cm past the ligament of Treitz. Three-hour manometric studies were done after surgery and for 3 postoperative days. The migrating motor complex was identified visually on the manometric tracings, and pressure waves were identified with computer and a motility index calculated. Motility data were compared with healthy control data previously reported in the literature. Small bowel transit was determined with barium and serial abdominal radiographs. RESULTS All patients had ileus develop with return of bowel sounds at 2 to 7 days (median, 6 days) and flatus at 3 to 9 days (median, 7 days) after surgery. Jejunal motor activity was present within 6 hours of surgery, but the motility index was less in patients then in control subjects. The postoperative migrating motor complexes differed from control subjects in having more phase I, less phase II, and more frequent phase IIIs. Phase III retrograde migration was common in the patients but not in the control subjects. Small bowel transit was 2 days or greater in all patients. CONCLUSION Motor activity is present in the jejunum shortly after aortic surgery. However, the activity is decreased in intensity and the fasting cycle differs from control subjects. Retrograde migration of phase III is the most likely abnormality, resulting in delayed small bowel transit. The data would predict a high rate of enteral feeding intolerance early after surgery. Future studies should focus on pharmacologic manipulation to rapidly return small bowel motility to a more normal state after aortic surgery.
Collapse
Affiliation(s)
- Brent W Miedema
- Department of Surgery, University of Missouri Hospitals & Clinics, and Harry S. Truman VA Hospital, Columbia, 65212, USA.
| | | | | | | | | | | |
Collapse
|
34
|
Abstract
Postoperative nutrition is best provided enterally; however, patients often develop intolerance to enteral feedings. Our aim was to prospectively identify abdominal examination and jejunal pressure activity associated with postoperative intolerance of enteral feedings. Twenty-nine patients underwent abdominal operation and needle catheter jejunostomy placement. Elemental tube feedings were started on the day after surgery and advanced to the caloric goal rate over three days. Patients whose feedings were slowed at the attending surgeon's discretion were defined as intolerant. Jejunal manometry and a standardized abdominal exam were performed on postoperative days 1, 3, and 5. Fifteen patients (52%) were intolerant of tube feedings and had decreased jejunal motor activity but more active bowel sounds prior to feedings. After feedings, intolerant patients developed abdominal distension, but other abdominal findings were inconsistent. A marked decrease in phase II of the migrating motility complex (MMC) and the lack of a fed response were present in both groups. The overall jejunal motility present on day 1 following surgery identifies patients that will not tolerate enteral feedings. The abdominal examination, MMC parameters, and motor response to feeding did not predict feeding intolerance.
Collapse
Affiliation(s)
- B W Miedema
- Department of Surgery, University of Missouri Medical Center and Harry S. Truman Veterans Administration Hospital, Columbia, Missouri, USA
| | | | | | | | | |
Collapse
|
35
|
Phillips JO, Olsen KM, Rebuck JA, Rangnekar NJ, Miedema BW, Metzler MH. A randomized, pharmacokinetic and pharmacodynamic, cross-over study of duodenal or jejunal administration compared to nasogastric administration of omeprazole suspension in patients at risk for stress ulcers. Am J Gastroenterol 2001; 96:367-72. [PMID: 11232677 DOI: 10.1111/j.1572-0241.2001.03522.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aim of this study was to characterize absorption and pH control of simplified omeprazole suspension (SOS), 2 mg/ml in 8.4% sodium bicarbonate, administered via the nasogastric versus jejunal or duodenal route. METHODS Nine critically ill surgical patients, NPO and mechanically ventilated, were enrolled in this randomized cross-over study. Patients received a single 40 mg dose of SOS by the nasogastric and either the jejunal or duodenal route. Twenty-four-hour continuous intragastric pH monitoring was performed during the study period. Sequential blood samples were collected over 24 h to characterize SOS absorption and pharmacokinetic parameters. RESULTS Nasogastric administration of SOS resulted in lower maximum mean +/- SD serum concentrations compared to jejunal/duodenal dosing (0.970 +/- 0.436 vs 1.833 +/- 0.416 microg/ml, p = 0.006). SOS absorption was significantly slower when administered via nasogastric tube (108.3 +/- 42.0 vs 12.1 +/- 7.9 min, p < 0.001). However, all routes of administration resulted in similar SOS area under the serum concentration-time curves (AUC(0-infinity)) (415.1 +/- 291.8 vs 396.7 +/- 388.1 microg x min/ml, p = 0.91) [corrected]. Mean intragastric pH values remained >4 at 1 h after SOS administration and remained >4 for the entire 24-h study (6.32 +/- 1.04, 5.57 +/- 1.15, nasogastric vs jejunal/duodenal, p = 0.015), regardless of administration route. CONCLUSIONS In critically ill surgical patients, pharmacokinetic parameters and subsequent pH control after the administration of SOS are similar by the jejunal, nasogastric, or duodenal route. SOS suspension offers an alternative acid control measure when patients are unable to take oral medications, yet have an enteral tube in place.
Collapse
Affiliation(s)
- J O Phillips
- Department of Surgery, School of Medicine, University of Missouri-Columbia, USA
| | | | | | | | | | | |
Collapse
|
36
|
Shailubhai K, Yu HH, Karunanandaa K, Wang JY, Eber SL, Wang Y, Joo NS, Kim HD, Miedema BW, Abbas SZ, Boddupalli SS, Currie MG, Forte LR. Uroguanylin treatment suppresses polyp formation in the Apc(Min/+) mouse and induces apoptosis in human colon adenocarcinoma cells via cyclic GMP. Cancer Res 2000; 60:5151-7. [PMID: 11016642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
The enteric peptides, guanylin and uroguanylin, are local regulators of intestinal secretion by activation of receptor-guanylate cyclase (R-GC) signaling molecules that produce cyclic GMP (cGMP) and stimulate the cystic fibrosis transmembrane conductance regulator-dependent secretion of Cl- and HCO3-. Our experiments demonstrate that mRNA transcripts for guanylin and uroguanylin are markedly reduced in colon polyps and adenocarcinomas. In contrast, a specific uroguanylin-R-GC, R-GCC, is expressed in polyps and adenocarcinomas at levels comparable with normal colon mucosa. Activation of R-GCC by uroguanylin in vitro inhibits the proliferation of T84 colon cells and elicits profound apoptosis in human colon cancer cells, T84. Therefore, down-regulation of gene expression and loss of the peptides may interfere with renewal and/or removal of the epithelial cells resulting in the formation of polyps, which can progress to malignant cancers of the colon and rectum. Oral replacement therapy with human uroguanylin was used to evaluate its effects on the formation of intestinal polyps in the Min/+ mouse model for colorectal cancer. Uroguanylin significantly reduces the number of polyps found in the intestine of Min/+ mice by approximately 50% of control. Our findings suggest that uroguanylin and guanylin regulate the turnover of epithelial cells within the intestinal mucosa via activation of a cGMP signaling mechanism that elicits apoptosis of target enterocytes. The intestinal R-GC signaling molecules for guanylin regulatory peptides are promising targets for prevention and/or therapeutic treatment of intestinal polyps and cancers by oral administration of human uroguanylin.
Collapse
Affiliation(s)
- K Shailubhai
- Cancer Chemoprevention Group Nutrition Sector, Monsanto Life Sciences Company, St. Louis, Missouri 63167, USA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Patel M, Miedema BW, James MA, Marshall JB. Percutaneous cholecystostomy is an effective treatment for high-risk patients with acute cholecystitis. Am Surg 2000; 66:33-7. [PMID: 10651344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
We sought to determine the safety, efficacy, and outcome of percutaneous cholecystostomy (PC) in all patients undergoing the procedure at our institutions. We reviewed 53 consecutive cases of acute cholecystitis seen at our hospitals over 5.5 years in which PC was performed at the initial treatment. Follow-up was obtained by chart review and telephone questionnaire. Acute cholecystitis was the primary admitting diagnosis in 18 cases. In the remaining 35, cholecystitis developed during hospitalization. All patients were considered high surgical risks on the basis of the presence of comorbid conditions. The gallbladder was successfully catheterized under radiologic guidance in all patients and with no immediate procedure-related morbidity. Acute cholecystitis resolved in 44 of 53 patients (83%), whereas nine patients (17%) did not improve clinically after PC and died during the same hospitalization. A total of 33 (62%) eventually survived hospitalization. Elective cholecystectomy was done in 25 patients with no mortality. After cholecystectomy, three of these patients subsequently died of other causes, whereas 22 are alive. Eight patients did not undergo cholecystectomy because of underlying medical conditions or because they had acalculous cholecystitis. These patients remained free of biliary problems after removal of their cholecystostomy tube, but two have subsequently died of nonbiliary conditions. Percutaneous cholecystostomy is a safe, effective treatment for high-risk patients with acute cholecystitis. Cholecystostomy can be followed by elective cholecystectomy at a later time if the patient's condition permits or by expectant conservative management in patients who have had acalculous cholecystitis or have a very high mortality risk with surgery.
Collapse
Affiliation(s)
- M Patel
- Division of Gastroenterology, University of Missouri Hospital and Clinics, Columbia, USA
| | | | | | | |
Collapse
|
38
|
Patel M, Miedema BW, James MA, Marshall JB. Percutaneous Cholecystostomy is an Effective Treatment for High-Risk Patients with Acute Cholecystitis. Am Surg 2000. [DOI: 10.1177/000313480006600107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We sought to determine the safety, efficacy, and outcome of percutaneous cholecystostomy (PC) in all patients undergoing the procedure at our institutions. We reviewed 53 consecutive cases of acute cholecystitis seen at our hospitals over 5.5 years in which PC was performed at the initial treatment. Follow-up was obtained by chart review and telephone questionnaire. Acute cholecystitis was the primary admitting diagnosis in 18 cases. In the remaining 35, cholecystitis developed during hospitalization. All patients were considered high surgical risks on the basis of the presence of comorbid conditions. The gallbladder was successfully catheterized under radiologic guidance in all patients and with no immediate procedure-related morbidity. Acute cholecystitis resolved in 44 of 53 patients (83%), whereas nine patients (17%) did not improve clinically after PC and died during the same hospitalization. A total of 33 (62%) eventually survived hospitalization. Elective cholecystectomy was done in 25 patients with no mortality. After cholecystectomy, three of these patients subsequently died of other causes, whereas 22 are alive. Eight patients did not undergo cholecystectomy because of underlying medical conditions or because they had acalculous cholecystitis. These patients remained free of biliary problems after removal of their cholecystostomy tube, but two have subsequently died of nonbiliary conditions. Percutaneous cholecystostomy is a safe, effective treatment for high-risk patients with acute cholecystitis. Cholecystostomy can be followed by elective cholecystectomy at a later time if the patient's condition permits or by expectant conservative management in patients who have had acalculous cholecystitis or have a very high mortality risk with surgery.
Collapse
Affiliation(s)
- Mrunal Patel
- Division of Gastroenterology, University of Missouri Hospital and Clinics and Harry S Truman Veterans Affairs Hospital, Columbia, Missouri
| | - Brent W. Miedema
- General Surgery, University of Missouri Hospital and Clinics and Harry S Truman Veterans Affairs Hospital, Columbia, Missouri
| | - Mark A. James
- Radiology, University of Missouri Hospital and Clinics and Harry S Truman Veterans Affairs Hospital, Columbia, Missouri
| | - John B. Marshall
- Division of Gastroenterology, University of Missouri Hospital and Clinics and Harry S Truman Veterans Affairs Hospital, Columbia, Missouri
| |
Collapse
|
39
|
Abstract
BACKGROUND AND OBJECTIVES The use of continuous infusion 5-Fluorouracil (5-FU) immediately after surgery may improve the adjuvant treatment of resected colon cancer and is the subject of a national phase III trial (Intergroup no. 0136). The aim was to determine the effect of continuous infusion 5-FU on the bursting pressure of a colon anastomosis. METHODS Twenty Lewis rats weighing approximately 300 g were subject to sigmoid colectomy and single-layer anastomosis. Ten rats received 5-FU continuously at 600 mg/m2 per day for 7 days; 10 rats served as controls. Ten days postoperatively, the rats were sacrificed and bursting pressure of the colon containing the anastomosis was determined. RESULTS No anastomotic leaks or intra-abdominal abscesses were identified. Burst pressure of the colon in controls (124+/-13 mm Hg; mean+/-SEM) was not significantly different from those animals receiving 5-FU (115+/-9, P > 0.05). The control rats gained weight (13+/-7 g), which is significantly different from the rats receiving 5-FU (-19+/-13, P=0.04). CONCLUSIONS Continuous infusion 5-FU postoperatively results in weight loss, but does not affect anastomotic bursting strength in rats. This evidence supports the safety of continuous infusion 5-FU postoperatively in humans.
Collapse
Affiliation(s)
- G P Yazdi
- Department of Surgery, Harry S. Truman VA Hospital, University of Missouri-Ellis Fischel Cancer Center, Columbia, USA
| | | | | |
Collapse
|
40
|
Abstract
BACKGROUND AND OBJECTIVES The use of continuous infusion 5-Fluorouracil (5-FU) immediately after surgery may improve the adjuvant treatment of resected colon cancer and is the subject of a national phase III trial (Intergroup no. 0136). The aim was to determine the effect of continuous infusion 5-FU on the bursting pressure of a colon anastomosis. METHODS Twenty Lewis rats weighing approximately 300 g were subject to sigmoid colectomy and single-layer anastomosis. Ten rats received 5-FU continuously at 600 mg/m2 per day for 7 days; 10 rats served as controls. Ten days postoperatively, the rats were sacrificed and bursting pressure of the colon containing the anastomosis was determined. RESULTS No anastomotic leaks or intra-abdominal abscesses were identified. Burst pressure of the colon in controls (124+/-13 mm Hg; mean+/-SEM) was not significantly different from those animals receiving 5-FU (115+/-9, P > 0.05). The control rats gained weight (13+/-7 g), which is significantly different from the rats receiving 5-FU (-19+/-13, P=0.04). CONCLUSIONS Continuous infusion 5-FU postoperatively results in weight loss, but does not affect anastomotic bursting strength in rats. This evidence supports the safety of continuous infusion 5-FU postoperatively in humans.
Collapse
Affiliation(s)
- G P Yazdi
- Department of Surgery, Harry S. Truman VA Hospital, University of Missouri-Ellis Fischel Cancer Center, Columbia, USA
| | | | | |
Collapse
|
41
|
Abstract
BACKGROUND Gallstones are the most common cause of acute pancreatitis during pregnancy. Without intervention, gallstone pancreatitis during pregnancy is associated with an antepartum recurrence rate of 70%, which exposes the mother and fetus to an increased risk of morbidity and mortality. A safe, effective means to prevent recurrent gallstone pancreatitis during pregnancy is desirable. METHODS Since 1991, we have managed gallstone pancreatitis in three pregnant patients with endoscopic retrograde cholangiogram (ERC), followed by spincterotomy, despite the absence of common bile duct stones. RESULTS All patients were judged to have mild pancreatitis by modified Ranson criteria and the Multiorgan System Failure criteria. During cholangiogram, fetal shielding was employed and fluoroscopy times ranged from 36 s to 7.2 min. One patient experienced postprocedure pancreatitis of 48-h duration. None of the patients experienced further episodes of pancreatitis and none underwent predelivery cholecystectomy. CONCLUSIONS In pregnancy-associated gallstone pancreatitis, endoscopic sphincterotomy prevents recurrence of pancreatitis and the need for cholecystectomy during gestation. We believe endoscopic sphincterotomy represents a promising management alternative for gallstone pancreatitis during pregnancy. Further investigation is warranted.
Collapse
Affiliation(s)
- J S Barthel
- Division of Gastroenterology, Department of Medicine, MA-421, University of Missouri School of Medicine, Columbia, MO 65212, USA
| | | | | |
Collapse
|
42
|
Abstract
Lymph node metastasis is the most important predictor of prognosis, after surgery, in colorectal carcinoma. The term "micrometastasis" has evolved from a morphological definition to one that is used with molecular-based techniques. We review the literature to evaluate the significance of detecting micrometastases in colorectal carcinoma, either by morphological or molecular techniques, and address technical difficulties encountered with both. Routine use of immunohistochemistry is not recommended as most studies show little change in staging or prognosis. Radioimmunoguided surgery may prove beneficial, but problems of false positives in benign diseases need to be addressed. Immunohistochemical detection of micrometastatic deposits in bone marrow aspirates holds the most promise for clinical practice. Molecular techniques are more sensitive than immunohistochemistry, but prognostic value needs to be determined. Molecular diagnostics can also determine genetic alterations and mutations that should improve our understanding of metastatic colon cancer and staging accuracy.
Collapse
Affiliation(s)
- R Calaluce
- Department of Pathology and Anatomical Sciences, Ellis Fischel Cancer Center and Harry S. Truman Veterans Administration Hospital, University of Missouri, Columbia 65203, USA.
| | | | | |
Collapse
|
43
|
Abstract
Lymph node metastasis is the most important predictor of prognosis, after surgery, in colorectal carcinoma. The term "micrometastasis" has evolved from a morphological definition to one that is used with molecular-based techniques. We review the literature to evaluate the significance of detecting micrometastases in colorectal carcinoma, either by morphological or molecular techniques, and address technical difficulties encountered with both. Routine use of immunohistochemistry is not recommended as most studies show little change in staging or prognosis. Radioimmunoguided surgery may prove beneficial, but problems of false positives in benign diseases need to be addressed. Immunohistochemical detection of micrometastatic deposits in bone marrow aspirates holds the most promise for clinical practice. Molecular techniques are more sensitive than immunohistochemistry, but prognostic value needs to be determined. Molecular diagnostics can also determine genetic alterations and mutations that should improve our understanding of metastatic colon cancer and staging accuracy.
Collapse
Affiliation(s)
- R Calaluce
- Department of Pathology and Anatomical Sciences, Ellis Fischel Cancer Center and Harry S. Truman Veterans Administration Hospital, University of Missouri, Columbia 65203, USA.
| | | | | |
Collapse
|
44
|
Abstract
This study evaluated whether twice daily isotonic perfusion of the bypassed ileum for six weeks would enhance its motor activity and its absorption of fluids, electrolytes, and vitamin B12. The study also determined if patients undergoing perfusion had improved bowel function and decreased hospital stay after ileostomy closure. Following proctocolectomy, ileal pouch-anal canal anastomosis, and diverting loop ileostomy, six patients self-infused an isotonic solution (sucrose and sodium chloride) into the bypassed ileum twice daily, while seven patients did not (controls). Two months following proctocolectomy, and just prior to ileostomy closure, a manometric catheter assembly was placed into the unused distal ileum via the stoma and the distal ileum perfused with an isotonic sodium chloride solution for 3 hr during fasting and 3 hr after a meal. Absorption was measured, single and clustered pressure waves were identified, and a motility index was calculated. Water absorption, motility index, and cluster parameters did not improve in perfused patients compared to controls during fasting or after a meal, nor did perfused patients have improved vitamin B12 absorption. The perfused patients also did no better clinically following ileostomy takedown; the onset of bowel movements, their frequency, time to tolerate a diet, and hospital stay were similar to controls. We conclude that six weeks of twice daily isotonic perfusion did not improve motor activity or water, electrolyte, and vitamin B12 absorption in the bypassed distal ileum after proctocolectomy, ileal pouch-anal canal anastomosis, and loop ileostomy. The perfusion also did not improve bowel function after ileostomy takedown.
Collapse
Affiliation(s)
- B W Miedema
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | | |
Collapse
|
45
|
Abstract
BACKGROUND We sought to determine whether a reduced gallbladder ejection fraction, (GBEF) ascertained by cholecystokinin-cholescintigraphy (CCK-CS), predicts symptomatic improvement after cholecystectomy. METHODS Medical records of patients who had had CCK-CS as well as negative results of gallbladder ultrasonography were reviewed, and patients were contacted by telephone to determine whether they had benefited from cholecystectomy. RESULTS There were 35 patients (33 female, 2 male) who had a decreased GBEF. Cholecystectomy was done in 30, of whom 20 (67%) had resolution of pain, 8 (27%) had partial improvement, and 2 (7%) had no change. The 5 who declined cholecystectomy included none (0%) who were pain free, 2 (40%) who had partial improvement, and 3 (60%) who had no change. The clinical outcome of the two groups was significantly different. There were 14 patients (10 female, 4 male) with a normal GBEF. The 2 patients who had cholecystectomy were asymptomatic. Of the 12 patients who did not have cholecystectomy, 9 (75%) were asymptomatic, 1 (8%) had some improvement, and 2 (17%) had no change. CONCLUSIONS Cholecystectomy is indicated for patients with acalculous biliary pain and reduced GBEF, since symptoms will likely resolve with surgery and will persist without it. Cholecystectomy for patients with a normal GBEF should be considered only after failure of a nonoperative trial, since improvement usually occurs over time.
Collapse
Affiliation(s)
- R Khosla
- Division of Gastroenterology, University of Missouri Hospital and Clinics, Columbia, USA
| | | | | | | |
Collapse
|
46
|
Abstract
Advanced intra-abdominal cancers are frequently associated with malignant ascites. The aim of this study was to document the frequency and clinical course of patients found to have large-volume ( > or = 3 L) malignant ascites when undergoing a major abdominal operation. Between October 1, 1987 and September 1, 1992, 385 patients with malignant ascites were admitted to hospitals associated with a university medical center. Seventeen with large volume ascites underwent exploration for palliation of bowel obstruction or debulking of tumor. Operative mortality was 41% and mortality correlated with the presence of a nonovarian primary and advanced age. We conclude that patients with large volume nonovarian malignant ascites have a high mortality rate following a major abdominal operation. New approaches such as neoadjuvant or intraperitoneal chemotherapy or possibly peritoneovenous shunt placement at the time of the abdominal operation, are needed to improve the dismal results in this subgroup of patients.
Collapse
Affiliation(s)
- G P Yazdi
- Department of Surgery, University Hospital & Clinics, Columbia, Missouri 65212, USA
| | | | | |
Collapse
|
47
|
Scheer MF, Miedema BW. Laparoscopic assisted percutaneous endoscopic gastrostomy. Surg Laparosc Endosc Percutan Tech 1995; 5:483-6. [PMID: 8611999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Percutaneous endoscopic gastrostomy (PEG) cannot be accomplished in some patients and should not be performed if a distinct indentation in the stomach is not seen with finger pressure on the abdominal wall. We describe a technique of laparoscopic assisted PEG as an alternative to evaluate the intraabdominal organs after failed PEG placement. A needle is placed percutaneously into the stomach under laparoscopic and gastroscopic control. A wire is placed through the needle, encircled with a snare, and the PEG completed. We have performed this technique in three patients without complication. This simple and safe procedure has become our technique of choice for gastrostomy tube placement in those patients where upper endoscopy is possible but a PEG alone cannot be performed safely.
Collapse
Affiliation(s)
- M F Scheer
- Department of Surgery, University of Missouri Hospital and Clinics, Columbia, USA
| | | |
Collapse
|
48
|
Affiliation(s)
- D N Brown
- Division of Gastroenterology, University of Missouri Hospital and Clinics, Columbia, USA
| | | | | | | |
Collapse
|
49
|
Scheider DM, King PD, Miedema BW. Ascites and secondary bacterial peritonitis associated with small bowel obstruction. Am J Gastroenterol 1994; 89:1238-40. [PMID: 8053442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Wide albumin gradient (transudative) ascites is usually due to liver disease but may also result from many other disorders, including heart failure, hepatic infiltration by tumor, hepatic vein thrombosis, and veno-occlusive disease. It has not been linked with small bowel obstruction. Narrow albumin gradient (exudative) ascites, usually due to peritoneal carcinoma or inflammation, has been noted in cases of necrotic or perforated bowel, but simple small bowel obstruction has not previously been appreciated as a possible cause for ascites. We report a patient who developed wide albumin gradient ascites and secondary bacterial peritonitis in association with small bowel obstruction. The small bowel obstruction, ascites, and peritonitis resolved with lysis of a single abdominal adhesion.
Collapse
Affiliation(s)
- D M Scheider
- Department of Internal Medicine, University of Missouri Health Sciences Center, Columbia
| | | | | |
Collapse
|
50
|
Sexe R, Miedema BW. Rectal cancer. Postgrad Med 1993; 94:183-193. [PMID: 29219677 DOI: 10.1080/00325481.1993.11945687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Preview When in rectal cancer surgery can the anal sphincter be spared? For which patients is iliac lymphadenectomy advisable? Should radiation therapy and chemotherapy be given before surgery rather than after? Drs Sexe and Miedema address these and other questions in this discussion of recent advances and future trends in therapy for rectal cancer.
Collapse
|