Browsing by Author "Madoff, R.D."

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Preoperative adjuvant radiation with chemotherapy for rectal cancer: its impact on stage of disease and the role of endorectal ultrasound
(Springer International, 1996) Bernini, A.; Deen, K.I.; Madoff, R.D.; Wong, W.D.
BACKGROUND: Preoperative adjuvant radiation combined with chemotherapy is a recent development in the management of patients with rectalcancer invading perirectal tissue and regional lymph nodes. This study was performed to assess the impact of preoperative adjuvant therapy in patients judged by endorectal ultrasound to have extramural invasion of rectal cancer and/or regional lymph node involvement on tumor regression in bowel wall and lymph nodes. The predictive value of ultrasound in staging wall penetration and lymph node involvement after preoperative adjuvanttherapy was also assessed. METHODS: Patients (n = 43) were selected by ultrasound to have preoperative irradiation (4,500-5,040 cGy over 5-6 weeks). In 30 patients this was combined with 5-fluorouracil, 370 mg/m(2), for 5 days in the first and last weeks of irradiation. Pretreatment ultrasound was compared with pathologic findings in the resected specimen in all patients. Twenty-one were assessed by ultrasound after adjuvant therapy and findings compared with histology. RESULTS: Downstaging was seen in 23 (53%) patients with wall invasion and in 23 (72%) of 32 patients with lymph node involvement. Overall, downstaging was achieved in 30 (70%). Positive predictive values of ultrasound after irradiation were 72% and 56% for wall penetration and lymph node status, respectively. Negative predictive values of ultrasound after irradiation were 100% and 82%, respectively. CONCLUSION: In the majority of patients with rectal cancer invading perirectal tissues or lymph nodes, lesions may be downstaged by preoperative adjuvant therapy. Endorectal ultrasound after adjuvant therapy for rectal cancer is of a lesser predictive value chiefly because of overstaging.
Preoperative staging of rectal neoplasms with endorectal ultrasonography
(Elsevier-W.B. Saunders, 1995) Deen, K.I.; Madoff, R.D.; Belmonte, C.; Wong, W.D.
Rectal prolapse: impact on pelvic floor physiology and current management
(Elsevier-W.B. Saunders, 1996) Deen, K.I.; Madoff, R.D.
Rectal prolapse may be associated with fecal incontinence or constipation. Incontinence results from reduced internal sphincter tone and may be worsened by direct or neurogenic damage to the external sphincter and puborectalis muscles. Impaired anal sensation and previous anal sphincter injury may also contribute to incontinence. Constipation results from either difficulty in evacuation, delayed transit, or both. Management should aim to identify the extent of prolapse and degree of functional impairment. Almost all patients with occult prolapse should be treated conservatively. However, rare, markedly symptomatic patients with convincing evidence of occult prolapse may benefit from surgery. Abdominal fixation techniques are the abdominal operations of choice for fit patients with complete rectal prolapse. There is no evidence that addition of foreign material slings enhance the outcome of surgery. Considerable recent data support the use of a sigmoid resection in conjunction with rectal fixation, although this remains a contentious issue. Resection is not advised for patients with poor sphincter function associated with significant neuropathy. Patients with severe preoperative constipation require complete evaluation before surgery; those with documented slow-transit constipation may benefit from subtotal, rather than sigmoid colectomy, performed in conjunction with rectopexy. The Delorme operation and perineal rectosigmoidectomy are both acceptable choices for high-risk patients and patients who wish to avoid abdominopelvic dissection. Our preference is for the perineal rectosigmoidectomy, and we advocate associated levator plication at the time of surgery, particularly in incontinent patients. The Thiersch operation is associated with a high complication rate and should be avoided. The chief advantages of perineal over abdominal repair are avoidance of laparotomy and related complications, preservation of autonomic nerve function, avoidance of ureteric injury, and the ability to perform a concomitant sphincter or pelvic floor repair through the same incision. Laparoscopic prolapse repair is in its infancy with no data on long-term follow-up, making it impossible to evaluate its impact on the treatment of rectal prolapse.
Surgical management of left colon obstruction: the University of Minnesota experience
(Elsevier, 1998) Deen, K.I.; Madoff, R.D.; Goldberg, S.M.; Rothenberger, D.A.
BACKGROUND: Management of left-sided colonic obstruction is a surgical challenge. This study was performed to review our management of patients with left colon obstruction presenting to the University of Minnesota Hospitals over a 10-year period, 1985 to 1994. STUDY DESIGN: We did a retrospective chart review of 143 patients (48 male and 95 female; mean age 70 years). RESULTS: Sites of obstruction were rectosigmoid, 40%; sigmoid colon, 47%; descending colon, 5%; and splenic flexure, 8%. Fifty-two percent of patients had obstructing colorectal cancer. Two patients presented with generalized peritonitis secondary to colonic perforation. The majority (n = 121, 85%) of patients underwent resection (subtotal in 39 [32%], and segmental in 82 [68%]) and anastomosis in a single stage after appropriate resuscitation. Intraoperative colonic cleansing was undertaken in 40 patients (28%). Morbidity within 30 days of operation was 11%, including 1 anastomotic leak, and mortality was 3%. The 4 deaths occurred in patients over 75 years of age and were not from anastomotic complications. CONCLUSIONS: A single stage resection and an anastomosis facilitated by intraoperative colonic cleansing in one-third of cases was performed in 85% of patients presenting with left colon obstruction. One anastomotic leak occurred. Our current policy of strongly favoring a single stage, definitive operation for patients presenting with left colon obstruction appears reasonable on the basis of this retrospective review of our experience.