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Gunderson LL, Martenson JA, Kvols LK, Devine RM, Beart RW. Indications for and results of intraoperative irradiation for locally advanced colorectal cancer. Front Radiat Ther Oncol 2015; 25:284-306; discussion 330-3. [PMID: 1908419 DOI: 10.1159/000429599] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- L L Gunderson
- Department of Radiation Oncology, Mayo Clinic, Mayo Medical School, Rochester, Minn
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Abstract
BACKGROUND Presacral tailgut cysts are uncommon and few data exist on the outcomes following surgery. METHODS Patients undergoing tailgut cyst resection at the Mayo Clinic between 1985 and 2008 were analysed retrospectively. Demographic data, clinicopathological features, operative details, postoperative complications and recurrence were reviewed. RESULTS Thirty-one patients were identified (28 women), with a median age of 52 years. Seventeen patients were symptomatic and 28 had a palpable mass on digital rectal examination. Median cyst diameter was 4.4 cm. Four patients had a fistula to the rectum. Complete cyst excision was achieved in all patients; eight underwent distal sacral resection or coccygectomy. Postoperative complications occurred in eight patients but without 30-day mortality. Malignant transformation was present in four patients: adenocarcinoma in three and carcinoid in one. The cyst recurred in one patient after surgery for a benign lesion. CONCLUSION Presacral tailgut cysts should be removed due to the risk of malignant transformation.
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Affiliation(s)
- K L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA
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3
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Schwartz DA, Wiersema MJ, Dudiak KM, Fletcher JG, Clain JE, Tremaine WJ, Zinsmeister AR, Norton ID, Boardman LA, Devine RM, Wolff BG, Young-Fadok TM, Diehl NN, Pemberton JH, Sandborn WJ. A comparison of endoscopic ultrasound, magnetic resonance imaging, and exam under anesthesia for evaluation of Crohn's perianal fistulas. Gastroenterology 2001; 121:1064-72. [PMID: 11677197 DOI: 10.1053/gast.2001.28676] [Citation(s) in RCA: 323] [Impact Index Per Article: 14.0] [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: 12/13/2022]
Abstract
BACKGROUND & AIMS To determine accuracy of endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI) for evaluation of Crohn's disease perianal fistulas. METHODS Thirty-four patients with suspected Crohn's disease perianal fistulas were prospectively enrolled in a blinded study comparing EUS, MRI, and examination under anesthesia (EUA). Fistulas were classified according to Parks' criteria, and a consensus gold standard was determined for each patient. Acceptable accuracy was defined as agreement with the consensus gold standard for > or =85% of patients. RESULTS Three patients did not undergo MRI; 1 did not undergo EUS or EUA; and consensus could not be reached for 1. Thirty-two patients had 39 fistulas (20 trans-sphincteric, 5 extra-sphincteric, 6 recto-vaginal, 8 others) and 13 abscesses. The accuracy of all 3 modalities was > or =85%: EUS 29 of 32 (91%, confidence interval [CI] 75%-98%), MRI 26 of 30 (87%, CI 69%-96%), and EUA 29 of 32 (91%, CI 75%-98%). Accuracy was 100% when any 2 tests were combined. CONCLUSIONS EUS, MRI, and EUA are accurate tests for determining fistula anatomy in patients with perianal Crohn's disease. The optimal approach may be combining any 2 of the 3 methods.
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Affiliation(s)
- D A Schwartz
- The Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Wilson CL, Song LM, Chua H, Ferrara M, Devine RM, Dozois RR, Nehra V. Bleeding from cavernous angiomatosis of the rectum in Klippel-Trenaunay syndrome: report of three cases and literature review. Am J Gastroenterol 2001; 96:2783-8. [PMID: 11569713 DOI: 10.1111/j.1572-0241.2001.04110.x] [Citation(s) in RCA: 21] [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
Klippel-Trenaunay syndrome (KTS) is a congenital vascular anomaly characterized by limb hypertrophy, cutaneous hemangiomas, and varicosities. GI hemorrhage is a potentially serious complication secondary to diffuse hemangiomatous involvement of the gut. We report on three patients with KTS who presented with transfusion-dependent anemia and life-threatening bleeding due to extensive cavernous hemangiomas involving the rectum. Two patients were treated by proctocolectomy and coloanal anastomosis, which preserved anal function while controlling bleeding. The third patient required an abdominoperineal resection because of extensive rectal, perianal, and perineal angiomatosis. The literature on the evaluation and management of GI hemorrhage in KTS, particularly of colorectal origin, is reviewed.
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Affiliation(s)
- C L Wilson
- Divisions of Gastroenterology and Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA
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Haddock MG, Gunderson LL, Nelson H, Cha SS, Devine RM, Dozois RR, Wolff BG. Intraoperative irradiation for locally recurrent colorectal cancer in previously irradiated patients. Int J Radiat Oncol Biol Phys 2001; 49:1267-74. [PMID: 11286833 DOI: 10.1016/s0360-3016(00)01528-5] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Information in the literature regarding salvage treatment for patients with locally recurrent colorectal cancer who have previously been treated with high or moderate dose external beam irradiation (EBRT) is scarce. A retrospective review was therefore performed in our institution to determine disease control, survival, and tolerance in patients treated aggressively with surgical resection and intraoperative electron irradiation (IOERT) +/- additional EBRT and chemotherapy. METHODS AND MATERIALS From 1981 through 1994, 51 previously irradiated patients with recurrent locally advanced colorectal cancer without evidence of distant metastatic disease were treated at Mayo Clinic Rochester with surgical resection and IOERT +/- additional EBRT. An attempt was made to achieve a gross total resection before IOERT if it could be safely accomplished. The median IOERT dose was 20 Gy (range, 10--30 Gy). Thirty-seven patients received additional EBRT either pre- or postoperatively with doses ranging from 5 to 50.4 Gy (median 25.2 Gy). Twenty patients received 5-fluorouracil +/- leucovorin during EBRT. Three patients received additional cycles of 5-fluorouracil +/- leucovorin as maintenance chemotherapy. RESULTS Thirty males and 21 females with a median age of 55 years (range 31--73 years) were treated. Thirty-four patients have died; the median follow-up in surviving patients is 21 months. The median, 2-yr, and 5-yr actuarial overall survivals are 23 months, 48% and 12%, respectively. The 2-yr actuarial central control (within IOERT field) is 72%. Local control at 2 years has been maintained in 60% of patients. There is a trend toward improved local control in patients who received > or =30 Gy EBRT in addition to IOERT as compared to those who received no EBRT or <30 Gy with 2-yr local control rates of 81% vs. 54%. Distant metastatic disease has developed in 25 patients, and the actuarial rate of distant progression at 2 and 4 years is 56% and 76%, respectively. Peripheral neuropathy was the main IOERT-related toxicity; 16 (32%) patients developed neuropathies (7 mild, 5 moderate, 4 severe). Ureteral narrowing or obstruction occurred in seven patients. All but one patient with neuropathy or ureter fibrosis received IOERT doses > or =20 Gy. CONCLUSION Long-term local control can be obtained in a substantial proportion of patients with aggressive combined modality therapy, but long-term survival is poor due to the high rate of distant metastasis. Re-irradiation with EBRT in addition to IOERT appears to improve local control. Strategies to improve survival in these poor-risk patients may include the more routine use of conventional systemic chemotherapy or the addition of novel systemic therapies.
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Affiliation(s)
- M G Haddock
- Division of Radiation Oncology, Mayo Clinic and Mayo Medical School, Rochester, MN 55905, USA.
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6
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Myers RP, Cahill DR, Kay PA, Camp JJ, Devine RM, King BF, Engen DE. Puboperineales: muscular boundaries of the male urogenital hiatus in 3D from magnetic resonance imaging. J Urol 2000; 164:1412-5. [PMID: 10992424] [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
PURPOSE The aims of this report are 1) to extend our previous two-dimensional magnetic resonance imaging study to create a three-dimensional image of the pelvic floor, including the puboperinealis, the most anteromedial component of the levator ani; 2) to clarify the historical controversy about this particular component of the levator ani; and 3) to present clinical implications of this muscle with respect to urinary continence and radical prostatectomy. MATERIALS AND METHODS We reused the axial magnetic resonance imaging series from 1 of 15 men in a previous series. Analyze AVWTM allowed creation of three-dimensional images. Further, a movie clip of all three-dimensional images was developed and placed at the manuscript-dedicated Web site: http://www.mayo. edu/ppmovie/pp.html. RESULTS Our three-dimensional images show how the puboperinealis portion of the levator ani flanks the urethra as it courses from the pubis to its insertion in the perineal body. CONCLUSIONS The puboperinealis corresponds to muscles previously designated as the levator prostatae, Wilson's muscle, pubourethralis, and levator urethrae, among others. The images suggest that the puboperinealis is the muscle most responsible for the quick stop phenomenon of urination in the male. Our study supports the suggestion that weakening of the puboperinealis by transection, traction injury, or denervation may affect urinary continence after radical prostatectomy.
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Affiliation(s)
- R P Myers
- Departments of Urology, Anatomy, Physiology and Biophysics, and Diagnostic Radiology, Division of Anatomic Pathology, and Division of Colon and Rectal Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
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7
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Abstract
PURPOSE This study examines the risk factors for developing perianal abscess or fistula formation after ileal pouch-anal anastomosis procedure for chronic ulcerative colitis or familial adenomatous polyposis. METHODS A total of 1,457 patients with J-pouch, 1,304 (89.5 percent) with chronic ulcerative colitis and 153 (10.5 percent) with familial adenomatous polyposis who had a two-stage procedure without any evidence of previous perianal disease were included in the study. The effect of pouch-to-anal anastomosis type on perianal abscess or fistula formation was evaluated. RESULTS A total of 108 patients (7.4 percent) had a perianal abscess or fistula after the ileal pouch-anal anastomosis procedure after at least one year of follow-up. No statistically significant difference was identified in fistula formation regarding the age and gender of the patients (P > 0.05), nor did the risk of fistula formation differ significantly between the patients with handsewn vs. stapled anastomoses (P > 0.05). However, patients with a diagnosis of chronic ulcerative colitis, compared with patients with familial adenomatous polyposis, had a statistically higher risk of developing abscess or fistula (P = 0.012). CONCLUSION The most important risk factor in developing perianal sepsis in long-term patients with ileal pouch-anal anastomosis is the initial disease type. After excluding patients without Crohn's disease, the risk of developing an abscess or fistula was found to be significantly greater in patients with chronic ulcerative colitis compared with patients with familial adenomatous polyposis, and this risk is independent of anastomotic technique.
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Affiliation(s)
- I E Gecim
- Division of Colon and Rectal Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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8
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Wolff BG, Devine RM. Surgical management of diverticulitis. Am Surg 2000; 66:153-6. [PMID: 10695745] [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
Diverticular disease, and particularly diverticulitis, has an increasing incidence in Westernized countries because of low-fiber diet. Diverticular disease may be classified as asymptomatic, atypical, acute or uncomplicated, and complicated. Conservative or medical management is usually indicated for acute or uncomplicated diverticulitis, with elective surgical resection generally being recommended after two documented episodes. Complicated diverticulitis, because of the high rate of recurrent problems, is generally managed promptly with sigmoid resection. Sigmoid resection for diverticulitis, under appropriate circumstances, has one of the highest success rates of any of the common gastrointestinal procedures.
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Affiliation(s)
- B G Wolff
- Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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Mathias CAC, Pemberton JH, Wolff BG, Dozois RR, Nelson H, Young-Fadok TM, Devine RM, Nivatvongs S, Mathison S, Larson D, Ilstrup D. Long-term functional results of radiation after coloanal anastomosis. Acta Cir Bras 1999. [DOI: 10.1590/s0102-86501999000400012] [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] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Abstract
PURPOSE We examined and defined anatomical structures relevant to radical prostatectomy using magnetic resonance imaging. MATERIALS AND METHODS Before radical prostatectomy, 15 men underwent high-resolution magnetic resonance imaging studies of their pelvic floors (fast spin echo, T2 weighting of 3- to 4-mm. contiguous or overlapping slices) in axial, coronal, and sagittal planes. RESULTS Pubovesical ligaments, rather than the commonly reported puboprostatic ligaments, were observed attaching the bladder-prostate unit to the pubis. We suggest that the part of the urethra that extends from the apex of the prostate to the bulb of the penis, which is surrounded by the striated sphincter, should be termed the sphincteric urethra rather than the membranous urethra. Further, we found no evidence that supports the traditional concept of a urogenital diaphragm. The lower part of the striated urethral sphincter was flanked on its sides by the anterior recesses of the ischioanal fossae. The portion of the levator ani, which we have termed the puboanalis sling, flanked the apex of the prostate. The most anteromedial portion of this sling inserts into the perineal body and should be termed the puboperinealis. The terminal part of the gastrointestinal tract (the part continued beyond the levator ani) should be termed the anal canal, not the rectum, as used frequently in the urologic literature. Therefore, the initial plane of dissection in radical perineal prostatectomy passes along the anterior portion of the anal canal, not the rectum. CONCLUSION We used magnetic resonance imaging to study male pelvic floor and perineal anatomy without the artifact of dissection. This study allowed us to devise a more precise nomenclature with respect to radical prostatectomy and, in so doing, to provide a better understanding of both the retropubic and the perineal operations.
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Affiliation(s)
- R P Myers
- Department of Urology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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Radice E, Nelson H, Devine RM, Dozois RR, Nivatvongs S, Pemberton JH, Wolff BG, Fozard BJ, Ilstrup D. Ileal pouch-anal anastomosis in patients with colorectal cancer: long-term functional and oncologic outcomes. Dis Colon Rectum 1998; 41:11-7. [PMID: 9510305 DOI: 10.1007/bf02236889] [Citation(s) in RCA: 41] [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] [Indexed: 02/06/2023]
Abstract
UNLABELLED When colorectal cancer complicates chronic ulcerative colitis or familial adenomatous polyposis, the role of ileal pouch-anal anastomosis is uncertain because of concerns that the procedure may compromise oncologic therapy and that oncologic therapy may compromise ileal pouch-anal anastomosis function. AIM This study was undertaken to investigate the impact both of ileal pouch-anal anastomosis on cancer outcomes and of cancer treatments on ileal pouch-anal anastomosis function. PATIENTS AND METHODS Of 1,616 patients undergoing ileal pouch-anal anastomosis for chronic ulcerative colitis or familial adenomatous polyposis (1981-1994), 77 patients were identified with adenocarcinoma of the colon (56), rectum (17), or both (4). Data were obtained from an ileal pouch-anal anastomosis registry, case notes, and postal and telephone surveys. RESULTS Mean age of the 77 index patients was 37 (range, 13-60) years. Stage distribution was as follows: Stage 0, 9; Stage I, 31; Stage II, 15; Stage III, 22 patients. Twelve patients died with systemic disease (6 with a local component) after a mean follow-up of 6 (range, 2-15) years. Twenty-two patients received adjuvant therapy (chemotherapy, 16; radiotherapy, 2; both, 4 patients). Chemotherapy complications requiring dose reduction or interruption occurred in three (15 percent) patients. One patient developed radiation enteritis (17 percent). Pouch failure occurred in 16 percent of cancer patients, compared with 7 percent for the overall registry. There were no differences between cancer and non-cancer groups in operative complications, median stool frequency, incontinence, pad usage, or pouchitis. CONCLUSIONS Although pouch failure is more common, ileal pouch-anal anastomosis can be performed in the setting of colorectal cancer without significant impact on oncologic outcome or long-term ileal pouch-anal anastomosis function.
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Affiliation(s)
- E Radice
- Mayo Clinic and Mayo Foundation, Division of Colon and Rectal Surgery, Rochester, Minnesota 55905, USA
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Reilly WT, Pemberton JH, Wolff BG, Nivatvongs S, Devine RM, Litchy WJ, McIntyre PB. Randomized prospective trial comparing ileal pouch-anal anastomosis performed by excising the anal mucosa to ileal pouch-anal anastomosis performed by preserving the anal mucosa. Ann Surg 1997; 225:666-76; discussion 676-7. [PMID: 9230807 PMCID: PMC1190866 DOI: 10.1097/00000658-199706000-00004] [Citation(s) in RCA: 106] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The purpose of the study is to compare the results of ileal pouch-anal anastomosis (IPAA) in patients in whom the anal mucosa is excised by handsewn techniques to those in whom the mucosa is preserved using stapling techniques. SUMMARY BACKGROUND DATA Ileal pouch-anal anastomosis is the operation of choice for patients with chronic ulcerative colitis requiring proctocolectomy. Controversy exists over whether preserving the transitional mucosa of the anal canal improves outcomes. METHODS Forty-one patients (23 men, 18 women) were randomized to either endorectal mucosectomy and handsewn IPAA or to double-stapled IPAA, which spared the anal transition zone. All patients were diverted for 2 to 3 months. Nine patients were excluded. Preoperative functional status was assessed by questionnaire and anal manometry. Twenty-four patients underwent more extensive physiologic evaluation, including scintigraphic anopouch angle studies and pudendel never terminal motor latency a mean of 6 months after surgery. Quality of life similarly was estimated before surgery and after surgery. Univariate analysis using Wilcoxon test was used to assess differences between groups. RESULTS The two groups were identical demographically. Overall outcomes in both groups were good. Thirty-three percent of patients who underwent the handsewn technique and 35% of patients who underwent the double-stapled technique experienced a postoperative complication. Resting anal canal pressures were higher in the patients who underwent the stapled technique, but other physiologic parameters were similar between groups. Night-time fecal incontinence occurred less frequently in the stapled group but not significantly. The number of stools per 24 hours decreased from preoperative values in both groups. After IPAA, quality of life improved promptly in both groups. CONCLUSIONS Stapled IPAA, which preserves the mucosa of the anal transition zone, confers no apparent early advantage in terms of decreased stool frequency or fewer episodes of fecal incontinence compared to handsewn IPAA, which excises the mucosa. Higher resting pressures in the stapled group coupled with a trend toward less night-time incontinence, however, may portend better function in the stapled group over time. Both operations are safe and result in rapid and profound improvement in quality of life.
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Affiliation(s)
- W T Reilly
- Eyvazzadeh Colon and Rectal Center, Bethlehem, Pennsylvania, USA
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Gunderson LL, Haddock MG, Nelson H, Cha S, Devine RM, Fieck JM, Wolff BG, Dozois RR, O'Connell MJ. Locally recurrent colorectal cancer: IOERT and EBRT +/-5-FU and maximal resection. Front Radiat Ther Oncol 1997; 31:224-8. [PMID: 9263828 DOI: 10.1159/000061157] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- L L Gunderson
- Division of Radiation Oncology, Mayo Clinic, Rochester, Minn., USA
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Gunderson LL, Nelson H, Martenson JA, Cha S, Haddock MG, Devine RM, Fieck JM, Wolff BG, Dozois RR, O'Connell MJ. Locally advanced primary colorectal cancer: IOERT and EBRT +/-5-FU. Front Radiat Ther Oncol 1997; 31:204-8. [PMID: 9263823 DOI: 10.1159/000061163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- L L Gunderson
- Radiation Oncology, Mayo Clinic, Rochester, Minn., USA
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Abstract
PURPOSE Our aims were to determine the morbidity, survival and its influencing factors, and patterns of failure for patients who underwent further surgery with the hope of cure for locally recurrent rectal cancer. METHODS Between January 1981 and December 1988, 224 patients with a preoperative diagnosis of recurrent rectal cancer underwent additional surgery at Mayo Medical Center in Rochester, Minnesota. Of these, 65 underwent further surgery with the hope of cure, i.e., no gross/microscopic residual disease at tumor margins after reoperation. Factors assessed included type of original operation, time interval between operation for primary tumor and initial operation for recurrence, symptom status, degree of fixation, types of reoperations for recurrence, and adjuvant therapy. RESULTS None of the patients died within 30 days of reoperation. Seventeen complications requiring hospitalization and/or surgical procedure were observed in 14 patients. Extended operations (involving partial or complete removal of surrounding organs/structures) required more time to perform, a greater number of transfusions, and a longer hospital stay than more limited operations. Three-year, five-year, and median survival were 57, 34, and 44.7 months, respectively. Survival was greater after curative than after palliative resection (P < 0.001). Survival tended to be greater in females (P < 0.075) and in patients without pain (P < 0.065). Cumulative probability of local failure was 24, 41, and 47 percent at 1, 3, and 5 years, respectively. Cumulative risk of distant metastasis was 30, 51, and 62 percent at 1, 3, and 5 years, respectively. CONCLUSIONS Our results indicate that complete excision of locally recurrent rectal cancer can provide a significant number of patients with long-term survival and can be accomplished safely in select patients.
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Affiliation(s)
- K Suzuki
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA
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Loessin SJ, Meland NB, Devine RM, Wolff BG, Nelson H, Zincke H. Management of sacral and perineal defects following abdominoperineal resection and radiation with transpelvic muscle flaps. Dis Colon Rectum 1995; 38:940-5. [PMID: 7656741 DOI: 10.1007/bf02049729] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.3] [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: 01/26/2023]
Abstract
PURPOSES In this study we present our experience with treating persistent sacral and perineal defects secondary to radiation and abdominoperineal resection with or without sacrectomy. METHODS Fifteen consecutive patients were treated with an inferiorly based transpelvic rectus abdominis muscle or musculocutaneous flap. RESULTS Fourteen of the 15 patients achieved healing, and 7 patients had no complications. The remaining eight patients required one or more operative debridements and/or prolonged wound care to accomplish a healed wound. Our technique for the dissection and insetting of the transpelvic muscle flap is presented. CONCLUSION The difficult postirradiated perineal and sacral wounds can be healed with persistent surgical attention to adequate debridement, control of infections, and a well-vascularized muscle flap. The most satisfying aspects for patients are the discontinuance of foul-smelling discharge, discontinuation of multiple, daily dressing changes, and reduction in the degree of chronic pain.
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Affiliation(s)
- S J Loessin
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Affiliation(s)
- N B Meland
- Section of Plastic and Reconstructive Surgery, Mayo Clinic, Scottsdale, Ariz, USA
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Suzuki K, Gunderson LL, Devine RM, Weaver AL, Dozois RR, Ilstrup DM, Martenson JA, O'Connell MJ. Intraoperative irradiation after palliative surgery for locally recurrent rectal cancer. Cancer 1995. [PMID: 7531113 DOI: 10.1002/1097-0142(19950215)75:4<939::aid-cncr2820750408>3.0.co;2-e] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND In patients with locally recurrent rectal cancer, long-term disease control and survival is uncommon with single-modality therapy. This report evaluates results achieved at the Mayo Clinic (Rochester, MN) with single- or combined-modality treatment, including intraoperative irradiation. METHODS From 1981 to 1988, 106 patients underwent palliative surgical resections at the Mayo Clinic for locally recurrent rectal cancer. None had evidence of extrapelvic disease, and 42 received intraoperative electron beam irradiation (IORT) as a component of treatment. Gross residual disease remained after maximal surgical resection in 34 of the 42 patients and 61 of the patients who did not receive IORT. The IORT dose was 15-20 Gy in 39 patients and 10, 25, and 30 Gy in the other 3. External beam irradiation (EBRT) was administered to 41 of the 42 patients (doses > or = 45 Gy to 38 patients). RESULTS Kaplan-Meier survival estimates at 3 and 5 years were analyzed for the 106 patients. Palliative surgical resection alone (12 patients) resulted in a 3-year survival of 8% and a 5-year survival of 0%. Statistically significant factors relative to survival based on the univariate analysis of all patients included amount of residual tumor (microscopic vs. gross, P = 0.032) treatment method (P = 0.005), IORT versus no IORT (P = 0.0006), type of symptoms (P = 0.0075), type of fixation (P < 0.0001), and preoperative Eastern Cooperative Oncology Group status (P = 0.03). For patients who received IORT, 3-year survival with gross residual tumor or presentation with pain was 44% and 43%, respectively. Factors not associated with survival (univariate) included extended versus conventional surgical resection, grade, age, and sex. The 3-year cumulative probability of distant metastasis was 60% in the patients who received IORT and 54% in those who did not. The 3-year local relapse rates were 40% versus 93% in patients who received IORT versus those who did not. CONCLUSIONS Although the addition of IORT to external irradiation and maximal surgical resection appears to improve local tumor control and survival in patients who undergo palliative surgical resection for locally recurrent rectal cancer, further gains in treatment are necessary. Considering the high rates of distant metastasis, more routine systemic therapy with 5-fluorouracil (5-FU) leucovorin, 5-FU levamisole, or all three needs to be incorporated into aggressive treatment approaches. In patients with gross residual tumor after maximum surgical resection, local tumor control is inadequate despite treatment combinations including IORT. The evaluation of radiation sensitizers or biologic modifiers during external irradiation and IORT is indicated.
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Affiliation(s)
- K Suzuki
- Section of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN 55905
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Abstract
BACKGROUND In patients with locally recurrent rectal cancer, long-term disease control and survival is uncommon with single-modality therapy. This report evaluates results achieved at the Mayo Clinic (Rochester, MN) with single- or combined-modality treatment, including intraoperative irradiation. METHODS From 1981 to 1988, 106 patients underwent palliative surgical resections at the Mayo Clinic for locally recurrent rectal cancer. None had evidence of extrapelvic disease, and 42 received intraoperative electron beam irradiation (IORT) as a component of treatment. Gross residual disease remained after maximal surgical resection in 34 of the 42 patients and 61 of the patients who did not receive IORT. The IORT dose was 15-20 Gy in 39 patients and 10, 25, and 30 Gy in the other 3. External beam irradiation (EBRT) was administered to 41 of the 42 patients (doses > or = 45 Gy to 38 patients). RESULTS Kaplan-Meier survival estimates at 3 and 5 years were analyzed for the 106 patients. Palliative surgical resection alone (12 patients) resulted in a 3-year survival of 8% and a 5-year survival of 0%. Statistically significant factors relative to survival based on the univariate analysis of all patients included amount of residual tumor (microscopic vs. gross, P = 0.032) treatment method (P = 0.005), IORT versus no IORT (P = 0.0006), type of symptoms (P = 0.0075), type of fixation (P < 0.0001), and preoperative Eastern Cooperative Oncology Group status (P = 0.03). For patients who received IORT, 3-year survival with gross residual tumor or presentation with pain was 44% and 43%, respectively. Factors not associated with survival (univariate) included extended versus conventional surgical resection, grade, age, and sex. The 3-year cumulative probability of distant metastasis was 60% in the patients who received IORT and 54% in those who did not. The 3-year local relapse rates were 40% versus 93% in patients who received IORT versus those who did not. CONCLUSIONS Although the addition of IORT to external irradiation and maximal surgical resection appears to improve local tumor control and survival in patients who undergo palliative surgical resection for locally recurrent rectal cancer, further gains in treatment are necessary. Considering the high rates of distant metastasis, more routine systemic therapy with 5-fluorouracil (5-FU) leucovorin, 5-FU levamisole, or all three needs to be incorporated into aggressive treatment approaches. In patients with gross residual tumor after maximum surgical resection, local tumor control is inadequate despite treatment combinations including IORT. The evaluation of radiation sensitizers or biologic modifiers during external irradiation and IORT is indicated.
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Affiliation(s)
- K Suzuki
- Section of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN 55905
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20
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McIntyre PB, Pemberton JH, Beart RW, Devine RM, Nivatvongs S. Double-stapled vs. handsewn ileal pouch-anal anastomosis in patients with chronic ulcerative colitis. Dis Colon Rectum 1994; 37:430-3. [PMID: 8181402 DOI: 10.1007/bf02076186] [Citation(s) in RCA: 57] [Impact Index Per Article: 1.9] [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: 02/08/2023]
Abstract
UNLABELLED Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice for most patients with chronic ulcerative colitis. Whether or not a double-stapled technique, which should preserve the anal transition zone and avoid prolonged and dilation, facilitates superior fecal continence compared with conventional mucosal resection and handsewn anastomosis is unknown. PURPOSE The aim of this study was to compare functional results after double-stapled and handsewn IPAA. METHODS Twenty-seven consecutive patients (13 females, 14 males; mean age, 37 years) who had proctocolectomy and double-stapled IPAA (J) for chronic ulcerative colitis were identified. Each was matched by sex, age, and surgeon to a control who had undergone a conventional handsewn anastomosis. Functional results at six months after ileostomy closure were compared. RESULTS Median stool frequency in each group was seven. The prevalence of pouchitis was 22 percent in both groups. One pouch failure occurred in each group. The percentage of patients from the double-stapled group with daytime spotting was similar to that of the handsewn group (18 percent vs. 26 percent, P > 0.5). Nighttime soiling rates were similar as well (41 percent vs. 48 percent, P > 0.5). CONCLUSIONS Double-stapled IPAA appears to convey no early functional advantage over handsewn IPAA for chronic ulcerative colitis.
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Affiliation(s)
- P B McIntyre
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota 55905
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Burnes JU, O'Keefe SJ, Fleming CR, Devine RM, Berkner S, Herrick L. Home parenteral nutrition--a 3-year analysis of clinical and laboratory monitoring. JPEN J Parenter Enteral Nutr 1992; 16:327-32. [PMID: 1640629 DOI: 10.1177/0148607192016004327] [Citation(s) in RCA: 81] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
We report a 3-year analysis (1986 to 1989) of the management of 63 home parenteral nutrition patients, 40 with short-bowel syndrome and 23 with chronic intestinal obstruction with or without intestinal resection. Intravenous fluid requirements varied from 0.9 to 6 L/day, and the content of glucose varied between 46 and 531 g/day, protein varied from .0 to 85 g/day, fat from .0 to 100 g/day, sodium from 37 to 695 mEq/day, potassium from 30 to 220 mEq/day, chloride from 60 to 760 mEq/day, and acetate from 0 to 200 mEq/day. Body weight was normalized and well maintained in the majority of patients, but using the strict definition of deficiency as the presence of one abnormal value during 3 years, more than half had abnormal plasma chloride, glucose, alkaline phosphatase, serum glutamic oxaloacetic transaminase, total protein, albumin, selenium, and iron concentrations, and more than a third had low calcium, magnesium, vitamin D, and vitamin C levels. Normochromic anemia was seen in 73% and high blood creatinine associated with low urine volumes in 42%. Most (78%) returned to relatively normal lifestyles, but employability was occasionally impaired by loss of third-party insurance coverage resulting from a therapy that may cost $100,000 per year. Overall mortality was low (5% per year), but 73% needed readmission to hospital, mainly for suspected catheter sepsis. The results indicate that home parenteral nutrition has allowed many patients to survive gut failure and return to work but problems with chronic fluid, electrolyte and micronutrient deficiencies, catheter sepsis, and insurance coverage often restrict optimal rehabilitation.
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Affiliation(s)
- J U Burnes
- Department of Internal Medicine, Rochester Methodist Hospital, Minnesota
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22
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Abstract
Approximately 5% of rectal cancers are locally advanced with adherence to the vagina, uterus, bladder, prostate, or other structures. Sacral involvement is fortunately rare in primary cancers. In about 50% of patients there is histologic confirmation of tumor invasion in the area of adherence. It is important to recognize the nature of these tumors pre-operatively so that the patient can be prepared for an exenterative procedure should this be necessary. When these tumors are removed en bloc, 5-year survival rates of 50% can be obtained with survival depending on the presence or absence of regional metastasis and also the presence or absence of histologic tumor invasion into adjacent structures.
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Affiliation(s)
- R M Devine
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota 55905
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Galandiuk S, Scott NA, Dozois RR, Kelly KA, Ilstrup DM, Beart RW, Wolff BG, Pemberton JH, Nivatvongs S, Devine RM. Ileal pouch-anal anastomosis. Reoperation for pouch-related complications. Ann Surg 1990; 212:446-52; discussion 452-4. [PMID: 2171442 PMCID: PMC1358276 DOI: 10.1097/00000658-199010000-00007] [Citation(s) in RCA: 135] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The aim was to assess the value of reoperative surgery for pouch-related complications after ileal pouch-anal anastomosis (IPAA) for chronic ulcerative colitis and familial adenomatous polyposis. Between January 1981 and August 1989, 114 of 982 IPAA patients (12%) seen at the Mayo Clinic had complications directly related to IPAA that required reoperation. Among the 114 patients, the complications prevented initial ileostomy closure in 33 patients (25%), occurred after ileostomy closure in 68 patients (60%), and delayed ileostomy closure in the remaining patients. The salvage procedures performed included anal dilatation under anesthesia for anastomotic strictures, placement of setons and/or fistulotomy for perianal fistulae, unroofing of anastomotic sinuses, simple drainage and antibiotics for perianal abscesses, abdominal exploration with drainage of intra-abdominal abscesses with or without establishment of ileostomy, and complete or partial reconstruction of the reservoir for patients with inadequate emptying. None of the reoperated patients died. Reoperation led to restoration of pouch function in two thirds of patients and, of these, 70% had an excellent clinical outcome. However approximately 20% of the 114 pouches required excision. Excision was common, especially among patients who had pelvic sepsis. Salvage procedures for pouch-specific complications can be done safely and will restore pouch function in two thirds of patients. Complications after reoperation, however, may ultimately lead to loss of the reservoir in one in five patients.
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Affiliation(s)
- S Galandiuk
- Department of Surgery, Mayo Clinic, Rochester, Minnesota 55905
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24
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Abstract
Since 1982, intraoperative colonoscopy has been performed on 66 patients. Preoperative intent was to perform a colonoscopic polypectomy during an intra-abdominal procedure in 44 patients, localize lesions that might subsequently lead to either colon resection or colotomy and polyp excision in 13, localize bleeding sites in 4, determine the extent of inflammatory bowel disease in 2, survey the colon in 2 who did not have preoperative colon radiography, and assess bowel viability in 1. Surgery proceeded as planned in 54 patients; however, colonoscopic findings extended the resection to include additional segments of bowel in 4. In four patients, polypectomy or bowel resection was avoided as a result of the colonoscopic findings. Intraoperative colonoscopy was not possible in four patients. No complications were related directly to this procedure. Intraoperative colonoscopy is a useful adjunct for localizing lesions or "clearing" the colon. In some patients, colonoscopic findings may change the extent of resection performed.
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Affiliation(s)
- T J Saclarides
- Section of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota 55905
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25
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Devine RM, Kelly KA. Surgical therapy of the short bowel syndrome. Gastroenterol Clin North Am 1989; 18:603-18. [PMID: 2509357] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Patients with the short bowel syndrome should be managed initially by giving total parenteral nutrition and by maximizing the function of the remaining intestine. Enteral feedings should be instituted as soon as the patient stabilizes, usually after 2 to 4 weeks. The gastric hypersecretion that accompanies the syndrome can usually be controlled with an H2-receptor blocker. In those patients who fail to recover adequate digestion and absorption after 6 months to 1 year, operations to improve absorption should be considered. The reversed intestinal segment and the intestinal lengthening procedures are most often employed, but neither type of operation can be recommended without reservation. Newer procedures, such as growing new intestinal mucosa on serosal patches, intestinal pacing, and intestinal transplantation may play a role in future therapies. At present, long-term parenteral nutrition remains the cornerstone of therapy.
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Affiliation(s)
- R M Devine
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
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Wolff BG, Pembeton JH, van Heerden JA, Beart RW, Nivatvongs S, Devine RM, Dozois RR, Ilstrup DM. Elective colon and rectal surgery without nasogastric decompression. A prospective, randomized trial. Ann Surg 1989; 209:670-3; discussion 673-5. [PMID: 2658880 PMCID: PMC1494121 DOI: 10.1097/00000658-198906000-00003] [Citation(s) in RCA: 80] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Nasogastric (NG) decompression after colorectal surgery is practiced commonly. Our aim was to determine whether routine NG decompression benefitted patients undergoing this type of surgery. Five hundred thirty-five patients were randomized prospectively to either NG decompression or no decompression. Stratification was by type of operation and patient age. Excluded were patients who had emergency surgery with peritonitis, extensive fibrous adhesions, enterotomies, previous pelvic irradiation, intra-abdominal infection, pancreatitis, chronic obstruction. prolonged operating times, or difficult endotracheal intubation. Two hundred seventy-four patients received NG decompression (Salem sump, Argyle Co., Division of Sherwood Medical, St. Louis, MO) and two hundred sixty-one did not. There were 33 protocol violations included in the 535 patients. Patients who were not decompressed experienced significantly more abdominal distention, nausea, and vomiting than did those patients who were. Moreover, 13% required subsequent NG decompression as opposed to a reinsertion rate of 5% for patients routinely decompressed. The mean length of hospitalization for both groups was 11 days. There were no significant differences in nasopharyngeal or gastric bleeding, inability to cough effectively, respiratory infections, wound disruptions, reoperation, and wound infection rates (5%) between the two groups. We conclude that even though there is an increase in the rate of minor symptoms of nausea, vomiting, and abdominal distention, routine nasgastric decompression is not warranted after elective colon and rectal surgery.
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Affiliation(s)
- B G Wolff
- Section of Colon and Rectal Surgery, Mayo Medical School, Mayo Clinic, Rochester, Minnesota 55905
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Abstract
Malignant lymphoma involving the rectum is rare. Of 61 patients with malignant lymphoma involving the rectum seen at the Mayo Clinic between 1950 and 1977, 49 had extensive lymphoma with secondary involvement of the rectum, and 12 had lymphoma confined to the rectum. Patients with widespread lymphoma were treated with radiation, chemotherapy, or both. Of the 12 patients with lymphoma confined to the rectum, five had surgical excision and seven were treated nonoperatively; the overall five-year survival was 20 percent. Patients with widespread lymphoma had a five-year survival of 15 percent. Patients with lymphoma confined to the rectum had a five-year survival of 50 percent, and patients who had surgical excision did better than those treated nonoperatively.
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Abstract
Acute cholecystitis after operation or trauma is associated with reported mortalities of 10% to 50%. During a 16-year period at the Mayo Clinic, Rochester, Minn, 75 such patients were examined, eight of whom had traumatic injuries. The incidence of this complication was approximately one for every 10,000 surgical procedures. In contrast with acute cholecystitis that occurs de novo, elderly men who had other antecedent complications seemed to be at an increased risk. Also, acalculous cholecystitis with associated gangrene and perforation of the gallbladder was more commonly encountered. The diagnosis is difficult to establish in patients who have had recent abdominal operations and is based on physical signs and symptoms, although cholescintigraphy will be of value in future cases. The most common treatment is cholecystectomy. Clinicians must maintain a high index of suspicion and carefully examine any surgical patient in whom abdominal pain or unexplained fever develops. Once the diagnosis is confirmed, early operative intervention is indicated.
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Devine RM, van Heerden JA, Grant CS, Muir JJ. The role of methylene blue infusion in the management of persistent or recurrent hyperparathyroidism. Surgery 1983; 94:916-8. [PMID: 6648804] [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: 01/21/2023]
Abstract
Several reports have suggested that methylene blue be used for the selective staining of the parathyroid glands. To date, there have been no reports on the use of methylene blue in persistent or recurrent hyperparathyroidism. In 30 such cases, we found that the dye was safe and easy to administer and that the level of methemoglobinemia after infusion was insignificant. We suggest that the dye be used in all cases involving cervical or mediastinal (or both) reexploration for persistent or recurrent hyperparathyroidism.
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