Tracy L. Hull

Cleveland Clinic, Cleveland, Ohio, United States

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Publications (125)514.22 Total impact

  • Annals of Surgery 07/2015; DOI:10.1097/SLA.0000000000001386 · 8.33 Impact Factor
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    ABSTRACT: The optimal technique for curative resection of colonic cancer includes high ligation of the mesenteric vessels, wide excision of the colonic mesentery and prevention of tumour cell spillage. This article reports results from the authors' institution for patients in whom complete mesocolic excision was performed long before the term was coined. Patients operated on for cure for primary adenocarcinoma of the colon between January 1994 and December 2004 were identified from a prospectively maintained, institutional review board-approved, colorectal cancer registry. Medical records and operation notes were reviewed. The primary outcomes were recurrence (local and distal) and age-adjusted 5-year survival. Some 1013 patients (560 men and 453 women) were identified, with a median age of 69 (range 21-96) years. The most common location of the cancer was the sigmoid colon (32·9 per cent), followed by the caecum (26·7 per cent) and ascending colon (17·0 per cent). Operations were performed laparoscopically in 134 patients (13·2 per cent). Median duration of hospital stay was 7 (range 1-64, mean 8·2) days. Overall morbidity and mortality rates were 13·5 and 2·2 per cent respectively; there were 20 anastomotic leaks (2·0 per cent). Some 282 patients (27·8 per cent) had stage I, 386 (38·1 per cent) stage II and 345 (34·1 per cent) stage III disease. Median lymph node yield was 28·3 (range 0-241, mean 28·3), and 12 or more nodes were examined in 88·1 per cent of patients. Adjuvant chemotherapy was administered to 277 patients (80·3 per cent) with stage III disease. Overall local and distant recurrence rates at 5 years were 5·1 and 17·1 per cent respectively. The 5-year local recurrence rate was 2·2, 5·3 and 7·7 per cent for American Joint Committee on Cancer stages I, II and III respectively. Corresponding distant recurrence rates were 4·0, 14·7 and 30·5 per cent. The 5-year overall cancer-free age-standardized survival rate was 85·3 per cent. Five-year age standardized survival rates for patients with disease stages I, II and III were 97·7, 90·8 and 69·8 per cent respectively. These data define modern results of surgery for colonic cancer with conservative use of chemotherapy. © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd.
    British Journal of Surgery 04/2015; 102(7). DOI:10.1002/bjs.9805 · 5.21 Impact Factor
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    ABSTRACT: Diagnosing outlet obstruction after IPAA can be challenging because the etiology is multifactorial. The aim of this study was to assess possible factors associated with outlet obstruction from paradoxical anal muscle contraction (paradox) after IPAA unrelated to strictures or structural abnormalities. This was a retrospective study from a prospectively maintained pouch database. The study was conducted at a tertiary referral center. All of the patients with paradox after ileal J-pouch-anal anastomosis verified by anal physiology were identified from our prospectively maintained database. Patients with endoscopic or digital evidence of strictures or other anatomic abnormalities were excluded. Demographic, clinical, and perioperative factors were obtained, including previous abdominal operations, history of pouchitis, need for anal intubation, diagnosis of small-bowel obstruction, and radiologic findings at the time of paradox diagnosis. There were 40 patients (17 women) with an overall mean age of 39 years (range, 17-60 years) and a mean follow-up of 15 years (range, 1-28 years) after IPAA. Pathologic diagnoses at the time of ileal pouch creation were ulcerative colitis (n = 27), indeterminate colitis (n = 11), Crohn's disease, and familial adenomatous polyposis (1 case each). A total of 15 (37%) of 40 patients were diagnosed with small-bowel obstruction before their paradox diagnosis, 8 of whom underwent surgery, which revealed diffusely dilated small bowel and pouch without intraoperative identification of a transition point. The time from ileal pouch creation to paradox diagnosis was significantly longer in patients receiving a diagnosis of small-bowel obstruction than in the remaining paradox patients (7.2 vs 2.6 years; p < 0.001). This study was limited by its nonrandomized retrospective nature. After an IPAA, patients with outlet obstruction from paradox can appear to have a small-bowel obstruction. A high incidence of suspicion is needed to make the correct diagnosis and avoid an unneeded laparotomy.
    Diseases of the Colon & Rectum 03/2015; 58(3):328-32. DOI:10.1097/DCR.0000000000000264 · 3.20 Impact Factor
  • Journal of the American College of Surgeons 10/2014; 219(4):e76-e77. DOI:10.1016/j.jamcollsurg.2014.07.587 · 4.45 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; 26(8). DOI:10.1111/nmo.12360 · 3.42 Impact Factor
  • Gastroenterology 05/2014; 146(5):S-1029. DOI:10.1016/S0016-5085(14)63751-3 · 13.93 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. DOI:10.1097/DCR.0000000000000094 · 3.20 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; 28(8). DOI:10.1007/s00464-014-3464-3 · 3.31 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 04/2013; 15(4). DOI:10.1111/codi.12058 · 2.02 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; 27(5). DOI:10.1007/s00464-012-2663-z · 3.31 Impact Factor
  • 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. DOI:10.1586/erd.12.37 · 1.78 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. DOI:10.1111/j.1463-1318.2011.02808.x · 2.02 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; 15(1). DOI:10.1111/j.1463-1318.2012.03075.x · 2.02 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. DOI:10.1111/j.1463-1318.2012.03018.x · 2.02 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. DOI:10.1097/DCR.0b013e31823deb85 · 3.20 Impact Factor
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    ABSTRACT: Emerging evidence suggests that a laparoscopic approach to colorectal procedures generates fewer adhesions. Even though laparoscopic ileal pouch-anal anastomosis (IPAA) is a lengthy procedure, the prospect of fewer adhesions may justify this approach. The aim of this study was to assess abdominal and adnexal adhesion formation following laparoscopic versus open IPAA in patients with ulcerative colitis. A diagnostic laparoscopy was performed at time of ileostomy closure. All abdominal quadrants and the pelvis were video recorded systematically and graded offline. The incisional adhesion score (IAS; range 0-6) and total abdominal adhesion score (TAS; range 0-10) were calculated, based on the grade and extent of adhesions. Adnexal adhesions were classified by the American Fertility Society (AFS) adhesion score. A total of 43 patients consented to participate, of whom 40 could be included in the study (laparoscopic 28, open 12). Median age was 38 (range 20-61) years. There was no difference in age, sex, body mass index, American Society of Anesthesiologists grade and time to ileostomy closure between groups. The IAS was significantly lower after laparoscopic IPAA than following an open procedure: median (range) 0 (0-5) versus 4 (2-6) respectively (P = 0·004). The TAS was also significantly lower in the laparoscopic group: 2 (0-6) versus 8 (2-10) (P = 0·002). Applying the AFS score, women undergoing laparoscopic IPAA had a significantly lower mean(s.d.) prognostic classification score than those in the open group: 5·2(3·7) versus 20·0(5·6) (P = 0·023). Laparoscopic IPAA was associated with significantly fewer incisional, abdominal and adnexal adhesions in comparison with open IPAA.
    British Journal of Surgery 02/2012; 99(2):270-5. DOI:10.1002/bjs.7759 · 5.21 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. DOI:10.1111/j.1463-1318.2012.02944.x · 2.02 Impact Factor
  • M Zutshi, T Hull, B Gurland
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    ABSTRACT: The effect of a biological material to support an overlapping sphincter repair was investigated in patients with damage to the entire circumference of the external sphincter due to radiation or trauma. A tunnel is created under the damaged external anal sphincter muscle to encircle the anal canal. A biological graft (Surgisis™; 6 ply, 2×20 cm) is then inserted through the tunnel and sutured to the muscle after being pulled firmly to close the patulous anus. An overlapping repair is then carried out. Between January 2009 and June 2010, 13 patients underwent this procedure. The average age at surgery was 68.6 years. The mean follow up was 16.3 (range 6-24) months. The average length of stay was 1 day. No complications were reported. Postoperatively, incontinence severity scores and quality of life scales [39.22 (±16.1) to 9.66 (±11.9)] showed improvement. Incontinence episodes were markedly decreased to one per week. Anal encirclement using a biological graft with sphincter augmentation may achieve continence in patients with circumferential anal sphincter damage.
    Colorectal Disease 05/2011; 14(5):592-5. DOI:10.1111/j.1463-1318.2011.02675.x · 2.02 Impact Factor
  • Annual Meeting of the American-Society-of-Colon-and-Rectal-Surgeons; 05/2011
  • Annual Meeting of the American-Society-of-Colon-and-Rectal-Surgeons; 05/2011

Publication Stats

4k Citations
514.22 Total Impact Points


  • 1999–2014
    • Cleveland Clinic
      Cleveland, Ohio, United States
    • Good Samaritan Hospital
      Cincinnati, Ohio, United States
    • Medical University of South Carolina
      • Department of Obstetrics and Gynecology
      Charleston, SC, United States