Comparing continent ileostomy (CI) conversion to repair/redo IPAA: favorable outcomes

PURPOSE

This study aims to compare the outcomes of repair/redo ileal pouch-anal anastomosis (repair/redo-IPAA) with the conversion of IPAA to continent ileostomy (CI) in an effort to prevent the need for a permanent ileostomy (IS) following IPAA failure.

METHODS

This research involved a retrospective analysis of surgical records, employing descriptive statistics and Kaplan-Meier survival analysis.

RESULTS

Among 57 patients with an IPAA, up to three revisions were necessary due to complications or complete failure. Ultimately, repair/redo-IPAA preserved the IPAA in 14 patients (24.6%), conversion to CI salvaged the pouch in 21 patients (36.8%), and IS was unavoidable in 22 patients (38.6%). The cumulative probability of requiring conversion surgery was calculated to be 54.0% at 20 years, thereby reducing the cumulative risk of IS to 32.3%. The 20-year cumulative probability of pouch salvage by repair/redo IPAA was only 21.9%. However, this rate increased to 67.7% when conversion procedures were considered. Following repair/redo-IPAA, only 8.3% of patients reported evacuation frequencies of ≤ 4 during the day, and 16.7% were evacuation-free at night. In contrast, after conversion to CI, 98.0% of patients reported a maximum of four evacuations in a 24-h period. After undergoing repair/redo IPAA, between half and two-thirds of patients reported experiencing incontinence or soiling, while complete continence was achieved in all patients following conversion to CI. Notably, the majority of patients expressed overall satisfaction with their respective procedures. A positive correlation was identified between very high subjective satisfaction and positive objective surgical outcomes exclusively in patients who underwent conversion to CI.

CONCLUSION

When complications or failure of IPAA occur, conversion to CI emerges as a highly viable alternative to repair/redo IPAA. This conclusion is supported by the observation that patient satisfaction appears to be closely tied to stable surgical outcomes. To reinforce these findings, further prospective studies are warranted.

Conversion of ileo-pouch anal anastomosis to continent ileostomy: strategic surgical considerations and outcome

AIM

The aim was to evaluate surgical strategies for conversion of failed ileo-pouch anal anastomosis (IPAA) to continent ileostomy (CI), taking morbidity and overall outcome into account. The hypothesis was that complex conversions are equivalent to the primary construction of a CI at the time of proctocolectomy.

METHOD

This was a retrospective analysis of IPAA conversions acknowledging the underlying disease (inflammatory bowel disease [IBD] and non-IBD) and extent of pouch reconstruction (PR): type 1 (without PR), type 2 (partial PR), and type 3 (complete PR).

RESULTS

Twenty-six patients (IBD, n = 16; non-IBD, n = 10) were converted (type 1, n = 13; type 2, n = 7; and type 3, n = 6).12/26 patients (46.2%) presented postoperative complications directly related to the conversion with scarification of two pouches. In a mean follow-up time of 7.5 ± 6.6 years, 5/24 patients required revisional surgery. Of these, three required pouch excision. The cumulative probability of reoperation at the end of the second year increased to 21.7% and remained constant thereafter until the maximum follow-up time of 26 years. The total pouch loss rate was 19.2% (5/26), of which all occurred in the first 3 years. No statistically significant differences were found between the conversion types, complications or pouch survival. For all parameters, IBD patients performed slightly unfavourably. Due to the overall small number of respective patients, a differentiated investigation of IBD was not performed.

CONCLUSION

Complex conversion procedures (types 1 and 2) deliver comparable long-term results to new constructions (type 3), thereby limiting the loss of small bowel. IBD compromises outcome versus non-IBD.

A systematic description of continent ileostomy revision techniques

PURPOSE

Comprehensive description of surgical techniques for revision of complications of continent ileostomy (CI).

METHODS

By analyzing 133 revision procedures performed over 30 years, a systematically classified approach to the appropriate techniques for CI revision surgery has been derived. Based on the anatomic site and severity of the respective complication, four classes of revision surgeries have been defined: class 1 refers to the nipple valve, class 2 to the pouch, class 3 to the stoma, and class 4 to the afferent loop. The severity of the complication or the complexity of the revision procedure is indicated by a subdivision from a to d.

RESULTS

The surgical variants (class 1a-d, class 2a-c, class 3a-b, and class 4a-b) are shown in schematic illustrations with accompanying descriptions of technical details, the respective fields of application, and the special indications.

CONCLUSION

Based on these classes of revision surgeries, the specialized surgeon may find differentiated techniques at their disposal to save the CI and avoid unnecessary sacrifice of the artificial continence organ.

Continent ileostomy: short- and long-term outcomes of a forgotten procedure

Background

Continent ileostomy (CI) aims to provide control of gas and faecal evacuation; however, it is rarely performed. This paper reports on outcomes of CI in a large single-surgeon series.

Methods

All consecutive patients who underwent CI between 1986 and 2015 were reviewed. Patients were classified according to the CI procedure (single stage versus two stage) and according to the underlying disease conditions (inflammatory bowel disease (IBD) versus no IBD). Primary outcome measures were early mortality and complications requiring surgical revision within 30 days (group Ia), those requiring surgical revision within 1–12 months (group Ib), and long-term complications after more than 12 months (group II). Secondary outcome measures were pouch survival and quality of life (QoL) assessed using questionnaires for occupational, sports, sexual, and travel activities; patients undergoing CI after conversion from ileostomy. Analyses were performed using descriptive statistics and Kaplan–Meier curves for the long-term outcomes.

Results

Sixty-two consecutive patients (28 men, 34 women) who underwent CI were reviewed, including 48 with IBD, and 14 without inflammatory conditions. Mean(s.d.) follow-up was 14.4 (9.5) (range 1–30) years. Twenty-seven patients (44 per cent) developed group I complications, of which 25 were corrected successfully. Two patients dropped out of the analysis: one who died from sepsis and the other owing to pouch loss attributed to unsolvable nipple complications. Of the remaining 60 patients, 23 (38 per cent) developed between one and five group II complications. The cumulative probability of reoperation was 54. per cent at 25 years. Overall, pouch survival was achieved in 90 per cent. The two-stage approach led to significantly fewer complications in group Ia (single stage versus two stage: 8 of 25 versus 2 of 37; P = 0.005), whereas complication rates in group Ib (5 of 23 versus 14 of 37) and group II (9 of 23 versus 14 of 37) were similar. Four CIs failed because of IBD complications. CI pouch and function were preserved in all patients without IBD, whereas in the group with IBD 2 of 31 with ulcerative colitis and 2 of 17 with Crohn’s colitis lost the CI owing to severe intractable inflammatory complications. In 16 patients who had conversion from ileostomy to CI, QoL improved significantly above precolectomy levels in all domains

Conclusions

CI remains an alternative to conventional ileostomy. Although affected by high reoperation rates, it has the benefit of a high rate of pouch survival.

Development of ulcerative colitis after heart transplantation during immunosuppressive therapy

BACKGROUND

Cardiac transplantation has become an accepted treatment modality for end-stage heart failure. Immunosuppressive agents, which are used after transplantation, are considered as therapeutic options for inflammatory bowel disease.

CASE REPORT

We report on a 53-year-old patient who was treated for 2 years with cyclosporine A, azathioprine and prednisolone after heart transplantation. He developed a distal colitis with all features of ulcerative colitis. An infectious or ischemic etiology was carefully excluded. In spite of high-dose treatment with prednisolone the patient's abdominal symptoms worsened and he developed a progression of the inflammation in the entire colon and a colectomy with ileostomy was necessary. The histology was consistent with ulcerative colitis. After colectomy he recovered and remained in a good state of health.

CONCLUSIONS

This report supports the concept that new onset inflammatory bowel disease can develop in a heart transplantation recipient in spite of immunosuppression.

Oral budesonide significantly improves water absorption in patients with ileostomy for Crohn disease

BACKGROUND

In addition to their anti-inflammatory effects, steroids influence electrolyte and water transport systems in the intestinal mucosa. This study analysed the effect of the topically acting glucocorticoid budesonide on ileostomy output in patients with Crohn disease.

METHODS

Oral budesonide (3 mg/three times daily for 8 days; n = 20) was compared to placebo (n = 20) in a double-blind design using matched-pair randomization according to ileal resection length in patients without detectable inflammatory activity. Under controlled hospital conditions, absolute output volumes were measured and response was defined as a reduction in intestinal output of > 25% compared to pretreatment conditions.

RESULTS

In the treatment group, we observed an absolute decrease in median intestinal output from 1,240 ml to 865 ml (30.2%), compared to 0.3% under placebo (from 950 ml to 947.5 ml). Response was documented in 60% (12/20 patients) in the treatment group compared to no response under placebo (P < 0.0001). While both treatment groups showed similar absolute median reductions (400 ml with ileal resection < or = 20 cm and 405 ml with ileal resection > 20 cm), the relative reduction (response rate) was lower in the subgroup of an ileal resection > 20 cm (36%) due to the greater increase in output secondary to the loss of ileum.

CONCLUSIONS

These data support the assumption that the absorptive capacity of the intestinal mucosa for water may be improved by topically acting steroids and suggest that this occurs independently of their anti-inflammatory effect.

The in vitro anti-inflammatory effects of recombinant anti-CD25 immunotoxin on lamina propria T cells of patients with inflammatory bowel disease are not sufficient to cure experimental colitis in mice

BACKGROUND AND AIMS

In chronic inflammatory bowel disease (IBD) such as Crohn's disease and ulcerative colitis an aberrant mucosal immune regulation is observed accompanied by upregulation of proinflammatory cytokines. Lamina propria T cells of inflamed mucosa have an activated phenotype characterized by increased expression of surface markers such as CD25. We therefore determined the anti-inflammatory effect of a recombinant immunotoxin consisting of an anti-CD25 single chain variable fragment (scFv) fused to a deletion mutant of Pseudomonas exotoxin A [RFT5(scFv)ETA'] on isolated lamina propria lymphocytes of patients with IBD and in the murine model of trinitrobenzene sulfonic acid (TNBS) induced colitis. PATIENTS AND/METHODS: Lamina propria lymphocytes of 25 patients with IBD and 19 control patients were stimulated in absence or presence of RFT5(scFv)ETA'. Interferon-gamma production was determined in the supernatant by ELISA and the induction of apoptosis by flow cytometry after propidium iodide staining. BALB/c mice received TNBS intrarectally and were treated with RFT5(scFv)ETA'.

RESULTS

In vitro the administration of RFT5(scFv)ETA' significantly reduced interferon-gamma production and increased apoptosis in lamina propria lymphocytes isolated of inflamed mucosa. However, this contrainflammatory regulation did not result in gain of weight or increased life span in experimental colitis in vivo.

CONCLUSION

In addition to the downregulation of the proinflammatory cytokine in vitro, RFT5(scFv)ETA' induced neither a direct nor a bystander effect in an in vivo model of colitis. Therefore our data do not support potential therapeutic implications of targeting CD25 by RFT5(scFv)ETA' in chronic IBD.

Reoperations at the ileostomy in Crohn's disease reflect inflammatory activity rather than surgical stoma complications alone

After ileostomy construction for Crohn's disease reoperations due to ileal recurrences are thought to be unusually rare, whereas reconstructions of the ileostomy due to stoma complications are considered to be unusually frequent. It remains unclear why the natural course of a disease as well as outstanding results of a standardized surgical procedure should be perverted. Therefore reconstructions of the ileostomy in 92 patients colectomized during a 12.5-year period and followed up for 5.4 years were analyzed concerning preoperative indication and postoperative histology. In 28 patients (30.4%) a total of 42 reoperations were necessary. The clinical indication was prestomal recurrence in 5 reoperations (11.9%) and stoma complications in 37 (88.1%). In contrast, ileal recurrence was demonstrated histologically in 28 specimens (66.7%) and healthy ileum in the rest. There was a statistically significant association between fibrotic recurrence and stoma stenosis/retraction and a trend for association between penetrating recurrence and peristomal ulceration. The cumulative risk for a first reoperation due to clinical recurrence was calculated at 3.3% and 14.0% at 5 and 10 years postoperatively, whereas the corresponding figures for stoma complications were 25.7% and 40.0%. In contrast, the cumulative risk that a recurrence was found histologically on the occasion of the reoperation was 23.0% and 35.0%, while the probability that the ileum was healthy in the case of a stoma complication remained low. In conclusion, most reoperations after ileostomy-construction in Crohn's disease are associated histologically with recurrent inflammation. The accentuation of the inflammatory recrudescence at the stoma itself or the prestomal ileum is decisive for the clinical presentation as stoma complication or intestinal complication. These findings reinforce both well known characteristics of the inflammatory disease and of established surgery.

Comparable expression of matrix metalloproteinases 1 and 2 in pouchitis and ulcerative colitis

BACKGROUND AND AIMS

Matrix metalloproteinases (MMPs) are implicated in the tissue destruction associated with inflammatory diseases. Proctocolectomy with ileo-anal pouch (IAP) anastomosis is associated with pouchitis, particularly in patients with ulcerative colitis (UC). The aim of this study was to quantify MMP-1 and MMP-2 in inflamed and uninflamed pouches of patients with UC compared with those with active UC. IAP patients with familial adenomatous polyposis (FAP) served as controls.

METHODS

Biopsies were taken from 33 patients with IAP (UC, n=25; FAP, n=8) and from 10 UC patients. MMP-1 and MMP-2 were quantified using sandwich enzyme linked immunosorbent assays. In addition, northern and western blotting and in situ hybridisation experiments were performed.

RESULTS

In pouchitis (n=11), MMP-1 and MMP-2 concentrations were increased compared with uninflamed pouches of patients with UC (n=14) or FAP (n=8) (MMP-1 17.7 ng/mg protein v 7.8 (UC) v 7.6 (FAP), p</=0.05; MMP-2 16.4 v 9.5 (UC) v 6.3 (FAP), p</=0.05). Western and northern blots revealed increased MMP-1 and MMP-2 protein and transcript concentrations in inflamed pouches. Mesenchymal cells were identified as major producers of MMP-1 and MMP-2 in pouchitis. A similar increase in MMPs was observed in tissues of patients with active UC.

CONCLUSIONS

Our results support the hypothesis that MMPs are involved in mucosal destruction and crypt hyperplasia, as seen in pouchitis.

Establishment of an immunocompetent nipple valve anastomosis to prevent faecal reflux after ileocolic resection in dogs

OBJECTIVE

To construct an immunocompetent nipple valve anastomosis (NVA) to exclude faecal reflux and compare it with an end-to-end anastomosis to see if it would prevent recurrent inflammation caused by intraluminal bacterial antigens in Crohn's disease.

DESIGN

Laboratory study.

SETTING

Teaching hospital, Germany.

ANIMALS

Two groups of six beagle dogs each of which had NVA or end-to-end anastomosis.

INTERVENTIONS

Construction of a NVA by stapling the telescoped nipple, and replacing the ileal mucosa on the valve by colonic mucosa; end-to-end anastomosis.

MAIN OUTCOME MEASURES

Radiological, bacteriological, angiographic, and morphometric results.

RESULTS

Absolute retrograde pressure-competence and free orthograde permeability of the NVA resulted in significantly lower intestinal bacterial counts compared with the end-to-end anastomosis (p < 0.05). Transposition of colonic mucosa was successful as demonstrated by revascularisation from the ileal nipple and looked normal on morphometry.

CONCLUSION

If NVA were constructed in patients with Crohn's disease, recurrences should be prevented, which would verify the immunopathogenetic hypothesis of new inflammation.

Granulocyte elastase and systemic cytokine response after laparoscopic-assisted and open resections in Crohn's disease

PURPOSE

The aim of this study was to assess whether systemic proinflammatory cytokines (IL-6), anti-inflammatory cytokines (IL-4, IL-10), acute phase proteins (C-reactive protein), or granulocyte elastase are valuable indicators for determining the degree of surgical trauma after open vs. laparoscopic-assisted resections in Crohn's disease.

METHOD

Eleven patients in each group (open and laparoscopic-assisted surgery) were matched for indication, surgical procedure, and Crohn's disease activity index. Serum IL-4, IL-6, and IL-10 were measured using enzyme-linked immunosorbent assay. Serum C-reactive protein was determined by immunoturbidimetric assay. Plasma granulocyte elastase was determined by immunoactivation immunoassay. Blood was sampled preoperatively, six hours after the operation, and at postoperative Days 1 to 5.

RESULTS

IL-4 was not detectable in any sample analyzed. Serum IL-6 and IL-10 levels peaked postoperatively in both groups without significant differences between laparoscopic-assisted (185.6 +/-54.1 pg/ml and 112.1 +/- 19.4 pg/ml, respectively; mean +/-standard error of the mean) and open surgery (431.1 +/-240.4 pg/ml and 196.7 +/- 56.5 pg/ml, respectively). Serum C-reactive protein levels also rose postoperatively, with a peak on the second day, but showed similar values after laparoscopic-assisted (107.1 +/- 12.1 mg/l) and open (128.3 +/- 17.5 mg/l) surgery. Plasma granulocyte elastase levels peaked on the first and second postoperative day and were found elevated almost throughout the five-day observation period. Comparison between the groups revealed significantly (P < 0.02) lower values after laparoscopic-assisted (Day 1, 46.5 +/- 8.9 microg/l; Day 2, 41.9 +/- 5.9 microg/l) when compared with open surgery (Day 1, 89.7 +/- 13.8 microg/l; Day 2, 91.4 +/- 14).

CONCLUSIONS

Serum IL-6 and IL-10 may not be ideal measures for evaluation of the degree of tissue trauma in laparoscopic-assisted and open resections in Crohn's disease, probably because of interference with disease-specific cytokine interactions. In contrast, granulocyte elastase has to be considered a strong marker discriminating the different severity of surgical trauma induced by laparoscopic-assisted vs. open resection in Crohn's disease.

Pattern of mucosal adaptation in acute and chronic pouchitis

PURPOSE

Variant pathological changes have been observed in ileoanal pouches, including inflammation, villous atrophy, and crypt hyperplasia. Therefore, we investigated the type and degree of mucosal adaptation in patients with ulcerative colitis and familial adenomatous polyposis.

METHODS

Forty-two patients with ulcerative colitis and 14 patients with familial adenomatous polyposis with ileoanal pouches were assessed. Samples were taken from three months to eight years after creation of an ileoanal pouch. Mucosal architecture was examined by morphometry after microdissection.

RESULTS

Structural changes of the mucosa can be categorized into three groups. Compared with preoperative values, patients without pouchitis (73 percent) has only minor decrease of villous length (402 microm vs. 540 microm) and increase in crypt depth (274.5 microm vs. 177 microm). In patients with acute pouchitis (20 percent), a slight increase in villous length (477 microm vs. 402 microm) and pronounced crypt hyperplasia (376 microm vs. 274.5 microm) was observed compared with noninflamed ileoanal pouches. In contrast, in patients with chronic pouchitis (7 percent), severe villous atrophy (62.5 microm) and crypt hyperplasia (543 microm) was found.

CONCLUSIONS

Minor structural changes of ileoanal pouch mucosa develop early as an adaptive response to a new environment. Only in a small group of patients with chronic pouchitis does severe villous atrophy and crypt hyperplasia of the ileoanal pouch mucosa develop, most likely as a consequence of mucosal inflammation.

[The continent ileostomy. Current indications, techniques and results]

Over a period of 12 years, 73 patients received a continent ileostomy. 19 Kock pouches were primarily constructed due to contraindications against the ileoanal pouch, 30 ileostomies were converted due to psychological rejection of the incontinent stoma and 9 ileoanal pouches for dysfunction. 15 Kock pouches had to be corrected for nipple valve complications. Perioperative complications (14/73) were related to the Kock pouch in only one third of cases. Surgical late complications of the nipple valve function decreased with technical modifications from 41.1% to 20.0% and then to 4.8%. They could always be dealt with surgically. Pouchitis was observed in 26.8% of cases of ulcerative colitis (11/41), and in 6/15 patients with Crohn's disease (40.0%) complicated ileal recurrences developed. The definitive rate of success over the time was 98.1% in ulcerative colitis and familial adenomatous polyposis (53/54) and 63.2% in other conditions (12/19). Continent ileostomy has become universal and safe method for conversion of any previous operation.

Low-dose budesonide treatment for prevention of postoperative recurrence of Crohn's disease: a multicentre randomized placebo-controlled trial. German Budesonide Study Group

OBJECTIVE

Endoscopic recurrence of Crohn's disease frequently occurs within weeks after 'curative' operation. Treatment with 3 x 1 mg oral pH-modified release budesonide was tried to prevent postoperative recurrence.

DESIGN

A multicentre randomized double-blind placebo-controlled trial of 1 year duration was performed.

SETTING

Departments of surgery, endoscopy and pathology of three university hospitals participated in the trial.

PATIENTS

Patients with Crohn's disease who underwent ileal and/or colonic resection and whose anastomosis was accessible to colonoscopy were admitted to the study. Of the 88 randomized patients, 83 patients were included in the efficacy analysis (budesonide n = 43, placebo n = 40). Treatment was started within 2 weeks after surgery.

INTERVENTIONS

Colonoscopy was performed 3 and 12 months postoperatively. The anastomosis and the adjacent bowel were evaluated by endoscopy and histology. For follow-up of the clinical course of the disease the Crohn's disease activity index (CDAI) was used.

MAIN OUTCOME MEASURES

The primary outcome variable was recurrence of Crohn's disease based on endoscopic findings. Secondary efficacy variables were histology scores, CDAI, time-to-failure and global judgement of well-being of the patient.

RESULTS

The recurrence rate after 1 year (endoscopic and/or clinical) was 57% (20/35) in the budesonide group and 70% (19/27) in the placebo group (n.s.). Mean time-to-failure was 196 days under budesonide and 154 days under placebo (n.s.). Median CDAI (relapse 19% vs. 28%) and global patients' judgement at the end of treatment (bad 5% vs. 15%) was slightly in favour of budesonide. One patient in each group discontinued the trial because of adverse events. Potentially steroid-related side effects were reported more frequently in the placebo than in the budesonide group (32% vs. 17%) (n.s.).

SUMMARY AND CONCLUSION

Although the effect of budesonide was altogether positive in almost all variables studied in this trial (e.g. endoscopic and histopathological score, time-to-failure, CDAI, patients' global judgement and rate of side effects), this increase in efficacy was small and the power for detecting differences versus placebo was too low to be statistically significant. According to these results, low-dose oral budesonide cannot be recommended to be used for the prevention of postoperative relapse in Crohn's disease.

IgG, albumin, and sCD44 in whole-gut lavage fluid are useful clinical markers for assessing the presence and activity of pouchitis

Pouchitis is the most significant long-term complication in patients with ileoanal pouch anastomosis (IAP) and is especially frequent in patients with ulcerative colitis. There is an urgent need for simple and objective parameters to assess the presence and activity of pouchitis. Whole-gut lavage fluid (WGLF) was collected from 34 patients [8 with pouchitis (PDAI > or = 7 points) and 26 without pouchitis (Pouchitis Disease Activity Index, PDAI, < 7)]. Patients with active ulcerative colitis (n = 8) served as controls. Concentrations of IgG and sCD44 in WGLF were measured by enzyme-linked immunosorbent assays and those of albumin by immunoturbidimetry. Similar to the case in active ulcerative colitis, concentrations of IgG, albumin, and sCD44 in WGLF were significantly increased in acute pouchitis and reached high specificity (IgG 96%, albumin 96%, sCD44 100%) and acceptable sensitivity (75%) for the diagnosis of acute pouchitis. These parameters were also closely correlated with disease activity as determined by PDAI and endoscopic scoring indices. Assay of protein concentrations in WGLF is thus a simple and objective means for grading inflammation of the pouch and may be useful as a quantitative index of disease activity in clinical studies.

Increased state of activation of CD4 positive T cells and elevated interferon gamma production in pouchitis

BACKGROUND

Immunoregulatory abnormalities of T cells might be of importance in the pathogenesis of pouchitis after ileoanal pouch anastomosis (IAP).

AIMS

To characterise T cell subsets, their state of activation, and production of cytokines in inflamed and non-inflamed pouches in patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). The influence of T cell activation on mucosal transformation was also studied.

PATIENTS

Mucosal biopsy specimens were taken from 42 patients with IAP (33 with UC and nine with FAP).

METHODS

Mononuclear cells were isolated by standard techniques and characterised by three colour flow cytometry. Interferon gamma (IFN-gamma) production was studied using the ELISPOT technique.

RESULTS

In patients with UC with pouchitis there was a significant increase in the CD4:CD8 ratio, expression of activation markers on CD3+ cells, and number of IFNgamma producing mononuclear cells compared with patients with UC without pouchitis (CD4:CD8 ratio 1.3 (range 0.7-2.7) versus 0.6 (0. 1-1.0), p=0.012). In addition, a positive correlation between increased crypt depth and the number of CD4+ cells (r=0.57) was shown.

CONCLUSION

The observed increase in activated mucosal CD4+ T cells and IFN-gamma production might lead to mucosal destruction and crypt hyperplasia as seen in pouchitis.

[Minimally invasive surgery and Crohn disease]

Patients with Crohn's disease are operated on with a morbidity of 15% and a mortality of 0% if the indication for surgery is decided in good time. After ileocecal resection the probability of having a second resection in 15-20 years is about 50%. When elective surgery is done at an early disease stage, ileocecal resections and reoperations for anastomotic stenosis can be performed by assisted laparoscopy assisted. Laparoscopic colonic resections are done more rarely. Acute and life-threatening conditions such as obstruction, perforation and sepsis are excluded from the laparoscopic approach. In a combined series of 222 laparoscopic resections for Crohn's disease, the following types of surgery were included: ileocecal resections (75), anastomotic resections (26), small intestinal resections (4), loop ileostomies (17), gastrojejunostomies (3), partial colonic resections (15), colectomies (16), loop colostomies (2) and one adhesiolysis. Two patients who sustained intraoperative bleeding underwent conversion of laparotomy. The conversion rate ranged from 0 to 22%. Reasons for 32 conversions were: large inflammatory mass (14), severe inflammation (5), fistula (3), abscess (1), perforation (1), small intestine dilation (1) and mesenteric thickening (1). Mean operative time for ileocecal resections ranged from 105 to 200 min. The postoperative hospital stay was 5 to 8 days. As more experience is gained and technical improvement is achieved, additional procedures such as resolution of severe adhesions, fistula closure and resections of colonic segments will be offered to the majority of patients who require elective surgery for localized Crohn's disease.

[Changes in colitis surgery. II: Corrective interventions and conversion operations]

Over a period of 9 years in 48 patients already operated on for ulcerative colitis secondary surgical interventions had to be planned. 25 patients had an ileostomy (IS), 10 a Kock-pouch (KP), 11 an ileoanal pouch (IAP) and 2 an ileorectal anastomosis (IRA). Whereas in 4 patients only the subjective wish for another procedure with better quality of life predominated, in 44 patients (91.7%) also objective, sometimes multiple indications for reoperation existed. In 37 patients main indications were complications or dysfunctions of the preexisting procedures, combined with the need for further resection of the colitis in 6 of them. Resection of the residual colitis was the main indication in the remaining 7 patients. The aim of the reoperation in all patients was both complete elimination of the eventually persisting colitis and restoration of quality of life in the best way wished or possible. Our of 25 IS 3 remained, 3 were reconstructed, 17 were converted to KP and 2 to IAP. Out of 10 KP one remained and in 9 corrective surgery of the nipple valve was performed. Out of 11 IAP 2 had to be resected with construction of IS, 5 were converted to KP and 4 were corrected. Two IRA were converted to IAP. The rate of early complications was 8.3% (n = 4), lethality was zero. Late complications occurred in 13 cases (27.1%) and were associated ten times with KP. Complications of KP decreased with time to zero due to technical modifications. They could always be corrected restoring function. Since only one KP had to be resected due to severe pouchitis, KP was an important secondary procedure for 31 out of 48 patients also in the long-term course ensuring both complete elimination of colitis and good quality of life owing to voluntary fecal control.

[Surgical concepts in Crohn disease of the terminal ileum and colon]

Most patients with Crohn's disease have to be operated on. Necessity to loose some amount of the intestine and time-point of the surgical intervention may be derived from the irreversible cascade of the inflammatory process and the limitations of the conservative treatment. In ileocecal disease indications for surgery are represented by stenotic and/or penetrating complications of the inflamed bowel, whereas in Crohn's colitis acute or terminal medical refractority is predominating. Standard-procedures result from constantly definable patterns of the disease manifestation: ileocecal resection and colectomy/-proctocolectomy. In segmental colitis sometimes "resections within Crohn's" may be adequate in a first attempt to avoid anticipating the natural course by surgical means. In these cases the further prognosis depends on the treatment possibilities of the remaining colon. In contrast, true recurrence is a new inflammation of the neoterminal ileum and may indicate repeated resections. The frequence decreases with the number of resections. Nevertheless nutritional status is restored even by multiple resections, whereas specific functional sequelae of the resection--distal resection- and dehydration syndromes--are well treatable mostly. In the case of appropriate timing of the operation and the reoperation operative morbidity and mortality are remarkable low today resulting in an almost normal life expectancy. Most important as negative prognostic factor remains sepsis resulting from pre-existing or postoperative infectious complications. Keeping this in mind experimental pharmaco-therapy to delay the operation and not profoundly substantiated tendencies to minimize surgery are to be considered only with critical scepticism. At the moment, future research is thought to be more successful in focussing prophylaxis of ileal recurrence than avoiding surgery.

[Surgical treatment of Crohn disease based on the inflammatory pattern]

286 patients with Crohn's disease were classified on the basis of the inflammatory pattern at their first operation as type 1 (Ileitis: n = 116), type 2a (segmental colitis: n = 60), and type 2b (total colitis: n = 108); 2 patients remained unclassified. At the same age at operation of 31.9 +/- 10.7 yrs symptoms were known in type 1 for 3.4 +/- 3.9 yrs, but for 7.5 +/- 5.7 yrs in type 2b. Main indication in type 1 was stenosis (56.9%), whereas in type 2b intractabilitiy (68.5%) predominated. Type 2a was intermediate concerning duration of symptoms and relationship of indications including fistulas. Standard-procedures were ileocecal resection (92.2%) in type 1, and colectomy (90.7%) in type 2b. In type 2a ileocolic resections and partial colectomies were mostly done. During the following 3.9 +/- 3.8 yrs reoperation rate due to disease progression was 13.6% in type 1, 25.5% in type 2a and 18.5% in type 2b. The cumulative risk of ileal resection at ten years due to new inflammation was significantly (p < 0.01) higher in the case of ileocolic/ileorectal anastomosis than of ileostomy (38% vs. 11%). In contrast, cumulative probability of a colorectal resection was significantly (p < 0.05) higher in type 2 (16%) when compared to type 1 (1.5%). Primary ileal loss was significantly (p < 0.01) higher in type 1 (37 +/- 23 cm) compared with type 2a (25 +/- 28 cm) and type 2b (17 +/- 21 cm). Loss of continence occurred in 0%, 3.3% and 53.7% respectively. With reoperations additional loss of ileum decreased in all types, whereas in type 2 loss of anorectal function increased. Including reoperations the rate of major complications was 9.8% and lethality was 0.8% (3/386). Resections in Crohn's disease are unavoidable due to shrinking therapeutical alternatives in the course of the disease. Owing to limited resections, loss of bowel may not exceed ileum in type 1, whereas the same resectional policy cannot avoid the total loss of the colorectum eventually in type 2. Both limited surgery and repeated resections help to maintain function as long as possible. Due to the high safety-standard the number of operations does not impair the success of the surgical concept.

[Surgical options in ulcerative colitis]

Surgery is needed in every second patient with pancolitis. Historically four surgical options have been developed: conventional ileostomy, ileorectostomy, continent ileostomy (Kock's pouch) and ileo-anal pouch. However, in emergent or unclear situations subtotal colectomy, ileostomy and preservation of the rectum is the most suitable operation. After recovery and in elective indications proctectomy and proctocolectomy establish the general surgical standard. Today, in most cases ileo-pouch-anal anastomosis is performed instead of creation of an ileostomy. Both lowered frequency of defecation and acceptable continence contribute to a better quality of life. However, functional disturbances are not uncommon and result in most cases from complications of the demanding technique. Definitive cure of the colitis is in interference with the risk of pouchitis in about 30%. The cumulative probability to loose the pouch may rise to 15-20% in the long-term course. Thus, ileorectostomy may be considered as a first step of surgical treatment, since pelvic nerve damage is excluded, function is much better and persistent proctitis can be treated topically. The attractively is that ileo-anal pouch can be performed later on, when decreasing function and increasing risk of malignant change will eventually require proctectomy. A Kock-pouch is seldom considered, especially in patients with ileostomy wishing sure fecal control. But the continent reservoir becomes more and more interesting again since it can be reconstructed from a failed ileo-anal pouch without loss of bowel. Conventional ileostomy should be reserved for patients not suitable for reconstructive methods or those who consider pough operations risk. However, it is the safest procedure with absolute cure of disease. The optimal choice of method considers medical and surgical aspects as well as patients conception and desire.

[Laparoscopically-assisted proctocolectomy with ileoanal pouch in ulcerative colitis]

Laparoscopic assisted proctocolectomy with ileoanal pouch is a technical alternative to the conventional open procedure. The aim of this technique are better cosmetics. Mobilisation of the colon is achieved laparoscopically. Rectal resection, J-pouch creation, and pouchanal anastomosis are performed via a Pfannenstiel incision. Laparoscopic assisted proctocolectomy has been performed in five selected patients, three female and two male aged 17 to 36 years. Operative time ranged from 305 to 420 minutes. Intra- and postoperative complications were not encountered. Postoperative hospital stay ranged from 13 to 16 days. On a scale from 1 to 10 the average quality of life was graded 9 and the overall satisfaction level with the results of surgery scored 10. Function was identical to open surgery in not selected patients.

[Laparoscopically assisted surgery in Crohn disease]

From Jan. 1993 to Apr. 1997 intestinal resections in Crohn's disease have been performed in 275 patients. 89 patients have been operated on laparoscopic assisted. The following parameters were analyzed: previous laparotomies, extent of resection, steroid medication, conversionrate, complications, operative time and postoperative stay. Endpoints were: conversionrate, complications, reconvalescence and overall satisfaction with the laparoscopic technique.

RESULTS

The duration of the disease ranged from 1 to 16 years (x = 6). 47 patients were under steroid medication at the time of surgery. 30 patients had undergone previous laparotomies. In 10 patients the operation had to be converted into open surgery. The following procedures have been performed: ileocaecal resections (45), anastomotic resections (14), small bowel resections (4), hemicolectomies (12), colectomies (9), loopileostomies (4), adhesiolysis (1). Minor complications occurred in 6.7% of patients, major complications in 5.6%. Operative time ranged from 70 to 420 minutes (x = 173.7). The postoperative hospital stay was 13.3 days in the average.

CONCLUSION

The morbidity of 12.3% is not higher than in open surgery. When complications do not occur the patients benefit from early convalescence, better cosmetics and shorter hospital stay.

[Changes in colitis surgery. I: Is there a standard in primary surgical treatment?]

In a 15 years period surgery of ulcerative colitis expanded from ileostomy (IS) via Kock's pouch (KP) and ileoanal pouch (IAP) to ileorectal anastomosis (IRA). Interactions between availability of methods and frequency of operations are investigated retrospectively in order to establish an optimal primary procedure. With an overall amount of 80 operations the yearly operative frequency raised in correlation to the introduction of continence reconstructive procedures. As a consequence of this fact history of disease was shortened to less than 8 year and global colitis-associated morbidity markedly decreased. For patients readiness to undergo operation Kock's pouch was only important at the beginning (n = 9/11.3%). Most decisive was IAP (n = 49/61.3%) which could be realized last even in an one-stage-procedure with better early results due to improved patients conditions and simplified technical modifications. IRA (n = 7/8.8%) played only a limited role in the last years for selected patients, whereas IS (n = 15/18.8%) kept reserved for contraindications to reconstructive surgery. For all procedures operative complications decreased from 46.1% (12/26) to 11.0% (6/54) and lethality to 0%. Late complications were related to proctectomy (nerve damage) and construction of IAP (pouchitis in 34.8% and defunctioning of the pouch in 10.4%), whereas IRA was free of specific morbidity so far. Surgery of ulcerative colitis is characterized today by restoration of anal continence. The advantage of the changed surgical concept lies within the ability to perform colectomy at an earlier stage of the disease. Safe construction of IAP is the most important technical progress. Early operation of colitis and late morbidity of pouch justify (preliminary) IRA. Thus, surgical standard in colitis-surgery is defined more individually.

Low dose oral pH modified release budesonide for maintenance of steroid induced remission in Crohn's disease. The Budesonide Study Group

BACKGROUND

The relapse rate after steroid induced remission in Crohn's disease is high.

AIMS

To test whether oral pH modified release budesonide (3 x 1 mg/day) reduces the relapse rate and to identify patient subgroups with an increased risk of relapse.

METHODS

In a multicentre, randomised, double blind study, 179 patients with steroid induced remission of Crohn's disease received either 3 x 1 mg budesonide (n = 84) or placebo (n = 95) for one year. The primary study aim was the maintenance of remission of Crohn's disease for one year.

RESULTS

Patient characteristics at study entry were similar for both groups. The relapse rate was 67% (56/84) in the budesonide group and 65% (62/95) in the placebo group. The relapse curves in both groups were similar. The mean time to relapse was 93.5 days in the budesonide group and 67.0 days in the placebo group. No prognostic factors allowing prediction of an increased risk for relapse or definition of patient subgroups who derived benefit from low dose budesonide were found. Drug related side effects were mild and no different between the budesonide and the placebo group.

CONCLUSION

Oral pH modified release budesonide at a dose of 3 x 1 mg/day is not effective for maintaining steroid induced remission in Crohn's disease.

Long-term function of experimental substitutes of the ileocecal valve

The bacteriological barrier function of the ileocecal valve (ICV) can be replaced according to the principle of the nipple-valve anastomosis. Since late complications due to technical measures for stabilizing the ileal nipple have been hitherto unknown, 12 adult beagle dogs were operated on by three technical modifications of a nipple-valve anastomosis and were followed up for 1 year: In three cases the ileal nipple was stabilized by longitudinal staples (NVA), in three cases an intestinal neosphincter (INS) was produced by healing of the muscular layers between the ileal nipple and colon, and in six cases an oral zone of stabilization, preserving an aboral valve zone (S-NVA) was constructed. Measures for valve function at the end of the study period were the weight course of the animals and the intestinal bacterial profile, considering morphological complications of the substituted valves. As reference the respective bacterial counts in ICV and end-to-end anastomosis (EEA) were used, which had been determined in the same animals in earlier experiments. Following an initial increase in weight the 3 animals with NVA and the three animals with INS continuously lost weight from the 4th postoperative month onward. The 6 animals with S-NVA, however, showed from the 4th postoperative month onward a significantly higher weight level (p < 0.05), which remained constant up to the end of the 1-year observation period. Because of a morphologically intact structure of the substituted valve a significantly (p < 0.05) better bacteriological clearance of the ileum was confirmed in these animals after 12 months when compared with the EEA group. In contrast, in the NVA and INS animals a severe bacterial overgrowth of the entire small intestine was observed. This was caused by an intestinal stagnation due to partial prolapse of the nipple in NVA and due to fibrotic stenosis in INS. The results of our study suggest that technical measures to relieve the tendency to devaginate are only successful, if they do not lead to obstruction of the orthograde intestinal passage in the long term. Thus, only the clinical introduction of the S-NVA model may be justified.

Biomechanical stabilization of the nipple valve in continent ileostomy

Despite stapler stabilization, sliding complication of nipple valve function occur in 19 per cent of continent ileostomies. Because the tendency of the ileum to desuscept is triggered by traction forces on the mesentery of the nipple during filling of the reservoir, a technique was developed to neutralize this biomechanical strain. In addition, to obtain fibrous healing between the muscular layers, the mucosa of contacting intestinal walls was removed by selective ultrasonic fragmentation. The valves of 18 consecutive patients were operated on with this technique. In six of these, a sliding valve was restabilized in a median time of 1.2 (range 0.4-2.9) years after conventional construction of the pouch. All are functioning well after a median of 4.6 (range 3.0-6.0) years. Between 1.8 and 4.8 years after operation a healed area between the musculature of the nipple and pouch of 4.5-7.2 cm2 was shown by endosonography. This procedure may provide long-term prevention of sliding complications in continent ileostomies.

Conversion of the failing ileoanal pouch to reservoir-ileostomy rather than to ileostomy alone

PURPOSE

We report the indications, technique, and results of conversion of the ileoanal pouch to the Kock's pouch in five patients. The indication was functional disturbance that could not be corrected by operation. Aim of the conversion operation was re-establishment of fecal control and complete preservation of existing ileal surface.

METHODS

The ileal pouch was used again, and in one case an augmentation was made. The continence valve was made three times from the afferent loop and in two cases from a higher ileal segment.

RESULTS

Following conversion, function was excellent in three patients with ulcerative colitis and in one patient with familial adenomatous polyposis. One woman who underwent proctocolectomy for slow-transit constipation needed a Brooke ileostomy for continuous abdominal distention pain.

CONCLUSION

We conclude that conversion to a continent ileostomy is a rewarding method of safely eliminating dysfunction of the ileoanal pouch that cannot be corrected by operation. Presumption is, however, that the surgeon is familiar with both methods and that the primary disease is suitable for pouch surgery.

[Current proctology--modern functional diagnosis]

The large majority of pathological conditions in proctology can be recognized and distinguished from each other by clinical and endoscopic means of diagnosis. Manometric and neurophysiological investigations are especially useful for understanding pathophysiology; these methods are of great clinical value whenever their results contribute to a specific concept of therapy. Functional tests are able to distinguish among the various causes of sphincteric dysfunction. Defaecography might provide the decisive hint for operative treatment for manometric investigations of the ano-rectum, balloons, perfusion tubes and microtransducers are available. In cases of incontinence, especially in females, endosonography is the investigation of choice, providing most relevant information with regard to possible surgical reconstruction of the sphincter muscle.

[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.

[An intestinal neosphincter attained by circumscribed muscle proliferation. Technical development and functional evaluation in the dog]

In an experimental study an intestinal neosphincter (INS) was constructed by modifying the principle of the ileocolic nipple-valve anastomosis by means of ultrasonic tissue fragmentation of the contacting serosa of the ileum and the corresponding mucosa of the ileum and colon. The healing of the muscle layers was studied histologically. The function of the INS was investigated in six dogs and compared intraindividually with that of the ileocecal valve and conventional end-to-end anastomosis. Morphologically the neospincters healed within 3 months without major fibrosis. The reference values of the aerobic and anaerobic bacterial counts in the terminal ileum were more than 2 logs lower than in the colon with the normal ileocecal valve, and after ileo-colonic end-to-end-anastomosis bacterial colonization of the terminal ileum was found both qualitatively and quantitatively. Subsequent interposition of the INS led to bacterial clearance of the terminal ileum. The median aerobic bacterial counts were lower by six logs and the an aerobic bacterial counts by 3 logs than in the colon. However, differences were not statistically significant owing to the wide variation in the individual values. Nevertheless, the demonstrable clearance of the terminal ileum could be explained by the orthograde passage with absolutely no stagnation and the relative competence of the INS in resisting retrograde pressure competence. In conclusion, ultrasonic fragmentation of the serosa and mucosa of the bowel allows construction of an INS from three muscle layers, which acts as a bacteriological barrier. Before it is introduced into the clinical setting its integration into the intestinal motility should be evaluated by further studies.

Familial adenomatous polyposis: mutation at codon 1309 and early onset of colon cancer

The clinical course of familial adenomatous polyposis (FAP) varies considerably between patients. Prediction of the severity of the disease is important in the interest of effective cancer prevention. We examined whether age at diagnosis of FAP due to gastrointestinal symptoms and age at death due to colorectal cancer are related to the site of mutation in the responsible gene. 225 families with FAP were screened for mutations. The deletion of 5 base pairs at codon 1309 within exon 15 (known to be the most common mutation) was identified in 20 families; other mutations within exons 7-15 were found in 49 families. In patients with the 5 base-pair deletion at codon 1309, gastrointestinal symptoms and death from colorectal cancer occurred about 10 years earlier than in patients with other mutations. The 1309 mutation leads to development of colonic polyps at a younger age, thus giving rise to an earlier malignant transformation. This relationship should be taken into account in strategies for preventing cancer in patients with FAP.

Surface versus needle electrodes in determination of motor conduction time to the external anal sphincter

Patients were referred to our neurophysiological department in order to investigate anorectal function. By the means of magnetic stimulation the total motor conduction can be determined. Only patients with normal latency of the pudendal nerve and normal EMG of the external anal sphincter were examined. Stimulation was carried out above the motor cortex with a MO between 80 and 100%. The recording was carried out in 22 patients with concentric needle electrodes and in the other 18 patients with surface electrodes. The mean latency in the group with surface electrodes was 19.4 ms (SD 1.7), and in the group with needle electrodes 23.4 ms (SD 4). Our results suggest, that in magnetic stimulation above the motor cortex and recording with a concentric needle electrode, the range and the mean was higher than with surface electrodes. In our opinion surface electrodes are preferable to needle electrodes in determining motor conduction time to the external anal sphincter.

[Blind loop of the large intestine--bypass enteropathy or diversion colitis?]

Investigating three patients with longstanding diarrhoea, severe abdominal bloating and cramps revealed an exclusion of the right hemicolon in all patients and additionally of the terminal ileum in one of them. The anastomosis of the ileo-colic bypass, performed decades ago due to complicated appendicitis, was stenotic in two of them. Because a classical blind-loop-syndrome could not be proven, the functional disorder is described as a clinical entity characterized by signs of bypass-enteropathy and diversion-colitis. The importance of the radiological examination for diagnosis and therapy-planing is emphasized, because endoscopically and histologically Crohn's disease might be suspected. The surgical reintegration of the bowel into the orthograde continuity of the intestinal tract is recommended as the causative treatment. Symptoms disappear completely and patients win normal health even after some decades, because the morphological signs of inflammation are reversible and bowel function is not lost during the exclusion.

[Fournier's gangrene]

Today Fournier's gangrene ranks among necrotizing fasciitis. Most of the cases reveal the origin of the disease (proctogenic, urologic, gynecologic). Untreated, the polybacterial synergistic infection will overwhelmingly spread along anatomically defined fascias of the pelvic floor. Thus the lethality rate is high, especially in patients with risk factors i.e. diabetes, alcoholism, arterial occlusive disease, chronic consumptive disorders and obesity. Only by instant and radical surgical excision of the total gangrenous tissue the spreading of the disease and the developing of sepsis can be stopped together with calculated antibiotic therapy and intensive care. Mutilating operations (i.e. penectomy, orchiectomy) are seldom necessary; thus plastic reconstructions will show good results both in function and cosmetic. Based on the experience with 6 patients, a pathogenic concept, concerning both diagnosis and therapy, is presented: after radical emergency surgery in the first risky stage, an elective approach can safely be performed in a second stage for the repair of functional lesions.

Optimization of isolated hyperthermic limb perfusion

During isolated limb perfusion, we studied the impact of limb temperature on the concentration of cytostatic drugs in the tissue to identify a possible selective absorption of cytostatic agents by the various tissues. Ten consecutive patients with malignant melanoma were randomly divided into two different groups and perfused with 1 mg cisplatin per kg body weight. In one group the cytostatic agents were injected under hyperthermic conditions (39.5 degrees C) and in the other group under normothermic conditions (37 degrees C). The platinum concentration in the melanoma was twice as high in the hyperthermic group as in the group under normothermic conditions. In the tumor-free tissue the platinum concentration decreased with temperature while it remained constant in the musculature. This selective concentration of cisplatin in the tumor under hyperthermic conditions is accompanied by fewer side effects. Follow-up will show whether the oncological results will be improved in the hyperthermic conditions as one might expect.

Improved stabilization of conventional (Brooke) ileostomies with the stapler technique

The rate of functional complications of conventional (Brooke) ileostomy is high and endangers the complete postoperative rehabilitation of the patients. About half of these complications (retraction with/without stenosis, intermittent recession, and prolapse) occur within the classical prominent stoma and are caused by displacement of the serosa surfaces. We have stabilized conventional ileostomies in 39 patients with rows of staples placed paramesenterially and longitudinally. The ileum was everted in the classical way in the primary construction of ileostomies in 19 patients. On the other hand, in 11 patients the prominence of the stoma was established by pulling the ileum out through the previously plane-sutured stoma. In addition, 9 patients with ileostomies which were not primarily stabilized were corrected with the stapler technique to treat complications. With follow-up ranging from 0.2 years to 4.2 years, there have been no complications due to sliding of the nipple in these 39 patients. In contrast, there were complications in 37% of 38 patients with non-stabilized ileostomies with follow-up to the second postoperative year. It was more easily reproducible, more exact, and less traumatic to create the stoma prominence by pulling the intestine out from a primarily plane stoma than with classical eversion. With use of the stapler in repairing complications, local ileostomy constructions were no longer required in every second patient. Consequently, a Brooke ileostomy can be constructed more easily with the stapler technique, ensuring long-term function or restoration of function.

Endosonographic differentiation of mucosal and transmural nonspecific inflammatory bowel disease

Thirty-seven patients with nonspecific inflammatory bowel disease were examined with an ultrasonic colonoscope and the inflammation classified as mucosal or transmural. Mucosal inflammation was characterized by preservation of the five-layer structure of the wall with thickening of the submucosa. Transmural inflammation was endosonographically defined as sectional interruption or loss of the five-layer structure. In 14 of the 37 patients a colectomy was performed. Examination of 3 of the 14 resected specimens revealed inflammation confined to the mucosa. This was consistent in all three cases with the preoperative endosonographic evaluation. Eleven of the 14 resected specimens showed sectional transmural inflammation. Ultrasonographically all of the 11 patients fulfilled the criteria for transmural inflammation, whereas endoscopic and microscopic signs were consistent with transmural inflammation in 9 of the 11. Endosonography of the colon enables definition of mucosal inflammation thus providing criteria for selection of patient for ileoanal pouch construction.

[Changes in cell-mediated immune reactions in Crohn's disease]

In a prospective study the effect on cell-mediated immunity (Mérieux-Multitest), nutritional state and parameters of inflammation was compared in conservatively (n = 21) and surgically (n = 20) treated patients with Crohn's disease. Before therapy both groups showed a significantly lower immune response compared with healthy controls. The therapeutical effect was similar in both groups concerning normalization of parameters of inflammation, CDAI and state of nutrition. In contrast, normalization of immune response in skin test was only observed after bowel resection, while conservatively treated patients remained in hyperergy. In conclusion, the impairment of the cell mediated immunity in Crohn's disease must be secondary. Excluding patients with steroid therapy there was no correlation between preoperative annergy or hyperergy and postoperative complications.

[Ileostomy--stabilization by stapler technique]

In order to prevent nipple-sliding of the everted small bowel, conventional Brooke ileostomies in 26 patients were stabilized on both sides of the mesentery by longitudinal rows of staples. There were no early complications. With respect to historical controls with unstapled ileostomies, late complications (retraction, prolapse) could be reduced from about 16 to 0% in a median observation time of 2 years. The ileostomies were stable in size and form and therefore appliances were facilitated.

[Complete reconstruction of the natural anus in complicated rectal prolapse]

In a 44-year old woman a severe case of prolapse of the rectum was complicated by complete incontinence and rectal stenosis. Continence was restored by colo-anal anastomosis between an oral smooth-muscle-plasty and the anal skin introduced in a newly created anal canal by a distal voluntary muscle-plasty. The successfully applied one-stage technique in reestablishing non-voluntary and voluntary muscular continence is described in detail.

Tests for the absorption of 75Se-labelled homocholic acid conjugated with taurine (75Se-HCAT)

The absorption of selenomethionine Se 75-labelled homocholic acid conjugated with taurine (75-SE-HCAT) was tested in 46 patients. Retention measurements using (1) an uncollimated gamma camera and (2) a measuring arrangement similar to a human-body counter were compared in order to obtain a quantitative assessment of the absorption capacity of the terminal ileum for bile acids. The retention curve obtained after the oral administration of the 75Se-labelled bile-acid analogue showed a monoexponential decline; in the case of unimpaired absorption, the half-life was greater than 2.5 days. When more than 30 cm of the ileum had been eliminated by inflammatory infection or resection, the measured half-life was below 0.5 days due to malabsorption. We also performed a quantitative determination of the hepatic secretion of 75-Se-HCAT into the gall bladder. If more than 80% of the activity administered is found in the gall bladder, disturbed absorption of bile acids in the terminal ileum can be excluded. Values smaller than 80%, however, do not provide proof of disturbed absorption.