Endorectal mucosal resection without proctectomy as an adjunct to abdominoperineal resection for nonmalignant conditions: clinical experience with five patients

Histopathological evaluation and risk factors related to the development of pouchitis in patients with ileal pouches for ulcerative colitis

OBJECTIVE

Many changes in mucosal morphology are observed following ileal pouch construction, including colonic metaplasia and dysplasia. Additionally, one rare but potential complication is the development of adenocarcinoma of the reservoir. The aim of this study was to evaluate the most frequently observed histopathological changes in ileal pouches and to correlate these changes with potential risk factors for complications.

METHODS

A total of 41 patients were enrolled in the study and divided into the following three groups: a non-pouchitis group (group 1) (n = 20; 8 males; mean age: 47.5 years) demonstrating optimal outcome; a pouchitis without antibiotics group (group 2) (n = 14; 4 males; mean age: 47 years), containing individuals with pouchitis who did not receive treatment with antibiotics; and a pouchitis plus antibiotics group (group 3) (n = 7; 3 males; mean age: 41 years), containing those patients with pouchitis who were administered antibiotics. Ileal pouch endoscopy was performed, and tissue biopsy samples were collected for histopathological analysis.

RESULTS

Colonic metaplasia was found in 15 (36.6%) of the 41 patients evaluated; of these, five (25%) were from group 1, eight (57.1%) were from group 2, and two (28.6%) were from group 3. However, no correlation was established between the presence of metaplasia and pouchitis (p = 0.17). and no differences in mucosal atrophy or the degree of chronic or acute inflammation were observed between groups 1, 2, and 3 (p>0.45). Moreover, no dysplasia or neoplastic changes were detected. However, the degree of mucosal atrophy correlated well with the time of postoperative follow-up (p = 0.05).

CONCLUSIONS

The degree of mucosal atrophy, the presence of colonic metaplasia, and the degree of acute or chronic inflammation do not appear to constitute risk factors for the development of pouchitis. Moreover, we observed that longer postoperative follow-up times were associated with greater degrees of mucosal atrophy.

Endoscopic transanal rectal mucosal ablation in the surgical treatment of ulcerative colitis: preliminary results of a novel technique

PURPOSE

We describe a new technique that endoscopically eradicates rectal stump mucosa after total colectomy for ulcerative colitis.

METHODS

Seven patients (5 males; median age, 56 (range, 36-72) years) underwent attempted endoscopic transanal rectal mucosal ablation using the 28-French-gauge urologic resectoscope, either at the time of total colectomy and ileostomy for failed medical therapy (5 patients) or as an alternative to completion proctectomy (2 patients) with rectal stump discharge. All had declined restorative proctocolectomy. Clinical, endoscopic, and histologic follow-up was undertaken during a mean of 15 (range, 3-28) months.

RESULTS

The operative technique evolved during these cases; mucosal ablation was successfully performed leaving a denuded muscular rectal tube in situ in six patients. Mean operative time was 45 minutes. Postoperative endoscopic surveillance has not demonstrated any viable rectal mucosa in these six patients, with only granulation tissue detected histologically. Narrowing of the rectal tube has occurred in two patients. Although all patients report insignificant rectal discharge, urinary and sexual function have remained unchanged.

CONCLUSIONS

Diathermy ablation of the rectal mucosa via endoscopic transanal rectal mucosal ablation avoids the complications of pelvic dissection and might offer an effective alternative to proctectomy for ulcerative colitis.

Gastrointestinal hemorrhage in children. A pragmatic update

Gastrointestinal hemorrhage in infants and children is notable for its association with benign disease and its varied, age-dependent etiologies. We have presented these in brief. Much of the information presented, particularly that related to diagnostic endoscopy and sclerotherapy, represents extension of commonly used adult techniques to the pediatric population. Guidelines for resuscitation and diagnosis are provided with the expectation that an individual clinical assessment will lead to modification. Rigidity in approach is to be avoided. Notable recent changes in the management of children with GI hemorrhage are summarized and placed in perspective.

Eversion technique for distal mucosal proctectomy in ulcerative colitis: a preliminary report

A technique is described for assisting the performance of distal mucosal proctectomy in ulcerative colitis by peranal eversion of the lower rectum. The ease, accuracy and expedition of the mucosal excision have been impressive. In 9 of 16 patients having this procedure as part of an ileo-anal anastomosis (with a pelvic ileal reservoir) the functional results seemed to be similar to those obtained in 14 patients submitted to the same operation but with an endocavitary technique of rectal mucosectomy.

Rectocolectomy with anal conservation in inflammatory colitis

Eleven patients with inflammatory colitis underwent total colectomy and rectal excision with conservation of the anus. This is a lesser procedure than proctocolectomy and achieves total extirpation of diseased large-bowel mucosa.

Current concepts of rectum and sphincter preservation in inflammatory bowel disease

The treatment of inflammatory bowel disease has gone through a dramatic evolution in the last 40 years. Although the medical treatment has shown little progress during this time, surgical concepts have continued to change. Resection of the disease with formation of a well-functioning ileostomy stoma was a great milestone. In recent years, the development of an internal reservoir with a continent ileostomy has greatly improved the status of these patients. However, a pelvic reservoir, using the natural anorectal sphincter, may well be the next step in this evolutionary process.