Postoperative liver enzyme abnormalities are related to staged restorative proctocolectomy

BACKGROUND

Transient homeostatic derangements are found after major abdominal and pelvic surgery. We observed elevated liver function tests (LFTs) after restorative proctocolectomy (RPC). This study was undertaken to determine the etiology and implications of elevated LFTs before RPC and postoperatively.

METHODS

One hundred and thirty-four RPC-patients were prospectively evaluated for LFT abnormalities. Patients were assigned to two groups: hand-sewn ileal-reservoir after mucosoproctocolectomy (n=83) or stapled anastomosis (n=9), both with loop ileostomy and stapled anastomosis without loop ileostomy (n=42). Serum alanine-aminotransferase (ALAT) and alkaline phosphatases (ALP) were assessed preoperatively, 1-10 weeks postoperatively before loop ileostomy closure and 1-10 weeks after ileostomy closure. These findings were correlated with anesthesia time, transfused blood volume, perioperatively administered drugs, and length of the diverted bowel while having a loop ileostomy.

RESULTS

A large number of patients showed initial elevated serum ALAT and ALP levels, suggesting liver cell damage. There was a substantial and significant increase in ALAT and ALP in the first postoperative week. The values normalized within 2 weeks for the group without loop ileostomy, but not until after loop ileostomy closure in first group. A significant correlation as to length of diverted bowel (<0.05) while having a loop ileostomy was noted. When the length of diverted bowel was more than 105 cm, liver enzymes were higher than baseline levels (p<0.05) until after closure.

CONCLUSIONS

Patients may develop elevated LFTs after RPC; however, its etiology and significance remains unclear. A loop ileostomy with RPC seemed to delay the normalization. Consideration of further diagnostic imaging may be indicated to exclude other liver pathology such as sclerosing cholangitis.

Detection of pre-neoplastic and neoplastic prostate disease by MALDI profiling of urine

The heterogeneous progression to the development of prostate cancer (PCa) has precluded effective early detection screens. Existing prostate cancer screening paradigms have relatively poor specificity for cancer relative to other prostate diseases, commonly benign prostatic hyperplasia (BPH). A method for discrimination of BPH, HGPIN, and PCa urine proteome was developed through testing 407 patient samples using matrix assisted laser desorption-mass spectrometry time of flight (MALDI-TOF). Urine samples were adsorbed to reverse phase resin, washed, and the eluant spotted directly for MALDI-TOF analysis of peptides. The processing resolved over 130 verifiable signals of a mass range of 1000-5000 m/z to suggest 71.2% specificity and 67.4% sensitivity in discriminating PCa vs. BPH. Comparing BPH and HGPIN resulted in 73.6% specificity and 69.2% sensitivity. Comparing PCa and HGPIN resulted in 80.8% specificity and 81.0% sensitivity. The high throughput, low-cost assay method developed is amenable for large patient numbers required for supporting biomarker identification.

Serum biochemical evaluation of patients with functional pouches ten to 20 years after restorative proctocolectomy

BACKGROUND

Restorative proctocolectomy with an ileal pouch-anal anastomosis is a surgical treatment of choice for ulcerative colitis and familial adenomatous polyposis (FAP). Pouchitis is a significant enigmatic morbidity. In the long-term, these patients, we anticipated, would experience biochemical profiling alterations after years of retaining functionally acceptable pouches. This pilot study was aimed at assessing results of essential biochemical variables more than 10 years after surgery.

METHODS

The investigation was carried out in 91 patients; 39 were women. Eight-eight had ulcerative colitis, while three had FAPs. The hand-sewn ileal reservoirs after mucoso-proctocolectomy were 66 S and 25 J. The analyses were compared short-term vs long-term. Patients were investigated and were their own control.

RESULTS

Long-term, incidence of acute and chronic pouchitis was 2 and 13%. Eleven and 4% of patients had hypomagnesaemia and hypocalcaemia. Mean levels were significantly enhanced (p<0.01 and p<0.0002). Hypomagnesaemia corresponded to episodes of pouchitis and was corrected with oral magnesium and antibiotics. Hypoferric anaemia was diagnosed in 7% and treated with oral iron tablets. Chronic pouchitis and recurrent pouch mucosa bleeding were the cause. Hypohemoglobinemia and hypocyanocobalaminemia were noted in 5% and 5%, respectively. Erythrocyte sedimentation rate and white blood cells were supra-normal in 13 and 10%, which corresponded with pouchitis. A significant (p<0.03) steady rise of mean serum immunoglobulin G without correlation to pouchitis was noted.

CONCLUSION

Long-term functional results did not deteriorate. Pouchitis was a significant enigmatic morbidity. Severe or chronic pouchitis complicated hypoferric and vitamin B(12) anemia and hypomagnesaemia.

Observations in the blood lipid profile in patients undergoing restorative proctocolectomy

BACKGROUND

Ileal dysfunction, and resection or exclusion may affect intestinal bile acid resorption resulting in alterations in serum lipid concentration. In restorative proctocolectomy, the different procedures may involve the ileum in all three ways.

AIM

The aim of the present study was to analyse possible changes of the blood lipid profile during the different steps of restorative proctocolectomy operative procedure.

METHOD

There were nineteen elective patients on their ordinary diet and 19 emergency patients on total parenteral nutrition. The former group were primarily operated on with colectomy; ileoanal pouch and loop ileostomy while the later group had had an emergency colectomy and terminal ileostomy before the pouch operation. Thirty five of the patients had ulcerative colitis, 2 had familial colon polyposis and 1 familial cancer syndrome. Blood specimens were collected in the mornings with the patients in a fasting state. The emergency patients were on unchanged ordinary diet during the preoperative period. Serum cholesterol and triglyceride were determined by enzymatic methods. Lipoproteins, studied only in the elective patients, were analysed by a combination of ultracentrifugation and precipitation. Student's t-test with Bonferroni's correction for multiple comparisons was used for statistic calculations.

RESULTS

Preoperatively, the emergency group had significantly lower serum cholesterol but not serum triglycerides values compared to the elective group. This finding is probably due to difference in the preoperative nutrition. The cholesterol levels among patients who received steroids in the two groups were compared and found to be significantly lower in the emergency group. Later, no significant differences concerning cholesterol and triglycerides were found between the groups. The cholesterol level was not significantly different in the elective group between patients who receive hydrocortisone and those who did not. During the period with loop ileostomy cholesterol was significantly lowered while the triglycerides were significantly increased compared to the preoperative values of the elective group. The decrease of serum cholesterol levels was correlated to the length of the excluded ileum. During the same period alpha-lipoprotein decreased significantly and reached values below the normal of the reference material. Beta-lipoproteins, which were subnormal already preoperatively, increased but not significantly. Pre-beta-lipoproteins were at the same level at all stations. At 12 months with functioning pouches all analysed values, with the exception of beta-lipoproteins. were within the normal limits set by the reference material. In the emergency group the patterns for triglycerides and cholesterol were similar but for the preoperatively depressed cholesterol values. After 12 months with functioning pouch the serum cholesterol and triglycerides were at the same level as for the elective patients.

CONCLUSION

A serum lipid profile was studied in patients undergoing restorative proctocolectomy. Serum cholesterol and alpha-lipoprotein decreased and triglycerides increased when the patients had a diverting loop ileostomy. At 12 months after it's closure and with a functioning pouch, the patients had the same profile as the elective patients preoperatively, and with exception of beta-lipoproteins within normal limits in spite of the loss of the colon and the construction of a pouch of the distal ileum.

A study of plasma immunoglobulins profile in connection with restorative proctocolectomy

BACKGROUND

Restorative proctocolectomy is an operative procedure that in principle means proctocolectomy, preserving the anal sphincters and construction of an ileal pouch which is sutured to the dentate line. The method is used mostly in case of surgical treatment of ulcerative colitis or familial polyposis coli. The procedure means different manipulations with the distal ileum that may influence the function of gut-associated lymphoid tissues, a major subdivision of the immune system.

AIM

The aim of the present investigation was to study the plasma concentration of immunoglobulins in connection with the restorative proctocolectomy operation.

METHODS

Forty five patients received an ileoanal pouch (IAP) because of ulcerative colitis. Twenty seven patients were males and 18 females. The mean age was 34 (range 18-55) years. Twenty six patients were first operated on emergency by subtotal colectomy with terminal ileostomy. In a second operation, the rectum was excised and an ileoanal pouch and a loop ileostomy that diverted the bowel content from the distal ileum was performed. Eighteen elective patients had their colectomy performed at the same time as the pouch operation. As a last procedure the diverting loop ileostomy was closed and thereby the distal ileum and the ileoanal pouch was put into function. Blood samples for plasma immunoglobulin analyses was collected from the patients before the colectomy, after colectomy with terminal ileostomy before construction of the pouch, during the period with pouches prior to loop ileostomy closure and 12 months after its closure. Immunoglobulins in plasma were determined by nephelometry method. The data was analyzed statistically by ANOVA and linear regression analysis.

RESULTS

There was a significant difference preoperatively, in plasma immunoglobulin G (P-IgG) between the patients who were operated on electively compared to the emergency patients (p < 0.03). This was the only significant difference between values for the emergency and elective groups throughout the study. In the emergency patients after colectomy and with terminal ileostomy plasma immunoglobulin A (P-IgA) and immunoglobulin A (P-IgM) concentrations in plasma had increased significantly compared to preoperative (p < 0.03) and (p < 0.002) respectively. During the time with loop ileostomy plasma IgM was still found to be significantly elevated (p < 0.02) compared to the level before colectomy. In the electively operated patients plasma IgA and IgM were significantly increased after colectomy and pouch construction during the time with loop ileostomy compared to preoperatively (p < 0.04) and (p < 0.0004). After 12 months with functional pouches the plasma immunoglobulins in both groups were similar to the elective patients preoperatively.

CONCLUSION

The immunoglobulins IgG, IgA and IgM were studied in connection with restorative proctocolectomy. Preoperatively, IgG was found to be significantly lower in emergency compared to elective patients. The difference is probably due to increased losses and impaired production of IgG in the acute phase of ulcerative colitis. IgA and IgM were found to increase significantly after colectomy and construction of an ileostomy but how these measures were responsible for the changes could not be determined in the present study. Twelve months after loop ileostomy closure there were no longer any significant changes of the immunoglobulins compared to elective patients with ulcerative colitis preoperatively.

Effect of restorative proctocolectomy on gastric acid secretion and serum gastrin levels: a prospective study

PURPOSE

The aim of the present study was to analyze gastric acid secretion after restorative proctocolectomy, because it has been shown that ileal resection or exclusion may increase gastric acid secretion. An increased output of gastric acids may decrease the intestinal passage time and contribute to looser stools.

METHODS

Eleven patients who had elective colectomy and ileoanal pouch because of ulcerative colitis were investigated. Eight patient were males. Eight S-pouches and three J-pouches were constructed. Gastric acid secretion (retention, basic, and stimulated) was studied, together with serum gastrin, pentagastrin, and pepsinogen, in patients before colectomy and after having had the pelvic pouch functioning for 12 months.

RESULTS

A significant increase, compared with preoperative levels, in retention, basic, and stimulated gastric acid secretion was found after 12 months with the pouch functioning. Levels of serum gastrin, pentagastrin, and pepsinogen were unchanged.

CONCLUSION

Restorative proctocolectomy leads to a significant increase in gastric acid secretion. These findings may be of importance with regard to intestinal passage time and consistency of the stools.

Follow-up results of hematology data before and after restorative proctocolectomy. Clinical outcome

PURPOSE

This study was designed to investigate the development of anemia during functional ileoanal pouch.

METHODS

Eighty-three patients received an ileoanal pouch between 1980 and 1987. The hematology data deviations among the preoperative period, defunctionalized stage, and after ileal pouch in function were monitored. Aspects studied included serum hemoglobin, iron, folates, vitamin B12, white blood cell, erythrocyte sedimentation rate, pt-B12, and fat absorption. Specimens were collected before colectomy, during ileostomy prior to pouch operation, before loop ileostomy closure, and at 6, 12, 18, 24, and 36 months after loop ileostomy closure.

RESULTS

Two patients developed iron deficiency anemia after 2.5 and 5 years of pouch function: one patient, a vegetarian, had low hemoglobin, iron, and vitamin B12 postoperatively, the other patient developed low iron and hemoglobin 5 years after the operation. Significant elevations of serum hemoglobin, iron, and folates were seen preoperatively vs. postoperatively from 123.46 +/- 2.845 g/l, 10.282 +/- 0.992 mumol/l, and 9.983 +/- 1.308 mmol/l to 138.842 +/- 1.563 g/l (P < 0.0001), 17.544 +/- 1.529 mumol/l (P < 0.0003), and 16.784 +/- 1.757 mmol/l (P < 0.01) (mean +/- SE) of the defunctionalized loop ileostomy. Serum B12 decreased insignificantly. After loop ileostomy closure, at 6 and 36 months of functional ileal pouch-anal anastomosis, the elevations were still significant; serum hemoglobin was P < 0.0001 and P < 0.01, and serum iron was P < 0.001 and P < 0.01, respectively. Vitamin B12 levels decreased insignificantly at six months in controls and significantly (P < 0.01) at 36 months. There was a significant increase of serum folates (P < 0.01 and P < 0.001). Patients with low iron were 50 percent at precolectomy, 23 percent with ileostomy, 16 percent with loop ileostomy, 15 percent at six-month follow-up, and 11 percent at 12-month follow-up. Although only 3 percent and 11 percent of the patients with ileal pouch-anal anastomosis had low serum vitamin B12 values at the 12-month and 36-month follow-up, 31 percent and 36 percent had decreased Schilling tests. Thirty-three percent and 41 percent had decreased 14C-triolein breath tests. In five patients vitamin B12 deficiency began during the first six months of pouch function: in two patients after one year and in one patient after two years. Eight of 83 patients have had substitution therapy with vitamin B12. The therapy was discontinued in three patients after two to four years; these patients developed no further symptoms and had normal Schilling tests in the succeeding 30 months to 46 months. Five patients continue with substitution after 40 months to 68 months. During the functional period, serum erythrocyte sedimentation rate and white blood cells were elevated in some controls on different occasions. Folates were normal throughout the functional period.

CONCLUSION

For predicting hematologic data outcome in patients with functional ileal reservoir, the results justify the necessity for control during both manipulative and functional periods until evaluations are reliable and satisfying.

Biochemical laboratory data in patients before and after restorative proctocolectomy. A study on 83 patients with a follow-up of 36 months

From 1980 to 1987 ileoanal pouches were made in 83 patients. Specimen for a set of laboratory analyses were taken preoperatively, during the ileostomy and loop ileostomy periods and repeatedly during 36 months of follow-up. Cobalamine absorption and 14C-triolein breath tests were performed preoperatively in electively operated patients and postoperatively in all patients at 12 and 36 months. Low S-Ca was most pronounced preoperatively in patients who were to undergo acute colectomy (53%). Decreased S-Mg was detected in 16-36% at all stations. None had signs or symptoms of hypomagnesemia. Low S-albumin was rarely seen except for preoperatively in acute patients. Increased IgM was found in 40% of the patients during the loop ileostomy phase compared to 6-10% preoperatively. Substantially increased orosomucoid and/or haptoglobin were seen in patients during the functional periods but these increased values could not be correlated to episodes with acute pouchitis. High values of S-ALAT and ALP were much more frequent during the loop ileostomy periods than it was preoperatively and during pouch function. Low S-haemoglobin and/or iron were noticed during the functional period in 3-8% and 10-16%, respectively. Severe anaemia, due to iron deficiency developed in one patient after 2.5 years of pouch function. Preoperatively, slight decreases of S-B12 were found in 13% and impaired cobalamine absorption was revealed in 38% of the electively operated patients. The corresponding figures were 3% and 31% after 12 months and 5% and 36% after 36 months of follow-up, respectively. B12 substitution was given to in all 8 patients during the follow-ups. Lipid absorption was disturbed in 38% preoperatively and in 35% and 41% at 12 and 36 months, postoperatively.