Ileal pouch-anal anastomosis for chronic ulcerative colitis and familial polyposis coli complicated by adenocarcinoma

Of 518 patients undergoing the ileal pouch-anal anastomosis (IPAA), 17 (13 with chronic ulcerative colitis [CUC] and four with familial polyposis coli [FPC] ) also had a total of 22 cancers of the colorectum. Tumors were concentrated distally (rectum 6; sigmoid colon 5; proximal colon 11) and were diagnosed preoperatively in eight patients. Histologic grade and stage were as follows: grade I, 36 percent; II, 23 percent; III, 23 percent; IV, 18 percent; stage A, 5 percent; B1, 32 percent; B2, 18 percent; C1 and C2, 45 percent. Median hospital stay was 17 days with no operative mortality. Relaparotomy was required in 35 percent (sepsis in four patients; obstruction in two) and minor procedures were done in 12 percent (anastomotic dilatation in one; rectovaginal fistula in one). Mean frequency of defecation was 6.4/day, 1.0/night; incidence of minor seepage, 17 percent (day), 50 percent night); incidence of pouchitis, 8 percent; intermittent dyspareunia, 17 percent of six women. One patient died from hepatic metastases nine months after operation. IPAA should be considered in favorable cancers complicating CUC or FPC, although it may be contraindicated in advanced rectal cancer, and may be unsuitable in advanced proximal cancer.

Roux-Y stasis syndrome after gastrectomy

The aim of the present study was to determine which factors lead to upper gastrointestinal stasis after Roux-Y reconstruction. Among the 214 patients with Roux-Y reconstructions performed between 1961 and 1983, follow-up data were obtained for 187 (87 percent) after a mean of 6.2 years. Patients with vomiting of food but not bile, postprandial pain, and nausea were considered to have the Roux-Y stasis syndrome. The syndrome was found in 49 patients with gastrojejunostomy (30 percent of those at risk) but in only 2 patients with esophagojejunostomy (8 percent, p less than 0.05). The condition was more common in women than men (p less than 0.05), but it was equally common in patients with and without vagotomy. The mean length of the Roux-Y limb in patients with stasis was 41 cm, which was longer than the 36 cm in patients without stasis (p less than 0.001). When multiple logistic regression was used, the length of the Roux-Y limb emerged as the major risk factor (p less than 0.01). In conclusion, construction of Roux-Y limbs greater than about 40 cm in length may increase the incidence of the Roux-Y stasis syndrome.

Trends in peptic ulcer surgery. A population-based study in Rochester, Minnesota, 1956-1985

We evaluated trends in peptic ulcer surgery among residents of Rochester, Minnesota, where medical care delivered to the population by all providers is well documented. The incidence of elective operations on previously unoperated patients declined dramatically during the 30-yr study period, from 49/100,000 population per year in 1956-1960 to 6/100,000 per year in 1981-1985. The decline was greatest for men with duodenal ulcer, less for men and women with gastric ulcer, and least for women with duodenal ulcer. These trends were established long before the introduction of H2-receptor drug therapy in 1977. In contrast to elective operations, the incidence of emergent operations remained at about 10/100,000 population per year. Perhaps because of an increasing proportion of emergency operations, overall survival appeared to worsen from the first decade of study to the last; but, after adjustment for age at operation and sex, no difference in survival over time was detected.

Young age as a prognostic factor in cervical cancer: analysis of population based data from 10,022 cases

The effect of young age on survival in cervical cancer is not fully known, although evidence has suggested that it is a poor prognostic factor and that young patients should therefore be treated differently from older patients. All 10,022 cases of invasive cervical cancer in the west Midlands during 1957-81, which comprised 10% of the cases in England and Wales, were analysed to determine the prognostic effect of age. Univariate analysis showed a median survival time of 54 months for all cases, with survival rates at five years of 69% for patients aged under 40 and 45% for those aged 40 or older (chi 1(2) (log rank) = 331.4; p less than 0.0001). This difference remained significant after stratification for stage (chi 1(2) (log rank) = 7.1; p = 0.008). Cox regression analysis with nine covariables, including age and year of registration, reaffirmed the importance of conventional prognostic factors such as stage of disease, size of tumour, state of lymph nodes, and differentiation of the tumour. After allowance was made for the effects of other prognostic factors young age was found to be a small but significant favourable factor that did not change during the period of the study. Estimated survival distributions obtained from the Cox model showed that for women presenting with the common characteristics associated with stage Ib disease who were treated with radical radiotherapy the survival rate at five years fell non-linearly from 71% in the group aged 25-29 to 65% in the group aged 65-69. Young age alone is not a reason to alter existing policies for treatment for patients with invasive cervical cancer.

Anal canal pressure and motility after ileoanal anastomosis

This study was done to determine the effect of mucosal rectectomy and ileal pouch to anal anastomosis (IAA) on pressure and motility of the anal canal. Fifty patients, 22 +/- 2 months after operation (mean plus or minus standard error of the mean), and 30 healthy control volunteers were studied. Twenty-eight patients had excellent continence, while 22 had episodic minor incontinence. The maximum resting pressure in the anal canal was reduced in patients with episodic incontinence compared with continent patients and control volunteers. The increase in pressure with squeeze was slightly greater in continent than in incontinent patients. The frequency of the anal slow waves was less after IAA than in control volunteers and the amplitude of the waves was greater. The frequency and amplitude, however, were not related to continence or resting pressure. In conclusion, decreased anal canal resting and squeeze pressures after ileal pouch to anal anastomosis are associated with episodic minor incontinence, while altered motility patterns in the anal canal are not.

Ileal pouch-anal anastomosis for chronic ulcerative colitis. Long-term results

The aim of this study was to determine the long-term outcome among 390 patients with ulcerative colitis who underwent ileal J pouch-anal anastomosis and whether patient or operative factors influenced results. The combined operative morbidity rate for the pouch-anal anastomosis and the subsequent closure of the temporary ileostomy was 29% (bowel obstruction, 22%; pelvic sepsis, 5%), with one death due to pulmonary embolus. The probability of a successful outcome at 5 years was 94%. Of the 24 patients who failed (6% of total), 18 did so within 1 year (4%), three during year 2 (1%), three during year 3 (1%), and none thereafter. Stool frequency (7 stools/24 h), the occurrence of pouchitis (14%), and satisfactory daytime continence (94% of patients) remained stable over 4 years after operation, whereas nocturnal fecal spotting decreased (51% of patients to 20%). Women had more spotting than men, whereas patients over 50 years old had more stools per day than those 50 years or younger. In conclusion, ileal pouch-anal anastomosis achieved a reasonable stool frequency and satisfactory continence in patients with ulcerative colitis over the long-term. These results support the ileal pouch-anal anastomosis as a safe, satisfactory alternative to permanent ileostomy.

Enteric transit and absorption after canine ileostomy. Effect of pacing

The aim was to determine whether retrograde jejunal pacing would slow gastroenteric transit and reduce stomal output of water and electrolytes in dogs with ileostomy. In five alert animals with an end ileostomy, and jejunal pacing and recording electrodes, 200 g of liver labeled with technetium Tc 99m and 50 mL of polyethylene glycol-labeled water were fed to each animal on eight occasions. In one half of the experiments, the jejunum was paced backward for the first three hours after the meal, while in the other half pacing was not done. Stomal output was collected for nine hours. In four other experiments per dog, gastric emptying of the meal was measured by scintigraphy and aspiration after three hours of pacing or control. Jejunal pacing delayed gastrointestinal transit of both liquids and solids, reduced stomal output, and increased fecal sodium concentration during the pacing period. Net postcibal absorption of water and electrolytes over nine hours, however, was not increased by pacing.

Speed of response to platinum-based chemotherapy: implications for the management of epithelial ovarian cancer

Seventy-nine patients with evaluable epithelial ovarian cancer following primary laparotomy and treated with one of three primary cis-platinum-containing regimens were studied to determine the rate at which clinical cytoreduction occurred and whether a rapid response to treatment was of prognostic significance by improving progression free interval (PFI) or survival. A rapid response to treatment improved PFI in patients treated with single agent cis-platinum (P = 0.04) and increased survival in patients treated with a sequential cis-platinum based combination regimen (P = 0.03). The rate of cytoreduction was not a significant variable, however, in a multiple regression analysis of prognostic factors. Over 75% of all clinical responses, regardless of the regimen, had begun by the completion of the third course of chemotherapy. We conclude that response to active chemotherapy is a rapid phenomenon in ovarian cancer and this has important implications in both the decision to change drug therapy and the timing of further surgical effort.

Total gastrectomy for benign disease

Among 37 patients who underwent total gastrectomy for nonmalignant disease, operative mortality was 4 per cent after 27 elective operations and 10 per cent after 10 emergency operations. Three other patients died 1 to 6 months after operation. Major postoperative complications occurred in 24 per cent. Long-term follow-up of 26 patients (81 per cent of survivors) after a mean +/- SEM of 8.4 +/- 1.1 years showed that 73 per cent of patients had no or only occasional, easily controlled, mild abdominal symptoms and good enough health to enable them to work or carry out normal activities for their age. The patients lost a mean of 15 per cent of their body weight, however, and about one third of them had weakness and diarrhea. A quarter of them had anemia despite iron and vitamin B12 therapy. Our conclusion was that total gastrectomy is a reasonable operation for benign diseases. Nonetheless, in view of the substantial postoperative mortality and morbidity, the operation should be used only when less extensive operations will not suffice.

Proximal gastric vagotomy and mucosal antrectomy: effect on gastric acid secretion, plasma gastrin, and experimental ulcerogenesis in the dog

The aim of this study was to determine whether mucosal antrectomy, which preserves antropyloric motility, would enhance the antiulcer properties of proximal gastric vagotomy (PGV). Hydrochloric acid and gastrin secretion were studied in five dogs before and after PGV and mucosal antrectomy, while the response to the Mann-Williamson operation (an ulcer-producing operation) was evaluated in four control dogs with intact stomachs, five dogs with PGV alone, and six dogs with PGV plus mucosal antrectomy. Proximal gastric vagotomy and mucosal antrectomy decreased mean +/- SEM basal and pentagastrin-stimulated acid secretion from 4.3 +/- 1.3 to 0.4 +/- 0.3 mEq/hr and from 21 +/- 0.7 to 7.4 +/- 1.8 mEq/hr, respectively (p less than 0.05). Basal plasma gastrin was altered little by the operation (68 +/- 9.7 pg/ml before, 58 +/- 11 pg/ml after; p greater than 0.05) but the 4-hour integrated plasma gastrin response to a 200 gm meat meal decreased from 13 +/- 1.8 to 3.3 +/- 0.7 ng X min/ml (p less than 0.05). Only one of six dogs with mucosal antrectomy and PGV developed peptic ulcer after the Mann-Williamson operation, whereas four of five with PGV alone and three of four controls developed ulcers (p less than 0.05, PGV alone versus PGV and mucosal antrectomy). In conclusion, PGV and mucosal antrectomy decreased acid secretion and postcibal gastrin response and provided greater protection against peptic ulcer than PGV alone.

Mechanisms of enhanced canine enteric absorption with intestinal pacing

Electrical pacing enhances absorption from the canine small bowel, but the mechanism of this effect is unknown. To explore the mechanism, conscious dogs with two Vella loops, a proximal jejunal and a distal ileal, each 50 cm long, were studied. Pacing the jejunal loop with 15-18 pulses/min entrained the pacesetter potentials of the jejunal loop and increased water, sodium, and glucose absorption from the jejunal loop. Jejunal pacing also increased water absorption from the unpaced, ileal loop. Conversely, ileal pacing did not entrain the ileal loop or enhance absorption from the ileal loop. However, it did enhance water absorption in the unpaced jejunal loop. After alpha-blockade with phentolamine or celiac and superior mesenteric ganglionectomy, jejunal pacing did not increase jejunal or ileal absorption. In contrast, after beta-blockade with propranolol, pacing still enhanced jejunal absorption in three out of four dogs. Vagotomy alone enhanced jejunal but not ileal absorption, but the enhancement was not further increased by pacing. In conclusion, electrical pacing of the small bowel elicited a local and distant increase in net water absorption; the effect was mediated in part by an alpha-adrenergic mechanism.

Determinants of stool frequency after ileal pouch-anal anastomosis

The aim of our study was to determine whether ileal pouch motility and evacuability and the 24 hour fecal output influence stool frequency after ileal pouch-anal anastomosis. In 23 patients, at a mean of 24 months postoperatively (range 22 to 26 months), ileal pouch motility was measured using an intraluminal bag and pressure-sensitive catheters. The pattern and efficiency of ileal pouch emptying was determined scintigraphically. A 24 hour stool collection was made and the stool output and stool frequency recorded. The volume of ileal pouch distention at which large amplitude propulsive waves appeared (the threshold volume) correlated closely with stool frequency. The larger the threshold volume, the fewer the stools per 24 hours (correlation coefficient -0.70; p less than 0.01). Also, the greater the 24 hour stool output, the greater the stool frequency (correlation coefficient 0.79, p less than 0.001). In contrast, the efficiency of ileal pouch evacuation was less strongly related to stool frequency (correlation coefficient -0.41, p = 0.05). We conclude that ileal pouch motility and stool output are major determinants of stool frequency after ileal pouch-anal anastomosis. Inefficient pouch emptying is less commonly associated with frequent bowel movements.

Influence of a jejunal fistula on gastric emptying

The aim was to determine whether a proximal jejunal fistula would speed gastric emptying after truncal vagotomy and Roux distal gastrectomy. Eight vagotomy-gastrectomy dogs were studied; 4 had a jejunal fistula, and 4 other dogs without a fistula served as controls. The rate of gastric emptying of 100 ml 25% dextrose in the fistula dogs with the fistula open (95 +/- 3 ml/20 min) was faster than in the same dogs with the fistula closed (62 +/- 10 ml/20 min; p less than 0.05) and faster than in dogs without a fistula (77 +/- 5 ml/20 min; p less than 0.05). The rate of emptying in dogs with the fistula closed, however, was similar to the rate in dogs without a fistula (p greater than 0.05). We concluded that diversion of the enteric content to the exterior through a proximal jejunal fistula increases the rate of gastric emptying of 25% dextrose solutions in dogs with truncal vagotomy and Roux gastrectomy.

Relationship of backwash ileitis to ileal pouchitis after ileal pouch-anal anastomosis

To assess whether the presence of backwash ileitis predisposed to the subsequent development of ileal pouchitis after ileal pouch-anal anastomosis, 131 patients who had the operation were studied. Fifteen patients had nonspecific inflammation in the terminal ileum noted at the time of the operation, while 20 patients subsequently developed pouchitis. No correlation between the two conditions was found. Pouchitis developed in two of 15 patients (13 percent) with backwash ileitis and in 18 of 116 patients (16 percent) without the ileitis (P greater than 0.05). Among the 20 patients with pouchitis only two (10 percent) had had previous backwash ileitis. It is concluded that the presence of backwash ileitis does not predispose to later development of pouchitis, and so does not contraindicate use of the inflamed terminal ileum for construction of the ileal pouch and anastomosis.

Effect of transection and pacing on human jejunal pacesetter potentials

The aim of this study was to determine whether transection and pacing alter the frequency of the human jejunal pacesetter potentials (PPs). In 8 patients undergoing Roux gastrectomy, three temporary bipolar electrodes were implanted on the jejunal seromuscularis at sites 5 cm proximal to and 10 and 20 cm distal to the jejunal transection. Three other patients not undergoing Roux transection (controls) had electrodes applied at similar sites. After recovery, the mean +/- SEM frequency of the jejunal PPs in Roux patients was slightly slower distal to the jejunal transection (11.0 +/- 0.2 cpm) than proximal to the transection (11.3 +/- 0.2 cpm, p less than 0.05), whereas the PP frequency in the two areas in control nontransected patients was identical (proximal, 12.0 +/- 0.3 cpm; distal, 12.0 +/- 0.3 cpm). In contrast to the change in frequency with transection, pacing with electric pulses (strength, 15 mA; duration, 50 ms; frequency, 0.2-1.0 cpm faster than native PP frequency) speeded the jejunal PP frequency in only 1 of 9 patients tested. We conclude that transection decreased the frequency of the human jejunal PPs, but only slightly. Pacing did not readily entrain the PPs in either intact or transected jejunum.

Sexual function in women after proctocolectomy

One hundred women who had undergone proctocolectomy with a continence-preserving procedure (50 Kock pouches, 50 ileoanal anastomoses) for ulcerative colitis or polyposis coli were interviewed regarding their preoperative and postoperative sexual function. Frequency of intercourse increased and the incidence of dyspareunia decreased after operation in both groups. Patients who had a Kock pouch had a greater incidence of persistent postoperative dyspareunia than patients who underwent an ileoanal procedure (38% vs. 18%, p less than 0.02). Only one patient in each group reported a postoperative disturbance in ability to achieve orgasm. Most women reported no change in their menstrual cycle, but patients with a Kock pouch had more episodic vaginal discharge than patients with an ileoanal anastomosis (18% vs. 0%, p less than 0.001). Postoperative fertility was minimally impaired. Overall, the majority of women in this study who underwent proctocolectomy for benign diseases experienced enhanced sexual function after operation, which they attributed mainly to improved health.

Enteric bacteriology, absorption, morphology and emptying after ileal pouch-anal anastomosis

The aim was to determine whether changes in enteric bacteriology, absorption, morphology, and emptying occur after ileal pouch-anal anastomosis for ulcerative colitis, and to relate any changes to the clinical result. Twenty patients were studied 26 +/- 2 months (mean +/- s.e.m.) after operation. Eight patients had a good result, six a poor result, and six a history of recurrent pouch ileitis. Anaerobic and aerobic overgrowth occurred in the jejunum of patients with a poor result, but not in those with a good result or with pouch ileitis. In contrast, ileal pouch bacterial overgrowth occurred in all patients regardless of the clinical result. Patients with jejunal overgrowth had increased 24 h stool volume and stool nitrogen, but other patients did not. The larger the stool volume, the greater the anaerobic overgrowth. Pouch biopsies showed chronic inflammation in all patients, while 45 per cent had colonic metaplasia. Neither the inflammation nor the metaplasia correlated with the clinical result, nor did the clinical result correlate with the efficiency of pouch emptying. In conclusion, jejunal bacterial overgrowth after ileal pouch-anal anastomosis was associated with an increased stool output, azotorrhoea, and a poor clinical result. A distinguishing bacterial, absorptive, morphological, or emptying abnormality was not found in patients with a history of recurrent pouch ileitis.

Prediction of ifosfamide/mesna associated encephalopathy

Ifosfamide and mesna were administered to 77 patients with advanced malignancies. Seven (9%) experienced a severe but reversible encephalopathy. In 56% of patients in whom EEG data was available, characteristic changes were seen with or without mild clinical toxicity. Discriminant analysis identified low serum albumin concentration, high serum creatinine concentration and the presence of pelvic disease as variables which predispose patients to the development of severe encephalopathy. A nomogram has been constructed which can be used to determine the probability that an individual patient may be given ifosfamide and mesna safely. This has important implications for the clinical use of a highly active chemotherapy regimen.

Achieving enteric continence: principles and applications

Continence may be defined broadly as the ability to defer the passage of enteric content voluntarily to a socially acceptable time and place. In health, continence is provided by the anorectum; several factors interplay to achieve control. When the colon and rectum are removed because of intractable inflammatory bowel disease, a Brooke ileostomy that is incontinent of stool and gas is traditionally constructed, and control of the stoma is provided by an external appliance. Although the functional results after a Brooke ileostomy are good, we believe that restoration of continence would enhance the quality of life. The methods by which continence is restored surgically have undergone evolutionary changes based on an expanding knowledge of the principles of continence gained in the laboratory. In this report, we detail the current status of our understanding of anorectal continence mechanisms and of the principles of ileal continence, in order to examine how "ileo-anal" continence has been achieved in patients who require proctocolectomy.

Canine mucosal antrectomy

Our primary aim was to determine whether mucosal antrectomy decreases postcibal serum gastrin and gastric acid secretion. In four dogs with proximal gastric vagotomy and a Heidenhain pouch, mucosal antrectomy decreased the integrated postcibal serum gastrin response from a mean +/- SEM of 2.0 +/- 0.2 ng X h/mL before antrectomy to 0.8 +/- 0.1 ng X h/mL after antrectomy, while it decreased postcibal output of hydrochloric acid from the pouch from 9.5 +/- 3.3 mEq/7 h (9.5 +/- 3.3 mmol/7 h) to 4.3 +/- 2.2 mEq/7 h (4.3 +/- 2.2 mmol/7 h). However, these decreases were temporary in two of the four dogs. In five additional dogs without vagotomy, the distal, antral, mucosal gastrin level increased from 1 +/- 1 micrograms/g of tissue before mucosal antrectomy to 5 +/- 1 micrograms/g of tissue after the antrectomy. Moreover, gastrin and G cells were present in corporal mucosa transferred to the antrum in three of five dogs after the antrectomy, where none had been present in the corporal mucosa before the antrectomy. The conclusion was that mucosal antrectomy decreased serum gastrin and hydrochloric acid output from the stomach, but that these changes were counteracted in part by hyperplasia of residual G cells and G-cell neogenesis after the operation.