Gideon Goldman

The correlation between quality of life and functional outcome in ulcerative colitis patients after proctocolectomy ileal pouch anal anastomosis.

Objective  The aim of this study was to evaluate functional outcome and quality of life (QOL) in patients undergoing proctocolectomy ileal pouch anal anastomosis (IPAA), to assess the correlation between functional outcome and QOL, and to identify factors influencing functional outcome and QOL in these patients.

Transanal endoscopic microsurgery: experience with 75 rectal neoplasms.

PURPOSE: The aim of this study was to describe a single institutions experience with transanal endoscopic microsurgery in patients with benign and malignant rectal tumors. PATIENTS: Between January 1992 and April 1998, 75 patients with a mean follow up of 38 months, underwent transanal endoscopic microsurgery excision of benign (46) or malignant (29) rectal tumors, located 3 to 18 cm from the dentate line. RESULTS: A total of 3 of 46 (6.5 percent) patients with benign tumors underwent conversion to radical surgery owing to tumor size. During the follow-up period, benign tumor recurrence was observed in four (9 percent) patients, three of whom were managed by repeat transanal endoscopic microsurgery, whereas one required radical surgery. Histologic staging of malignant tumors was T1 (10), T2 (10), and T3 (9). Seven patients with either inadequate resection margins or T3 tumors were complimented with radical surgery. Of the remaining 22 patients, 11 received adjuvant radiation therapy whereas 11 had no further treatment. Four (18 percent) had recurrent disease, which was managed by repeat transanal endoscopic microsurgery in two, radical surgery in one, and laser ablation in one. No cancer-related deaths were observed during the follow-up period. There was one operative mortality in a cardiac-crippled patient. Postoperative complications were mainly of a minor character and included fever, urinary retention, and bleeding; none of which required reintervention. Rectourethral fistula developed in one patient who underwent repeat transanal endoscopic microsurgery excision for a T3 malignancy. Fecal soiling was transient in three patients and persisted in two. CONCLUSION: Transanal endoscopic microsurgery excision is a safe and precise technique that is well tolerated even in high operative risk patients. Transanal endoscopic microsurgery may become a procedure of choice for benign rectal tumors and selected early malignant neoplasms.

Tumour Necrosis Factor Mediates Bacterial Translocation After Haemorrhagic Shock and Endotoxaemia

OBJECTIVE To assess the extent of bacterial translocation after haemorrhagic shock and reperfusion, and the involvement of tumour necrosis factor (TNF) in its mediation. DESIGN Controlled, randomised prospective experiment. SUBJECTS 87 rats in 7 groups. INTERVENTIONS Haemorrhagic shock was induced in rats for 1 hour. Endotoxaemia was induced in a second group by the injection of lipopolysaccharide. A third group was injected with exogenous TNF. Some of the animals were further treated with anti-TNF. MEASUREMENTS After 24 hours, bacterial translocation in blood and in several remote organs, and serum TNF concentrations were measured. RESULTS High bacterial counts were found in all remote organs of rats with haemorrhagic shock or endotoxaemia. Their serum TNF concentrations were significantly higher than in the corresponding sham-operated controls. Anti-TNF significantly reduced the extent of bacterial translocation. Rats, the only treatment of which was exogenous TNF, developed substantial bacterial translocation. CONCLUSION Bacterial translocation is associated with increased serum TNF, and can be minimised by anti-TNF. This, and the triggering of translocation in unprovoked animals by TNF alone, suggest that TNF may be the stimulator, and not the consequence, of bacterial translocation.

Biliary micellar cholesterol nucleates via the vesicular pathway

Biliary cholesterol nucleates primarily from phospholipid vesicles. In this study, we investigated the mode of nucleation of micellar cholesterol. Ten biles (four human and six model) were examined. The vesicular and micellar fractions of each bile were separated by gel chromatography. The whole biles and their isolated carriers were incubated at 37 degrees C until nucleation time. In whole human biles, the proportion of total cholesterol in vesicles rose throughout the incubation (from zero time to nucleation time) from 15.5 +/- 8.6% to 28.0 +/- 12.5%, and in model biles from 46.8 +/- 22.4% to 75.5 +/- 8.2%. The vesicular isolated fraction remained unchanged throughout incubation. In isolated micelles devoid of vesicles at zero time, new vesicles formed during incubation, carrying increasing proportions of cholesterol. At nucleation time, these vesicles contained 11.0% of originally micellar cholesterol in human biles, and 41.2% in model biles. The new vesicles formed in whole bile and in the micellar fraction were chromatographically and chemically similar to the vesicles originally present in bile. These data suggest that micellar cholesterol nucleates via the neoformation of phospholipid vesicles, which seem to be the final common pathway for cholesterol nucleation in bile.

Leukergy in inflammatory bowel disease

In the phenomenon of leukergy, white blood cells agglomerate in peripheral blood slides. This agglomeration has been described in inflammatory infections of various causes. This study assesses this phenomenon in inflammatory bowel disease. A correlation was found between the severity of inflammatory bowel disease activity and the percentage of leukergy. Leukergy was found to parallel the clinical and endoscopic findings of inflammatory bowel disease. Furthermore, leukergy was found to be more accurate than white blood count and erythrocyte sedimentation rate. It is also found to accurately assess the course of the disease when clinical and other laboratory tests were masked by steroid and antibiotic administrations Leukergy is a quick, inexpensive test that can easily be performed at the patients bedside.

Familial adenomatous polyposis at the Tel Aviv Medical Center: demographic and clinical features

Familial adenomatous polyposis (FAP) is an uncommon, but widespread genetic disorder that develops multiple colonic adenomatous polyps and, if untreated, can lead to large bowel cancer. Little is known about its occurrence and characteristics in the Israeli population. Aims: To evaluate FAP prevalence, phenotypic manifestations and compliance for diagnosis and follow-up in our registry. Methods: Since 1993 approximately one-half of FAP patients in Israel have been seen and followed-up by us before and/or after colectomy. They and their families were encouraged to have mutation analysis, genetic and/or endoscopic screening. Results: 37 pedigrees were identified, including 2 non-Jewish. The Jewish ethnic distribution was similar to that of the general population and the point prevalence rate estimated as 28.4/one million Jewish inhabitants. There were 461 first-degree relatives at-risk for FAP. Genetic screening was completed and successful in 28 pedigrees (87.5%), and 73 FAP patients entered the registry. Marked intra-familial phenotypic variations with minimal disease manifestation were noted in 11 patients belonging to 4 pedigrees. Cancer occurred in 15.1% (11 patients), in 10 before FAP diagnosis or during follow-up elsewhere, but one non-compliant patient developed duodenal cancer. One other patient died from a massive, neglected, intra-abdominal desmoid. Compliance for evaluation and follow-up of pedigree members and individual FAP patients was inadequate in 29% and 27%, respectively. Conclusions: FAP occurs in the Israeli Jewish population at the expected rate, but is inadequately recognized in non-Jews. The inadequate compliance for screening and post-surgical follow-up needs to be addressed by educating the public, health care workers and Health Insurers.

Bacteremia in anal dilatation

One hundred patients underwent anal dilatation for acute or chronic anal fissure during the period 1983–1984; white blood count, serum, muscle enzymes, and blood cultures were done. Positive blood cultures were found following the procedure in eight patients. A correlation based on serum enzymes, bacteremia, and trauma can be made. Prophylactic broad-spectrum antibiotics are recommended for patients at risk.

Recurrent spontaneous perforation of the colon

A 58-year-old man with recurrent spontaneous perforations of the colon is reported. The first two events were of the sigmoid colon, and a sigmoidectomy was performed after the second perforation. The third spontaneous perforation had occurred in the transverse colon, however, although a patent sigmoid colostomy was present. Neither primary colonic pathology nor elevated intraluminal pressure were found, which means that the cause and pathogenesis of these perforations are unknown. Six months later, a subtotal colectomy with ileosigmoid anastomosis was performed with an apparent satisfactory result.

Intrarectal Bypass Graft in Low Anterior Resection and Sigmoid Obstruction – An Experimental Study

The most common causes for morbidity and mortality in colorectal resections are anastomotic leaks. In low anterior resection, the incidence of anastomotic leakage ranges from 17 to 50%. With the use of the stapler technique, leakage incidence rate remains high and ranges from 10 to 25%. Colostomy formation and closures are associated with considerable morbidity and mortality. Due to the high incidence of anastomotic leakage rate in low anterior resection, and the additional complications of diverting colostomy formation and closure, the use of a rectal stent-intrarectal bypass graft has been instituted. This is carried out by means of a silastic graft, which prevents the fecal stream and gas pressure from coming into contact with the anastomotic site at the low rectum. The efficacy of intrarectal bypass graft was examined in two high-risk surgical situations, the first in very low anterior resection and the other, after early sigmoid obstruction. In both situations the intrarectal bypass graft provided for a safe anastomosis. Even when dehiscence and early obstructions occur, the tube may prevent leakage. This procedure presents effective practical implications which obviate the need for a proximal colostomy formation, thereby eliminating the physical and psychological stress that accompanies colostomies.

Acute dilation of a J-pouch

To the Editor--We are reporting a case of acute dilation of a J-pouch ileoanal anastomosis. Awareness of this postoperative complication can avoid the need for surgery. A 27-year-old male with ulcerative colitis underwent a restorative proctocolectomy J-pouch ileoanal-stapled anastomosis and protective loop ileostomy. Nine weeks later, the patient was readmitted for routine closure of the ileostomy. In the interim period, the pouch had been evaluated with barium enema studies, which revealed no inlet or outlet obstruction, normal capacity, and normal evacuation. In addition, digital examination ruled out any ileoanal anastomotic stricture or sphincter stenosis. Two days after routine closure, the patient developed severe abdominal pain and vomiting. On examination, there was abdominal distention, and the patient was dehydrated, pale, clammy, and tachycardic. Apart from a mild hypokalemia (3.2), routine blood studies were normal, and the patient failed to respond to conservative treatment. He was taken to the operating room for an exploratory laparotomy, which showed evidence of dilated small intestine proximal and distal to the ileostomy closure site and no evidence of an anastomotic leak. The pouch, however, was grossly dilated, tense, and edematous, with areas of tears. In view of these findings, an attempt was made to decompress the pouch per rectum using a standard rectal tube. This proved successful, resulting in release of large amounts of small-bowel contents. Acute dilation of the pouch appears to be a rare complication of pouch surgery. The exact etiology is unclear, but dilation secondary to rapid filling after closure of the ileostomy is one possibility. In the case reported, hypokalemia and corticosteroid therapy could also have contributed. Awareness of this complication would allow a simple endoanal drainage of the pouch without the need for surgery.