P. R. O'Connell

Neutrophil apoptosis is delayed in patients with inflammatory bowel disease.

Delayed neutrophil apoptosis is a feature of persistent acute inflammation. Neutrophil-mediated damage has been shown to be associated with the development of inflammatory bowel disease (IBD). Persistence of these cells both at the colonic site and circulation may further contribute to IBD. The aims of this study were to determine whether neutrophils isolated from IBD patients delay apoptosis and to investigate possible mechanisms involved in this delay. We studied 20 patients with IBD, 13 with Crohns disease, and 7 with ulcerative colitis, all of whom were undergoing intestinal resection for symptomatic disease. Seventeen patients undergoing elective resection of colon cancer acted as operative controls. Systemic, mesenteric arterial, and mesenteric venous blood was harvested. Neutrophils isolated from patients with IBD showed decreased spontaneous apoptosis compared to cancer patients. Mesenteric venous serum of IBD patients contributed to this delay, which contained higher concentrations of interleukin-8 (IL-8). Pro-caspase 3 expression was also reduced in IBD neutrophils, which may contribute to decreased spontaneous and Fas antibody-induced apoptosis. Neutrophil apoptosis may be altered in Crohns disease and ulcerative colitis through release of anti-apoptotic cytokines and altered caspase expression. The alterations in cell death mechanisms may lead to persistence of the inflammatory response associated with IBD.

Cesarean delivery and anal sphincter injury

Objective Cesarean delivery has been thought to prevent all obstetric anal sphincter damage. The objective of this study was to determine the relationship between the timing of cesarean during primiparous delivery and injury to the anal sphincter mechanism. Methods A prospective observational study was conducted, using a continence questionnaire and anorectal physiology assessment before and six weeks after primiparous delivery. A cohort of 234 women were recruited from the antenatal clinics at the National Maternity Hospital, Dublin. Thirty-four women delivered subsequently by cesarean, and 200 women by spontaneous vaginal delivery. Results Thirty-four women underwent cesarean delivery without attempted vaginal delivery: eight prior to labor and 26 during labor, 17 in early labor (cervical dilatation less than 8 cm) and 9 in late labor (dilatation greater than 8 cm). No woman delivered by cesarean had altered fecal continence postpartum. Anorectal physiology was unaltered in women delivered by elective cesarean or cesarean in early labor. Pudendal nerve terminal motor latency was prolonged, anal squeeze pressure increment reduced, but vector symmetry index was unchanged in women delivered by cesarean delivery late in labor, indicating neurologic injury to the anal sphincter mechanism. Conclusion Cesarean delivery performed in late labor, even in the absence of attempted vaginal delivery, does not protect the anal sphincter mechanism.

A prospective, randomized study comparing the effect of augmented biofeedback with sensory biofeedback alone on fecal incontinence after obstetric trauma

PURPOSE: This study was designed to compare prospectively the effects of augmented biofeedback with those of sensory biofeedback alone on fecal incontinence and anorectal manometry after obstetric trauma. METHODS: A consecutive cohort of 40 females with impaired fecal continence after obstetric anal sphincter injury were recruited from a dedicated perineal clinic. Patients were randomly assigned to receive either augmented biofeedback or sensory biofeedback alone. All patients were assessed before and after twelve weeks of biofeedback training, using a fecal continence questionnaire and anorectal manometry. RESULTS: Thirty-nine of 40 females recruited completed the study. Continence scores improved in both treatment groups, but the results were better for those who received augmented biofeedback. Anorectal manometry was unchanged by sensory biofeedback, whereas anal resting and squeeze pressures increased with augmented biofeedback. No change in anal vector symmetry was observed in either group. CONCLUSION: Augmented biofeedback training is superior to sensory biofeedback alone in the treatment of impaired fecal continence after obstetric trauma.

Laparoscopic versus open appendicectomy: A prospective evaluation

A prospective evaluation of laparoscopic surgery for acute appendicitis over a 6-month period is reported. Sixty-five patients with signs and symptoms of appendicitis necessitating surgery were assigned to open (n = 36) or laparoscopic (n = 29) appendicectomy. Thirty-seven patients were female (22 open) and 28 were male (14 open). The median age was 24 (range 14-64) years for open appendicectomy and 18 (range 14-60) years for the laparoscopic procedure. The mean postoperative stay for open operation was 4.8 (range 1-21) days and for the laparoscopic route 2.2 (range 1-11) days (P < 0.05). Inflammation was confirmed histologically in 72 per cent of the open cases and in 74 per cent of the laparoscopic cases (P not significant). The wound infection rate was 11 per cent (n = 4) for open and 4 per cent (n = 1) for laparoscopic appendicectomy (P < 0.05). The median anaesthesia time was 52 (range 15-90) min for open appendicectomy and 48 (range 20-120) min for laparoscopic surgery (P not significant). After open appendicectomy patients had a median of 5 (range 2-12) intramuscular injections of analgesia compared with a median of 1 (range 0-5) in the laparoscopic group (P < 0.05). Two laparoscopic operations were converted to an open procedure. The results suggest that emergency laparoscopic appendicectomy should be explored further as an alternative to open surgery for acute appendicitis.

Sentinel lymph node mapping in colorectal cancer

Ultrastaging, by serial sectioning combined with immunohistochemical techniques, improves detection of lymph node micrometastases. Sentinel lymph node mapping and retrieval provides a representative node(s) to facilitate ultrastaging. The impact on staging of carcinoma of the colon and rectum in all series emphasizes the importance of this technique in cancer management. Now the challenge is to determine the biological relevance and prognostic implications.

Increased vascular endothelial growth factor production in fibroblasts isolated from strictures in patients with Crohn's disease†

Vascular endothelial growth factor (VEGF) is a potent angiogenic factor that is implicated in early wound healing and fibrosis. Fibroblasts may initiate stricture formation in Crohns disease through overexpression of VEGF. The aim of this study was to examine VEGF expression and regulation in fibroblasts isolated from patients with Crohns disease.

Postpartum fecal incontinence is more common in women with irritable bowel syndrome

PURPOSE: Anal sphincter damage can occur during vaginal delivery and may lead to impairment of fecal continence. The aim of this study was to determine the influence of irritable bowel syndrome on symptoms of fecal incontinence following first vaginal delivery. METHODS: A prospective, observational study was performed before delivery, six weeks, and six months following delivery in primiparous women. A bowel function questionnaire was completed, and anal vector manometry, mucosal electrosensitivity, pudendal nerve terminal motor latency, and anal endosonography were performed. A total of 208 women were assessed before and after delivery, and 104 primigravid women were studied after delivery only. A total of 34 of 312 (11 percent) had an existing diagnosis of irritable bowel syndrome. RESULTS: The prevalence of abnormal manometry or endosonography was similar in women with and without irritable bowel syndrome. However, six weeks after delivery, women with irritable bowel syndrome had a higher incidence of defecatory urgency (64 percent) and loss of control of flatus (35 percent) compared with those without (urgency, 10 percent,P<0.001; flatus, 13 percent,P=0.007). The incidence of frank fecal incontinence was similar in the two groups. Women with IBS had increased mucosal sensitivity to electrical stimulation of the upper anal canal both before and after delivery. CONCLUSION: Women with IBS are more likely to experience subjective alteration of fecal continence postpartum compared with the healthy primigravid population, but they are not at increased risk of anal sphincter injury.

Sentinel lymph node mapping in colorectal cancer (Br J Surg 2003; 90: 659‐667)

Sir Potential advantages of sentinel lymph node (SLN) mapping include identification of aberrant drainage, as well as upstaging. While we agree that a multi-centre trial employing a standard technique of SLN mapping in colorectal cancer is timely, there are some caveats. The inherent challenges of this technique may result in variability of the results. Therefore, mapping technique (e.g. in-vivo colonic and ex-vivo rectal mapping; and lymphoscintigraphy and/or blue dye in all), degree of nodal sectioning (e.g. 4 sections), and method of ultrastaging (e.g. immunohistochemistry if negative on H & E staining) should be standardised between institutions. Furthermore, strict criteria for trial entry should be established in advance and data recording standardised (e.g. pre-operative radiotherapy, type of operation, aberrant drainage, tumour stage, etc.). Finally, power calculation (as alluded to in the letter of Smith et al.1) and the trial end-points (e.g. success of mapping, accuracy of sentinel node in predicting nodal status, survival of those patients who are sentinel node positive only etc.) would have to be determined clearly in advance. In order to overcome some of these biases, surgeons considering joining such a trial should perform a local audit of 100 procedures. A success rate > 90 per cent should indicate proficiency with sentinel lymph node mapping in colorectal cancer that would be sufficient to begin entering patients into the trial. J. Mulsow, D. C. Winter, C. O’Keane and P. R. O’Connell Mater Misericordiae Hospital, Dublin 7, Ireland DOI: 10.1002/bjs.4444

Author's reply: Increased vascular endothelial growth factor production in fibroblasts isolated from strictures in patients with Crohn's disease (Br J Surg 2004; 91: 72-77)

Sir There is abundant evidence that Crohn’s disease is associated with smoking1 and the resulting ischaemia is said to be a possible mechanism for Crohn’s recurrence2. This paper suggests that increased fibroblast vascular endothelial growth factor (VEGF) production may play a role in initiating Crohn’s strictures; it would be interesting for the authors to explore whether ischaemia, which is known to upregulate VEGF3, explains this relationship. The authors go on to suggest that steroids may reduce fibrosis in Crohn’s disease by reducing VEGF production. It is thus tempting to hypothesise that since other agents used in the treatment of Crohn’s are also anti-angiogenic4, VEGF inhibition may be a mechanism common to Crohn’s treatments. G.F. Nash Department of Surgery, St Mark’s Hospital, Watford Road, Harrow, Middlesex HA1 3UJ, UK DOI: 10.1002/bjs.4655