Independent travel and people with learning disabilities: the views of a sample of service providers on whether this nee is being met

This paper describes part of a larger study that involved interviewing clients, carers and service providers to investigate barriers to independent travel for people with severe learning disabilities. The initial part of the study, reported here, involved interviewing service providers. A purposive sample of 2I service providers involved in promotion of independent travel for people with learning disabilities in the South East of one of the major cities in Northern Ireland were interviewed. Aims were to identify the number of clients on travel programmes, perceived barriers and suggestions to promote independent travel. Analysis involved mainly quantitative methods, with a small qualitative input. Findings indicated that although independent travel was viewed as a valuable skill for people with learning disabilities to possess, there were relatively few who practised this. In a population of 890 people, 187 (21 %) were reported as being able to travel independently. In the remaining 703 people, 65 (9%) were involved in programmes to promote independent travel. This data was obtained from the respondents who collated the figures from notes and records in the establishments in which they were based. The most significant obstacles to independent travel were suggested to be clients' cognitive abilities, and the wishes of carers, who according to the study, often did not wish the client to be involved due to perceived risks. Recommendations are made regarding practices to promote independent travel.

Rectal cancer threatening or affecting the prostatic plane: is partial prostatectomy oncologically adequate? Results of a multicentre retrospective study

AIM

The management of rectal cancer threatening or affecting the prostatic plane is still under debate. The role of preoperative chemo radiotherapy and the extent of prostatectomy seem to be key points in the treatment of these tumours. The aim of the present study was to evaluate the pathological circumferential margin status and the local recurrence rate following different therapeutic options.

METHOD

A multicentre, retrospective study was conducted of patients with rectal cancer threatening or affecting the prostatic plane, but not the bladder, judged by magnetic resonance imaging (MRI). The use of preoperative chemoradiotherapy and the type of urologic resection were correlated with the status of the pathological circumferential resection margin (CRM) and local recurrence.

RESULTS

A consecutive series of 126 men with rectal cancer threatening (44) or affecting (82) the prostatic plane on preoperative staging and operated with local curative intent between 1998 and 2010 was analysed. In patients who did not have chemoradiotherapy but had a preoperative threatened anterior margin the CRM-positive rate was 25.0%. In patients who did not have preoperative chemoradiotherapy but did have an affected margin, the CRM-positive rate was 41.7%. When preoperative radiotherapy was given, the respective CRM infiltration rates were 7.1 and 20.7%. In patients having preoperative chemoradiotherapy followed by prostatic resection the rate of CRM positivity was 2.4%. Partial prostatectomy after preoperative chemoradiotherapy resulted in a free anterior CRM in all cases, but intra-operative urethral damage occurred in 36.4% of patients who underwent partial prostatectomy, resulting in a postoperative urinary fistula in 18.2% of patients.

CONCLUSION

Preoperative chemoradiation is mandatory in male patients with a threatened or affected anterior circumferential margin on preoperative MRI. In patients with preoperative prostatic infiltration, prostatic resection is necessary. In this group of patients partial prostatectomy seems to be oncologically safe.

Primacy of surgery for colorectal cancer

BACKGROUND

The optimal technique for curative resection of colonic cancer includes high ligation of the mesenteric vessels, wide excision of the colonic mesentery and prevention of tumour cell spillage. This article reports results from the authors' institution for patients in whom complete mesocolic excision was performed long before the term was coined.

METHODS

Patients operated on for cure for primary adenocarcinoma of the colon between January 1994 and December 2004 were identified from a prospectively maintained, institutional review board-approved, colorectal cancer registry. Medical records and operation notes were reviewed. The primary outcomes were recurrence (local and distal) and age-adjusted 5-year survival.

RESULTS

Some 1013 patients (560 men and 453 women) were identified, with a median age of 69 (range 21-96) years. The most common location of the cancer was the sigmoid colon (32·9 per cent), followed by the caecum (26·7 per cent) and ascending colon (17·0 per cent). Operations were performed laparoscopically in 134 patients (13·2 per cent). Median duration of hospital stay was 7 (range 1-64, mean 8·2) days. Overall morbidity and mortality rates were 13·5 and 2·2 per cent respectively; there were 20 anastomotic leaks (2·0 per cent). Some 282 patients (27·8 per cent) had stage I, 386 (38·1 per cent) stage II and 345 (34·1 per cent) stage III disease. Median lymph node yield was 28·3 (range 0-241, mean 28·3), and 12 or more nodes were examined in 88·1 per cent of patients. Adjuvant chemotherapy was administered to 277 patients (80·3 per cent) with stage III disease. Overall local and distant recurrence rates at 5 years were 5·1 and 17·1 per cent respectively. The 5-year local recurrence rate was 2·2, 5·3 and 7·7 per cent for American Joint Committee on Cancer stages I, II and III respectively. Corresponding distant recurrence rates were 4·0, 14·7 and 30·5 per cent. The 5-year overall cancer-free age-standardized survival rate was 85·3 per cent. Five-year age standardized survival rates for patients with disease stages I, II and III were 97·7, 90·8 and 69·8 per cent respectively.

CONCLUSION

These data define modern results of surgery for colonic cancer with conservative use of chemotherapy.

Digital sculpting in surgery: a novel approach to depicting mesosigmoid mobilization

BACKGROUND

The aim of the present study was to develop a unique anatomic replica of the mesocolon using digital graphical software in order to provide an educational template for mesosigmoidectomy.

METHODS

The colon and mesocolon were fully mobilized from ileocecal to mesorectal levels in a cadaver. Both colon and mesocolon provided a template from which to generate a three dimensional replica in ZBrush. The model was deformed in ZBrush, to compare and contrast current and classic interpretations of mesosigmoidal topography. An animation was developed in which the replica was deformed to mimic operative mobilization. Contiguous shape changes were captured in two-and-a-half-dimensional (2.5D) screen snapshots. This was repeated for medial to lateral and lateral to medial mobilization of the mesosigmoid.

RESULTS

Topographic differences between classic and current appraisals of mesocolic anatomy were evident in 2.5D format. Using the model generated, contiguous shape changes during mesosigmoidal mobilization (i.e., between the left mesocolon, mobile/apposed mesosigmoid, and mesorectum) were replicated in animation format. By extracting and compiling 2.5D screen grabs a pictorial chronology of mobilization was developed.

CONCLUSIONS

Recent advances in mesocolic topography can be captured and rendered using advanced digital sculpting software with high-end graphics capabilities. This approach permits a depiction of contiguous changes in mesosigmoidal topography during mesosigmoidal mobilization. A compilation of images in either animation or screen grab format obviates the interpolation of shape changes required using standard educational approaches.

Gender differences in mortality, quality of life and function after restorative procedures for rectal cancer

AIM

Studies investigating the functional outcome after restorative surgery for rectal cancer have mainly focused on the effect of different surgical techniques on bowel habit or sexual activity at a single time-point. The aim of this study was to assess, longitudinally, the effect of rectal cancer treatment on bowel function, quality of life and sexual activity.

METHOD

The study parameters were assessed using self-administered questionnaires, including the Short Form 36 (SF-36), repeatedly, over a 5-year period. Patient details were obtained from the Cleveland Clinic prospective database.

RESULTS

There were 260 (186 male) patients. The mean ages of male and female patients at the time of surgery were 60.5 and 57.5 years, respectively. There was no significant difference in comorbidity or stage between the groups. Women had a better overall survival. More women than men had postoperative radiation and perioperative blood transfusions. Men had a higher percentage of hand-sewn anastomoses (23.9%vs 10.8%, P = 0.018), but there was no overall difference in the mean level of anastomosis (2.3 cm vs 1.9 cm, P = 0.38). Men had worse nocturnal bowel function, more incontinence and a poorer mental component score on the SF-36. Pad use increased over time to a greater degree in women. Sexual activity, which was similar in men and women at baseline, had fallen at 5 years in both genders.

CONCLUSION

After restorative resection for rectal cancer, bowel function is worse in men than in women, especially night evacuation at 3 and 5 years postoperatively. Sexual function in both genders declines sharply initially within 1 year postoperatively and more gradually over 5 years.

Clinical outcomes of ileorectal anastomosis for ulcerative colitis

BACKGROUND

The aim of this study was to determine the fate of the rectum, functional results and quality of life after ileorectal anastomosis (IRA) in ulcerative colitis.

METHODS

Patients with ulcerative colitis and indeterminate colitis who underwent IRA from 1971 to 2006 were evaluated retrospectively. Twenty-two patients with an IRA were matched by age, sex and follow-up duration with 66 patients with an ileal pouch-anal anastomosis (IPAA) and compared for functional outcomes and quality of life.

RESULTS

Eighty-six patients with an IRA were included. Median follow-up was 9 (range 1-36) years. Rectal dysplasia and cancer rates were 17 and 8 per cent respectively. The rectum was resected in 46 patients (53 per cent) because of refractory proctitis in 24, rectal dysplasia in 15 and rectal cancer in seven. The cumulative probability of having a functioning IRA at 10 and 20 years was 74 and 46 per cent respectively. Patients with an IRA had fewer bowel movements (P = 0.020) and less night-time seepage (P = 0.020) but increased urgency (P < 0.001) compared with patients with an IPAA, whereas quality of life was similar.

CONCLUSION

In selected patients with ulcerative colitis IRA gives an acceptable quality of life and functional outcome that are comparable to those in patients with an IPAA. Owing to the risk of cancer, surveillance of the rectum is mandatory.

Effect of downstaging without complete pathologic response after neoadjuvant treatment on cancer outcomes for cIII and cII rectal cancers

4108

Background: Neoadjuvant chemoradiation followed by surgery is standard of care for locally advanced rectal cancer. The impact of downstaging on prognosis when pathologic complete response (pCR) cannot be achieved remains unclear. The aim of this study was to evaluate whether downstaging impacts prognosis in patients with cII vs. cIII rectal cancer. Methods: We identified from our colorectal cancer database 233 patients with primary cII and cIII rectal cancer staged by CT and ERUS/MRI who received 5FU-based chemoradiation followed by R0 surgery after a median interval of 7 weeks during 1997–2007. Median radiotherapy dose was 5040 cGy. We excluded 58 patients with pCR and. Compared among the remaining 175 patients pathologic downstaging (cII to ypI, cIII to ypII or ypI) vs. No pathologic downstaging (c stage ≤ yp stage). Outcomes evaluated were 5-year overall survival, 3-year recurrence-free survival, overall recurrence, local recurrence and distant recurrence. Results: Median age was 58 years and median follow-up was 48 months. Patients with cII vs. cIII stage were statistically comparable regarding demographics, chemoradiation regimen, interval to surgery after neoadjuvant treatment, tumor distance from anal verge, operations performed and follow-up. The incidence of downstaging was increased in stage cIII vs. cII patients (68% vs. 21%, p <0.001). With the exception of local recurrence rates, downstaging resulted in significantly improved cancer outcomes for cIII but not cII ( Table ). Conclusions: Downstaging without pCR is a significant prognostic factor for patients with stage cIII rectal cancer. A larger sample size is required to confirm lack of downstaging benefits in stage cII.

[Table: see text]

No significant financial relationships to disclose.

Peripheral intravenous cannulation: safe insertion and removal technique

The aim of this article is to reinforce good practice in insertion and removal techniques for peripheral intravenous cannulation. The article is intended as a practical guide. It is important that staff receive adequate education and training to undertake this skill competently, and also that they maintain competence in practice.

Prevention of infection in peripheral intravenous devices

This article focuses on peripheral intravenous cannulation devices as one source of infection. Using the chain of infection, each aspect is explored to help reduce or prevent infection.

Venepuncture: best practice

Venepuncture is the introduction of a needle into a vein to obtain a blood sample for haematological, biochemical or bacteriological analysis. It is the most common invasive procedure undertaken in hospital. This article provides guidance on the theory and practice of venepuncture.

Clostridium difficile colitis in the critically ill

Morbidity and treatment of Clostridium difficile colitis (CDC) continue to be controversial. Some claim minimum morbidity, which may be a function of differences in patient population and/or bacterial virulence.

METHODS

To evaluate the effect of CDC in the critically ill, we retrospectively reviewed the records of 59 intensive care unit patients with CDC who were diagnosed by fecal toxin assays or clinical evidence of pseudomembranous colitis from January 1991 to October 1994. Symptoms, signs, antibiotic regimens, diagnostic tests, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, morbidity, and mortality were analyzed, and results of surgical treatment were compared with the literature.

RESULTS

Mean age was 66.4 (17-95) years, with a male to female ratio of 1.8:1. First treatment was metronidazole by mouth in 15 patients (25.4 percent), vancomycin by mouth in 30 patients (50.8 percent), sequential by mouth vancomycin/metronidazole in 3 patients (5.1 percent), and intravenous metronidazole in 5 patients (8.5 percent). Six patients had no medical therapy before surgery or discharge. Ten patients (17 percent) had recurrence and 12 (20.3 percent) required surgery for progressive toxicity or peritonitis. Of three patients who were initially treated by diverting stomas, one died and two required total colectomy (TAC). Two underwent partial resection (1 that was nearly a total colectomy), and seven others had a TAC. Surgical patients had worse mean APACHE II scores at diagnosis (24.4 vs. 19.9; P < 0.001). Thirty-day mortality in surgical patients was 41.7 vs. 14.7 percent in medical patients (P < 0.5).

CONCLUSION

Twenty percent of critically ill patients with CDC required operation. TAC and diversion appeared to be more effective surgical treatments than diversion alone.

The results of strictureplasty in pediatric patients with multifocal Crohn's disease

This study is a retrospective review of eight pediatric patients with multifocal intestinal Crohn's disease who underwent strictureplasty with or without concomitant bowel resection between January 1978 and April 1992. The patients ranged in age from 9.9 years to 18.5 years. Indications for surgery were partial intestinal obstruction (n = 6), failure of medial therapy or steroid dependence (n = 4), growth failure (n = 2), and enterocutaneous fistula (n = 2). Thirty-six strictureplasties were performed in the eight patients (median, 4.5 strictureplasties per patient; range, 1-12). Bowel resection was performed in six of the eight patients in areas where strictureplasty was not feasible. The mean length of resection was 40 cm (range, 15-82 cm). The only complication was intestinal hemorrhage, which was conservatively managed in two patients. The patients were followed for a mean of 19 months (range, 3-55 months). Five patients had a weight below the fifth percentile prior to surgery. Postoperatively, there was a weight gain in seven patients, including all five patients who were originally below the fifth percentile. A statistically significant weight gain was found when a paired t test analysis was applied to the entire group (p = 0.04). Five of six patients who were on steroid medication at the time of surgery were successfully weaned within 1.5-3 months (mean, 2.3 months) from the time of surgery. Seven of eight patients had relief of their intestinal symptoms. Strictureplasty with small-bowel resection, or perhaps strictureplasty alone, in pediatric patients with multifocal intestinal Crohn's disease can improve gastrointestinal symptoms, promote weight gain, and allow discontinuation of steroid medications.(ABSTRACT TRUNCATED AT 250 WORDS)

Results of mucosal proctectomy versus extrarectal dissection for ulcerative colitis and familial polyposis in children and young adults

Over a 5-year period, the authors examined 30 consecutively treated patients, aged 16 years or younger, who underwent total colectomy and ileal pouch-anal anastomosis, (IPAA) using two different surgical methods. In 16 patients (group I), extrarectal dissection with stapled J pouch and anastomosis was performed. In 14 patients (group II), mucosal proctectomy with hand-sewn S pouch and anastomosis was performed. The mean follow-up period this study was approximately two years (range, 1 to 5 years). With regard to postoperative complications, quality of life, and occurrence of pouchitis, there were no significant differences between the groups. Stool frequency was not significantly different between the two groups, and approached four bowel movements per day at 1 year after surgery. In both groups, daytime continence was achieved by all patients 6 months after surgery. A greater number of patients in group II demonstrated temporary nocturnal leakage than in group I, but this difference was not statistically significant (P = .09). The authors conclude that both methods of IPAA are equally effective in preserving normal sphincter function. In patients with severe rectal inflammation, extrarectal dissection with stapled anastomosis may obviate the need for extended preoperative hyperalimentation or subtotal colectomy, but may carry a small increased risk of recurrent anorectal inflammation. The long-term risk of dysplasia is unknown, but may be slightly higher after extrarectal dissection with stapled anastomosis. Further study of both methods of IPAA is recommended.

Colectomy in patients with inflammatory bowel disease and primary sclerosing cholangitis

PURPOSE

The aim of this study was to assess risk factors for early postoperative death in patients with primary sclerosing cholangitis who are undergoing colectomy.

METHODS

The charts of 24 patients with primary sclerosing cholangitis who underwent colectomy between 1972 and 1990 at the Cleveland Clinic Foundation were reviewed. Clinical and laboratory data were collected and compiled to determine preoperative factors that might be helpful in predicting early postoperative death.

RESULTS

The only factor that predicted a poor outcome was cirrhosis at the time of surgery. Three of 8 patients with cirrhosis and 0 of 16 patients without cirrhosis had an early postoperative death (P < 0.05, Fisher's exact test).

CONCLUSION

We conclude that establishing whether or not patients with inflammatory bowel disease and primary sclerosing cholangitis have cirrhosis is helpful in determining the risk of colectomy.

Electrogalvanic stimulation for levator syndrome: how effective is it in the long-term?

Levator syndrome is a symptom complex of severe pain and pressure in the anorectal area. Electrogalvanic stimulation (EGS) has been proposed as a treatment for this condition. Several reports have described EGS as up to 90 percent "effective" in treating levator syndrome, but the length of follow-up was uncertain or short-term in these studies. The purpose of this study was to examine the long-term benefits of EGS in levator syndrome patients treated at one institution. All patients undergoing EGS for levator syndrome between 1985 and 1991 were studied. Initial complaints, physical examination, number of treatments, procedure tolerance, and long-term benefit were determined through personal interviews and chart reviews. There were 52 patients (63 percent females and 37 percent males) with a median age of 54 years (range, 24-84 years). All patients presented with anorectal pain. Tenderness was localized by examination to the left in 43 percent, to the right in 23 percent, and bilateral in 8.6 percent and was not localized in 2.6 percent. Fifty percent received fewer than four one-hour treatments, 33 percent received four to six treatments, and 17 percent received more than six treatments. Seventy-seven percent felt that the treatment was painless. Follow-up results were as follow: number, 52; percent follow-up, 88; mean follow-up, 28 months (range, 0-71 months); symptoms relieved, 19 percent; partial relief, 24 percent; no relief, 57 percent. Of four patients with a wrong diagnosis, three were ultimately diagnosed with recurrent pelvic cancer and one had an anal fissure. At our institution, EGS was a tolerable treatment, but a substantial number of patients received no benefit. An organic etiology of anorectal pain must always be excluded.

Endoluminal ultrasound defines anatomy of the anal canal and pelvic floor

The aims of this study were to determine whether endoluminal ultrasound (ELUS) could identify various layers of the normal anal canal and to evaluate whether a 10-MHz probe provided better image resolution than a 7-MHz probe. Sonographic anatomy of the anal canal on ELUS was directly correlated with anatomic dissection of various layers (mucosa-submucosa, internal anal sphincter, and external anal sphincter) in cadavers. Sonographic appearance of the anal sphincters was further evaluated in patients by "tagging" various layers using sonodense needles. A higher frequency 10-MHz ultrasound probe (focal length, 1-4 cm) provides improved sonographic images of the anal canal, compared with the 7-MHz probe (focal length, 2-5 cm). ELUS can also successfully identify various structures of the pelvic floor including the puborectalis, urethral sphincter, vagina, and outlines of the pelvis and ischiorectal fossae. Its role in the evaluation of anorectal disorders appears promising.

Noncytotoxic drug therapy for intra-abdominal desmoid tumor in patients with familial adenomatous polyposis

Forty of 416 patients with familial adenomatous polyposis were noted to have intra-abdominal desmoid tumors, and a subgroup of 16 were treated with noncytotoxic drug therapy. Drugs used were sulindac (14 patients), sulindac plus tamoxifen (3 patients), indomethacin (4 patients), tamoxifen (4 patients), progesterone (DEPO-PROVERA; Upjohn Co., Kalamazoo, MI) (2 patients), and testolactone (1 patient). Therapy with these drugs for continuous periods of six months or more resulted in three complete and seven partial remissions. When treated patients were compared with untreated patients (n = 12), there were significant benefits for the treated group, both in reduction of desmoid size and in improvement of symptoms, despite the inherent selection bias against this. Sulindac was the only drug used in enough patients to permit independent evaluation of its effect, with one complete and seven partial reductions of tumor size. Some patients had a delayed response to sulindac, with tumor shrinkage occurring after an initial period of tumor enlargement. When using sulindac for the treatment of desmoid tumors, this phenomenon should be considered.

Radioimmunoguided surgery using iodine 125 B72.3 in patients with colorectal cancer

Preliminary data using B72.3 murine monoclonal antibody labeled with iodine 125 suggested that both clinically apparent as well as occult sites of colorectal cancer could be identified intraoperatively using a hand-held gamma detecting probe. We report the preliminary data of a multicenter trial of this approach in patients with primary or recurrent colorectal cancer. One hundred four patients with primary, suspected, or known recurrent colorectal cancer received an intravenous infusion of 1 mg of B72.3 monoclonal antibody radiolabeled with 7.4 x 10 Bq of iodine 125. Twenty-six patients with primary colorectal cancer and 72 patients with recurrent colorectal cancer were examined. Using the gamma detecting probe, 78% of the patients had localization of the antibody in their tumor; this included 75% of primary tumor sites and 63% of all recurrent tumor sites; 9.2% of all tumor sites identified represented occult sites detected only with the gamma detecting probe. The overall sensitivity was 77% and a predictive value of a positive detection was 78%. A total of 30 occult sites in 26 patients were identified. In patients with recurrent cancer, the antibody study provided unique data that precluded resection in 10 patients, and in another eight patients it extended the potentially curative procedure.

Continent ileal urinary reservoir (Kock pouch)

The Kock pouch has three major limitations at the present time: The efferent nipple valve remains by far the weakest link in the procedure. A 10 to 20 per cent failure rate is too high, and it remains to be seen whether further modifications will be successful in the long run. The long-term function is unproven, and it is possible that deleterious effects may be seen as additional follow-up is obtained. Theoretically, the low-pressure system afforded by the Kock pouch may be superior in long-term safety to that provided by reservoirs made from other bowel segments. A stoma is still necessary. In spite of the above, there is a need for this type of procedure. We cannot remain content with the ileal conduit and should continue to search for better functional diversions. It is a debatable issue relative to the superiority of an internal functional reservoir to the urethra, which may lead to night-time incontinence, versus a Kock pouch with a stoma, which must be intubated. Improvement in overall survival from bladder cancer may be hard to come by, unless effective systemic chemotherapy is available; one means is to perform the surgery without delay in patients with potentially lethal cancers. To do this on a large scale, we must make the surgery as safe as possible and provide the least disruption of lifestyle. In some patients an internal intestinal reservoir attached to the urethra will be possible. Other patients may elect for a Kock pouch, whereas others may even be best served by standard ileal conduit. The growth pains of the Kock pouch have been significant but not without a reward.

Conservative management of paraileostomy ulcers in patients with Crohn's disease

Paraileostomy ulcers (PSU) are uncommon after construction of an ileostomy and are difficult to manage. Seventeen patients with Crohn's disease developed 28 parastomal ulcers at least 1.5 cm in diameter from two weeks to seven years after ileostomy construction (mean 45.6 weeks, median 8 weeks). Some patients had multiple episodes of parastomal ulceration. The etiology and clinical features of PSU are discussed. Conservative management included debridement, curettage, unroofing of the ulcer complex, pouching of the stoma with Telfa strips placed in the ulcer base and a conventional appliance or a Perry Model #51 device. Most of the ulcers healed between two and 32 weeks (mean 12.7 weeks, median 8 weeks). In the six patients in whom the ulcers did not heal, Crohn's disease or another ileostomy complication necessitated ileostomy relocation. This conservative management allowed most patients to be treated on an outpatient basis, carrying out their daily tasks and delaying or obviating the need for ileostomy relocations. When required, relocations were done electively.

Hepatic artery infusion with 5-fluorouracil and mitomycin-C in metastatic colorectal carcinoma phase II study

Thirty-two patients with hepatic metastases colorectal carcinoma were treated with hepatic artery infusion (HAI) employing 5-fluorouracil (5-FU) and mitomycin-C (mito-C). Catheters were placed percutaneously via the femoral artery. Two schedules were employed: (I) 5-FU 1,200 mg/m2 IA (D1-4) and mito-C 8 mg/m2 IA (D1 + D4); (2) 5-FU 1,200 mg/m2 IA (D1-6) and mito-C 8 mg/m2 IA (D1 + D4). Courses were repeated every 4 weeks. Thirty patients with measurable disease were evaluable, 22 received schedule I and 8 patients schedule II. Complete response occurred in two patients (6.7%) and partial response in 13 patients (43.3%). Five patients (16.7%) had minimal regression. The overall response rate as 66.7%. Median survival of all patients from start of treatment was 11.2 months. Median survival of responders and nonresponders was 12.4 months and 4.6 months, respectively (P less than 0.05). No differences in response rates, duration of response, or survival was seen between the two schedules. Drug toxicity was moderate to severe, but morbidity of HAI per se was minimal. Intermittent HAI of 5-FU and mito-C is a well-tolerated treatment modality associated with few serious complications. The response rate, duration of response, and the survival is comparable to continuous HAI infusion of 5-FU or floxuridine (FUDR). As given in this study, mito-C did not appear to provide added benefit.

The risk of cancer following colectomy and ileorectal anastomosis for extensive mucosal ulcerative colitis

A retrospective study was performed on 89 patients who underwent total colectomy and ileorectal anastomosis for extensive mucosal ulcerative colitis between the years 1957 and 1977 in order to determine the risk of developing cancer of the rectum. The 30-day operative mortality rate was 0%. Of the 84 patients available for follow-up study, four patients, (4.8%) developed a carcinoma of the rectum. The risk of cancer per patient-year was zero in the first decade, 1/206 in the second decade, and 1/116 in the third decade. The cumulative risk of developing cancer was 0% at 10 years, 2.1% +/- 2.1% at 15 years, 5.0% +/- 3.5% at 20 years, and 12.9% +/- 8.3% after 25 years of disease. Patients with cancer or precancer in the colon at the time of colectomy appear to be at high risk for the later development of rectal cancer.

Portal vein bile acids in patients with severe inflammatory bowel disease

The incidence of several forms of liver disease associated with inflammatory bowel disease has been putatively ascribed to a toxic effect on the liver of portal vein bile acids abnormal in type or amount. To examine this possibility, total bile acid concentrations (sulphated and non-sulphated) were measured by gas-liquid chromatography in inferior mesentric vein serum of 19 patients undergoing colectomy for severe inflammatory bowel disease (IBD). Similar determinations were obtained on a control group of eight patients requiring colectomy for other non-inflammatory conditions. Mean values for mesenteric vein serum bile acid concentrations (muM/1) were 19.6+/-1.8 in controls and 16.3+/-2.0 in IBD. The mean sulphated bile acid fraction did not exceed 10% of total, although there was considerable variability (up to 40% of total). Lithocholic acid levels (entirely sulphated in all patients) were low. Although the IBD group showed a more than two-fold increase in mean lithocholate concentration (0.54+/-0.15 muM/1) over controls (0.21 +/- muM/1), this difference was not statistically significant. No significant intra-group difference was noted in the non-sulphated and sulphated fractions for cholic, chenodeoxycholic, and deoxycholic acid species, respectively. No unidentified or unusual bile acids were observed. There was no correlation between bile acid measurements and liver histology. These findings fail to support the hypothesis that liver disease often found in association with severe inflammatory bowel disease represents a form of bile acid toxicity. The invariable finding of total sulphation of the lithocholic acid fraction even in the presence of severe mucosal disease was unexpected.