T L Hull

Cleveland Clinic, Cleveland, Ohio, United States

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Publications (146)552.97 Total impact

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    ABSTRACT: Purpose The aim of this study is to determine if resident involvement in a large cohort of laparoscopic colorectal surgery (LCS) cases negatively impacts outcomes and ultimately increases costs. Methods The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent LCS between 2005 and 2010. Patients were classified into two groups: postgraduate year (PGY; resident involvement) or Attending Only. A subgroup analysis was then conducted among the individual PGY levels (1–2, 3–5, ≥6) and Attending Only group. Results A total of 4,836 patients were included in the PGY group and 2,418 in the Attending Only group. Mean operative time (163.9 ± 66.7 vs. 140.7 ± 67.2 minutes, P < .001) and length of hospital stay (5.8 ± 5.4 vs. 5.6 ± 5.4 days, P = .015) were significantly longer in the PGY group. Surgical and nonsurgical complications and overall morbidity and mortality rates were similar between the two groups. Each individual PGY group was associated with longer operative time (P < .001), and PGY ≥ 6 was associated with an increased length of stay (P < .001). Conclusion Although resident participation in LCS does not affect overall mortality or morbidity, it may negatively impact hospital costs through increased operative time and length of hospital stay. Early and intensive laparoscopy training may be necessary for improving residents' laparoscopy skills before their involvement in LCS.
    Surgery 10/2014; 156(4):825–833. · 3.37 Impact Factor
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    ABSTRACT: Background Injectable bulking treatment for fecal incontinence (FI) is intended to expand tissue in the anal canal and prevent fecal leakage. Use of injectable bulking agents is increasing because it can be performed in an outpatient setting and with low risk for morbidity. This study evaluated the long-term (36-month) clinical effectiveness and safety of injection of non-animal stabilized hyaluronic acid/dextranomer (NASHA Dx) on FI symptoms.Methods In a prospective multicenter trial, 136 patients with FI received the NASHA Dx bulking agent. Treatment success defined as a reduction in number of FI episodes by 50% or more compared with baseline (Responder50). Change from baseline in Cleveland Clinic Florida Fecal Incontinence Score (CCFIS) and Fecal Incontinence Quality of Life Scale (FIQL), and adverse events were also evaluated.Key ResultsSuccessful decrease in symptoms was achieved in 52% of patients at 6 months and this was sustained at 12 months (57%) and 36 months (52%). Mean CCFIS decreased from 14 at baseline to 11 at 36 months (p < 0.001). Quality-of-life scores for all four domains improved significantly between baseline and 36 months of follow-up. Severe adverse events were rare and most adverse events were transient and pertained to minor bleeding and pain or discomfort.Conclusions & InferencesSubmucosal injection of NASHA Dx provided a significant improvement of FI symptoms in a majority of patients and this effect was stable during the course of the follow-up and maintained for 3 years.
    Neurogastroenterology and Motility 05/2014; · 2.94 Impact Factor
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    ABSTRACT: After IPAA, the timing, management, and outcome of pouch-vaginal fistulas are poorly defined. The purpose of this study was to evaluate the frequency, management, and outcome of patients who develop a pouch-vaginal fistula. This was a retrospective analysis of a prospectively maintained database. The study was conducted in a single-center, high-volume tertiary referral colorectal unit. Women with a pouch-vaginal fistula after IPAA from 1983 to 2010 were included in the study. The healing rate of pouch-vaginal fistulas was measured. Of 152 patients with a pouch-vaginal fistula after IPAA, 59 fistulas occurred at <12 months, constituting the early onset group, and 43 occurred at >12 months, constituting the late-onset group. Seventy-five patients (77.3%) underwent local repair (48 (49.5%) had ileal pouch advancement flap and 27 (27.8%) had transvaginal repair). The healing rate after ileal pouch advancement flap performed as a primary procedure was 42% and 66% when performed secondarily after a different procedure. The healing rate for transvaginal repair was 55% when done as a primary procedure and 40% when performed secondarily. Nineteen patients underwent redo ileal pouch construction, with an overall pouch retention rate of 40%. At median follow-up of 83 months (range, 5-480 months), 56 (57.7%) of the 102 patients had healed the pouch-vaginal fistula, whereas pouch failure occurred in 34 women (35%, 12 early onset and 22 late onset). Healing of the fistula was significantly lower (22% versus 73%; p < 0.001) and pouch failure higher (52.7% versus 22.7%, p < 0.001) when compared with Crohn's disease. On multivariate analysis, a postoperative delayed diagnosis of Crohn's disease was associated with failure (p = 0.01). No other factors were associated with pouch failure. This was a retrospective study. Pouch-vaginal fistula after IPAA surgery is indolent and may persist after repairs. A delayed diagnosis of Crohn's disease is associated with a poor outcome and a higher chance of pouch failure.
    Diseases of the Colon & Rectum 04/2014; 57(4):490-496. · 3.34 Impact Factor
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    ABSTRACT: Fecal incontinence is a frequent and debilitating condition that may result from a multitude of different causes. Treatment is often challenging and needs to be individualized. During the last several years, new technologies have been developed, and others are emerging from clinical trials to commercialization. Although their specific roles in the management of fecal incontinence have not yet been completely defined, surgeons have access to them and patients may request them. The purpose of this project is to put into perspective, for both the patient and the practitioner, the relative positions of new and emerging technologies in order to propose a treatment algorithm.
    Surgical Endoscopy 03/2014; · 3.43 Impact Factor
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    ABSTRACT: Tumors occurring within the retrorectal space are rare and their low incidence has led to a paucity of literature regarding them. Adult patients with retrorectal tumors managed at this institution from 1981-2011 were identified. A retrospective chart review was conducted to obtain relevant data. Retrorectal tumors were identified in 87 patients (67 female) with median age at diagnosis of 44 years (19-88), and median follow-up 8 months (0.1-225). Of the 25 different histologic tumors diagnosed, hamartomas were most common (32 %; n = 28) followed by epidermal cysts (11 %; n = 10), and teratomas (10 %; n = 9). Twenty-six percent (23/87) of all tumors were malignant. CT scans were obtained in 84 % (73/87) of patients, MRI in 59 % (51/87), and TRUS in 16 % (14/87). While 74 % (64/87) of tumors were at or below the S4 level, operative approach was strictly posterior in 73 % (46/63) of these tumors. Twenty-eight percent (24/87) of patients underwent diagnostic biopsy with no reported biopsy site recurrence. Thirty percent (7/23) of resected malignant (all recurrences: distant) and eleven percent (7/64) of benign tumors (all recurrences: local) recurred. Survival was 70 % (16/23) for malignant tumors and 98 % (63/64) for benign tumors. Retrorectal tumors remain heterogeneous and a diagnostic challenge. Pre-operative imaging may help guide surgeons; however, malignancy portends worse outcomes. Despite preoperative biopsy site recurrence concerns, no patient in this study had biopsy site recurrence. As their natural history remains unclear, more studies are necessary to further characterize their behavior.
    Journal of Gastrointestinal Surgery 10/2013; · 2.36 Impact Factor
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    ABSTRACT: Public reporting of the Hospital Consumer Assessment of Healthcare Providers and Systems survey is designed to produce data on patients' perceptions of the quality of hospital care. The aim of this study was to assess the impact of complications on patient responses to Hospital Consumer Assessment of Healthcare Providers and Systems "top-box" (most favorable) scores. All patients who underwent a colorectal procedure from October 2009 to June 2012 at a single center were included. Patient complications were categorized as major, minor, or no complications and "surgical technique" or "medical." Chi-square and Wilcoxon rank sum tests were used to compare binary and ordinal top-box scores, respectively. One thousand four hundred and nine surveys were collected for 1,233 patients (mean age 53 ± 15.7 years; 701 [52.2%] females) who underwent 955 (67.8%) major abdominal, 114 (8.1%) anorectal, and 340 (24.1%) stoma-related operations. There were 195 (13.8%) major and 396 (28.1%) minor complications. There were 159 (11.3%) technique complications and 411 (29.2%) medical complications. Patients without any complications were more likely to recommend the hospital than those with complications (p = 0.023) irrespective of type of complication (minor vs major; p = 0.72 or technique vs medical; p = 0.5). Responsiveness of hospital staff was also reported as higher for patients without complications (p = 0.0003) and the type of complication did not influence this assessment (minor vs major; p = 0.71 and technique vs medical; p = 0.95). The occurrence of any complication after colorectal surgery adversely impacts patients' self-reported perceptions of hospital care as measured by Hospital Consumer Assessment of Healthcare Providers and Systems. An instrument that more accurately reflects patients' assessment of quality in the context of variations in patient, disease, and surgical factors is required.
    Journal of the American College of Surgeons 09/2013; · 4.50 Impact Factor
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    ABSTRACT: Presacral tumors are rare with few published studies in the literature. It is unknown whether the course of the disease and the required treatment differs between pediatric and adult patients. The aim of the study was to compare presenting symptoms, surgical treatment, pathology, and recurrence rates of presacral tumors in these two groups. Material and methods. An IRB-approved chart review was conducted for patients diagnosed with a presacral tumor at the Cleveland Clinic between 1981 and 2011. Symptoms, physical exam, surgical details, tumor histology, and outcomes were collected as part of the review. Patients were divided into two groups: pediatric (< 18 years n=14) and adult (> 18 years n=50). Results. The most common symptom was a mass in pediatric and pain in adult patients. The most common pediatric primary tumor was a teratoma (n=5, 36%) versus Hamartoma/tailgut cyst (n=17, 34%) in adult patients. Three pediatric and nine adult patients developed tumor recurrences, and 2/14 (14%) pediatric and 4/50 (8%) adult patients developed metastases. Conclusions. This study summarizes the presentation, evaluation and management of pediatric and adult presacral tumors at tertiary referral center. The presentation, histology, and management of presacral tumors vary depending upon whether they occur in pediatric or adult patients and recognition of potential differences may influence management.
    Polish Journal of Surgery 05/2013; 85(5):253-61.
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    ABSTRACT: BACKGROUND: Patient selection is a crucial step when considering total abdominal colectomy and ileorectal anastomosis (TAC/IRA) for refractory constipation. PURPOSE: This study aimed to evaluate the results of short- and long-term outcomes for patients with pure slow transit constipation (STC) compared to those with slow transit and features of obstructive defecation (STC + OD). METHODS: This study included all patients who underwent TAC/IRA for constipation from 1999-2010. Patients were divided into two groups: group A (STC) and group B (STC + OD) based on abnormal physiology or motility testing in addition to the surgeon's clinical impression of symptomatic obstructive defecation. Demographics, operative variables, and short-term outcomes were collected by retrospective chart review and were compared between groups. Long-term functional outcomes were assessed by telephone survey. This included: number of bowel movements, use of laxatives, antidiarrheal medications, and surgery satisfaction. Validated questionnaires were collected postoperatively. RESULTS: One hundred forty-four patients (143 females; mean age, 40 (18-68) years old) underwent TAC/IRA by either laparoscopic (63 (44 %)) or open (81 (56 %)) techniques. One hundred three patients had pure STC and 41 had STC + OD. Four patients underwent TAC with end ileostomy at first procedure. Seven patients underwent surgery after a trial of diverting ileostomy. One patient died unexpectedly, 2 days after uneventful surgery. Median follow-up was 43 (IQR, 16-75) months. Five (5 %) patients in group A and two (5 %) in group B underwent subsequent ileostomy for poor functional outcomes. Eighty-eight (68 %) patients were available by telephone. Short- and long-term outcomes were equivalent in both groups as well as patient satisfaction (89 vs. 85 %, p = 0.7). CONCLUSIONS: Total abdominal colectomy can be offered to selective patients with slow transit constipation and obstructive defecation with equivalent long-term results.
    International Journal of Colorectal Disease 03/2013; · 2.24 Impact Factor
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    ABSTRACT: BACKGROUND:: Limited data have been published regarding the long-term results of sacral nerve stimulation, or sacral neuromodulation, for severe fecal incontinence. OBJECTIVES:: The aim was to assess the outcome of sacral nerve stimulation with the use of precise tools and data collection, focusing on the long-term durability of the therapy. Five-year data were analyzed. DESIGN:: Patients entered in a multicenter, prospective study for fecal incontinence were followed at 3, 6, and 12 months and annually after device implantation. PATIENTS:: Patients with chronic fecal incontinence in whom conservative treatments had failed or who were not candidates for more conservative treatments were selected. INTERVENTIONS:: Patients with ≥50% improvement over baseline in fecal incontinence episodes per week during a 14-day test stimulation period received sacral nerve stimulation therapy. MAIN OUTCOME MEASURES:: Patients were assessed with a 14-day bowel diary and Fecal Incontinence Quality of Life and Fecal Incontinence Severity Index questionnaires. Therapeutic success was defined as ≥50% improvement over baseline in fecal incontinence episodes per week. All adverse events were collected. RESULTS:: A total of 120 patients (110 women; mean age, 60.5 years) underwent implantation. Seventy-six of these patients (63%) were followed a minimum of 5 years (maximum, longer than 8 years) and are the basis for this report. Fecal incontinence episodes per week decreased from a mean of 9.1 at baseline to 1.7 at 5 years, with 89% (n = 64/72) having ≥50% improvement (p < 0.0001) and 36% (n = 26/72) having complete continence. Fecal Incontinence Quality of Life scores also significantly improved for all 4 scales between baseline and 5 years (n = 70; p < 0.0001). Twenty-seven of the 76 (35.5%) patients required a device revision, replacement, or explant. CONCLUSIONS:: The therapeutic effect and improved quality of life for fecal incontinence is maintained 5 years after sacral nerve stimulation implantation and beyond. Device revision, replacement, or explant rate was acceptable, but future efforts should be aimed at improvement.
    Diseases of the Colon & Rectum 02/2013; 56(2):234-245. · 3.34 Impact Factor
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    ABSTRACT: AimWhether bowel related dysfunction adversely affects postoperative recovery after total colectomy with ileorectal anastomosis (C + IRA) for colonic inertia (CI) has not been previously well evaluated. This study compared the early postoperative outcome of C + IRA for CI and for other noninflammatory indications. Method Patients undergoing elective C + IRA from 1999 to 2010 were identified from a prospectively maintained database. Since inflammation in the rectum or small bowel may influence the outcome, patients with inflammatory bowel disease were excluded. Patients undergoing surgery for CI (group A) were compared with patients having the operation for other benign noninflammatory diseases (group B). Demographics, American Society of Anesthesiologists (ASA) score, body mass index (BMI), surgical procedure and 30‐day complications were assessed. ResultsThe study population consisted of 333 patients undergoing elective C + IRA (99 men, mean age 39 ± 16 years). The procedure was laparoscopic in 163 (49%) patients. Groups A (n = 131) and B (n = 202) had similar age and ASA score (39 ± 11 vs 39 ± 19 years, P = 0.4; 2.2 ± 0.5 vs 2.4 ± 0.7). Group A patients had lower BMI (25 ± 5 vs 28 ± 8 kg/m2, P = 0.002), more women (99 vs 51%, P 0.001) and fewer laparoscopic procedures (43 vs 53%, P = 0.04). Compared with group B, group A had a greater incidence of postoperative ileus (32 vs 19%, P = 0.009), higher overall morbidity (36 vs 15%, P 0.001) and increased length of stay (8.4 ± 6 vs 7.2 ± 5 days, P 0.006). These differences persisted when subgroups of patients who underwent laparoscopic or open surgery were compared. Conclusion Although CI is considered a ‘benign’ condition, patients undergoing C + IRA for this indication have significant morbidity compared with patients having the operation for other noninflammatory benign conditions.
    Colorectal Disease 01/2013; 15(4). · 2.08 Impact Factor
  • A Reshef, T L Hull, R P Kiran
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    ABSTRACT: BACKGROUND: Risk of adhesive small-bowel obstruction (SBO) is high following open colorectal surgery. Laparoscopic surgery may induce fewer adhesions; however, the translation of this advantage to a reduced rate of bowel obstruction has not been well demonstrated. This study evaluates whether SBO is lower after laparoscopic compared with open colorectal surgery. METHODS: Patients who underwent laparoscopic abdominal colorectal surgery, without any previous history of open surgery, from 1998 to 2010 were identified from a prospective laparoscopic database. Details regarding occurrence of symptoms of SBO (colicky abdominal pain; nausea and/or vomiting; constipation; abdominal distension not due to infection or gastroenteritis), admissions to hospital with radiological findings confirming SBO, and surgery for obstruction after the laparoscopic colectomy were obtained by contacting patients and mailed questionnaires. Patients undergoing open colorectal surgery for similar operations during the same period and without a history of previous open surgery also were contacted and compared with the laparoscopic group for risk of obstruction. RESULTS: Information pertaining to SBO was available for 205 patients who underwent an elective laparoscopic procedure and 205 similar open operations. The two groups had similar age, gender, and sufficiently long duration of follow-up. Despite a significantly longer duration of follow-up for the laparoscopic group, admission to hospital for SBO was similar between groups. Patients who underwent laparoscopic surgery also had significantly lower operative intervention for SBO (8% vs. 2%, p = 0.006). CONCLUSIONS: Although the rate of SBO was similar after laparoscopic and open colorectal surgery, the need for operative intervention for SBO was significantly lower after laparoscopic operations. These findings especially in the context of the longer follow-up for laparoscopic patients suggests that the lower incidence of adhesions expected after laparoscopic surgery likely translates into long-term benefits in terms of reduced SBO.
    Surgical Endoscopy 12/2012; · 3.43 Impact Factor
  • Polish Journal of Surgery 12/2012; 84(11):601-4.
  • Angela Skull, Tracy L Hull
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    ABSTRACT: Fecal incontinence (FI), which can severely affect a person's quality of life, is a difficult problem to treat. For some patients, limited management options exist. Sacral nerve stimulation, also known as sacral neuromodulation, although long established for urinary incontinence, has gained acceptance in treating FI. One unique aspect is that the procedure is performed in two stages. During the first stage, a temporary lead is inserted into the S3 sacral foramen and the patient can monitor improvement before a permanent device is implanted. While this procedure has proven to be effective for treating FI, it is also attractive owing to the low morbidity and low infection risk reported in the literature.
    Expert Review of Medical Devices 09/2012; 9(5):477-82. · 2.43 Impact Factor
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    ABSTRACT: Aim  Long-term results of the overlapping sphincter repair (OSR) have been disappointing, attributed to poor tissue quality that deteriorates with time. Biological grafts enforce tissues. The aim was to compare functional outcome and quality of life at 1 year with and without Permacol® reinforcement to evaluate short-term benefit.Method  From November 2007 to November 2008, women undergoing OSR using Permacol (group 1, n = 10) under institutional review board approval (safety trial) were age matched with patients from an institutional review board approved database (group 2, n = 10) who underwent the traditional OSR. Permacol mesh was placed under the two overlapped muscles. Group 2 underwent traditional repair. Preoperative and postoperative management of the groups was similar. The Fecal Incontinence Severity Index (FISI), the Cleveland Clinic Incontinence Score (CCFIS) and the Fecal Incontinence Quality of Life (FIQL) scale were used preoperatively and 1 year post-surgery.Results  No significant differences in demographics, symptom duration, number of vaginal deliveries, comorbidities and symptom severity were noted. Group 2 underwent concomitant procedures. Group 1 reported no complications. Group 2 reported urinary retention and dehiscence. A significant difference was found in preoperative and postoperative FIQL subscales of coping/behaviour between groups. However, comparing the pre and post scores, significant improvements on FISI (P = 0.02), the CCFIS (P = 0.005) and two subscales of FIQL (coping/behaviour, P = 0.02, and embarrassment, P = 0.01) were found in group 1. Patient satisfaction was higher in group 1.Conclusion  Biologic tissue enhancers (Permacol) do not add morbidity. Sphincter augmentation results in significant improvement in continence and quality of life scores compared with the preoperative scores in the short term over traditional repair. Long-term studies are needed to determine if this effect is sustained.
    Colorectal Disease 06/2012; 14(7):866 - 871. · 2.08 Impact Factor
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    ABSTRACT: Aim:  Studies investigating the functional outcome after restorative surgery for rectal cancer have mainly focussed on the effect of different techniques on bowel habit or sexual activity at a single point of time. The aim of this study was to assess in a longitudinal manner the effect of rectal cancer treatment on bowel function, quality of life and sexual activity. Method:  The parameters to be studied were assessed using self administered questionnaires including the Short Form 36 (SF-36) repeatedly over a 5 year period. Patient details were obstained from the Clevelend Clinic prospective database. Results:  There were 260 (186 male) patients. The mean ages at the time of surgery for males and females were 60.5 and 57.5 years. There was no significant difference in comorbidity or stage between the groups. Women had a better overall survival. More women had post operative radiation and perioperative blood transfusions than men. Men had a higher percentage of hand-sewn anastomoses (23.9% vs. 10.8%, p=0.018), but there was no overall difference in the mean level of anastomosis (2.3 vs. 1.9 cm, p=0.38). Men had worse nocturnal bowel function, more incontinence, and a poorer mental component score on the SF 36. Pad use increased over time to a greater degree in females. Sexual activity, equivalent at baseline fell at 5 years in both genders. Conclusion:  Bowel function in males after restorative resection for rectal cancer is worse than in females, especially night evacuation at 3 and 5 years. Sexual function in both genders declines sharply initially within one year and more gradually till 5 years. © 2012 The Authors Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland.
    Colorectal Disease 05/2012; · 2.08 Impact Factor
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    ABSTRACT: Aim  There is poor consensus in the literature about measuring perineal descent. We aimed to assess symptoms and quality of life in constipated patients with abnormal perineal descent. Method  Constipated patients were categorized into those with obstructed defaecation, colonic inertia, mixed disorders and irritable bowel syndrome constipation types. Anal physiology was performed. KESS score, Irritable Bowel Syndrome Quality of Life and SF-12 questionnaires were completed. The position of the perineum was measured by defaecography. Patients were divided into two groups according to the position of the perineal descent at rest: group 1 (normal < 3.5 cm) and group 2 (abnormal > 3.5 cm). Results  Fifty-eight patients were identified, 23 (40%) in group 1 and 35 (60%) in group 2. Patients in group 2 were older (P = 0.007), had a higher body mass index (BMI; P = 0.003), a higher rate of hysterectomy (P = 0.04) and more vaginal deliveries (P = 0.001). Obstructed defaecation was the predominant subtype of constipation. Group 1 had more difficulty in initiating defaecation and group 2 presented more cases with intussusception and enterocele (P = 0.03 for both). Group 2 had a lesser degree of perineal descent between rest and straining. Rectal compliance was greater in group 2 (P = 0.03). Symptoms and quality of life scores were similar between the groups. Conclusion  Radiologically determined excessive perineal descent is not indicative of worse symptoms or quality of life. This radiological finding does not warrant further investigation.
    Colorectal Disease 03/2012; 14(11):1372-9. · 2.08 Impact Factor
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    ABSTRACT: The predictors of the outcomes following anal sphincteroplasty have not been well documented. The aim was to evaluate age as a predictor of functional outcome and quality of life after overlapping sphincter repair. This study is a retrospective review of chart review followed by a prospective evaluation by the use of validated questionnaires. Patients were assigned to group A (≤ 60 years old) or group B (>60 years). Included were patients with obstetric sphincter injuries who underwent overlapping sphincteroplasty between 1996 and 2007. The Fecal Incontinence Quality of Life Scale, Fecal Incontinence Severity Index, the Cleveland Global Quality of Life scale, and a patient satisfaction questionnaire were used to assess outcome. Three hundred twenty-one women underwent sphincteroplasty and 197 responded to this study, 146 (74.1%) patients in group A and 51 (25.9%) patients in group B. Median follow-up was 7.7 years (range, 4.7-10.0). The mean overall Fecal Incontinence Quality of Life Scale was 11.0 ± 3.5. Median Fecal Incontinence Severity Index score was 29.8 ± 15.9. Mean Cleveland Global Quality of Life scale was 0.7 ± 0.2. The 2 groups were comparable for BMI (p = 1.0), ethnic background (p = 0.8), smoking (p = 0.8), and follow-up duration (p = 0.9). Intergroup comparison showed no significant difference in the Fecal Incontinence Quality of Life Scale scores (p = 0.5) in all subscales: lifestyle (p = 0.8), coping behavior (p = 0.5), depression and self-perception (p = 0.2), and embarrassment (p = 0.1). No significant differences were noted in Fecal Incontinence Severity Index (p = 0.2), Cleveland Global Quality of Life scale (p =1.0), or postoperative satisfaction (p = 0.6). The study was limited by its retrospective nature. Comparable long-term Fecal Incontinence Severity Index score and Fecal Incontinence Quality of Life Scale scores following overlapping sphincter repair suggest that age is not a predictor of outcome for overlapping sphincter repair. This procedure can be offered to both young and older patients.
    Diseases of the Colon & Rectum 03/2012; 55(3):256-61. · 3.34 Impact Factor
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    ABSTRACT: Aim  The role of biological therapy in perianal fistulas associated with Crohn's disease (CD) is uncertain as available data are confused and conflicting. In order to provide some clarity to the issue we have examined a large cohort of patients with perianal fistulas and CD and stratified them according to use of biological agents. Method  Patients with perianal Crohn's fistulas treated between June 1999 and June 2009 were stratified according to use of biological agents and outcome was examined. Healing was defined as absence of fistula or drainage. Prior to surgery perianal sepsis was eradicated with drains or setons. Endpoints were defined as either complete healing, improvement (minimal symptoms and drainage) or unhealed, as noted at subsequent outpatient follow-up. Variables assessed were age, body mass index, smoking, perineal involvement with Crohn's granuloma and type of procedure. Fisher's exact test and χ(2) test were used for analysis. Results  Two hundred and eighteen patients had anal fistulas and CD. Mean follow-up was 3.2 ± 3 years with mean age 38.8 ± 12.2 years and body mass index of 25.3 ± 6. One hundred and seventeen patients (53.7%) underwent surgery alone (Group A) and 101 patients (46.3%) underwent surgery and biological immunomodulator treatments (Group B). Demographic data and CD history were similar between groups. Surgeries included seton drainge (n = 90), fistulotomy (n = 22), rectal advancement flap (n = 39), fistulotomy plus seton (n = 47) and others (n = 20). Overall improvement in Group A was in 42 patients (35.9%) vs 72 patients (71.3%) in Group B (P = 0.001). There was no significant difference in other studied variables between both groups. Conclusions  There is a definite role for biological therapy as an adjuvant to surgery in patients with perianal fistulas and CD.
    Colorectal Disease 01/2012; 14(10):1217-23. · 2.08 Impact Factor
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    ABSTRACT: The aim of the present analysis was to report on the relationship between long-term improvement in quality of life (QOL) and fecal incontinence (FI) severity and long-term reduction in FI episodes after sacral nerve stimulation (SNS) or sacral neuromodulation. Patients who met inclusion/exclusion criteria, and initially had more than 2 FI episodes per week, were offered SNS therapy. Patients with 50% or higher reduction in FI during a 2-week test period were implanted with a neurostimulator (InterStim; Medtronic, Minneapolis, Minn). Assessments were completed by patients at baseline and at 3, 6, and 12 months after implant, and annually thereafter. The present report includes data from the 4-year postimplant follow-up. A total of 133 patients underwent test stimulation with a 90% success rate, and as a result, 120 (110 females) with a mean age of 60.5 years and a mean duration of FI of 6.8 years received long-term implantation. Of them, 78 patients completed all or part of the 4-year follow-up assessment. Fecal incontinence episodes decreased from a mean of 9.4 per week at baseline to 1.9 per week at 48 months (P < 0.001). The 4-year analyses showed that SNS had a positive and sustained impact on all 4 scales of the Fecal Incontinence Quality of Life questionnaire (P < 0.001), Fecal Incontinence Severity Index scores improved from a mean of 39.9 to 28 (P < 0.001), and self-rated bowel health scores improved from a mean of 3.5 to 6.9 (P < 0.001). Sacral nerve stimulation not only restores or improves continence in treated patients with chronic FI but also improves their quality of life and symptom severity.
    Journal of Pelvic Medicine and Surgery 01/2012; 18(2):103-12.
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    ABSTRACT: The purpose of this study was to evaluate the 30-day postoperative complications rate in patients undergoing elective total abdominal colectomy (TAC) for chronic constipation, neoplastic disorders, and inflammatory bowel disease (IBD) using the American College of Surgeons National Quality Improvement Database (ACS-NSQIP). The 2007 ACS-NSQIP sample was used to identify the Current Procedural Terminology codes for TAC and International Classification of Diseases, 9th Revision codes for chronic constipation, neoplasia, and IBD. Preoperative and intraoperative variables and postoperative complications were compared among the three diagnosis groups. Wilcoxon rank sum and Fisher exact tests were used for analysis. P < 0.05 was considered significant. Seven hundred forty-four patients were identified; chronic constipation was found in 107 (14.4%) patients, neoplasia in 312 (42.3%), and IBD in 322 (43.3%). Patients with constipation were predominantly females (85.2%). The neoplastic group was older and had greater body mass index when compared with the other groups. Patients with IBD presented greater use of steroids, lower albumin and hematocrit levels, and higher morbidity probability. Constipated patients had more neurologic and renal complications when compared with the IBD group (P = 0.01). None of the other categories of complications were statistically different among the diagnosis groups. With the exception of urinary tract infection being higher in the constipation patients compared with IBD (10 vs 4%, P = 0.03), there were no statistically significant differences among the other short-term specific complications. The 30-day complication rate after TAC is similar for chronic constipation, neoplasia, and IBD.
    The American surgeon 12/2011; 77(12):1613-8. · 0.92 Impact Factor

Publication Stats

3k Citations
552.97 Total Impact Points

Institutions

  • 1999–2014
    • Cleveland Clinic
      • Digestive Disease Institute
      Cleveland, Ohio, United States
    • Good Samaritan Hospital
      Suffern, New York, United States
    • Medical University of South Carolina
      • Department of Obstetrics and Gynecology
      Charleston, SC, United States
  • 2011
    • University of Minnesota Duluth
      Duluth, Minnesota, United States