Jan Kewenter

Precancer and carcinoma in chronic ulcerative colitis. A histopathological and clinical investigation.

Sixty patients with chronic ulcerative colitis and carcinoma have been studied. The morphological features of the tumours and colonic mucosa were examined in 27 cases. The long-term outcome of the total material was estimated. The patients age at which the carcinoma developed was low and the prognosis mostly unfavourable (5-year survival about 25%). The bad prognosis seems to be an expression of a specific tumour biology at that particular age rather than characteristic features of colitic carcinoma per se. since the histological features of the idiopathic colo-rectal carcinomas in patients at the same age arc very similar to the colitic carcinomas. Precancerous mucosal changes could be demonstrated in all cases except one. The occurrence of precancerous changes in a rectal biopsy seems to justify a prophylactic proctocolectomy, since these patients have a special risk of developing a colonic carcinoma.

The occurrence of severe epithelial dysplasia and its bearing on treatment of longstanding ulcerative colitis.

One hundred twenty-four patients with extensive ulcerative proctocolitis were operated upon with proctocolectomy. The mean observation time was 10.3 years. Before surgery rectal biopsies were taken in all patients. The relationship between precancerous lesion in rectal biopsies and the presence of precancer and/or cancer in the rectum or colon in the removed specimen was evaluated. Thirteen out of 14 patients showed evidence of severe rectal dysplasia as well as severe dysplasia in the large bowel specimen, and five of these patients had a carcinoma as well. The 14th patient showed severe dysplasia only in the rectum as well as a rectal carcinoma. Of 110 patients without severe rectal dysplasia, 36 showed evidence of severe colon dysplasia, and three of these patients had a large bowel carcinoma as well. Only one patient had a large bowel carcinoma without evidence of severe dysplasia in the rectum or colon. Thus, nine patients out of ten with large bowel carcinoma showed severe dysplasia in rectum and/or colon. Four of these carcinomas were unknown before surgery. Although severe dysplasia in the rectal biopsy is a strong indication of a large bowel carcinoma (6/14), a negative rectal biopsy does not exclude a large bowel carcinoma (4/110). Proctocolectomy cannot be looked upon only as a prophylactic procedure in patients with severe dysplasia in the rectal biopsy, but also as an attempt to curative surgery, as large bowel carcinoma may have already developed in a considerable number of patients where precancer is diagnosed in biopsies.

The effect of parietal cell vagotomy and selective vagotomy with pyloroplasty on body weight and dietary habits. A prospective randomized study.

Body weight and dietary habits were studied in 32 male patients in a consecutive randomized series of parietal cell vagotomy (PCV) and selective vagotomy with pyloroplasty (SV + P). There were 16 patients in each group. One month after surgery all patients had lost weight. During the first 2 postoperative years following PCV most patients regained their preoperative weight. SV + P led to an impaired ability to gain weight. Following PCV the consumption of fat was reduced but the carbohydrate consumption increased, leading to an unchanged total daily energy intake. The daily energy intake decreased following SV + P in spite of an increased consumption of protein-rich foods such as meat, fish, and eggs. The decreased energy intake was due to a reduced intake of fat, sugar, and milk following SV + P. It is concluded that dumping is a contributory cause of the reduced energy intake following SV + P.

The Effect of Parietal Cell Vagotomy and Selective Vagotomy with Pyloroplasty on Gastric Emptying of a Solid Meal: A Prospective Randomized Study

A new technique is described whereby gastric emptying of a 51Cr-labelled solid meal (hamburger, vegetables, potatoes) was measured by way of a movable NaJ(T1) detector. The technique allowed separate measurements over the proximal and the distal part of the stomach. Seven volunteers took part in a study which revealed good correlation between two individual consecutive tests. Eight patients who took part in a controlled randomized series of parietal cell vagotomy (PCV) versus total gastric selective vagotomy and pyloroplasty (SV+P) underwent the test preoperatively and 6 to 8 months postoperatively. Following both operations gastric emptying was retarded. The time taken for the amount of meal remaining in the stomach to be reduced to 75,50 and 25% respectively was significantly longer postoperatively than before surgery, but there were no differences in this respect between PCV and SV+P. The retardation of gastric emptying of solids was in contrast to the emptying of 10% glucose solution, which in the same series of patients was found to be accelerated. Following PCV there was a change in the distribution of the meal within the stomach immediately after the intake of the meal: a larger part of the meal was found in the proximal stomach post-operatively than before operation. There was no significant change in this intragastric distribution of the meal after SV+P.

Clinical and Morphological Characteristics of Colitis Carcinoma and Colorectal Carcinoma in Young People

Two series of young patients (less than 40 years of age) with colorectal carcinoma (22 idiopathic carcinomas and 25 carcinomas complicating ulcerative proctocolitis), well matched for age and sex, were compared with regard to clinical features, tumour morphology and stage, and ultimate outcome after surgery. The cure rate in both series was low. Although a failure to diagnose colitis carcinoma accurately at an early stage might have contributed to the poor results, such a delay could hardly be responsible for the bad prognosis in patients with idiopathic carcinoma. The vast majority of the patients in both groups studied had highly malignant and/or mucoid adenocarcinoma, and surgery was palliative in about 40% of the patients in both series, owing to widespread dissemination. The general impression gained from this study of factors of histologic grade of malignancy, extent of spread, and survival rate was that colorectal carcinomas in the young, irrespective of being idiopathic or complicating ulcerative colitis, run a rapid course and have a gloomy prognosis. The outloook depends largely on the biologic characteristics of the tumours concerned. The results support previous statements that prophylactic surgery is justified in patients with long-standing ulcerative colitis with total involvement of the colon, particularly in the young. Regrettably, patients with idiopathic carcinoma will not have this chance.

The Effect of Parietal Cell Vagotomy and Selective Vagotomy with Pyloroplasty on Iron Absorption: A Prospective Randomized Study

Iron absorption from a composite meal was studied in 37 male patients before and 1 year after parietal cell vagotomy (PCV) and selective vagotomy with pyloroplasty (SV + P) in a prospective randomized series. The ability to absorb dietary non-haem iron was studied by relating in each subjects the food iron absorption to the absorption from a small dose of ferrous iron, which has been shown to be unaffected by gastric surgery. After both PCV and SV + P there was a malabsorption of food iron which was statistically significant in patients with increased iron requirements caused by phlebotomy. Malabsorption of food iron was less marked after PCV and SV + P than in patients after gastric resection, and it is concluded that there may be no need for a general prophylactic iron supplementation in patients operated on with PCV and SV + P.

Gastric Emptying of a Liquid Meal in Health and Duodenal Ulcer Disease

In the present investigation an extension of the method of George was used, which allows the rate of emptying of the gastric content (GC) to be assessed. The aim of the study was to find out whether ther is any difference in gastric emptying rate of a liquid meal of 750 ml 10% glucose (glucose monohydrate, mol. wt. 198) between healthy subjects and duodenal ulcer patients (DU). The straight numerical volume of GC, the logarithm and the square root of GC were related to time, and these functions were compared. The correlation coefficient for the regression line for these functions showed that data both for healthy subjects and DU gave a better fit to the GC/time and GC/relationship than to a semi-logarithmic function, when the starting point at time zero was excluded. Regardless of the type of transformation of the basic data, there was no difference between healthy controls and DU as regards the regression coefficient, indicating that from 20 min after the installation of the test volume the GC is decreasing at the same rate in the two groups. When the straight numerical volume of GC was used, there was a significant difference in the extrapolated Y-intercept for the regression lines between healthy subjects and the DU, indicating an increased initial emptying in the DU patients. This was further confirmed when the volume emptied during consecutive 20-min periods was estimated. Furthermore, there was a shorter emptying time in patients with duodenal ulcer than in healthy controls.

The Long-Term Results of Partial Resection of the Large Bowel for Intestinal Carcinomas Complicating Ulcerative Colitis

On long-term follow-up of 9 patients who had colonic or rectal carcinoma in association with ulcerative colitis treated by limited resection or colectomy and ileo-rectal anastomosis, 3 were found to have subsequently developed a further primary carcinoma in the remaining colon or rectum. It is strongly recommended, therefore, that cases of intestinal carcinoma complicating ulcerative colitis should always be managed by complete proctocolectomy and ileostomy rather than by more limited surgery.

The effect of parietal cell vagotomy and selective vagotomy with pyloroplasty on gastric emptying of a liquid meal. A prospective randomized study.

Gastric emptying was measured with the double sampling technique of George in 48 patients, who were randomized for 2 different types of vagotomy, parietal cell vagotomy (PCV) and total gastric selective vagotomy (SV + P), respectively. The emptying tests were performed preoperatively, 6 and 12 months after surgery. As test meal was used 750 ml of 10% glucose solution (glucose monohydrate m.w. 198). The operative techniques in the 2 groups of patients were identical as regards the proximal gastric denervation. Both PCV and SV + P showed an increased emptying during the first 10 minutes after the instillation of the test meal as compared with the preoperative values both 6 and 12 months after surgery. The initial emptying was significantly faster after SV + P than following PCV. The final emptying time was unchanged after PCV but decreased following SV + P as compared with preoperatively.A significantly slower initial emptying 12 months after SV + P as compared with 6 months after surgery was the only chang...

Clinical results of parietal cell vagotomy and selective vagotomy with pyloroplasty in the treatment of duodenal ulcer. Two-year follow-up of a prospective randomized study.

Fifty patients were randomized in a consecutive series of parietal cell vagotomy (PCV) and selective vagotomy with pyloroplasty (SV +P) in the treatment of duodenal ulcer. There were no operative deaths, and the length of the hospital stay and time off from work were the same in both groups. The clinical results were evaluated at 1 and 2 years after operation. Within the first 3 years there were two recurrences after PCV and three after SV +P. The overall clinical result 2 years after surgery did not significantly differ between the two groups; 16/24 after PCV and 17/23 after SV +P classified as excellent results (Visick I). Significantly fewer patients had dumping after PCV (3/23) than after SV +P (13/22). No patient had diarrhoea postoperatively. It is concluded that parietal cell vagotomy gives less dumping than selective vagotomy with pyloroplasty. It is, however, too early to say whether the overall clinical result in a long-term follow-up favours PCV rather than SV +P.