Nutritional considerations in inflammatory bowel diseases

Although many foods have been suggested to play a role in the cause of IBD, there are not yet definitive data to support diet as a cause of either CD or UC. Malnutrition is a common occurrence in IBD, and this must be considered in the treatment of these diseases. Nutritional support in IBD has limited use as primary therapy (Table 2). Even though parenteral and enteral nutrition have been associated with remission, relapse frequently occurs when normal food intake is resumed. Likewise, fistulae may resolve with aggressive, nutritional therapy, but they frequently recur with reinstitution of food. In short bowel syndrome caused by extensive intestinal resection performed in CD, parenteral nutrition provides an important mode of therapy. In addition, perioperative use of nutritional support may decrease the incidence of postoperative complications in patients who are malnourished. Nutritional support in pediatric patients with CD who have growth failure has been effective in stimulating growth.

Perioperative blood transfusion does not prevent recurrence in Crohn's disease. A pooled analysis

The effect of perioperative blood transfusion on the recurrence of Crohn's disease is controversial. Various studies have suggested that perioperative blood transfusions reduce the risk of recurrence; others have failed to find a protective effect. Since all the studies are based on relatively small numbers, we performed a pooled analysis. We contacted the senior authors of seven previously published studies and asked for the original data. Four authors provided their data. The pooled database included 622 patients with a primary and complete resection of macroscopic disease. Recurrence was defined as the need for repeat surgery for disease control. Kaplan-Meier life table analysis was performed. Of the study sample, 366 cases (59%) were female. Disease distribution was as follows: small bowel (47%), small/large bowel (35%), and large bowel only (18%). Three hundred thirty-one patients (53%) received blood in the perioperative period. Mean follow-up was 72.8 months. For the overall sample, the 5-year recurrence rates were 26.9% for the transfused group and 25.2% for the nontransfused (p = 0.456). When the data were stratified by age, gender, disease location, and length of resection, no difference in 5-year recurrence rates between transfused and nontransfused cases could be detected. In this pooled analysis of four retrospective studies on the effect of blood transfusions on the risk of recurrence in Crohn's disease, we were unable to document a protective effect.

Phospholipase A2 gene expression and activity in histologically normal ileal mucosa and in Crohn's ileitis

Increased activity of phospholipase A2 (PLA2) in the ileal mucosa may contribute to the inflammation in Crohn's disease. The results of this study showed that (a) three months after ileocolonic resection for Crohn's disease the neoterminal ileal mucosa showed endoscopically new inflammation and had higher PLA2 activity than at the time of the operation (n = 8); no such findings were seen in controls (n = 7), (b) histologically normal ileal mucosa (n = 3) contained mRNA for three isoforms of PLA2 (PLA2-I, PLA2-II, and cPLA2), but the amounts of PLA2-II mRNA clearly exceeded the amounts of mRNA for PLA2-I and cPLA2, (c) ileal mucosa from Crohn's patients (n = 2) contained higher values of PLA2-II mRNA than ileal mucosa from two controls, (d) ileal mucosa from Crohn's patients (n = 4) showed increased PLA2-II mRNA three months after ileocolonic resection. In conclusion, these results show that the predominating PLA2 mRNA in the human ileal mucosa is type II PLA2, and the increased synthesis of PLA2-II might be responsible for the increased PLA2 activity found in the ileal mucosa accompanying recurrent ileal inflammation in Crohn's disease.

Surgical therapy for ulcerative colitis

Ulcerative colitis is a curable disease. Despite newer medications, many patients either fail medical therapy or develop dysplasia or carcinoma requiring surgery. Surgical techniques have improved, and complication rates have declined. The functional results of ileoanal reservoir surgery are excellent in most patients, and most patients agree that a pouch is better than the disease. One must balance poor function secondary to disease, cancer risk, need for medication, and side effects of medication against surgical morbidity and postoperative function.

[Care patterns and resumption of social and occupational activities after exeresis surgery in Crohn's disease. Study of 58 patients]

The aim of this retrospective study was to describe care patterns and conditions surrounding the resumption of social and work activities after intestinal resection for Crohn's disease. Fifty-eight patients were evaluated regarding their stay in the department of surgery, use of care and resumption of social and work activities within the first year after intestinal resection. Data were obtained from medical records and answers to a medical questionnaire. Forty patients replied to the questionnaire. Mean length of stay in the department of surgery was 16 +/- 9 days. Length of stay was positively correlated to non-elective surgery, colonic resection, presence of fistulae or abscesses, and to the creation of a stoma. Main interval between surgery and resumption of work was 11 +/- 8 weeks. Only one patient was unable to return to work because of the disease. Seventy per cent of the patients who went back to work said that their quality of life was improved after surgery in comparison with their preoperative status. In conclusion, this study suggests that most of the patients undergoing intestinal resection for Crohn's disease can go back to work without particular difficulties, and consider that their quality of life has been improved by surgery.

Effect of intestinal resection on serum antibodies to the mycobacterial 45/48 kilodalton doublet antigen in Crohn's disease

Interest in the role of mycobacterial infection in Crohn's disease has been revived by the cultural detection of Mycobacterium paratuberculosis in patients with Crohn's disease. This hypothesis was examined serologically using assays with high specificity for Crohn's disease. The effect of intestinal resection on serum antibodies specific for Crohn's disease was investigated with an immunoblot assay and an enzyme linked immunosorbent assay using the 45/48 kilodalton doublet antigen of Mycobacterium tuberculosis. Antibodies were detected in 64.7% of patients with Crohn's disease (n = 17), 10% of patients with ulcerative colitis (n = 10), 5% of patients with carcinoma of the colon (n = 20), and none of 10 healthy subjects with the immunoblot assay. Statistical comparison of the Crohn's disease patients with each control group resulted in p = 0.0000236. Immunoglobulin G was essentially unchanged 75 days (mean) after surgery. After more than 180 days, however, the antibody response was reduced in all of five patients studied, and was no longer demonstrable in two of them (40%). Simultaneously, the Crohn's disease activity index (CDAI) decreased. Both the high specificity of this assay for Crohn's disease and the diminished antibody response after intestinal resection in parallel with decreased CDAI support a mycobacterial aetiology of Crohn's disease.

Surgical therapy for Crohn's disease

Recurrence of disease after restorative operation for Crohn's disease is the rule rather than the exception. In fact, studies using colonoscopic surveillance show that minute recurrent lesions appear early on after operation in the majority of patients. Radical extirpation of disease does not reduce the rate of recurrence but only predisposes to the development of short bowel syndrome. Unfortunately, although in preliminary studies some prophylactic drug regimens seem to delay recurrence, no agent has been shown to be sufficiently potent to change this basic picture. Cure is possible in many cases of predominately colonic disease, but this comes at the expense of a permanent ileostomy. Despite these gloomy statistics, 70% or more of patients require one or more operations during their course. This conundrum is managed by using conservative indications for operation and by bowel-conserving operative procedures. Thus employed and carried out, operation has a favorable impact on the quality of life of these patients. Similarly conservative surgical treatment of the perineal complications, which are frequent and devastating, can be of enormous benefit.

Prophylactic mesalamine treatment decreases postoperative recurrence of Crohn's disease

BACKGROUND & AIMS

Recurrence of Crohn's disease frequently occurs after surgery. A randomized controlled trial was performed to determine if mesalamine is effective in decreasing the risk of recurrent Crohn's disease after surgical resection is performed.

METHODS

One hundred sixty-three patients who underwent a surgical resection and had no evidence of residual disease were randomized to a treatment group (1.5 g mesalamine twice a day) or a placebo control group within 8 weeks of surgery. The follow-up period was a maximum of 72 months.

RESULTS

The symptomatic recurrence rate (symptoms plus endoscopic and/or radiological confirmation of disease) in the treatment group was 31% (27 of 87) compared with 41% (31 of 76) in the control group (P = 0.031). The relative risk of developing recurrent disease was 0.628 (90% confidence interval, 0.40-0.97) for those in the treatment group (P = 0.039; one-tail test) using an intention-to-treat analysis and 0.532 (90% confidence interval, 0.32-0.87) using an efficacy analysis. The endoscopic and radiological rate of recurrence was also significantly decreased with relative risks of 0.654 (90% confidence interval, 0.47-0.91) in the effectiveness analysis and 0.635 (90% confidence interval, 0.44-0.91) in the efficacy analysis. There was only one serious side effect (pancreatitis) in subjects in the treatment group.

CONCLUSIONS

Mesalamine (3.0 g/day) is effective in decreasing the risk of recurrence of Crohn's disease after surgical resection is performed.

Crohn's disease in the Hunter Valley region of Australia

Between 1967 and 1991, 130 patients underwent surgery for Crohn's disease at The Royal Newcastle Hospital, New South Wales. There were more patients in recent years, which suggested an increased incidence of the condition (2.1/100 000/per year). The clinical profile and recurrence rate were similar to other studies. However, a greater proportion of patients required surgery for chronic small bowel obstruction and fulminant colitis compared with patients in other countries.

Crohn's disease: a colon and rectal department experience

This study reviewed a series of patients with Crohn's disease managed by surgeons of the Department of Colon and Rectal Surgery, St Vincent's Hospital, Melbourne, since 1978. There were 306 patients: 171 males and 135 females. The mean age at diagnosis was 33.4 years (ranger 11-93). The distribution of the disease was small bowel 32.3%, small bowel and colon 26.5%, colon 39.9%, and anal disease alone 1.6%. A total of 416 abdominal operations were performed on 204 patients. The commonest indications for surgery were failed medical therapy (21.9%), small bowel obstruction (15.9%), enteric fistula (10.1%), and intra-abdominal abscess (10.1%). The most frequently performed procedures were ileocolic resection with anastomosis (28.8%), small bowel resection (9.4%), and total colectomy and ileostomy (7.0%). Postoperative complications included anastomotic leaks in 4.0%, intra-abdominal abscess formation in 3.6%, and enterocutaneous fistulae developed in 6%. Three patients died during the review period. During follow up (mean 84.4), 30% of patients developed recurrence requiring further surgery at a mean of 72.7 months postoperatively. The most frequent site for a recurrence was the pre-anastomotic terminal ileum (61.7%). In conclusion, the majority of patients with Crohn's disease will require resectional surgery at some stage. This can be performed with a low mortality and morbidity, and a recurrence rate of around 5% per year.

Ileal pouch-anal anastomoses complications and function in 1005 patients

BACKGROUND

Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) has become an established surgery for patients with chronic ulcerative colitis and familial adenomatous polyposis.

PURPOSE

The authors report the results of an 11-year experience of restorative proctocolectomy and IPAA at a tertiary referral center.

METHODS

Chart review was performed for 1005 patients undergoing IPAA from 1983 through 1993. Preoperative histopathologic diagnoses were ulcerative colitis (n = 858), familial adenomatous polyposis (n = 62), indeterminate colitis (n = 75), and miscellaneous (n = 10). Information was obtained regarding patient demographics, type and duration of diseases, previous operations, and indications for surgery. Data were collected on surgical procedure and postoperative pathologic diagnosis. Early (within 30 days after surgery) and late complications were noted. Follow-up included an annual function and quality-of-life questionnaire, physical examination, and biopsies of the pouch and anal transitional zone.

RESULTS

Of the 1005 patients (455 women), postoperative histopathologic diagnoses were as follows: ulcerative colitis (n = 812), familial adenomatous polyposis (n = 62), indeterminate colitis (n = 54), Crohn's disease (n = 67), and miscellaneous (n = 10). During a mean follow-up time of 35 months (range 1-125 months), histopathologic diagnoses were changed for 25 patients. The overall mortality rate was 1% (n = 10 patients, early = 4, late = 6); one death (0.1%) was related to pouch necrosis and sepsis. The overall morbidity rate was 62.7% (1218 complications in 630 patients; early, n = 27.5%; late, n = 50.5%). Septic complication and reoperation rates were 6.8% and 24%, respectively. The ileal pouch was removed in 34 patients (3.4%), and it is nonfunctional in 11 (1%). Functional results and quality of life were good to excellent in 93% of the patients with complete data (n = 645) and are similar for patients with ulcerative colitis, familial adenomatous polyposis, indeterminate colitis, and Crohn's disease. Patients who underwent operations from 1983 through 1988 have similar functional results and quality of life compared with patients who underwent operations after 1988.

CONCLUSION

Restorative proctocolectomy with an IPAA is a safe procedure, with low mortality and major morbidity rates. Although total morbidity rate is appreciable, functional results generally are good and patient satisfaction is high.

[Laparoscopic resections in Crohn disease]

39 patients with Crohn's disease underwent laparoscopic bowel resections during January 1993 to May 1995 (16 female, 23 male, with an average age of 33 years). The duration of the disease ranged from one to 18 years. 21 of the 39 patients were under steroid therapy at the time of operation. Seven patients have had ileocaecal resection for Crohn's disease. The operative technique is laparoscopically assisted. We performed: small bowel resections (8), ileocaecal resections (16), hemicolectomies (11), subtotal colectomies (2), colectomies (2). Operative time ranged from 90 to 280 min for ileocaecal resections and from 330 to 420 min for colectomies. Intraoperative complications were not encountered. Postoperatively one patient developed a subhepatic abscess which was drained under sonographic guidance on day 6. One patient was reoperated for a different disease on postoperative day 2. Two patients had fever till day 9 and 13 without clinical relevance. Two patients had delayed incision site healing. Postoperative clinical stay was 11 days. The main benefit for the patients was early mobilisation due to reduced pain. Patients experienced the small abdominal incision as a ray of hope in their chronic disease.

Exercise capacity in patients undergoing proctocolectomy and small bowel resection for Crohn's disease

The effect of proctocolectomy and small bowel resection on working capacity has not been assessed objectively in previous research. Twenty-nine patients with Crohn's disease were investigated with cycle ergometry and a questionnaire, following proctocolectomy with and without small bowel resection. Maximal exercise load is known to correspond well with working capacity, particularly when account is taken of body composition and metabolic variables. Maximal exercise load was reduced marginally (by 9 per cent) in patients without small bowel resection and by 22 per cent in patients with moderate small bowel resection (15-30 per cent resection). Patients with extensive bowel resection (more than 50 per cent) had a 40 per cent reduction in the maximal exercise load. This reduction in maximal exercise load was greater than predicted when accounting for reduction in muscle mass. All patients had a normal oxygen uptake including resting energy expenditure. Urinary sodium and magnesium excretion was low in the group with moderate bowel resection, whereas the extensively resected patients were malnourished and had a reduced body cell mass. The authors conclude that the significantly reduced working capacity was of multifactorial origin secondary to malabsorption. However, the patients seemed unaware of the degree of their diminished working capacity. This reduced capacity makes it unlikely that they would be able to perform any labour involving high energy consumption at the level of 500-700 W, and this inability was reflected by a high rate of unemployment among the patients.

[Surgical therapy of recurrent Crohn disease]

The surgical therapy of recurrent Crohn's disease requires due to a recurrence rate of 60% after 15 years special precautions. The major principle of therapy is a minimal resecting surgery. This concerns mainly strictures and stenosis. Strictures should be treated by stricturoplasty and stenosis by limited resection. Recurrent fistulas should be treated conservatively. Just in case of interenteric and enterocutaneous fistula with a concomitant short bowel syndrome, in blind ending fistulas with an abscess or in enterovesical fistulas we recommend immediate operation. The therapy of recurrent anorectal Crohn's disease underlies the same rules as the primary therapy. If necessary, proctectomy remains an important option. Also emergency surgery in recurrent Crohn's disease follows the same rules as in elective surgery.

Rediversion after ileal pouch-anal anastomosis. Causes of failures and predictors of subsequent pouch salvage

PURPOSE

The aim of this study was to understand better the cause and predictability of pouch failure requiring rediversion after ileal pouch-anal anastomosis and to assess the ultimate outcome of patients in a large ileal pouch series who required rediversion.

METHODS

Data from 460 patients completing ileal pouch-anal anastomosis at one institution were recorded from both a prospectively accumulated ileal pouch registry and patient medical records.

RESULTS

Of 460 patients, 21 (4.6 percent) who underwent ileal pouch-anal anastomosis required rediversion. Five of these patients subsequently had successful restoration of pouch continuity, leaving a permanent failure rate of 16 of 460 patients (3.5 percent). The most common reasons for rediversion were pouch fistula formation (12) and poor functional results (5). Preoperative factors, including age, previous colectomy, and indication for colectomy, did not predict eventual need for rediversion. Patients requiring rediversion had significantly higher rates of postoperative complications (95 vs. 43 percent; P < 0.001). Specifically, this group had a higher rate of postoperative pouch fistula (57 vs. 3.4 percent; P < 0.001). Additionally, a final diagnosis of Crohn's disease significantly predicted the need for rediversion. Permanent pouch failure occurred in 36.8 percent of patients with a final diagnosis of Crohn's disease compared with 1.4 percent of patients with a final diagnosis of ulcerative colitis (P < 0.001). All five salvaged patients had fistula formation in the absence of Crohn's disease.

CONCLUSIONS

The overall rate of permanent pouch failure is low. The majority of failures were related to fistula formation associated with Crohn's disease or poor functional results. Pouches complicated by fistulas not associated with Crohn's disease can be salvaged with temporary rediversion.

[Risk factors for recurrence of Crohn disease after intestinal resection]

From 1965 to 1990, postoperative risk factors (age, sex, preoperative history of CD, initial location of CD, length of affected intestinum, extent of bowel resection) for recurrence of Crohn's Disease (CD) were retrospectively analysed from data of 172 patients (104 men, 68 women; age 14 to 65 yrs.) with primary bowel resection and compared with the international literature. The mean follow-up interval was 10 (1-21) years. Additionally full thickness biopsies from resection margins of 66 consecutive ileocecal specimen (45 men, 21 women; age 21-70 years) with ileitis were studied, histopathologically classified into 3 groups and correlated with the rate, manifestation and onset of early recurrence. The cumulative CD recurrence rate was 69% after 10 years and 86.4% after 15 years. There was no statistically significant correlation between recurrence rate and age, sex, initial location or extent of bowel resection, only an higher rate with an preoperative duration of CD longer than 5 years (p < 0.05). The histopathology of the ileocecal resection specimen showed no statistically significant differences of the recurrence rate within the 3 groups. Surgery cannot minimize the recurrence rate of CD after resection but do clearly improve the quality of life.

[Role of CT in the evaluation of patients with painful symptoms located in the lower right abdominal quadrant]

Eleven patients presenting signs and symptoms related to flogistic disease of the right inferior abdominal region were studied with Computed Tomography. Four out of the eleven patients also underwent Magnetic Resonance examination. In 9 patients final diagnosis was correctly reached after surgery and in 1 case diagnosis was made on the basis of endoscopic findings and delayed echographic controls. Among the eleven patient a correct diagnosis was possible on the basis of CT findings in seven of the examined patients; 4 of them were correctly diagnosed as appendicitis; 1 case was diagnosed as Crohn disease; 1 case was a mucocele and 1 case was diagnosed as tubo-ovaric abscess. In 1 case no one diagnostic hypothesis was possible on the basis of CT and MR findings; on surgery the diagnosis was of appendicitis. In 2 cases of surgery proven tubo-ovaric abscesses a diagnosis of appendicitis was done on the basis of CT examination. In one case CT and MR findings were considered to be related to an ovaric tumor; on surgery the correct diagnosis was of post-surgical fibrosis. In 4 cases MR findings confirmed the diagnostic hypothesis reached with CT examination but only in two of them the final diagnosis was correct. In this paper we describe all the CT and MR findings found in each patient.

[Recurrent Crohn disease--definition and diagnosis]

Recurrence in Crohn's disease is a frequently encountered problem in the history of this chronic incurable disease. A number of studies have shown different recurrence and reoperation rates, which is partly due to different definitions and diagnostic strategies. 'Surgical relapse' as defined as reappearance of disease activity in operated patients, 'clinical relapse' after conservatively induced remission or 'endoscopical recurrence' with new pathological changes in the operated gut may be differentiated. The different definitions of recurrence are discussed and diagnostic procedures like endoscopical, laboratory or radiological methods are explained.

[Subjective assessment of quality of life, pain and surgical success after laparotomy for Crohn disease]

239 patients following major surgery for Crohn's disease (mean 8 years after first operation) were interviewed by mailed questionnaire. Main target parameters included reduction of quality of life, intensity/frequency of abdominal pain, and grading of success of the most recent operation for Crohn's disease. These targets were correlated in univariate as well as multivariate statistics with 28 different parameters of general medical history, surgical pretreatment, actual somatic and psychosocial findings. Reduction of quality of life correlated with stool frequency, employment status, rectal involvement, hematochezia, liquid stools, extraintestinal manifestations and time since first operation (all with p < 0.05 in multivariate analysis; listed in decreasing levels of significance). Abdominal pain at time of interview was significantly associated with actual intake of corticosteroids, stool frequency, employment status, extraintestinal manifestations, dietary restrictions, and number of previous operations (other than laparotomies). Regarding success of most recent laparotomy important parameters included stool frequency, intake of corticosteroids, number of previous laparotomies, hematochezia, and history of enterostomy. Overall, parameters of disease activity were found to be more important than characteristics of medical history or previous surgery. Despite marked symptoms in many cases 92% of the patients regarded the most recent laparotomy to be fully or partially successful. The results provide direct and indirect evidence that besides momentary disease activity the individual personality profile may be far more important than type and number of previous surgery in coping with this chronic disease.

Ileoproctostomy is preferred over ileoanal pull-through in patients with indeterminate colitis

A 15-year retrospective review was undertaken to evaluate the operative outcomes of patients with indeterminate colitis who were referred for rectal-sparing operations. Review of 95 consecutive patients operated for ulcerative colitis (UC) or indeterminate colitis (IC) revealed characteristics of IC in 13 patients. In the group as a whole, there were 45 females and 50 males; the average age was 33. A total of 64 patients had ileoanal pull-through (IAA). Analysis revealed that four of these patients had IC revealed by findings before operation in three patients and following the first stage of operation in one patient. Three of these four patients have subsequently required permanent ileostomy. Six patients who underwent IAA have subsequently demonstrated signs and symptoms of Crohn's disease (CD). All six have subsequently required ileostomy. Overall 10 patients with CD underwent IAA, and nine have required permanent ileostomy. Fourteen patients had ileorectal anastomosis (IRA) for UC or IC. IRA was performed for patients with IC in nine cases, and five patients with UC elected this operative option. Indications for IRA in patients with UC included obesity, 2; mental retardation, 1; advanced age, 1; and patient preference, 1. Of the patients with IC who underwent IRA, two have subsequently shown signs and symptoms of Crohn's disease. Overall, 14 of 14 patients who had IRA still have functioning IRA. None has required ileostomy. The poor results in patients with UC or IC subsequently shown to have CD have caused us to change our operative approach in patients with any question in the diagnosis of UC.(ABSTRACT TRUNCATED AT 250 WORDS)

[Perforation in Crohn's ileitis and its consequences in the natural history of disease. 2. Consequences of perforation in the peritoneal cavity: diffuse septic peritonitis, abscesses, external and internal fistulas]

Perforation of Crohn's ileitis occurring in the peritoneal cavity is always free perforation, but it causes usually a localized peritonitis, i.e. an abscess, and only in rare cases a diffuse septic peritonitis for the reasons expounded in the Part 1. Diffuse septic peritonitis has the common features of all perforative peritonitis; its surgical treatment must be ileocolic resection, simple suture of perforation being a serious mistake. Abscesses develop: as regards the ileum, about 30-45 cm from the ileo-caecal valve; as regards the abdominal cavity, in the right iliac fossa or in the pelvis, at a site where the ileum, weighed down by its chronic inflammation, rests. These abscesses have a wall like that of all abscesses, with no specific crohnian features. On operation, if technical considerations so require, part of the abscess wall may be left in place with no fear of recurrences or fistulas. Nowadays, most abscesses of the right iliac fossa are opened surgically; an enterocutaneous fistula follows. Most abscesses of the pelvis still open spontaneously into a hollow organ (sigma-rectum, urinary bladder), and rarely into the vagina or onto the perineum after penetrating through the levator any muscle and causing suppuration of the ischiorectal fossa.

Laparoscopic-assisted intestinal resection for Crohn's disease

PURPOSE

The inflammatory process associated with Crohn's disease often makes dissection difficult, even in "open" surgery. This study was undertaken to determine if dissection and resection could be performed laparoscopically and whether it would benefit this group of patients.

METHODS

Between November 1992 and November 1994, laparoscopic-assisted intestinal resection was attempted in 18 patients with Crohn's disease and was successfully completed in 14. One patient had ileal disease, requiring ileal resection with ileoileal anastomosis. The remainder had disease requiring ileocolic resections. Muscle-splitting incisions averaging 5 cm in length were made to facilitate removal of specimens.

RESULTS

Commencement of oral alimentation was possible at an average of 3.6 (range, 1-7) days postoperatively. Discharge occurred at an average of 6.6 (range, 4-9) postoperative days. In comparison, 14 patients operated on by the authors for the same disease in the open manner during the past six months stayed an average of 8.5 (range, 5-14) postoperative days. Postoperative complications were minimal.

CONCLUSIONS

On the basis of this initial study, it appears that laparoscopic-assisted intestinal resection can be readily performed in patients with Crohn's disease. In our early experience, we have found that laparoscopic mobilization and resection may be difficult or impossible in patients with large fixed masses, multiple complex fistulas, or recurrent Crohn's disease. Extraction incisions are frequently so large in these patients that they do not derive the same benefits from laparoscopic surgery that are enjoyed by patients without these findings. Most patients having laparoscopic resections eat earlier, may require fewer narcotics, and are able to be discharged from the hospital an average of two days earlier than patients operated on in an open manner. In addition, it appears that laparoscopic-assisted intestinal resection results in a shorter, easier convalescence and an earlier return to full activity.

A controlled study of bone mineral density in patients with inflammatory bowel disease

To assess the prevalence of and risk factors for low bone mineral density in inflammatory bowel disease (IBD), 152 IBD patients and 73 healthy controls were studied. Sixty seven patients had ulcerative colitis, 78 had Crohn's disease (52 of them (66.7%) had ileal disease), and seven had indeterminate colitis. Bone mineral density values (g/cm2) measured by dual energy x ray absorbtiometry at the spine (L2-L4), the femoral neck, Ward's triangle, and the trochanter were 1.177, 0.948, 0.850, and 0.838 in the patients and 1.228 (p = 0.034), 1.001 (p = 0.009), 0.889 (NS), and 0.888 (p = 0.012) in the control group, respectively. The type or extent of the disease or previous small bowel resection did not have any significant effect on the bone mineral density values. There was a weak, but statistically significant negative correlation between bone mineral density and the total lifetime corticosteroid dose (in the lumbar spine r = -0.164, p = 0.04, the femoral neck r = -0.185, p = 0.02, Ward's triangle r = -0.167, p = 0.04, and the trochanter r = -0.237, p = 0.003). The patients whose lifetime corticosteroid dose (prednisone/prednisolone) was more than 10 g had especially low bone mineral density (p < 0.05 compared with the groups with no or less than 5 g of corticosteroid). The patients who had never taken peroral corticosteroids did not have decreased bone mineral density. In conclusion, IBD patients have significantly lower bone mineral density values than healthy controls, but the difference is not so great as has been reported previously. Low bone mineral density values in these patients are related to high lifetime corticosteroid doses.