S. Fasth

Abdominal rectopexy for rectal prolapse: Influence of surgical technique on functional outcome

PURPOSE: The aim of this study was to investigate the influence of surgical technique on functional and manovolumetric results in patients treated with Marlex® mesh abdominal rectopexy. METHODS: The lateral ligaments were completely divided (the Wells procedure) in 16 patients and preserved (the Ripstein procedure) in 16 patients. Clinical and physiologic assessment were performed before and at 3, 6, and 12 months after operation. RESULTS: Improvement of continence was similar. Bowel regulation problems which were unchanged after the Ripstein procedure increased significantly after the Wells procedure (P<0.01). Rectal volume became reduced in the group who received the Wells procedure (225 mlvs. 115 ml, P<0.05 at one year), but remained unchanged after receiving the Ripstein procedure. The pressure thresholds required to elicit sensation of rectal filling and defecation urge were increased after the Wells procedure (15 cm of H2Ovs. 25 cm of H2O, P<0.05 and 25 cm of H2O vs. 45 cm of H2O, P<0.05, respectively). In the Ripstein group there was only a slight increase of the threshold for urge (P<0.05). CONCLUSION: The Wells procedure was followed by severe rectal dysfunction accompanied by increased constipation and evacuation problems. The Ripstein procedure, preserving the lateral ligaments, appears not to affect such symptoms adversely. On the other hand, improvement is not likely to occur.

Cholelithiasis and Urolithiasis in Crohn's Disease

In a consecutive series of 107 patients operated on for Crohns disease involving the distal ileum, the overall incidence of gallstones was 17% and of renal stones 12%. Whereas the frequency of gallstone disease was 9% in patients with minor resections, patients with more than 100 cm diseased or resected small bowel had a frequency of 35%. The probability of gallstone development in both sexes was calculated to be approximately 50% after 20 years of distal ileopathy. The frequency of renal stone disease in patients with minor resection was comparable to that of a population in Sweden but was significantly commoner in patients with resection of more than 100 cm (28%), provided they were not colectomized. The high frequency of stone disease after resection of distal ileum is attributed to metabolic disturbances due to steatorrhea and bile salt malabsorption.

The effects of age, gender, and parity on rectoanal functions in adults.

The effects of age, gender, and parity on rectoanal function were examined in a cross-sectional population study, including 68 normal subjects (32 men and 36 women) aged 23 to 91 years. Rectal volumetry was evaluated with graded isobaric rectal distension with 5-60 cm H2O in combination with anal manometry. Data were analysed by use of the multiple regression technique. Increasing age correlated with a decrease in rectal volume (r = -0.285, p less than 0.05), resting anal pressure (r = -0.625, p less than 0.001), and maximal squeezing pressure (r = -0.557, p less than 0.001). The decrease in maximal squeeze pressure with age was similar in men and women (approximately = 1% x year-1), although the median of maximal squeeze pressure in women was 58.3-75.7% of that in men (p less than 0.001). Nor was there a difference in resting anal pressure between men and women. An age-dependent increase was observed for the pressure threshold to produce an initial sensation of rectal filling and the rectoanal inhibition reflex (r = 0.446, p less than 0.001). The sensory threshold increased with age, but this was more pronounced in women. No effect of parity on rectoanal function could be demonstrated. However, this would best be investigated in a longitudinal population study. We believe that identification of causes for interindividual variation and regression analysis procedures will increase the discriminative accuracy of analysis of rectoanal function. The present study shows that several of the demonstrated age-related changes have a tendency to expose elderly subjects, particularly women, to the problems of incontinence.

Long-Term Follow-up in Crohn's Disease: Mortality, Morbidity, and Functional Status

BACKGROUND The purpose of this study was to analyse long-term results of an active approach to surgical treatment of Crohns disease. METHODS One hundred and thirty-six patients were studied after first resection for primary Crohns disease during 1968-77. RESULTS Mean follow-up was 16.6 years; 18 patients had died (3 of Crohns disease). Cumulative risk for a second resection was 0.40 (95% confidence interval, 0.29-0.51) at 10 years and 0.45 (0.32-0.58) at 15 years, similar in classical disease and colitis. Cumulative risk of a third and fourth resection was 0.5 at 10 years. Median resected bowel length at the first operation was 8%. After two and three resections the cumulative resection was 23% and 33%, respectively. Of the patients 73% claimed full working capacity and 7% had disability pension. CONCLUSIONS An active surgical approach in Crohns disease is associated with low operative mortality and morbidity and good functional results and offers good symptomatic relief.

A Prospective Randomized Comparison of Two Different Pelvic Pouch Designs

The clinical manovolumetric, and functional results of restorative proctocolectomy were studied in patients randomly allocated to construction of either a J-shaped pouch (n = 29) or a pouch fashioned by the folding technique used for the Kock continent ileostomy (K-pouch) (n = 26). A complete endoanal mucosectomy was performed, and the pouches were all constructed from 30-cm lengths of ileum. There were no deaths and no significant difference in postoperative morbidity. Anal pressures were equal in the two groups. The K-pouch expanded more favourably postoperatively, and its volume at 1 year was significantly greater than that of the J-pouch (355 +/- 71 ml (SD); range, 225-495, versus 264 +/- 81 ml; range, 75-440; p less than 0.001). The pouches had similar motility patterns and sensory pressure thresholds. Initially after closure of the loop ileostomy there was a tendency for better functional outcome in K-pouch patients. At 1 year the overall distribution of functional defects did not differ, and the defaecation frequency was about equal in the groups.

Factors regulating sodium balance in proctocolectomized patients with various ileal resections.

Patients subjected to proctocolectomy together with an ileal resection will lose increased amounts of sodium with the ileostomy excreta and may develop sodium and water depletion. Studies of sodium balance and measurements of renin activity, aldosterone, and arginine vasopressin in plasma were made in 23 such patients, 8 of them under metabolic-ward conditions while receiving various salt loads. Salt loss never resulted in subnormal sodium levels in serum. The earliest sign of salt depletion was a nearly total inhibition of renal sodium excretion, which could precede activation of the renin-aldosterone axis in these patients. Secretion of vasopressin remained unaffected by sodium-water depletion and by activation of the renin system. The routine monitoring of these patients should include measurements of renal sodium excretion. Measurement of renin and aldosterone levels should be used for evaluation of the severity of a sodium deficiency.

The stapled ileal pouch--anal anastomosis. A randomized study comparing two different pouch designs.

Thirty patients were operated on with restorative proctocolectomy with an end-to-end ileal pouch-anal anastomosis constructed by double stapling (STP). Pouches were randomized to either J type or K type (folded by the principles used for the Kock continent ileostomy). Manovolumetric and functional results were compared. Patients were followed up for at least 6 months. K pouches acquired a significantly larger volume than the J-configurated pouches, and at 6 months the mean +/- SD volumes amounted to 361 +/- 59.8 ml versus 283 +/- 43.0 ml (p less than 0.01) with a concomitant reduction in 24-h frequency (4.4 +/- 1.5 versus 5.8 +/- 1.9; p less than 0.05). The initial postoperative mean reduction of resting anal pressure amounted to 33%. which was similar to that observed in a group of matched historical controls operated on with endoanal mucosectomy and hand-sutured pouch-anal anastomosis. Compared with these controls STP patients showed a superior overall functional result, most marked in the early postoperative period.

Faecal Excretion of Intravenously Injected 14C-Cholic Acid in Patients with Conventional Ileostomy and in Patients with Continent Ileostomy Reservoir

Bile salt absorption, as determined by the faecal excretion in i.v. injected 14C-cholic acid (FBS) was studied in 13 ileostomy patients before and after conversion to Kocks continent ileostomy reservoir. The result was compared with that obtained in 8 ileostomy patients in whom about 50 cm of the terminal ileum has also been removed. As compared with 16 healthy controls, FBS was moderately increased in the conventional ileostomy patients, but still within normal limits. After conversion to ileostomy reservoir all patients had pathological FBS, although less severe than in the ileostomy patients with ileal resection. Bacterial contamination probably contributes more than the structural mucosal changes to the bile malabsorption in the pouch, whereas reduced mucosal surface and short small-intestinal transit time are the main causes of malabsorption in ileostomy patients in whom an appreciable amount of the terminal ileum has been resected.

Fecal excretion of radiolabeled (51CrCl3) proteins in patients with Crohn's disease.

Intestinal leakage of plasma proteins was studied in 69 patients with Crohns disease. In vivo labeling of plasma proteins was performed by intravenous injection of trace amounts of 51CrCl3. Complete fecal collection was done for 5 days, carefully avoiding contamination with urine. The daily fecal radioactivity was measured in a whole-body counter and expressed as a percentage of given dose. In patients with a classic localization of the disease the mean fecal excretion of radiolabeled proteins was 2.8% (range, 0.8-5.5%). The excretion was significantly higher in patients with extensive ileojejunal involvement (8.8%; 4.3-14.0%) and in patients with a total colitis (5.5%; 2.0-8.2%) but not different from that in patients with prestomal recurrent ileal disease (3.5%; 1.6-5.3%). A close correlation was found between fecal excretion of 51Cr and extent of the small-intestinal disease as measured at laparotomy (r = 0.86, p less than 0.001). A highly significant inverse relationship was also demonstrated between fecal protein excretion and serum albumin concentration in patients without septic complications of the disease (r = -0.57, p less than 0.001). A pre-existing septic complication made the patients hypoalbuminemic despite limited intestinal loss of protein. It is concluded that estimation of intestinal protein loss is a sensitive and simple test for assessment of the extent of the small-intestinal involvement in patients with Crohns disease. The test may be of value in patients with unclear radiologic findings and in patients with hypoalbuminemia of unknown cause.

Intestinal Intraluminal Continuity Is a Prerequisite for the Distal Bowel Motility Response to Feeding

BACKGROUND We wanted to elucidate further the regulation of the intestinal motility response to feeding. METHODS After intraduodenal administration of an oleate solution, mimicking a meal, the distal bowel motility and the plasma levels of bile acids, cholecystokinin (CCK), and neurotensin were monitored in patients operated on with restorative proctocolectomy (n = 4) or low anterior resection of the rectum (n = 4). Investigations were performed both with and without a diverting loop ileostomy. RESULTS Intraduodenal sodium oleate elicited a prompt and significant increase in distal bowel motility. The motility response failed to appear when the luminal flow was diverted by a loop ileostomy. An increase in plasma CCK preceded the motility increase, but CCK was increased also in patients with a loop ileostomy. Whereas plasma bile acid levels were significantly increased after 30-45 min (p < 0.05), both with and without a loop ileostomy, neurotensin levels were not affected. CONCLUSION Intestinal continuity is a prerequisite for the distal bowel motility response, indicating that apart from other possible mechanisms, luminal factors are involved in the regulation of intestinal motility.