Martijn Gosselink

Delay of the First Onset of Pouchitis by Oral Intake of the Probiotic Strain Lactobacillus rhamnosus GG

PURPOSE:Proctocolectomy with ileal pouch-anal anastomosis is the operation of choice for patients with refractory or fulminant ulcerative colitis. The most common long-term complication in these patients is pouchitis. This study was designed to investigate the efficacy of probiotic Lactobacillus rhamnosus GG in long-term delaying the first onset of pouchitis.METHODS:Between 1989 and 2001, a consecutive series of 127 patients presenting with ulcerative colitis underwent an ileal pouch-anal anastomosis at the Erasmus Medical Center in Rotterdam. Histopathologic investigation of the resected specimens revealed unsuspected Crohn’s disease in five patients. Postoperative complications resulted in pouch excision in five patients. The remaining 117 patients were included in this study. All episodes of pouchitis occurring in this group were analyzed. Pouchitis was diagnosed on the basis of clinical symptoms and endoscopic and histologic features. The 39 patients, who underwent an ileal pouch-anal anastomosis between 1996 and 2001, started immediately after the operation with the daily intake of L. rhamnosus GG in a fermented product. The 78 patients, in whom an ileal pouch-anal anastomosis was performed between 1989 and 1996, received no L. rhamnosus GG.RESULTS:Except for the duration of follow-up, the patient characteristics, indications for proctocolectomy, number of postoperative complications, and functional outcome were similar in both groups. First episodes of pouchitis were observed less frequently in patients with a daily intake of L. rhamnosus GG (cumulative risk at 3 years: 7 vs. 29 percent; P = 0.011).CONCLUSIONS:Daily intake of fermented products containing L. rhamnosus GG provides significant clinical benefit, without side effects. Based on the results of this study, we recommend a daily intake of Lactobacillus rhamnosus GG (dose 1–2 × 1010 bacteria) to delay the first onset of pouchitis.

Smoking affects the outcome of transanal mucosal advancement flap repair of trans-sphincteric fistulas

The aim of the study was to identify variables affecting the outcome of transanal advancement flap repair (TAFR) for perianal fistulas of cryptoglandular origin.

Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann’s procedure be considered a one‐stage procedure?

Objective  Hartmann’s procedure (HP) still remains the most frequently performed procedure in acute perforated diverticulitis, but it results in a end colostomy. Primary anastomosis (PA) with or without defunctioning loop ileostomy (DI) seems a good alternative. The aim of this study was to assess differences in the rate of stomal reversal after HP and PA with DI and to evaluate factors associated with postreversal morbidity in patients operated for acute perforated diverticulitis.

Anocutaneous advancement flap repair of transsphincteric fistulas.

PURPOSE: The purpose of this study was to evaluate the healing rate of transsphincteric perianal fistulas after anocutaneous advancement flap repair and to examine the impact of this procedure on fecal continence. METHODS: Between January 1997 and June 1999, 26 consecutive patients with a transsphincteric perianal fistual passing through the middle or upper third of the external anal sphincter underwent anocutaneous advancement flap repair. There were six female patients, and the median age was 39 (range, 27–54) years. Twenty patients (77 percent) had previously undergone one or more prior attempts at repair. With the patient in the prone-jackknife position, the internal opening of the fistual was exposed using a Lone Star Retractor System, and the crypt-bearing tissue around the internal opening as well as the overlying anoderm was excised. An (inverted) U-shaped flap, including perianal skin and fat, was created. The base of the flap was approximately twice the width of its apex. The flap was advanced and sutured to the mucosa and underlying internal anal sphincter proximal to the closed internal opening. The median follow-up time was 25 months. Fecal continence was evaluated in 23 patients by means of a questionnaire. RESULTS: Anocutaneous advancement flap repair was successful in 12 patients (46 percent). Success was inversely correlated with the number of prior attempts. In patients who had undergone no or only one previous attempt at repair (n=9), the healing rate was 78 percent. In patients with two or more previous repairs (n=17) the healing rate was only 29 percent. In seven patients (30 percent) continence deteriorated after anocutaneous advancement flap repair. Eleven patients (48 percent) had a completely normal continence preoperatively. Two of these patients (18 percent) encountered soiling and incontinence for gas after the procedure, whereas two subjects (18 percent) complained of accidental bowel movements. Twelve patients (52 percent) presented with continence disturbances at the time of admission to our hospital. In this group, deterioration was observed in two patients (17 percent). CONCLUSION: The results of anocutaneous advancement flap repair in patients with no or only one previous attempt at repair are moderate. In patients who have undergone two or more previous attempts at repair the outcome is poor. Based on the relatively low healing rate and deterioration of continence, this procedure seems less suitable for high transsphincteric fistulas than transanal mucosal advancement flap repair.

Quality of life after transanal endoscopic microsurgery and total mesorectal excision in early rectal cancer

Objective  Total mesorectal excision (TME) is the gold standard in rectal cancer, if curation is intended. Transanal endoscopic microsurgery (TEM) is a much safer technique and seems to have comparable survival in early rectal cancer. The impact of both procedures on quality of life has never been compared. In this study we compared quality of life after TEM and TME.

Long-term follow-up of retrograde colonic irrigation for defaecation disturbances

Objective  Irrigation of the distal part of the large bowel is a nonsurgical alternative for patients with defaecation disturbances. In our institution, all patients with defaecation disturbances, not responding to medical treatment and biofeedback therapy, were offered retrograde colonic irrigation (RCI). This study is aimed at evaluating the long‐term feasibility and outcome of RCI.

Outcome after Emergency Surgery for Acute Perforated Diverticulitis in 200 Cases

Background: Mortality and morbidity rates of acute perforated diverticulitis remain high. The ideal treatment is still controversial. The object of this study was to compare patients with perforated diverticulitis treated either by resection with primary anastomosis (PA) or Hartmann’s procedure (HP). Methods: A multicenter study was carried out on 200 consecutive patients with acute perforated diverticulitis who were presented in the surgical units of four affiliated teaching hospitals in Rotterdam, The Netherlands, between 1995 and 2005. Mortality and morbidity were compared in relation to type of surgery, ASA classification, age, gender, Mannheim Peritonitis Index (MPI), Hinchey score, surgeon’s experience, and the time of operation. Results: There was a tendency for more severely affected patients (Hinchey, MPI, ASA and age) to undergo HP. Multivariate logistic regression analysis showed no significant difference in mortality between HP and PA. After HP, more patients needed one or more reinterventions to treat postoperative complications compared to PA. Besides, HP resulted in a longer total hospital and intensive care unit stay. Specialist colorectal surgeons performed significantly more frequently a PA instead of a HP and had fewer postoperative complications than general surgeons. The time of operation did not influence the choice of surgical procedure. Conclusion: Selected patients with perforated diverticulitis can be managed well by PA, as it does not seem to be inferior to HP in terms of severe postoperative complications that need surgical or radiological reintervention and mortality. This decision should be made while taking into account the patient’s concomitant diseases, response on preoperative resuscitation and the availability of a surgeon experienced in colorectal surgery.

Eradication of Pathogenic Bacteria and Restoration of Normal Pouch Flora: Comparison of Metronidazole and Ciprofloxacin in the Treatment of Pouchitis

PURPOSE:Pouchitis is the major long-term complication after ileal pouch-anal anastomosis for ulcerative colitis. Metronidazole and ciprofloxacin are commonly used for treatment; however, nothing is known about the effects on the pouch flora during and after pouchitis episodes. This study was designed to evaluate the effect of both antibiotics on eradication of pathogens and the restoration of normal pouch flora.METHODS:The fecal flora obtained from 13 patients with ulcerative colitis was examined at the beginning of a pouchitis episode before treatment, during treatment with metronidazole or ciprofloxacin, and during pouchitis-free periods. Some patients experienced more than one pouchitis episode. Therefore, a total of 104 samples was obtained. Each sample was cultured under aerobic and anaerobic conditions and the isolated bacteria were identified. Furthermore, the clinical response to both antibiotics was compared using the Pouchitis Disease Activity Index score.RESULTS:During pouchitis-free periods, the patients had a flora characterized by high numbers of anaerobes and no or low numbers of pathogens. This flora resembles normal colon flora. During pouchitis episodes, we found a significant decrease of anaerobes (P = 0.01), a significant increase of aerobic bacteria (P = 0.01), and significantly more numbers of pathogens, such as Clostridium perfringens (in 95 percent of the samples; P < 0.01) and hemolytic strains of Escherichia coli (in 57 percent of the samples; P = 0.05). Treatment with metronidazole resulted in a complete eradication of the anaerobic flora, including C. perfringens. However, no changes in the numbers of E. coli were found. In contrast, when the patient was treated with ciprofloxacin, not only C. perfringens, but also all coliforms including hemolytic strains of E. coli disappeared. The larger part of the anaerobic flora was left undisturbed during the administration of ciprofloxacin. Patients treated with ciprofloxacin experienced significant larger reductions in Pouchitis Disease Activity Index score compared with patients treated with metronidazole (P = 0.04).CONCLUSIONS:This study strongly suggests a role of pathogenic bacteria (C. perfringens and/or hemolytic strains of E. coli) in pouchitis. From a microbiologic and a clinical point of view, ciprofloxacin is preferable to metronidazole, because treatment with ciprofloxacin eradicates both pathogens and results in an optimal restoration of normal pouch flora.

Quality of life after total mesorectal excision for rectal cancer

Background  After total mesorectal excision for rectal cancer, many surgeons try to avoid an abdominoperineal resection (APR) by performing a transanally double stapled low colo‐rectal anastomosis (LRA), frequently without a pouch. This policy is mainly based on the assumption that the quality of life after such LRA is higher than after APR. It has been suggested that a better functional outcome and therefore a higher quality of life might be achieved by a colo‐anal J‐pouch anastomosis (CPA). The aim of this study was to assess quality of life among disease‐free survivors after APR, LRA and CPA.

High tie versus low tie in rectal surgery: comparison of anastomotic perfusion

PurposeBoth “high tie” (HT) and “low tie” (LT) are well-known strategies in rectal surgery. The aim of this study was to compare colonic perfusion after HT to colonic perfusion after LT.MethodsPatients undergoing rectal resection for malignancy were included. Colonic perfusion was measured with laser Doppler flowmetry, immediately after laparotomy on the antimesenterial side of the colon segment that was to become the afferent loop (measurement A). This measurement was repeated after rectal resection (measurement B). The blood flow ratios (B/A) were compared between the HT group and the LT group.ResultsBlood flow was measured in 33 patients, 16 undergoing HT and 17 undergoing LT. Colonic blood flow slightly decreased in the HT group whereas the flow increased in the LT group. The blood flow ratio was significantly higher in the LT group (1.48 vs. 0.91; p = 0.04), independent of the blood pressure.ConclusionThis study shows the blood flow ratio to be higher in the LT group. This suggests that anastomoses may benefit from better perfusion when LT is performed.