Svante Nordgren

The clinical and functional outcome after restorative proctocolectomy. A prospective study in 100 patients

One hundred consecutive patients treated by restorative proctocolectomy with construction of an ileo-anal anastomosis and a J-shaped (n=90) or an S-shaped ileal reservoir were studied prospectively to evaluate postoperative complications and functional outcome and to search for factors that might influence results. There were no deaths. Postoperative complications requiring surgery were pelvic sepsis (3 patients), pouch-related fistula (2), peritonitis following ileostomy closure (3) and small bowel obstruction (6), with an overall relaparotomy rate of 14%. The cumulative risk of pouchitis was 30% at 2 years. The average stool frequency decreased gradually, stabilising at about five evacuations/24 h after 1 year. At that time 9% of patients still had ≥7 day-time evacuations and 40% had night evacuations (>1/week). These parameters did not improve further with time. Mucous soiling, a frequent problem initially, also diminished with time, occurring in 30% of patients at 1 year. At 2 years, however, this mucous leak occurred in only 20%, suggesting that improvement of continence can be expected to occur even beyond one year. Despite defects in function patient satisfaction was generally excellent. So far only three patients have preferred conversion to an ileostomy. To establish which factors might influence the functional results a specially designed scoring system, combining all functional variables, was used. It was shown that results deteriorated with increasing age and that elderly women tended to have a poorer result than elderly men. Sex, previous parity or postoperative complications appeared not to affect the functional outcome. Male sexual disturbances occurred in 8%. Three had erectile problems and one loss of ejaculation. Female sexual dysfunction was frequent; dyspareunia and/or leaks during intercourse occurred in about 30%. These results confirm that resorative proctocolectomy with construction of an ileal pouch-anal anastomosis can be performed safely with a reasonable complication rate. Although patient satisfaction is often high, the functional results are not perfect, however, and further trials are in progress in this unit to determine whether results can be improved by altering the techniques for fashioning the pouch.

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.

Incidence and Characteristics of Pouchitis in the Kock Continent Ileostomy and the Pelvic Pouch

The incidence, the median time to first appearance, and the clinical pattern of pouchitis were prospectively studied in 180 patients operated on for ulcerative proctocolitis with a continent ileostomy (CI; 84 patients) and a pelvic pouch (PP; 96 patients). Median follow-up for CI patients was 8.5 years (range, 2-15 years) and for PP patients, 5 years (range, 1-8 years). Pouchitis, with symptoms severe enough to require treatment, developed in 33% (28 of 84) of CI and 47% (45 of 96) of PP patients. The cumulative risk of developing one or more episodes of pouchitis over a 5-year follow-up was 34% in CI patients and 51% in PP patients. The median time to first appearance of pouchitis was 5 and 12 months, respectively. Eighty-six per cent of CI patients with pouchitis (24 of 28) and 71% of PP patients (32 of 45) experienced their initial episode within the first 2 years. Sixty-four per cent (18 of 28) of the CI patients and 76% (34 of 45) of PP patients had one single or a few short-lasting episodes of pouchitis with various symptom-free intervals, whereas 18% of patients in each group (5 of 28 CI patients, 8 of 45 PP patients) had frequent relapses. Most of these patients responded promptly to metronidazole treatment. Eighteen per cent (5 of 28) of CI patients and 6% (3 of 45) of PP patients had long-lasting episodes with a poor response to treatment. In this long-term study the pouch inflammation proved eventually to be Crohns disease in four patients (2.2%).(ABSTRACT TRUNCATED AT 250 WORDS)

Loperamide improves anal sphincter function and continence after restorative proctocolectomy.

The physiological and clinical effects of loperamide treatment versus placebo were investigated in a randomized, double-blind, crossover study in patients operated with restorative proctocolectomy. Sixteen patients operated with endoanal mucosectomy and a handsewn ileal pouch-anal anastomosis and 14 patients operated with abdominal proctocolectomy and stapling of the pouch to the top of the anal canal were studied. While loperamide treatment increased resting anal pressure in both groups of patients by approximately 20% (P<0.05), squeeze pressure was not affected. Loperamide did not affect pouch volume or contractility. Sensory thresholds and the recto/pouch-anal inhibitory reflex were not influenced by loperamide treatment. Clinical function was improved, with a reduced bowel frequency and an improved nighttime continence, with less soiling (P<0.05) as well as need to wear a protective pad.

Sympathetic nervous influence on the internal anal sphincter and rectum in man

The effect of sympathetic nerve block and efferent stimulation of the sympathetic nerves on anorectal motility was studied in 21 patients undergoing operation for rectal carcinoma. Anal pressure and rectal volume were simultaneously recorded before and after epidural anaesthesia and during nerve stimulation. Efferent electrical stimulation of the presacral hypogastric nerves (HGN) elicited a contraction of the internal anal sphincter (IAS) in 13 out of 15 patients. The contraction was preceded by a relaxation in seven patients. In the rectum stimulation of the HGN caused variable responses. A weak contraction was the most frequent response. Efferent stimulation of the periarterial lumbar colonic nerves (LCN) elicited a clear-cut contraction of the IAS, while rectal motor responses were only occasionally observed. Epidural anaesthesia encompassing the thoraco-lumbar region (EDA), when used to block the sympathetic discharge to the IAS and the rectum, caused a reduction of anal pressure (28±11%) and an increased rectal tone. The results imply that the human IAS receives a sympathetic excitatory innervation via both the HGN and the LCN. Furthermore, it appears that the HGN convey inhibitory fibres to the IAS. The rectal responses to EDA and sympathetic nerve stimulation also indicate the presence of both excitatory and inhibitory neurones in the sympathetic nerve supply to the rectum in man.

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 ileostomy complications in patients with ulcerative colitis and Crohn's disease

Ileostomy complications in 203 patients operated on with proctocolectomy and ileostomy for ulcerative colitis and Crohns disease were investigated prospectively. The patients were examined at regular intervals by interview and thorough examination of the stoma. Stomal dysfunction was carefully assessed and patients presenting with surgical complications were admitted for reconstruction. The crude rate of ileostomy complications necessitating reconstruction was 34% and significantly higher in patients with Crohns disease compared with patients with ulcerative colitis. The cumulative rate of surgical revision after 8 years was 75% in the former group and 44% in the latter. Ileostomy stenosis and sliding recession were the two most common indications for reconstruction. Eighty-three per cent of the revisions were performed as local procedures, making a formal laparotomy unnecessary. Causative factors such as surgical technique, length of concomittant ileal resection and postoperative weight gain were analysed for possible influence on the rate of reconstruction, but no significant association was identified.

The functional results after colectomy and ileorectal anastomosis for severe constipation (Arbuthnot Lane's disease) as related to rectal sensory function

Rectoanal manovolumetry during graded isobaric rectal distension was carried out in 12 women with severe constipation classified as slow transit constipation (Arbuthnot Lanes disease). The resting anal sphincter pressure, the rectoanal inhibitory reflex and the rectal capacity were all normal. While thedistension volumes required to elicit sensation of rectal filling and an urge to defaecate were within normal limits in all patients thedistension pressures required to elicit such sensations fell outside the 95% limits of variation of control subjects in 4 patients. All patients were subsequently subjected to colectomy and ileorectal anastomosis. Patients with normal rectal sensory function had a satisfactory functional result after colectomy, whereas the four patients with blunted sensation did not improve. These findings suggest that rectoanal manovolumetry with determination of the distension pressures required to elicit rectal sensation is an important preoperative measure to be used in patients with severe constipation for selection of patients suitable for colectomy and ileorectal anastomosis.

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.

EP1-4 subtype, COX and PPARγ receptor expression in colorectal cancer in prediction of disease-specific mortality

The importance of prostaglandins in tumor growth and progression is well recognized, including antineoplastic activities by cyclooxygenase (COX) inhibitors. Variation in treatment response to COX inhibition has questioned differences in expression of cell surface and nuclear membrane receptors among tumors with different disease progression. The purpose of this study was to evaluate whether EP1–4 subtype, PPARγ receptor and COX‐1/COX‐2 expression in colorectal cancer are related to tumor‐specific mortality. Reverse transcription–polymerase chain reaction and immunohistochemistry were used to demonstrate expression and protein appearance in tumor tissue compared with normal colon tissue. EP1 and EP2 subtype receptor protein was highly present in tumor cells, EP3 occurred occasionally and EP4 was not visible. PPARγ, EP2 and EP4 mRNA were significantly higher in normal colon tissue compared with tumor tissue, without any distinct relationship to Dukes A–D tumor stage. Multivariate analyses indicated that increased tumor tissue EP2 and COX‐2 expression predicted poor survival (p < 0.001). COX‐1 expression was significantly higher than COX‐2 expression in normal colon tissue. Average COX‐2 mRNA was not increased in tumor tissue compared with normal colon. However, most tumor cells stained positive for COX‐2 protein, which was low or undetectable in normal mucosa cells. COX‐1 protein was preferentially visible in stroma. EP1–4 subtype receptor mRNAs were generally positively correlated to both COX‐1 and COX‐2 in tumor tissue, but not in normal colon. Our results imply that both prostaglandin production (COX‐2) and signaling via EP1–4 subtype receptors, particularly EP2, predict disease‐specific mortality in colorectal cancer