Kerstin Lindquist

Long-term histomorphological surveillance of the pelvic ileal pouch: Dysplasia develops in a subgroup of patients

BACKGROUND & AIMS Little is known about the long-term morphology of the pelvic ileal pouch after restorative proctocolectomy in patients with ulcerative colitis. This study analyzed the mucosal adaptation in the pouch during a long-term follow-up. METHODS Mucosal biopsy specimens were obtained from 87 patients during a follow-up of 6.3 years (SD, 2.7; range, 3-14 years). The villous surface density, degree of inflammation, and type of mucin were determined from glycolmethacrylate-embedded sections. RESULTS Three basic patterns of mucosal adaptation were observed: regular response with normal mucosa or mild villous atrophy and no or mild inflammation (type A, 51%), transient atrophy response with temporary moderate or severe villous atrophy followed by normalization of architecture (type B, 40%), and constant atrophy response with permanent subtotal or total villous atrophy developing from the early functioning period accompanied by severe pouchitis (type C, 9%). Low-grade dysplasia occurred in 3 patients with type C response. CONCLUSIONS In a small group of patients with ulcerative colitis, the mucosa of the pelvic pouch adapts with constant severe villous atrophy accompanied by long-standing pouchitis. This group of patients should be identified and undergo regular endoscopic and histomorphological surveillance because of risk of developing neoplasia in the pouch mucosa.

Dysplasia and DNA aneuploidy in a pelvic pouch

A patient with an 18-year history of ulcerative colitis was operated on with colectomy, mucosal proctectomy, ileoanal anastomosis, and an S-type pelvic pouch due to intractable chronic continuous disease. The patient was followed by endoscopic controls and biopsy sampling from the pouch at regular intervals. A gradual development of severe atrophy in the ileal mucosa was followed by the development of low grade dysplasia. At the most recent endoscopic control, 4 years after the construction of the pouch, biopsies were sampled also for flow cytometric DNA analyses. DNA aneuploidy was detected in a biopsy from the center of the pouch, and a biopsy taken immediately adjacent showed low grade dysplasia. These findings underline the importance of endoscopic follow-up after construction of a pelvic pouch and focus attention to the potential of malignant transformation of the mucosa.

Different types of mucosal adaptation in the ileal reservoir after restorative proctocolectomy

A histomorphologic study of the pelvic pouch mucosa during the first two years of function was performed in 11 consecutive patients treated for ulcerative colitis. Two types of mucosal adaptation were delineated. Type A response (5 patients) showed stable slight atrophy, normal numbers of goblet cells, and numerous sulphated mucin positive cells. The frequency of mitoses was higher than in the normal ileum. The degree of acute and chronic inflammation was low and decreasing or stable. Dysplasia was never seen. Type B response (5 patients) comprised progressive, finally severe atrophy accompanied by increasing degree of acute inflammation. The number of mitoses was higher than in type A response. In two patients the number of goblet cells was moderately/severely decreased and epithelial atypia or low grade dysplasia occurred repeatedly. The response was regarded as indeterminate in one patient. The determination of the types of mucosal adaptation may help in the planning of the follow‐up of these patients.

A reconstructive operation on malfunctioning S-shaped pelvic reservoirs

Patients with triple-loop pelvic reservoirs have often suffered from evacuation problems, clinically shown as the need for intubation, frequent stooling, leakage or ileoanal disruptions. In a recent study, the authors have shown that malposition of the reservoir and presence of a long, kinked, efferent limb constitute the main causes of these problems. A corrective operation consequently was designed in order to improve pouch topography. The pouch and its efferent conduit were completely mobilized and the efferent limb was shortened considerably. The reservoir then was placed in close proximity to the anus and the ileoanal anastomosis was reestablished. This operation now has been performed in seven patients who were considered “failures” and the results are gratifying. Six of these patients now have efficient evacuation and four are completely without leakage. Comparison of pre- and postoperative clinical and radiologic variables confirm the strong correlation between reservoir topography and clinical outcome.

Alterations in ileoanal pouch technique, 1980 to 1987: Complications and functional outcome

This study presents the results of 82 ileoanal pouch operations (57 S, 25 J) performed from 1980 to 1987. It also reports the development of the operative technique during these years. The functional outcome was evaluated in 66 patients followed for 2 to 84 months (mean, 23). The mean number of bowel movements per 24 hours was 5.0. Seventy-four percent of the patients had no leakage or staining and 82 percent had a deferral time of more than one hour. Nightly evacuations were significantly more common in men than in women. Leakage and short deferral time were significantly more common in patients over 40 years of age than in those under 25. Early experience with the S-pouch was encumbered by evacuation problems and ileoanal separations. Shortening of the efferent conduits and the muscle cuffs reduced these complications significantly. Postoperative continence was improved significantly after reduction of anal dilatation and preservation of the transitional zone. The length of bowel used for the double-loop reservoirs seemed to be of importance concerning frequency.

Anal manometry with microtransducer technique before and after restorative proctocolectomy

Anal manometry, with microtransducer technique, was performed in 55 patients after restorative proctocolectomy. Forty-two patients were followed regularly from before surgery until 12 months after surgery, and 23 patients until 24 months of function. Postoperatively, sphincter function was severely impaired. At 12 months, the mean height was less than 60 percent, mean area less than 50 percent, and mean length less than 90 percent of the preoperative values of the high pressure zone. There was no improvement between 12 and 24 months. Mean maximal squeeze pressure was restored at 12 months. Rectoanal inhibitory reflex was constantly present preoperatively, but in only 4 of 30 patients, postoperatively. Those patients with preoperative resting pressure 100 cm H2O or greater had significantly higher resting tones at 12 months than those with less than 100 cm H2O. Patients with 5 or fewer bowel movements every 24 hours had significantly higher resting tones than those with more than 6 movements every 24 hours (66vs.45 cm H2O). Patients with deferral 60 minutes or greater had significantly higher resting pressures than those with deferral less than 30 minutes (65vs.44 cm H2O). No correlation was found between resting pressure and state of continence.

Highly malignant carcinoma in chronic ulcerative colitis without preceding dysplasia or DNA aneuploidy

A 41-year-old female with a history of total ulcerative colitis for 15 years is presented. After eight years, she was enrolled in a colonoscopic surveillance program with regular examinations every second year and with biopsy sampling for histologic assessment of dysplasia as well as for flow cytometric analysis. Neither dysplasia nor DNA aneupoloidy developed during the course of the follow-up, but, after seven years, the patient developed a rapidly growing malignant stricture in the lower rectum. At the time of diagnosis, a local gluteal metastasis was found. Following preoperative radiation therapy, laparotomy disclosed a rectal cancer with local growth in the pelvis. Despite an attempt to perform curative surgery, the patient deteriorated and died within four months after the diagnosis. The carcinoma was of a poorly differentiated, mucinous, signet ring cell type, and DNA analyses of both the tumor and its metastases were diploid. Retrospective analyses of mucin content in colonoscopic biopsies showed a gradual shift from sulfated mucin to sialomucin. This case underlines the fact that even rigorous followups offer no absolute guarantee against incurable malignancy in surveillance programs for ulcerative colitis despite the inclusion of DNA analyses.

The mucosal blood flow in pelvic pouches in man

Fluorescein flowmetry implies the measurement of capillary blood flow, expressed as an index between the maximum fluorescence after the first circulatory passage of sodium fluorescein (NaF) and the rise time, defined as the time interval between ten and 90 percent of the maximum fluorescence. A mathematic model based on fluorescein flowmetry was deduced to distinguish a mucosal and muscular blood flow in an intact (unopened) intestine during surgery in man. The hypothesis was that if, at a certain point in time, there is a fixed relationship between the seromuscular fluorescence and the mucosal maximum fluorescence, obtained during the first circulatory passage of NaF, and if the rise times were equal, then a mucosal blood flow could be calculated based on the seromuscular fluorescence. The model was tested in intestinal anastomoses on 16 patients. A fixed relationship between the numeric value of the mucosal maximum fluorescence and the seromuscular fluorescence was found. After five minutes, the ratio was 1:1 and the correlation coefficient at its highest (0.97). It was also found that the rise times were practically identical (r=0.92). The validity of the model was then tested by comparing it with fluorescein flowmetry, and the correlation coefficient was 0.85. The model was therefore accepted and named indirect mucosal fluorescein flowmetry. Indirect mucosal fluorescein flowmetry was applied to measure blood flow in pelvic pouches in 14 patients, and fluorescein flowmetry in the ileoanal anastomoses in eight patients. The mucosal blood flow in the reservoir, compared with the normal intestine, was reduced to 58 percent if the ileocolic artery or distal branches of the mesenteric artery were ligated, and to 88 percent if the vessels were left intact (P<0.05). In the ileoanal anastomosis the mucosal blood flow was reduced to 23 percent compared with the normal intestine (P<0.01). The results suggest that stretching and compressing the mesentery might be critical for circulation in the ileoanal anastomoses.

Correlation between Fluorescein Flowmetry and Laser Doppler Flowmetry: A Study in the Intestine (Ileoanal Pouch) in Man

A study was undertaken to compare two new methods of capillary blood flow measurement, namely fluorescein flowmetry (FF) and laser Doppler flowmetry (LDF). The blood flow was measured in a pelvic pouch during its construction and in the completed ileoanal anastomosis in 12 patients. There was a high correlation between the two methods (correlation coefficient, 0.78) (p less than 0.01) when the blood flow was measured in the pelvic pouch. The correlation coefficient between the two methods for the difference between the blood flow in the pelvic pouch at the site of the planned anastomosis when the pouch resided in the abdomen and that in the completed ileoanal anastomosis was r = 0.99 (n = 12, p less than 0.001); the reduction amounted to 25% as measured by FF and 27% as measured by LDF (n = 12, p less than 0.01). All ileoanal anastomoses healed perfectly, the lowest FF and LDF values being 0.004 density units/sec and 0.3 V, respectively. The results indicate that either method can be considered for measuring capillary blood flow.

Effect of restorative proctocolectomy on gastric acid secretion and serum gastrin levels: a prospective study.

PURPOSE: The aim of the present study was to analyze gastric acid secretion after restorative proctocolectomy, because it has been shown that ileal resection or exclusion may increase gastric acid secretion. An increased output of gastric acids may decrease the intestinal passage time and contribute to looser stools. METHODS: Eleven patients who had elective colectomy and ileoanal pouch because of ulcerative colitis were investigated. Eight patient were males. Eight S-pouches and three J-pouches were constructed. Gastric acid secretion (retention, basic, and stimulated) was studied, together with serum gastrin, pentagastrin, and pepsinogen, in patients before colectomy and after having had the pelvic pouch functioning for 12 months. RESULTS: A significant increase, compared with preoperative levels, in retention, basic, and stimulated gastric acid secretion was found after 12 months with the pouch functioning. Levels of serum gastrin, pentagastrin, and pepsinogen were unchanged. CONCLUSION: Restorative proctocolectomy leads to a significant increase in gastric acid secretion. These findings may be of importance with regard to intestinal passage time and consistency of the stools.