Bertil Poppen

Colectomy-proctomucosectomy with S-pouch: operative procedures, complications, and functional outcome in 69 consecutive patients.

Sixty-nine patients were operated upon in a three-stage procedure. Early complications occurred in 29 percent after colectomy-ileostomy, in 25 percent after proctomucosectomy with ileoanal anastomosis and loop ileostomy, and in 9 percent after closure of loop ileostomy. Only three of these were considered serious. Seventy-one percent of the patients were readmitted into the hospital between the three operations or after the last one. Total hospital stay was 49 days (median); the range was 20 to 345 days. Reconstruction of the reservoir was performed in four patients owing to defecation problems, with satisfying functional results in two patients, while two emptied by catheter. There was no postoperative mortality or pelvic sepsis, and no pouches were excised. Ileostomy was re-established in two patients. At histopathologic reevaluation of colectomy specimens, the diagnosis was changed from ulcerative colitis to Crohns disease in three patients and to indeterminate colitis in five. Median follow-up was 4.3 years. Continent anal defecation without ileostomy was achieved in 67 patients (97 percent), with 4.1 bowel movements per day and 0.6 per night. Perfect continence was achieved in 55 percent in the daytime and in 43 percent at night. The low rate of reservoirthreatening complications is attributed to the three-stage procedure and the technical details in the surgical procedures.

Sexual life in women after colectomy-proctomucosectomy with S-pouch

In a consecutive series, 30 women were interviewed and gynecologically examined after pelvic pouch operation because of inflammatory bowel disease. The examination displayed: colpitis in two. bacterial vaginosis in one and cervical cancer in situ in one of the women. Unwanted infertility was reported by five women, probably due to female factors in three. Sixteen women had felt sexually unattractive by the temporary ileostomy. At follow‐up, after closure of the ileostomy, 23 women experienced a considerable sexual desire, 28 could experience orgasm and 20 nearly always had orgasm at intercourse. Insufficient vaginal lubrication during intercourse was reported by seven women. This could be explained by hormonal or other factors in four women and might be owing to side‐effects of the operation in three. Four women reported slight deep dyspareunia and one superficial dyspareunia. The result indicated a low frequency of sexual problems after pelvic pouch operation.

Parietal cell vagotomy for duodenal and pyloric ulcers

Abstract In a prospective study, 170 consecutive unselected patients with duodenal (n = 115) or pyloric (n = 55) ulcers underwent elective parietal cell vagotomy, with an additional drainage procedure in patients with stenosis. The patients were classified in two consecutive groups and were followed up for 3 to 7 years after operation, in 132 cases for more than 5 years. The follow-up was complete. Patients with symptoms suggestive of ulcer for more than 3 days, independent of roentgenographic or endoscopic findings, were classified as having symptoms of recurrent ulcer and were specially analyzed. There was no mortality; splenic injuries occurred in 5 cases (3 percent), dumping symptoms in 4 percent after parietal cell vagotomy but in 34 percent after vagotomy plus drainage. Diarrhea occurred in 3 percent of the patients after parietal cell vagotomy and in 20 percent after vagotomy plus drainage. Fifty-five patients had clinical recurrences, significantly more patients with pyloric ulcer (46 percent) than with duodenal ulcer (28 percent). In 27 patients, the symptoms responded well to conservative therapy. In the other 28 patients the symptoms were severe, and 14 underwent reoperation for proven recurrent ulcers. The difference in the recurrence rates for duodenal and pyloric ulcer was found only in patients who did not undergo a drainage procedure, while pyloric ulcer patients with stenosis and a drainage operation were comparable in this respect to duodenal ulcer patients with and without drainage. A decrease in the rate of recurrence was achieved between the earlier and later parts of the series, even considering the difference in length of follow-up. The decrease is considered to reflect mainly our increased experience with the method. The results in patients in the later part of the series, followed up for more than 5 years, were a 22 percent incidence of recurrent ulcer symptoms and an 8 percent incidence of proven recurrent ulcers in those with duodenal ulcer, and a 28 percent incidence of recurrent ulcer symptoms and a 22 percent incidence of proven recurrent ulcers in those with pyloric ulcer. The overall results in patients followed up to more than 5 years, according to a modified Visick scale which incorporates differences in the severity of recurrent ulcer symptoms and the results after reoperation, were satisfactory in 89 percent of the patients with duodenal ulcer and in 73 percent of those with pyloric ulcer.

Crohn's disease and adenocarcinoma of the intestinal tract: Report of four cases

Four patients with intestinal adenocarcinoma complicating Crohns disease are reported. The youngest of the four patients was a 21-year-old female with a 9-year history of Crohns disease of the terminal ileum as well as of the entire colon. She developed mucus-producing moderately differentiated adenocarcinoma in the cecum. Of the remaining three patients with Crohns disease, one presented an adenocarcinoma in the ascending colon, one in the rectum and the remaining one in the duodenum. All three colorectal adenocarcinomas originated in areas of high-grade dysplasia and all four in areas with chronic transmural inflammation. The review of the literature indicates that a total of 174 small and large bowel cancers occurring in Crohns disease have been recorded (including the four reported herein). The vast majority of the reported cases have been found in the North American subcontinent. Only in a few instances were bowel adenocarcinoma and Crohns disease observed in the European continent. It is therefore remarkable that three of our four cases were seen within a period of 12 months. Interestingly, six patients having colorectal adenocarcinoma in association with Crohns disease were recently reported from a single hospital in England. The question therefore arises whether our cases and those reported recently from England are unrelated and merely coincidental or whether carcinomas are now also affecting European CD patients. If the latter is the case, the surveillance policy for patients with CD should be reconsidered at this hospital.

Intraepithelial bodies in colorectal adenomas: Leuchtenberger bodies revisited

The presence of intraepithelial inclusion bodies (Leuchtenberger bodies) was recorded in rectal or colonic specimens from 130 patients. Large to moderate number of intraepithelial bodies were recorded in 81.8 percent of 55 colorectal adenomas from patients with familial adenomatous polyposis (FAP). Conversely, none of the 55 non-FAP adenomas or of the 20 specimens with ulcerative colitis (10 with dysplasia) had similar amounts of intraepithelial granules. Feulgen studies demonstrated that the granules contain DNA and are probably nuclear fragments of destroyed lymphocytes. Although the pathogenesis of this phenomenom remains obscure, it appears that the presence of large to moderate number of intraepithelial bodies in colorectal adenomas should strongly raise the suspicion of FAP.

Surgery after colectomy for ulcerative colitis

The need for surgery after colectomy in patients with ulcerative colitis in Stockholm County over a 30-year period, 1955 to 1984, was investigated. During this time 483 patients were discharged from the hospital after colectomy. The mean period of observation from colectomy was 11.6 years. In 325 (67 percent) of the 483 patients there was need for further surgery (932 surgical procedures) during the period of observation. In 95 (20 percent) patients 115 small intestinal obstructions requiring surgery developed. The 2-year and 15-year cumulative probabilities of a first small intestinal obstruction were 11 percent (confidence intervals [CI] 8–14 percent) and 23 percent (CI 19–27 percent), respectively. In 42 (16 percent) of 255 patients treated by proctocolectomy and ileostomy there was need for 64 ileostomy revisions. The 2-year and 15-year cumulative probabilities of a first ileostomy revision were 9 percent (CI 6–12 percent) and 19 percent (CI 14–24 percent), respectively. Ninety-one Kocks pouches were constructed and a total of 125 revisions of Kocks pouch were performed. The 2-year and 15-year cumulative probabilities of a first Kocks pouch revision were 52 percent (CI 41–63 percent) and 57 percent (CI 46–68 percent), respectively. In 75 patients a pelvic pouch and ileoanal anastomosis was constructed. In 32 patients 73 surgical procedures due to pouch-related dysfunction were performed. Alterations in ileoanal pouch technique and increasing surgical experience has resulted in a markedly decreasing frequency of complications during the last years. There was no need for further surgery in 116 (45 percent) of the 255 patients treated by proctocolectomy and ileostomy, in 31 (34 percent) of the 91 patients with Kocks pouch, in 20 (39 percent) of the 51 patients with ileorectal anastomosis, and in 43 (57 percent) of the 75 patients with pelvic pouch and ileoanal anastomosis (closure of loop ileostomy excluded).

Parietal cell vagotomy for duodenal and pyloric ulcers: II. Histopathology and gastric secretion

Abstract The clinical follow-up of patients with parietal cell vagotomy for duodenal and pyloric ulcers revealed more recurrent symptoms of ulcer in patients with pyloric ulcer. In an attempt to explain this finding, the clinical results were related to the results of histopathologic examination and gastric secretion tests. The location of the microscopic antral-fundic boundary in relation to the distal limit of denervation, as an indicator of the extent of denervation at the minor curvature, was found to be the same in patients with both types of ulcer and also in patients with and without recurrent symptoms of ulcer. The grade of gastritis was also found to be the same in the mentioned categories. Patients with duodenal and pyloric ulcer did not differ in their response to insulin postoperatively according to 10 criteria for incomplete vagotomy. More positive insulin tests were found in patients with recurrent symptoms of ulcer in both the duodenal and pyloric ulcer groups. In absolute values of gastric secretion, duodenal ulcer patients were found to have significantly higher values both pre- and postoperatively than pyloric ulcer patients, but both groups had the same postoperative reduction. Significantly higher postoperative gastric secretion was found in duodenal ulcer patients with recurrent ulcer symptoms than in those without, whereas the same differences in pyloric ulcer patients were small and insignificant. The higher rate of recurrent ulcer symptoms in pyloric ulcer patients than in duodenal ulcer patients cannot be explained either by anatomically or physiologically inadequate vagotomies or by differences in grade of gastritis.

Pelvic reservoir with S-pouch

PURPOSE: This study was designed to evaluate whether operating surgeons could follow up the functional outcome of their own operations, without bias, by using standardized methods at follow-up. METHODS: Fifty-five patients who received a pelvic reservoir with an S-pouch were evaluated regarding functional outcome after at least one year post-operative follow-up. The functional surgical outcome was evaluated by an internist especially trained in gastroenterology and the operating surgeon by using a standardized scale comprising eight functional variables. RESULTS: None of the variables analyzed reached statistically significant difference between the two observers, and a high degree of agreement could be shown by using kappa and weighted kappa analysis. CONCLUSIONS: Our results indicate that it is possible for an operating surgeon to assess the postoperative surgical outcome using standardized methods at follow-up.