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Brunner WC, Sierra R, Dunne JB, Simmang CL, Scott DJ. Incidental paraduodenal hernia found during laparoscopic colectomy. Hernia 2004; 8:268-70. [PMID: 14986175 DOI: 10.1007/s10029-004-0207-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [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: 05/13/2003] [Accepted: 12/11/2003] [Indexed: 11/25/2022]
Abstract
This paper describes a rare right paraduodenal hernia discovered during an elective laparoscopic colon resection. Our patient was a 60-year-old Asian man with a history of multiple bouts of diverticulitis and a lifelong history of mild constipation and postprandial abdominal pain. Prior CT scans and preoperative barium enema confirmed the diagnosis of diverticular disease, and no other abnormalities were appreciated. At laparoscopic exploration, a right paraduodenal hernia was found with complete herniation of the small intestine under the ascending colon and hepatic flexure. The unclear anatomy prompted conversion to an open laparotomy. This allowed safe reduction of the hernia and sac excision. Adhesions were lysed to relieve a partial duodenal obstruction, and a Ladd's procedure was performed to correct the incomplete rotation. Additionally, a sigmoid colectomy was performed. After prolonged ileus, the patient was discharged on postoperative day 14. At 6-month follow-up, the patient was asymptomatic and doing well.
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Affiliation(s)
- W C Brunner
- Tulane Center for Minimally Invasive Surgery, Tulane University Health Sciences Center, New Orleans, La., USA
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Lowry AC, Simmang CL, Boulos P, Farmer KC, Finan PJ, Hyman N, Killingback M, Lubowski DZ, Moore R, Penfold C, Savoca P, Stitz R, Tjandra JJ. Consensus statement of definitions for anorectal physiology and rectal cancer. ANZ J Surg 2001; 71:603-5. [PMID: 11552936 DOI: 10.1046/j.1445-2197.2001.02204.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Lowry AC, Simmang CL, Boulos P, Farmer KC, Finan PJ, Hyman N, Killingback M, Lubowski DZ, Moore R, Penfold C, Savoca P, Stitz R, Tjandra JJ. Consensus statement of definitions for anorectal physiology and rectal cancer: report of the Tripartite Consensus Conference on Definitions for Anorectal Physiology and Rectal Cancer, Washington, D.C., May 1, 1999. Dis Colon Rectum 2001; 44:915-9. [PMID: 11496067 DOI: 10.1007/bf02235475] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- A C Lowry
- American Society of Colon and Rectal Surgeons
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Lowry AC, Simmang CL, Boulos P, Farmer KC, Finan PJ, Hyman N, Killingback M, Lubowski DZ, Moore R, Penfold C, Savoca P, Stitz R, Tjandra JJ. Consensus statement of definitions for anorectal physiology and rectal cancer. Colorectal Dis 2001; 3:272-5. [PMID: 12790974 DOI: 10.1046/j.1463-1318.2001.00269.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- A C Lowry
- University of Texas Southwestern Medical Center, Dallas, 75390-9156, USA
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Abstract
PURPOSE With improved antiretroviral therapy, HIV-positive patients are achieving a longer life expectancy. An increased incidence of anal squamous cell carcinomas has been noted in these patients. The purpose of this study was to determine the outcome of HIV-positive patients with anal squamous cell carcinomas. METHODS We conducted a review based on our tumor registry from 1980 through 1999. We identified 73 patients with anal squamous cell carcinoma treated at the University of Texas Southwestern Medical Center affiliated hospitals; 23 were HIV positive (18 had AIDS). In the HIV-positive group, 9 had in situ squamous carcinomas and 14 had invasive squamous cell carcinomas. Data collected included age, CD4 count, treatment, complications, and survival; these data were analyzed by Student's t-test. RESULTS All patients were male. Those with squamous cell cancer of the anus were offered radiation therapy and chemotherapy. Beginning in 1998, all patients received highly active antiretroviral therapy before treatment. Seven of 14 anal squamous cell carcinoma patients had their therapy adjusted owing to toxicity. Morbidity included proctocolitis and diarrhea (n = 2) requiring diversion (n = 1), hemorrhagic cystitis (n = 1), neutropenic fever (n = 3), bone marrow suppression (n = 1), and urethral stricture (n = 1). Mean age was 42 years for anal squamous cell carcinoma patients and 36 years for squamous cell carcinoma in situ patients (P = 0.05). Mean CD4 count was 222 cells/ml in patients with infiltrating carcinoma and 200 in the in situ patients (P = NS). One-year and five-year mortality rates, respectively, were 40 percent and 80 percent for infiltrating carcinoma patients and 17 percent and 50 percent for the in situ patients. Both of the in situ patients who died had CD4 counts <20 cells/ml at diagnosis, whereas the rest had CD4 counts >100 cells/ml and are currently without anal disease. Mean CD4 count at diagnosis for all patients who died was 133 cells/ml, whereas for those surviving, it was 261 cells/ml (P = 0.03). Eight (all with infiltrating carcinoma) of the 10 patients who died had persistent anal disease, but none had metastasis. CONCLUSION HIV-positive patients with in situ carcinomas present at an earlier age than those with infiltrating lesions. In situ patients with CD4 counts as low as 105 cells/ml do well with local excision. A low CD4 count at diagnosis without highly active antiretroviral therapy predicts a poor prognosis. Because these patients appear to succumb to their HIV status and not the anal disease, anal squamous cell carcinoma should be included with cervical squamous cell carcinoma as an AIDS-defining illness. HIV-positive patients, particularly AIDS patients, with invasive anal cancers and without effective antiretroviral therapy obtain little benefit and significant toxicity from current radiation therapy and chemotherapy. Initiation of highly active antiretroviral therapy in HIV-positive patients before radiation therapy and chemotherapy are begun may decrease toxicity and improve survival. Additional clinical trials are warranted to test this theory.
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Affiliation(s)
- R J Place
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas 75390-9156, USA
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Abstract
PURPOSE The purpose of this study was to evaluate the effectiveness of ketorolac combined with local anesthetics for anorectal surgery. METHODS From June 1998 through March 1999, 123 outpatients undergoing anorectal surgery were entered into a prospective, randomized, double-blinded study involving three treatment groups. All patients received intravenous sedation consisting of fentanyl and a propofol infusion, with a local anesthesia mixture of lidocaine, bupivacaine, and bicarbonate. Group A (41 patients) received placebo (saline) injections. Group B (41 patients) received 60 mg of intravenous ketorolac at the onset of the procedure, and Group C (41 patients) received 60 mg of ketorolac mixed with the local anesthetic. Data were analyzed using analysis of variance and chi-squared tests. RESULTS All groups had similar demographic characteristics and operative procedures. Twenty-nine of the 123 patients were human immunodeficiency virus-positive. There was no difference in operative or anesthesia time. Anesthesia and fluids given were similar in across groups. A significantly higher percentage of Group A patients had pain (34 percent) and required additional oral analgesia (20 percent) in the Day Surgery Unit. Only 5 percent of Group B and Group C patients complained of pain, with oral analgesics given to 2 percent of Group B and none in Group C. Voiding difficulties were more common in Group A patients, one patient requiring catheterization. CONCLUSION The addition of ketorolac (60 mg), either intravenous or injected with local anesthetics, reduces voiding problems and significantly decreases postoperative analgesic requirements in outpatients undergoing anorectal surgery.
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Affiliation(s)
- R J Place
- Department of Surgery, University of Texas Southwestern School of Medicine, Dallas, USA
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Affiliation(s)
- T Anthony
- Division of Surgical Oncology, University of Texas, Southwestern Medical Center, Dallas 75235-9031, USA
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Place RJ, Simmang CL, Huber PJ. Appendiceal diverticulitis. South Med J 2000; 93:76-9. [PMID: 10653074] [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 report the case of a 56-year-old man with episodic right lower quadrant abdominal pain. Preoperative evaluation included computed tomography (CT) showing a right lower quadrant phlegmon consistent with cecal diverticulitis or appendicitis. The patient was treated with a short course of bowel rest and antibiotics. Four weeks later, he had an appendectomy. The patient was found to have chronic appendiceal diverticulitis and recovered uneventfully. Histopathologic studies revealed herniated mucosa through the muscular layer associated with chronic inflammation and marked fibrosis. These findings represent appendiceal diverticulitis. Diverticulosis of the appendix is believed to be uncommon and roentgenologic diagnosis of appendiceal diverticular disease is rarely made. We discuss the diagnosis and CT findings of appendiceal diverticulitis and present a thorough review of the literature.
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Affiliation(s)
- R J Place
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas 75235, USA
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Abstract
BACKGROUND AND OBJECTIVE Primary lymphoma of the anus is an extremely rare problem. In patients with the Acquired Immune Deficiency Syndrome (AIDS), there is a marked increase in gastrointestinal non-Hodgkin's lymphomas (NHL). The aim of this study was to evaluate the outcome of patients with anorectal NHL and AIDS. METHODS Over an 18-year period, we identified 6 patients with AIDS and primary anorectal NHL. Five were male. All were high-grade B-cell lymphomas and half showed systemic "B" symptoms. Patient's mean CD4 count was 93 (range 8 to 201). RESULTS The average life span for those with "B" symptoms was 6.7 months and 16 months for those without symptoms. No benefit was shown from radiation or chemotherapy in those with "B" symptoms. Younger patients and those without systemic constitutional symptoms of lymphoma do better. One patient without "B" symptoms was able to tolerate his radiation and chemotherapy and is disease free at 10 months. CONCLUSION Despite traditional non-Hodgkin's lymphoma treatment regimens, our AIDS patients (and those examined in a review of the pertinent literature) with anorectal NHL and "B" symptoms have a poor prognosis. For those without "B" symptoms and who can tolerate the therapy, NHL remission may be obtained.
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Affiliation(s)
- R J Place
- Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Simmang CL, Senatore P, Lowry A, Hicks T, Burnstein M, Dentsman F, Fazio V, Glennon E, Hyman N, Kerner B, Kilkenny J, Moore R, Peters W, Ross T, Savoca P, Vernava A, Wong WD. Practice parameters for detection of colorectal neoplasms. The Standards Committee, The American Society of Colon and Rectal Surgeons. Dis Colon Rectum 1999; 42:1123-9. [PMID: 10496550 DOI: 10.1007/bf02238562] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Simmang CL, Huber PJ, Guzzetta P, Crockett J, Martinez R. Posterior sagittal anorectoplasty in adults: secondary repair for persistent incontinence in patients with anorectal malformations. Dis Colon Rectum 1999; 42:1022-7. [PMID: 10458125 DOI: 10.1007/bf02236695] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [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: 02/08/2023]
Abstract
PURPOSE Posterior sagittal anorectoplasty, regarded as a standard surgical primary repair for anorectal malformations in infancy, was evaluated for effectiveness when performed as a secondary operation for establishing continence in the adult. The purpose of this review was to evaluate our results of performing posterior sagittal anorectoplasty in adult patients and to emphasize the extensive evaluation required to perform proper patient selection. METHOD From January 1, 1992, to December 31, 1996, eight patients with Grade 3 incontinence underwent posterior sagittal anorectoplasty. The ages ranged from 13 to 40 (mean, 26) years. RESULTS All patients had diverting stomas at the time of repair and all but one had restoration of intestinal continuity. Of eight patients who underwent posterior sagittal anorectoplasty, one failed secondary to rectal ischemia and retained a diverting stoma. Six patients had restoration of continuity. Five patients were continent and one had incontinence only to gas. DISCUSSION We have established that posterior sagittal anorectoplasty can effectively be used to establish continence as a secondary procedure for a select group of adult patients.
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Affiliation(s)
- C L Simmang
- University of Texas Southwestern Medical Center, Dallas 75235-9156, USA
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Abstract
BACKGROUND Although the syndrome of familial adenomatous polyposis is well known, sporadic patients with multiple polyposis are rare. There are no known syndromes associated with hyperplastic polyposis. In our search of the English surgical literature, we find no reference to a hyperplastic-adenomatous polyposis syndrome. STUDY DESIGN Over a 3-year period, we identified six patients ages 41 to 75 (mean age 61) with 50 to 100 hyperplastic polyps associated with adenomas. RESULTS Most of the hyperplastic polyps were found in the left colon and the largest ranged in size from 6 mm to 18 mm. The larger polyps were clinically indistinguishable from adenomas. Three of our six patients had invasive cancer of the proximal colon. All tumors were confined to the bowel wall. There was a family history of colon cancer in only one patient and no family history of polyposis. CONCLUSION These patients differ from previously described patients with polyposis syndromes; hyperplastic-adenomatous polyposis syndrome (HAPS) occurs in an older population with no family history of polyposis, has fewer polyps, most of which are hyperplastic, and is strongly associated with adenocarcinoma of the colon. In this series, we describe a previously unreported hyperplastic-adenomatous polyposis syndrome.
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Affiliation(s)
- R J Place
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas 75235-9156, USA
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Abstract
Successful repair of rectovaginal fistula in patients with Crohn's disease has been reported when these patients have a normal appearing rectum. We report the performance of stricturectomy in conjunction with circumferential rectal sleeve advancement for patients who have a rectovaginal fistula arising from an anorectal stricture secondary to Crohn's disease. This technique provides for repair of rectovaginal fistula and correction of the anal stricture and maintains continence.
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Affiliation(s)
- C L Simmang
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas 75235-9156, USA
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Abstract
PURPOSE A case of an adult patient with the anorectal malformation of a rectovestibular fistula successfully repaired by performing a posterior sagittal anorectoplasty is reported. This case should increase the awareness of both primary and secondary anorectal malformations in the adult patient. METHODS Management and outcome of an adult patient who presented with a rectovaginal fistula and underwent primary operative correction of her anorectal malformation using posterior sagittal anorectoplasty is reviewed. RESULTS Total continence was achieved in an adult patient undergoing primary repair of a rectovaginal fistula using posterior sagittal anorectoplasty. CONCLUSION Posterior sagittal anorectoplasty can be successfully performed in the adult patient for a primary repair of anorectal malformations. This operation should be considered in patients who have undergone another prior operative procedure with less than optimum function and now desire a secondary corrective procedure.
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Affiliation(s)
- C L Simmang
- Department of Surgery, The University of Texas Southwestern Medical Center, Dallas 75235-9156, USA
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Fleshman JW, Brunt LM, Fry RD, Birnbaum EH, Simmang CL, Mazor A, Soper N, Freeman L, Kodner IJ. Laparoscopic anterior resection of the rectum using a triple stapled intracorporeal anastomosis in the pig. Surg Laparosc Endosc Percutan Tech 1993; 3:119-26. [PMID: 8269231] [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: 01/29/2023]
Abstract
Laparoscopic anterior resection of the rectum was performed in the porcine model. Colorectal anastomosis was accomplished with a closed triple staple technique using a circular stapler. The anvil and shaft were passed beyond the level of resection and retrieved through the proximal transverse linear cutter staple line. The stapler post was passed through the distal rectal staple line transanally. The resulting stapled anastomosis contained portions of three staple lines. There were no anastomotic leaks or strictures at one month follow-up autopsy. The triple-stapled anastomosis via a laparoscopic approach after an anterior resection of the rectum in a pig is a safe, reliable technique.
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Affiliation(s)
- J W Fleshman
- Washington University Medical School, St. Louis, Missouri
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Simmang CL, Reed K, Rosenthal D. Leiomyomas of the gastrointestinal tract. Mil Med 1989; 154:45-7. [PMID: 2493607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Sixteen patients with leiomyoma of the gastrointestinal tract underwent operation and removal of their tumor during a four- and one-half-year period from January 1980 to July 1984. There were three esophageal, five gastric, two small bowel, four colon, and two anorectal leiomyomas. The majority of gastric leiomyomas presented with bleeding, as did half of the small bowel and colon cases. All were treated by excision without mortality. The various clinical presentations, evaluations, and choice of operative approach for this uncommon tumor are discussed.
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