Surgical repair and biological therapy for fecal incontinence in Crohn's disease involving both sphincter defects and complex fistulas

BACKGROUND AND AIMS

Surgeons have traditionally tried to avoid any complex surgical procedures in Crohn's patients with complex perianal diseases because of the fear of complications, worsening the patient's condition and risking an eventual proctectomy. The introduction of biological therapy has changed the management of Crohn's disease. This study assesses the long-term success of addressing defects in anal sphincter and complex fistula when patients receive anti-TNF-α antibodies.

METHODS

Ten consecutive patients were prospectively scheduled for induction therapy with 5mg/kg Infliximab at week 0, 2 and 6 and maintenance every 8 weeks associated with azathioprine. Elective surgery was performed conducting a simultaneous approach to the sphincter defect and fistula tracts. Outcomes were long-term continence, complications which were assessed by a Wexner's score along with a complementary questionnaire. Statistical analysis was performed using general linear model of repeated measures.

RESULTS

Three patients had complications related to surgery: two abscesses and low intersphincteric fistula and one case of rectal stenosis causing fecal urgency. There was no suture dehiscence. Wexner's score improved at 12 months (10.0±2.4 vs. 18.0±2.6; p=0.003) and over time (48 month 9.5±2.8; p=0.001). These scores were significantly worse when patients had urgency before treatment (12.8±1.2 vs. 9.5±2.8; p=0.03) but not when the urgency appeared later. No patient remained incontinent to solid stools. Three patients had occasional incontinence to liquid stools associated to disease reactivation.

CONCLUSION

Surgical repair and immunomodulator therapy with infliximab could be an option in incontinent patients with Crohn's disease involving both a sphincter defect and severe or refractory fistulas.

Negative regulation of central nervous system myelination by polysialylated-neural cell adhesion molecule

Many factors have been shown to promote myelination, but few have been shown to be inhibitory. Here, we show that polysialylated-neural cell adhesion molecule (PSA-NCAM) can negatively regulate myelin formation. During development, PSA-NCAM is first expressed on all growing fibers; then, axonal expression is down-regulated and myelin deposition occurs only on PSA-NCAM-negative axons. Similarly, in cocultures of oligodendrocytes and neurons, PSA-NCAM expression on axons is initially high, but decreases as myelination proceeds. Importantly, if expression of PSA-NCAM is prematurely decreased in cultures, by either antibody-mediated internalization or enzymatic removal of the PSA moieties with endoneuraminidase N (endo-N), myelination increases 4- to 5-fold. In the optic nerve, premature cleavage of PSA moieties by intravitreous injection of endo-N also induces a transient increase in the number of myelinated internodes, but does not interfere with the onset of myelination. Previously, we showed that axonal electrical activity strongly induced myelination, which could be prevented by tetrodotoxin (TTX), an action potential blocker. Interestingly, removal of PSA moieties does not reverse the inhibition of myelination by TTX. Together, this suggests that myelination is tightly controlled by both positive (electrical activity) and negative (PSA-NCAM expression) regulatory signals.

Prevalence and Distribution of Campylobacter jejuni and Campylobacter coli in Retail Meats

Nine cooperating laboratories, distributed throughout the United States, determined the interlaboratory reproducibility of a sensitive, selective method for isolation of Campylobacter jejuni and Campylobacter coli from foods, and determined the prevalence and distribution of the organism in retail meats. A double-blind inoculated/recovery experiment demonstrated the ability to detect two cells of C. jejuni and C. coli per g of meat at a rate of 96% among the cooperating laboratories. However, a 7.5% false-positive rate for the presumptive detection of the organism was also reported. Samples of ground beef, beef flank steak, lamb stew meat, broiler chicken, pork sausage (without antimicrobials), and pork chops were selected to assess the presence of campylobacters. Each cooperator purchased five of each of the above samples from the refrigerated case of two retail outlets at quarterly intervals throughout the year. A total of 2,160 retail samples were analyzed for the presence of C. jejuni and C. coli . Results indicated that about 30% of the 360 chickens sampled yielded the organism. Analysis of 1,800 red meat products yielded campylobacters at a rate of about 5.1%. Pork samples yielded C. coli and other meats yielded C. jejuni . Higher numbers of isolations from the red meats were made during June and September (8.6%) as compared with December and March (4.2%). These results provide a baseline, for the prevalence of campylobacters in these selected foods, and also support epidemiologic data associating mishandled foods of animal origin as a potential vehicle in human gastroenteritis.