M. G. W. Kettlewell

Acute colonic pseudo-obstruction.

Acute colonic pseudo‐obstruction is characterized by clinical and radiological evidence of acute large bowel obstruction in the absence of a mechanical cause. The condition usually affects elderly people with underlying co‐morbidities, and early recognition and appropriate management are essential to reduce the occurrence of life‐threatening complications.

Role of the faecal stream in the maintenance of Crohn's colitis.

The role of the faecal stream in the maintenance of the inflammation in Crohns disease has been studied. Small bowel effluent and a sterile ultrafiltrate of it were reintroduced into the defunctioned colon of patients with Crohns colitis treated by split ileostomy. The systemic effect of these challenges on the patients was assessed clinically and by laboratory tests, and the effect on the local disease was assessed by endoscopy, histology, and quantitative analysis of lamina propria plasma cell populations. There was little response to the ultrafiltrate challenge. In contrast the clinical responses to challenge with ileostomy effluent were marked in some patients. One patient relapsed and eight others had clinically detectable responses. On the other hand changes in laboratory, endoscopic, histological, and morphometric tests in response to the faecal challenge were less pronounced. The only significant changes in the laboratory results were a relative lymphopenia (p less than 0.05) and a raised ESR (p less than 0.02) after seven days challenge with the effluent. The plasma cell density also increased but not significantly. In conclusion, these results suggest that factors greater than 0.22 microns in the faecal stream are responsible for the maintenance and exacerbation of inflammation in Crohns disease.

Smoking may prevent pouchitis in patients with restorative proctocolectomy for ulcerative colitis.

Epidemiological studies have shown an increased risk of ulcerative colitis (UC) in non-smokers and particularly recent ex-smokers. Patients with UC have an increased risk of pouchitis following ileal pouch-anal anastomosis, which may be a manifestation of the original disease susceptibility. The aim of this study was to test the hypothesis that smoking habit may influence the incidence of pouchitis. All patients with a functioning pouch > or = 12 months at one centre were assessed. Patients were excluded if (a) the original indication was not UC (n = 5), (b) the excised pouch showed histology diagnostic of Crohns disease (n = 2), and (c) data were inadequate (n = 4). Smoking data were collected by questionnaire, or direct interview, or both. Ex-smokers were those who had stopped smoking < 7 years before colectomy. Non-smokers included ex-smokers who had stopped > 7 years before colectomy. Pouchitis was defined as an increase in stool frequency > 8/day with acute inflammation on biopsy specimen histology. Each presentation requiring treatment was regarded as an episode. For comparison smoking habit was assessed with regard to three other adverse outcomes - haemorrhage, sepsis, and pouch excision. Of 72 non-smokers (mean follow up 3.5 years) 18 had 46 episodes of pouchitis. Of 12 ex-smokers (mean follow up 3.3 years) four patients have had 14 episodes of pouchitis. Only one smoker from 17 has had a single episode of pouchitis. This shows that smokers have significantly less episodes of pouchitis compared with non-smokers (p = 0.0005) and ex-smokers (p = 0.05). There was no association of smoking habit with other adverse outcomes.

Quantification of histologic regression of rectal cancer after irradiation: A proposal for a modified staging system

AbstractPURPOSE: Long-course preoperative radiotherapy has been recommended for rectal carcinoma when there is concern about the ability to perform a curative resection, for example, in larger tethered tumors or those sited anteriorly or near the anal sphincter. “Downstaging” of the tumor may occur, and this is of importance when estimating the prognosis and selecting postoperative therapy for patients. We studied the effects of preoperative chemoradiotherapy on the pathology of rectal cancer, and we propose a simplified measurement of tumor regression, the Rectal Cancer Regression Grade. METHODS: We have reviewed those patients who received preoperative chemoradiotherapy followed by surgical resection for carcinomas of the mid or distal third of the rectum found to be Stage T3/4 on transrectal ultrasound or CT between January 1995 and December 1998. Patients received 45 to 50 Gy irradiation and an infusion of 5-fluorouracil. The surgical specimens were examined by one pathologist, and the Rectal Cancer Regression Grade was quantified. RESULTS: Forty-two patients, mean age 60 (range, 42–86) years, underwent chemoradiotherapy before surgery for rectal carcinoma. There were 28 anterior resections (67 percent; 9 with a colonic pouch), 12 abdominoperineal resections (27 percent), and 2 Hartmann’s procedures (5 percent). Comparison of preoperative and pathologic staging revealed that the depth of invasion was downstaged in 17 patients (38 percent), and the status of involved lymph nodes was downstaged in 13 (50 percent) of 26 patients. Tumor regression was more than 50 percent (Rectal Cancer Regression Grades 1 and 2) in 36 patients (86 percent), with 7 patients (17 percent) having complete regression with absence of residual cancer cells. CONCLUSION: Significant tumor regression was seen in 86 percent of cases after chemoradiotherapy, with 19 patients showing a “good” responsiveness. We propose a modified pathologic staging system for irradiated rectal cancer, the Rectal Cancer Regression Grade, which includes a measurement of tumor regression. The utility of the proposed Rectal Cancer Regression Grade must be tested against long-term outcomes before its value in predicting prognosis and survival can be determined.

Mucosal characteristics of pelvic ileal pouches

This study aimed to investigate the degree of colonic metaplasia in ileo - anal pouches. Biopsy specimens from 25 patients with functioning pouches, eight of whom had pouchitis, were studied using routine histology, mucosal morphometry, mucin histochemistry, and immunoperoxidase staining with monoclonal antibodies directed towards a 40kD colonic protein and a small bowel specific disaccharidase-sucrase isomaltase. Thirteen patients (including all eight with pouchitis) had subtotal or total villous atrophy and crypt hyperplasia. In this group, nine had colorectal type sulphomucin and the 40kD colonic protein was detected in two. These changes were not observed in patients with less severe villous abnormalities. Sucrase-isomaltase activity was, however, present in all 25 pouch specimens. We conclude that although some ileal pouches acquire certain colonic characteristics, complete colonic metaplasia does not occur.

The management and outcome of anastomotic leaks in colorectal surgery

Purpose  Anastomotic leaks in colorectal surgery are associated with significant morbidity and mortality and may result in poor functional and oncological outcomes. Diagnostic difficulties may delay identification and appropriate management of leaks. The aim of this study was to look at the diagnosis, clinical management and outcomes of anastamotic leaks in our department.

Cyclosporin for severe ulcerative colitis does not increase the rate of perioperative complications

PURPOSE: Cyclosporin is used in severe ulcerative colitis that is refractory to intravenous steroids. Cyclosporin is a potent immunosuppressant and can cause side effects such as opportunistic infections. This study aimed to investigate the incidence of perioperative complications in patients treated with intravenous cyclosporin and steroids compared with patients treated with intravenous steroids alone. METHODS: We retrospectively reviewed the case notes of 44 patients with severe ulcerative colitis who underwent total abdominal colectomy and ileostomy. Twenty-five patients were treated with intravenous steroids and 19 patients were treated with intravenous cyclosporin and steroids. Details were recorded with respect to age, length of illness, extent of disease, Truelove and Witts criteria, hemoglobin and albumin at surgery, surgical procedure, and perioperative morbidity. RESULTS: Twenty-four percent of patients treated with intravenous steroids alone and 15.8 percent of patients treated with intravenous cyclosporin and steroids had major surgical complications. Sixteen percent of patients treated with intravenous steroids alone and 5.2 percent of patients treated with intravenous cyclosporin and steroids had minor surgical complications. Eight percent of patients treated with intravenous steroids alone and 10.5 percent of patients treated with intravenous cyclosporin and steroids had major medical complications. There was no mortality in either group. CONCLUSIONS: There is no increased incidence of perioperative complications associated with the use of intravenous cyclosporin in addition to steroids in acute severe ulcerative colitis provided cyclosporin treatment is for a defined period and surgery is not delayed.

Split ileostomy and ileocolostomy for Crohn's disease of the colon and ulcerative colitis: a 20 year survey.

The clinical course of 140 patients who have had a split ileostomy for ulcerative colitis or colonic Crohns disease over a 20 year period is reported. In 37 patients with ulcerative colitis there was no sustained improvement. In the 102 patients with Crohns disease there was an immediate clinical improvement in 95, which was sustained in 65. Thirty patients have subsequently required a proctocolectomy for persistent inflammation, and 28 are still defunctioned. Bowel continuity was restored after 61 split ileostomies and in 44 patients intestinal continuity remains intact at the present time (mean follow up since closure = 62.5 months, range 0-231 months). It is concluded that a split ileostomy is a safe conservative operation producing at least temporary improvement in severely ill and malnourished patients with Crohns colitis, and that if a subsequent resection becomes necessary it may be less extensive than was thought applicable at the initial operation. In 27 patients a resection has not been required.

Randomized, Double-Blind, Placebo-Controlled Trial of Sildenafil (Viagra®) for Erectile Dysfunction After Rectal Excision for Cancer and Inflammatory Bowel Disease

AbstractPURPOSE: Controlled trials have demonstrated the efficacy of sildenafil for “mixed etiology” erectile dysfunction, but this may not be the case if there is underlying pelvic parasympathetic nerve damage. We aimed to determine the efficacy of sildenafil after rectal excision for rectal cancer and inflammatory bowel disease. METHODS: Patients with erectile dysfunction after rectal excision were randomly assigned in a double-blind manner to sildenafil or placebo groups. After unblinding, placebo patients crossed over to open sildenafil. Primary end points were improvement in erectile function on a global efficacy question and erectile function questionnaire scores. Secondary end points were frequency and severity of side effects. RESULTS: Thirty-two patients were randomly assigned, and two dropped out before randomization. Fourteen received sildenafil, and 18 received placebo. Eleven (79 percent) of 14 responded to sildenafil, on global efficacy assessment, compared with 3 (17 percent) of 18 taking placebo (mean difference, 61.9 percent; 95 percent confidence interval, 34.4 to 89.4 percent; P = 0.0009). Sildenafil improved both erectile function domain scores (mean difference, 13.3; 95 percent confidence interval, 7.9 to 18.7; P = 0.0001) and total International Index of Erectile Function scores (mean difference, 30.6; 95 percent confidence interval, 18.7 to 42.6; P < 0.0001) from pretreatment baseline scores. Placebo did not produce improvement in either erectile function (mean difference, 1.7; 95 percent confidence interval, −0.8 to 4.2; P = 0.16) or total International Index of Erectile Function scores (mean difference, 5; 95 percent confidence interval, −1.1 to 11.1; P = 0.1). Ten (100 percent) of 10 crossover patients not responding to placebo did respond to sildenafil (difference, 100 percent; P < 0.0001). Sildenafil improved both erectile function domain scores (mean difference, 16.8; 95 percent confidence interval, 9.7 to 24; P = 0.002) and total International Index of Erectile Function scores (mean difference, 29.5; 95 percent confidence interval, 15.8 to 43.2; P = 0.003) from precrossover baseline scores. Seven (50 percent) of 14 patients on sildenafil compared with 4 (22 percent) of 18 on placebo experienced side effects (difference, 28 percent; 95 percent confidence interval, −4.4 to 60.4 percent; P = 0.14), 91 percent of which were mild and well tolerated. CONCLUSION: Sildenafil completely reverses or satisfactorily improves postproctectomy erectile dysfunction in 79 percent of patients. Side effects are usually mild and well tolerated. The damage incurred by the pelvic nerves after proctectomy, less profound than after prostatectomy, is likely to result in a partial parasympathetic nerve lesion.

Recurrence after abdominal surgery for Crohn's disease. Relationship to disease site and surgical procedure

AbstractPURPOSE: We investigated the hypothesis that there is an “aggressive” subtype of Crohn’s disease characterized by early recurrence and that disease location and surgical procedure are associated with differing patterns of recurrence. METHODS: We analyzed 280 patient records totaling 482 major abdominal operations from a prospectively compiled Crohn’s disease database. Patterns of recurrence, as defined by reoperation, were analyzed by Kaplan-Meier plots and log-rank tests for the group as a whole, as well as according to disease location and operation performed using log-rank and Cox regression analysis. RESULTS: The overall survival curve followed a simple curve with no apparent early rise in recurrence. There was a significantly higher recurrence rate for ileal disease than for ileocolic or colic disease (median reoperation-free survival, 37.8 vs. 47.8 and 54.7 months, respectively; log-rank test = 13.6; P = 0.001), and there was a significantly shorter reoperation-free survival for those patients treated by strictureplasty alone or strictureplasty combined with resection than for those treated by resection alone (41.7 and 48.6 vs. 51 months, respectively; log-rank test = 12; P = 0.002), but only disease site was confirmed as an independent risk factor for recurrence by multiple regression analysis. CONCLUSIONS: These data suggest that there is no evidence for the existence of a separate, early recurring, aggressive disease type. Shorter reoperation-free survival after strictureplasty may reflect patterns of recurrence in ileal disease.