Intersphincteric resection for low rectal tumours

An abdominoperineal operation is described that extends rectal resection for low tumours into the intersphincteric plane with removal of the internal sphincter. Bowel continuity is restored by coloanal anastomosis. Of 38 patients who underwent surgery since 1984, 34 had low rectal cancer and four carcinoid or large villous adenoma. There was no mortality. Four patients developed local recurrence during a median observation period of 3 years. Continence was satisfactory in all patients. The median daily number of bowel movements during the first months after colostomy closure was 9 but decreased to 3 after 1 year and 1 after 2 years. Anal manometry demonstrated a significant reduction of mean resting pressure from 91.8 to 35.1 cmH2O with no recovery after 2 years (P < 0.0001). Squeeze pressure showed only a transient decrease.

Isolation and structural analysis of "urodilatin", a new peptide of the cardiodilatin-(ANP)-family, extracted from human urine

Two major forms of cardiac peptides have been established in the last few years: (a) a prohormone of 126 amino acids (CDD/ANP-1-126) in the endocrine heart and (b) the circulating CDD/ANP-99-126 (= alpha ANP) in blood plasma. The method we applied earlier to isolate the circulating form of cardiodilatin from human blood was used to detect and analyze the biologically active, predominant form of the same polypeptide family excreted by the kidneys. Each step of the isolation procedure was followed up by a bioassay using an in vitro vascular smooth muscle relaxation test and a highly specific RIA against cardiodilatin (CDD-99-126) for the initial purification steps. The polypeptides excreted in 1000 l of normal human urine were adsorbed to 2.5 kg of alginic acid, and after elution and lyophilization processed on a G-25 Sephadex column. The obtained crude polypeptide fractions were applied to ion-exchange chromatography. Thereafter four steps of HPLC were carried out to purify the polypeptide which was the suggested form of cardiodilatin (CDD) in human urine. The amino acid analysis and gas phase sequence analysis showed that the main form of urinary cardiodilatin is a 32 amino acid residue containing molecule, cardiodilatin-95-126. The molecule is N-terminally extended compared to the circulating CDD-99-126. This suggests that the analyzed urinary peptide is not the residual plasma form, filtrated and renally cleared from blood, but probably a polypeptide produced and processed in the kidney tubules and cleaved by a different postranslational process. Therefore, this vasorelaxant polypeptide is called urodilatin.

Endoscopic thoracic sympathectomy for primary hyperhidrosis of the upper limbs. A critical analysis and long-term results of 480 operations

OBJECTIVE

This evaluated the long-term outcome after endoscopic thoracic sympathectomy (ETS) from below D1 to D4, using a single-site access technique for primary hyperhidrosis of the upper limbs.

SUMMARY BACKGROUND DATA

Primary hyperhidrosis of the upper limbs is a distressing and often socially disabling condition. Endoscopic thoracic sympathectomy is considered the treatment of choice, causing minimal morbidity and high initial success rates. However, data regarding long-term results are scarce.

METHODS

Two hundred seventy of 323 patients (83.7%), in whom 480 sympathectomies were performed, answered a questionnaire after a mean of 14.6 years postoperatively regarding the early postoperative result, side effects, and complications caused by the operation and long-term results with particular emphasis on patient satisfaction.

RESULTS

There was no postoperative mortality and no major complications requiring surgical reintervention. A majority of the patients (98.1%) were relieved, and 95.5% were satisfied initially. Permanent side effects included compensatory sweating in 67.4%, gustatory sweating in 50.7% and Horner's trias in 2.5%. However, patient satisfaction declined over time, although only 1.5% recurred. This left only 66.7% satisfied, and a 26.7% partially satisfied. Compensatory and gustatory sweating were the most frequently stated reasons for dissatisfaction. Individuals operated for axillary hyperhidrosis without palmar involvement were significantly less satisfied (33.3% and 46.2%, respectively).

Local recurrence of colorectal cancer: effect of early detection and aggressive surgery

A prospective study was undertaken of the incidence, symptoms, diagnostic measures and therapy of local recurrences of colorectal carcinoma following radical surgical management. Out of 715 patients, 156 (22 per cent) developed recurrence of the tumour, which was local in 90 patients. In addition, 36 patients with local recurrence from other hospitals were treated. Half of the patients were symptom-free at the time of diagnosis. Out of the 126 patients, 109 were treated by surgery, a radical operation being feasible in 53 cases. Fifty per cent of these have survived for at least 17 months. The operative mortality was very low (4.6 per cent), although extensive surgery was necessary in most of the cases. The preliminary results of this study support the hypothesis that a postoperative follow-up programme for patients with colorectal cancer leads to early detection of local recurrence and improves the chance of cure by surgical treatment.

Gastrointestinal transit and prolonged ambulatory colonic motility in health and faecal incontinence

BACKGROUND

Colonic motor function has not been studied in the ambulatory setting over a prolonged period in the unprepared state. Furthermore, the disturbance of this function in patients with faecal incontinence is unknown.

AIM

To study colonic function over two to three days in the ambulatory, unprepared state in health and in patients with idiopathic faecal incontinence.

METHODS

Six healthy women and six women with faecal incontinence and a structurally intact anal sphincter ingested a dual radioisotope meal, and had a six sensor, solid state manometric probe colonoscopically inserted into the left colon. Scanning was performed until radioisotope left the gut and pressure was recorded for a median of 44 hours.

RESULTS

Three of six patients showed abnormal gastric emptying. Patients showed no disturbance of colonic radioisotope transit. Controls had a median of 12, whereas patients had a median of 16, high amplitude propagated waves per 24 hours. In three patients urge incontinence was associated with high amplitude (up to 500 cm water) propagated waves which often reached the rectum. These high pressure waves were identical to those occurring in healthy subjects, the only difference being the lack of adequate sphincter response. Passive incontinence was not associated with colonic motor activity. Defaecation in all subjects was associated with identical propagated waves, and distal movement of 13% (median) of right colonic content and excretion of 32% from the left colon and rectum. The urge to defaecate was associated with either propagated waves (45%) or non-propagated contractions (55%). Rectal motor complexes were recorded in both groups of subjects, but similar rhythmic activity was also recorded in the sigmoid and descending colon.

CONCLUSIONS

Normal colonic function consists of frequent high pressure propagated waves. Rhythmic activity occurs both proximal to and in the rectum. Defaecation is characterised by high pressure propagated waves associated with coordinated anal sphincter relaxation. Patients with faecal incontinence may have a widespread disturbance of gut function. Urge incontinence, an urge to defaecate, and defaecation can all be associated with identical high amplitude propagated pressure waves.

Efficacy of liver transplantation for alcoholic cirrhosis with respect to recidivism and compliance

Many transplant centers are reluctant to accept alcoholic patients for OLT because of their supposed potential for alcoholic recidivism and poor compliance with the required immunosuppressive regimen, both of which result in graft failure. Only inconclusive data related to these arguments are available. From May 1982 to January 1993, 58 patients received OLT at our institution for end-stage cirrhosis, where alcohol was the only toxic component. The indication for OLT in these patients was considered with particular attention to recidivism and compliance. Overall survival in this group was 71% and 63% at 1 and 5 years, respectively, with an average survival time of 78 months. Actuarial survival of patients transplanted since January 1989 (n = 37) was 86% and 83% at 1 and 2 years (average survival 42 months). Nonfatal clinical endpoints were analyzed in those patients surviving at least 3 months (n = 44). Return to alcohol abuse has been documented in 14 persons at routine short-term outpatient checkups. The estimated risk for alcoholic recidivism amounts to 31%, with a median follow-up of 33 months. Compliance with immunosuppressive regimen was expressed as a dependent value of acute rejection episodes (0.3 per patient, median follow-up 33 months), chronic rejection (occurred in none of the patients), and measurements of CsA HPLC blood trough level (92.2% within the target range). The preversus postoperative improvement of employment, marital, and social status after OLT showed a statistically significant difference. Unwillingness to offer OLT to individuals with alcoholic liver disease because of failure to demonstrate 100% long-term abstinence appears difficult to defend in the face of good results in survival, compliance, and social rehabilitation.

Significant association of strictures and internal fistula formation in Crohn's disease

Intestinal inflammation in Crohn's disease (CD) may be complicated by the occurrence of strictures and fistulae. The pathogenesis of fistula formation is unknown. We therefore wanted to determine whether mechanical factors might contribute to the development of fistulae. Furthermore, we tried to define the path of internal fistulae through the muscular layer. For this purpose, surgical resection specimens from 42 consecutive patients with CD were prospectively studied. In gross examination the whole bowel was cut into circumferential cross sections 0.3 cm thick. Abnormal areas were histologically examined. Strictures were found in 38 patients (90.5%), and fistulae were observed in 27 (64.3%) patients. In 11 (40.7%) specimens fistulae were found within a stricture, in 15 (55.6%) at the proximal end, and in 1 (3.7%) no stricture was found. In 7 (25.9%) cases with fistulae, herniated mucosa was found within the muscularis propria or the subserosa. In 7 (25.9%) cases a blood vessel was identified near a fistula traversing the muscularis propria. From these findings we conclude that that mechanical factors may contribute to fistula formation. This is further supported by the fact that fistulae appear to traverse the muscular layer along piercing vessels.

A prospective randomised phase III trial of adjuvant chemotherapy with 5-fluorouracil and leucovorin in patients with stage II colon cancer

The purpose of this trial was to investigate the efficacy of adjuvant chemotherapy with 5-fluorouracil (5-FU) and leucovorin (LV) in stage II colon cancer. Patients with stage II colon cancer were randomised to either adjuvant chemotherapy with 5-FU/LV (100 mg m⁻² LV+450 mg m⁻² 5-FU weekly, weeks 1–6, in 8 weeks cycles × 7) or surveillance only. Five hundred patients were evaluable for analyses. After a median follow-up of 95.6 months, 55 of 252 patients (21.8%) have died in the 5-FU/LV arm and 58 of 248 patients (23.4%) in the surveillance arm. There was no statistically significant difference in overall survival (OS) between the two treatment arms (hazard ratios, HR 0.88, 95% CI 0.61–1.27, P=0.49). The relative risk for tumour relapse was higher for patients on the surveillance arm than for those on the 5-FU/LV arm; however, this difference was not statistically significant (HR 0.69, 95% CI 0.45–1.06, P=0.09). Consequently, disease-free survival (DFS) was not significantly different between the two trial arms. In conclusion, results of this trial demonstrate a trend to a lower risk for relapse in patients treated with adjuvant 5-FU/LV for stage II colon cancer. However, in this study with limited power to detect small differences between the study arms, adjuvant chemotherapy failed to significantly improve DFS and OS.

Evaluation of perianal sepsis: comparison of anal endosonography and magnetic resonance imaging

The purpose of this study was to compare prospectively the diagnostic yield of anal endosonography (AES) and magnetic resonance imaging (MRI) in the assessment of perianal fistulae and abscesses. There were 39 patients (14 men, 25 women; mean age, 40 years) who underwent AES, performed with a 10-MHz rotating endoanal probe and MRI at 1.0 T (axial and coronal T2-weighted turbo spin-echo (TSE) and turbo-STIR sequences). Fistulae were classified as subcutaneous, intersphincteric, transsphincteric, high (i.e., high extrasphincteric or suprasphincteric), rectovaginal, and horseshoe and were compared with the surgical findings in all patients. Overall, 58 fistulae (subcutaneous, N = 7; intersphincteric, N = 9; transsphincteric, N = 16; high, N = 17; rectovaginal, N = 5; and horseshoe, N = 4) were detected at surgery. MRI showed a sensitivity of 84% and AES of 60% (P <.05). False-positive diagnoses were made in 6 patients (15%) with MRI and in 15 patients (26%) with AES, for a specificity of 68% and 21%, respectively (P <.05). Our findings show that MRI is superior to AES in the assessment of fistula-in-ano before major surgery. AES should be used only for orientation before minor procedures, such as incision or drainage of subcutaneous fistulae.

A decade of oral anticoagulant treatment to maintain autologous vein grafts for femoropopliteal atherosclerosis

To determine whether long-term oral anticoagulant treatment was effective in improving graft performance and preventing major amputation following vein bypass surgery for femoropopliteal atherosclerosis, a clinical trial was conducted in one single center and continued during 10 years. After 130 patients had electively received a femoropopliteal vein graft, they were randomly assigned to a therapy group (treatment with phenprocoumon [n = 66]) or to a control group (n = 64) that remained without any anticoagulant treatment. Primary end points of the study were graft reocclusion and limb loss. The median durations of primary patency and limb salvage were significantly longer for treated patients than that for controls. In addition, survival in the therapy group was longer. Following autologous vein bypass surgery in the treated group, the results were superior in terms of graft patency, limb salvage, and survival.

Limited endoscopic thoracic sympathetic block for hyperhidrosis of the upper limb: reduction of compensatory sweating by clipping T4

BACKGROUND

Endoscopic thoracic sympathicotomy of T2 to T4 (ETS 2-4) has evolved into an effective treatment for severe hyperhidrosis of the upper limb. Complications such as bleeding or Horner's syndrome are rare, but side effects such as compensatory and gustatory sweating occur in 30-50% of patients. Following the Lin-Telaranta classification, we aimed to reduce these side-effects by clipping T4 solely [endoscopic thoracic sympathetic block (ESB 4)]. We present our experience and clinical results using this method, with emphasis on patients' quality of life.

METHODS

A total of 176 procedures (91 patients) were carried out in the ETS 2-4 group and 103 procedures (53 patients) in the ESB 4 group: 60.4 and 43.4% had palmar hyperhidrosis, 8.8 and 5.7% had isolated axillary, and 30.8 and 50.9% had combined manifestations, respectively. Follow-up was 22.1 months (obtained from 79.1% of patients) for the ETS 2-4 group and 7.5 months for the ESB 4 group (obtained from 88.7%).

RESULTS

The success rate was similar for both groups: 87.9 and 64.5% had completely dry limbs, 9.9 and 35.5% ( p < 0.0002) were nearly dry, and 2.1 and 0% remained wet. (ETS 2-4 vs ESB 4). Although the armpits remained slightly humid in more patients in the ESB 4 group, 100% stated full satisfaction. Complications did not differ significantly. However, compensatory sweating (55.6 vs 8.5%, p = 0.0002) and gustatory sweating (33.3 vs 2.1%, p = 0.0019) were markedly reduced (ETS 2-4 vs ESB 4). Quality of life was assessed by a hyperhidrosis index, which significantly improved in most patients.

CONCLUSIONS

ETS 2-4 and ESB 4 have similar success rates in the treatment of upper limb hyperhidrosis. The major side effects of compensatory and gustatory sweating were effectively reduced by the limited method of clipping T4, and patients' satisfaction and improvement in quality of life were remarkable.

Peritumoral tissue reaction at transrectal US as a possible cause of overstaging in rectal cancer: histopathologic correlation

PURPOSE

To assess if peritumoral tissue reaction (PTR) can be differentiated from tumor with transrectal ultrasound (TRUS) to avert overstaging.

MATERIALS AND METHODS

Preoperative TRUS results in 40 consecutive patients with biopsy-proved rectal cancer were compared with histopathologic reports on the specimens (study 1). To test the hypothesis that areas more anechoic than the tumor were deemed responsible for incorrect staging in study 1, a prospective study was undertaken in another 40 consecutive patients (study 2). The thickest part of PTR was measured, and results were compared with the histopathologic findings.

RESULTS

In study 1, 28 (70%) of 40 rectal cancers were staged correctly with TRUS. PTR was responsible for the misinterpretation in six of seven overstaged cases. In study 2, 38 (95%) of 40 cancers were staged correctly, and the presence or absence of PTR was described in 39 cases (98%). A statistically significant positive correlation was noted between histopathologic classification of PTR and its thickness measured with TRUS (P = .0001).

CONCLUSION

Because of its more anechoic appearance, PTR may be differentiated from the tumor by means of TRUS. This may lead to a statistically significantly higher accuracy of TRUS in the staging of rectal cancer due to the avoidance of overstaging.

Video assistance reduces complication rate of thoracoscopic sympathicotomy for hyperhidrosis

BACKGROUND

Thoracoscopic sympathicotomy has proved successful in the treatment of palmar hyperhidrosis. However, up to 8% of patients experience Horner's syndrome, and about 50% show compensatory sweating. This study evaluates the role of video assistance in thoracoscopic sympathicotomy for primary hyperhidrosis of the upper limb.

METHODS

Six hundred fifty-six thoracoscopic sympathicotomies were performed from below T1 to T4 in 369 patients. Of the operations, 558 were done under direct view (CTS group) and 98, with video assistance (VATS group). Follow-up was complete for 78.3% of patients after a median observation period of 16 years.

RESULTS

Dry limbs were immediately achieved in 93% of the CTS group and 98% VATS group (p = 0.98). In the CTS group, Horner's syndrome occurred after 2.2% of all operations and rhinitis in 8.3%. No patient in the VATS group showed any symptom of Homer's triad (p = 0.03 versus CTS group) or rhinitis (p = 0.02 versus CTS group). Compensatory sweating was observed in 66.8% in the CTS group versus 69% in the VATS group (p = 0.73) and gustatory sweating, in 50.4% versus 27.6%, respectively (p = 0.01).

CONCLUSIONS

In performing thoracoscopic sympathicotomy for excessive upper-limb hyperhidrosis, we observed a significant decrease in the incidence of Horner's syndrome, rhinitis, and gustatory sweating when the procedure was guided by video imaging.

Staining patterns of p53 immunohistochemistry and their biological significance in colorectal cancer

Immunohistochemistry (IHC) is a cheap and rapid method to detect p53 inactivation but the results are often discordant with gene mutation analysis. This study aimed to investigate whether there is a difference in the immunohistochemical staining patterns of p53-positive cells on comparing tumours with inactivating gene mutations with those without. Tissues of 142 colorectal cancers were investigated for p53 inactivation simultaneously by IHC and gene analysis using SSCP of exons 4-9 and sequencing. In addition, tumours were investigated immunohistochemically for the expression of mdm-2 protein, known to be transcriptionally transactivated by the wild-type (wt) p53 gene. p53-positive cells of tumours without detectable p53 gene mutations were microdissected using a PALM laser microscope system and subjected to p53 sequence analysis. Among the 142 cases of colorectal cancer (male/female=88/54; mean age 66a+/-11 years, range 24-90 years), 74% (n=105) of tumours were positive by p53 IHC and mutations in the p53 gene were found in 51% (73 patients). In 16% (12 patients) with mutations in the p53 gene, IHC for p53 was negative. In tumours with mutations in the p53 gene and positive p53 IHC, staining of all nuclei of the tumour was more frequently (57/61, 93%) found than in tumours without p53 gene mutations, where staining of scattered single cells was predominantly seen (29/44, 66%; p<0.0001). mdm-2 positivity (n=33) showed only staining of scattered single cells, predominantly (24/33, 82%; p<0.0001) in tumours without gene mutations. Single cell microdissection followed by mutation analysis of scattered p53-positive cells revealed no gene mutations. A scattered positive immunohistochemical reactivity of p53 in colorectal cancer cells might therefore represent a functionally active non-mutated p53 gene and should not be considered as a marker of gene mutation and inactivation.

Polyol synthesis of non-stoichiometric Mn–Zn ferrite nanocrystals: structural /microstructural characterization and catalytic application

The structure and microstructure of polyol-made non-stoichiometric Mn–Zn ferrite nanoparticles were successfully investigated and correlated to their catalytic properties toward dimethyl ether oxidation reaction.

Genetic and immunological markers in pouchitis

OBJECTIVES

Previous studies of the interleukin-1 receptor antagonist (IL-1RN) have found an increased frequency of the associated variable number tandem repeat (VNTR) allele 2 for ulcerative colitis (UC) and further evidence has been reported that this allele is associated with increased severity of several other inflammatory conditions. The HLA type of UC patients has also been implicated in the extent of disease as has the presence of perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA). We therefore decided to test the hypothesis that the p-ANCA, HLA type or the presence of the IL-1RN allele 2 in patients who received a restorative proctocolectomy for UC had an effect on the risk of developing pouchitis.

PATIENTS

We determined the genotypes of the IL-1RN and HLA DR beta and DQ beta loci for 28 subjects with previous UC and a pouch with no evidence of pouchitis for a minimum of 2 years after formation of an ileo-anal reservoir (mean 6.3 years; range 2-17 years) and 25 subjects with previous UC and pouchitis confirmed by strict histological examination of pouch mucosal biopsy. The IL-1RN genotypes were also determined for 86 healthy controls and 61 unrelated patients with familial adenomatous polyposis (FAP). The p-ANCA status was determined for all 25 pouchitis subjects but only 23/28 non-pouchitis subjects, with 15 unaffected subjects as a negative control.

METHODS

The HLA haplotypes of the UC groups were determined by polymerase chain reaction sequence-specific primer (PCR-SSP) typing and the IL-1RN genotypes were determined by PCR and agarose gel electrophoresis. The p-ANCA status was determined by indirect immunofluorescence.

RESULTS

A chi 2 of 5.686 with 1 degree of freedom and a P value of 0.0171 using Yates' correction was obtained by comparing the IL-1RN allele frequencies of the combined UC groups to the FAP controls, and a chi 2 of 6.801 with 1 degree of freedom and a P value of 0.0091 comparing the pouchitis group to the FAP controls. The HLA haplotype frequencies did not vary significantly between groups nor did they correlate with p-ANCA status. There were also no significant associations of the p-ANCA status and pouchitis.

CONCLUSION

There is an increased frequency of IL-1RN allele 2 in UC, with the majority of the association arising from the pouchitis group, suggesting that the presence of allele 2 in patients with UC affects the disease outcome. However, the HLA frequencies and p-ANCA status do not have any significant associations.

Salvage surgery for ileal pouch outlet obstruction

Sixteen patients with ileal pouch outlet mechanical obstruction had major abdominal revision of the ileoanal anastomosis. Before operation all had severe difficulty in evacuation which required catheterization in 11. Eleven patients had a long efferent limb and/or long anorectal cuff, and five had a persistent stricture at the ileoanal anastomosis. None had pouchitis. The pouch was fully mobilized abdominally and the obstructing lesion resected. A new handsewn ileoanal anastomosis was formed. In two cases pouch volume was increased by incorporating an additional loop of ileum. All anastomoses but one were covered by a loop ileostomy. There were no deaths. Major complications occurred in two patients. Function was assessed in 15 patients; in one the ileostomy had not been closed. Median (interquartile range) frequency of defaecation per 24 h fell from 15 (7.3-19.5) to 6 (4.5-6.0) (P = 0.0033). Of the 11 patients who required a catheter before operation six evacuated spontaneously, three were improved but intubated on some occasions and two were unchanged after revisional surgery. Of the ten incontinent patients, five became continent, four were improved and one remained unchanged. There was a new continence disturbance in four (minor nocturnal in three) of the remaining five patients. One patient underwent further abdominal salvage surgery and another required establishment of an ileostomy because of poor function. Combined abdominoanal salvage surgery for outlet mechanical obstruction was successful in averting an ileostomy in 13 of 16 patients, and significantly improved pouch function in 12 of 15.

Transvaginal repair of pouch-vaginal fistula

BACKGROUND

The results of surgery for ileoanal pouch-vaginal fistula have been disappointing. Intra-anal procedures result in fistula healing in, at best, approximately 50 per cent of patients. A transvaginal approach was developed to achieve direct access to the internal opening, enabling closure without damage to the anal sphincter.

METHODS

Fourteen patients were treated between January 1992 and December 1998. All had had restorative proctocolectomy for ulcerative colitis and all were defunctioned. Histological review confirmed the diagnosis in all patients.

RESULTS

Median age was 40 (range 25-52) years. Median follow-up was 18 (range 6-60) months. The operation was successful in 11 of the 14 patients, after one attempt in six patients, after two attempts in four, and after three attempts in one patient. The operation failed in three patients, who had a permanent ileostomy. The number of bowel actions in the patients who had successful closure ranged from 2 to 10 (median 6) in 24 h, with no faecal incontinence reported.

CONCLUSION

This simple technique achieved healing in 11 of 14 patients. This compares favourably with the poor results in 28 patients treated by other procedures in the same hospital, with certain healing in five and definite failure in 20.

Isolation and structural analysis of the circulating human cardiodilatin (alpha ANP)

A new method was applied to isolate a polypeptide hormone from human blood. The polypeptides from 1,000 1 of hemofiltrate with a molecular weight lower than 20 kDaltons were adsorbed to 2.5 kg alginic acid, then eluted, precipitated, and desalted on a G-25 Sephadex column, thus obtaining a crude lyophilised plasma polypeptide extract. These polypeptides were further submitted to ion-exchange chromatography. Thereafter, two steps of HPLC were carried out to purify a distinct polypeptide which was the circulating form of cardiodilatin (CDD) in this case. The amino acid analysis, C-terminal enzymatic cleavage by carboxypeptidase A, and sequence analysis showed that the only form of circulating cardiodilatin is the 28 amino acid residue containing molecule, cardiodilatin-99-126 cleaved from the C-terminus of cardiodilatin-126 and identical with alpha-ANP (alpha atrial natriuretic polypeptide). Other bioactive molecular forms of the polypeptide hormones of the cardiodilatin family were not detected in the hemofiltrate. The isolation procedure was followed up by a bioassay using in vitro vascular smooth muscle relaxation.

Leucocyte typing, cytokine expression, and epithelial turnover in the ileal pouch in patients with ulcerative colitis and familial adenomatous polyposis

BACKGROUND/AIMS

Conventional histopathology, leucocyte typing, cytokine mRNA expression, and crypt cell turnover were compared in ileal pouch biopsy specimens from patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP).

METHODS

Biopsy specimens were taken from 17 patients with UC and seven with FAP at a median interval of 19 months (range 2-120) after ileostomy closure. All contained both epithelium and lamina propria. Cryostat sections were stained for lymphocyte subtypes (CD3, CD4, CD8), macrophages (CD68), common leucocyte antigen (CD45), and Ki-67, using a three stage immunoperoxidase reaction. Cytokine mRNA expression for interleukins 2 and 6, tumour necrosis factor alpha, and interferon gamma was studied using an in situ hybridisation technique.

RESULTS

Lymphocyte subtype and macrophage populations in epithelium and lamina propria were similar in UC and FAP. The labelling index (Ki-67) was significantly increased in biopsy specimens from patients with UC (UC median = 43.3 (interquartile range (IQR) 38.9-48.2) v FAP 34.9 (29.9-35.2), p < 0.05). There was little or no epithelial mRNA expression for any cytokine in any of the specimens. Lamina propria mRNA expression for interleukin 2 was significantly increased in UC (UC median (IQR) 10.7 (5.4-14.2) cells per unit area v FAP 2.8 (1.5-6.6) p < 0.05) but not for tumour necrosis factor alpha, interleukin 6, and interferon gamma.

CONCLUSIONS

While static morphological assessment (leucocyte type, conventional histopathological examination) was similar, tests of cell function (mRNA expression and labelling index) were different in ileal pouches in patients with UC compared with FAP. The study also showed that mRNA expression occurred almost entirely in the lamina propria.

Open approach in pancreatic and infected pancreatic necrosis: laparostomies and preplanned revisions

One hundred and two patients with acute necrotizing pancreatitis were treated in accordance with a combined regimen of necrosectomy, open drainage by laparostomies, and repeated re-explorations. The severity of pancreatitis was assessed by the APACHE II score (median 15 on admission). Eighty-seven (85%) patients were classified as having infected pancreatic necrosis and only 15 (15%) as having pancreatic necrosis. Overall, 36 (35%) patients died, most of multiple organ failure. Survival was significantly impaired by bacterial contamination of pancreatic necrosis (p = 0.008), bacteremia (p = 0.0001) and infected bronchial secretions (p = 0.05). The mortality rate was reduced from 53% to 28% by changing the regimen of re-explorations from on demand to regular 48 hour intervals. Despite the fact that open packing was associated with a high frequency of gastrointestinal fistulas (30%), this concept seems to be a successful and recommendable approach in the therapy of pancreatic and infected pancreatic necrosis.

Preoperative short-term radiation therapy (25 Gy, 2.5 Gy twice daily) for primary resectable rectal cancer (phase II)

To evaluate the feasibility, effectiveness, and long-term bowel function of preoperative hyperfractionated accelerated radiotherapy in primary resectable rectal cancer. A total of 184 consecutive patients (median age 65 years, male : female=2 : 1) with clinical T3Nx rectal adenocarcinoma received preoperative pelvic radiation therapy with single fractions of 2.5 Gy twice daily (interval 6 h between fractions) to a total dose of 25 Gy within 1 week. Surgery was conducted the following week. Postoperative histology revealed UICC stage I in 33%, stage II in 26%, stage III in 34%, and stage IV in 7% of the patients. Median follow-up was 43 months (53 months for surviving patients). The actuarial 4-year-local-recurrence rate was 2.1%, overall recurrence 23%. Disease-specific and disease-free survivals at 4 years (excluding stage IV) were 82 and 69%, respectively. Overall survival for 4 years was 68%. Postoperative mortality was 0.5% (one patient), early anastomotic leakage occurred in 11.4%, and anastomotic stenosis requiring treatment in 6%, of 132 patients with primary anastomosis. Seven of 184 patients (3.8%) died of abdominal complications, all within the first year. Bowel function was satisfactory after more than 5 years. Local control in primarily resectable rectal cancer after 10 × 2.5 Gy is excellent, warranting further evaluation of this treatment.

Abdominosacral resection of recurrent rectal cancer in the sacrum

PURPOSE

Resection of the sacrum is the only curative therapy of isolated sacral recurrence after primarily resected rectal cancer. The aim of the study was to assess whether there is a benefit in terms of overall survival, morbidity, and mortality when sacrum resection is performed more radically and in cooperation between colorectal and orthopedic surgeons. Possible prognostic factors were also assessed.

METHODS

Twelve consecutive patients who underwent interdisciplinary partial sacral resection were included in a retrospective cohort study. Furthermore, overall survival rate and survival time were calculated.

RESULTS

Histologic examination showed tumor-free resection margins in all cases. Extended resection was necessary in seven patients, including total pelvic exenteration in two. No perioperative death occurred and no patient required early reoperation. Complications were observed in 42 percent of patients, mainly caused by poor wound healing. All patients experienced relief from pain. One-year and three-year overall survival rates were 50 and 17 percent, respectively. The overall mean survival time was 21.7 months. Patients who died of recurrent disease within one year either underwent former resection for locoregional recurrence, had extensive local recurrent tumors affecting pelvic visceral structures, or retrospectively suffered from metastatic sacral tumor manifestation.

CONCLUSION

The mortality and morbidity rates observed in the present study seem to justify partial sacral resection as a means to achieve palliation of perineosacral pain in spite of rare overall long-term survival.

Effects of loperamide on ileoanal pouch function

BACKGROUND

Opioid analogues are used to manage increased bowel frequency in patients with an ileoanal reservoir. The aim of the study was to determine the clinical efficacy of loperamide in patients with an ileoanal reservoir and to assess its effect on pouch motility.

METHODS

Fourteen patients with a pouch who had normal pouch emptying and anal function were studied. Ambulatory pouch and anal motility, and stool weights, were recorded for 24 h while taking no medication and for 24 h while receiving 8 mg loperamide. In a second analysis, patients were divided on the basis of bowel frequency into those with 4 or fewer motions (good function; n=6) and those with more than 6 per day (poor function; n=8), to determine any differential effects of loperamide.

RESULTS

Loperamide decreased median bowel frequency (no loperamide 5.5 versus loperamide 4.0, P=0.03) and 24-h stool weight (610 g versus 413 g, P=0.03) but not individual stool weights. Patients with poor function had both higher bowel frequency (8.0 versus 3.5 per 24 h, P=0.004) and higher stool weight (728 g versus 430 g, P=0.05) with no treatment than those with good function. High-amplitude pouch pressure waves were greater in number before defaecation in patients with poor function and did not decrease with loperamide, in contrast to patients with good function. Pouch baseline pressure decreased after defaecation to a similar extent in both groups and was not affected by loperamide.

CONCLUSION

Loperamide 8 mg per day reduces bowel frequency by reducing total stool weight, not individual stool weights. In patients with good function it also affects pouch motility. High bowel frequency is associated with increased pouch high-pressure waves.

Postoperative course and long term follow up after colectomy for slow transit constipation--is surgery an appropriate approach?

OBJECTIVE

Patients with slow transit constipation who do not respond satisfactorily to common medical treatment are considered candidates for colectomy. The present observational long term study was designed to assess outcome after surgery.

METHOD

Twenty consecutive patients were treated by colectomy for slow transit constipation between 1996 and 2004. Preoperative and postoperative data were reviewed by using our institutional database. A questionnaire including validated scoring systems and questions about complications and subsequent surgical interventions was sent to all available patients.

RESULTS

Three patients (15%) died perioperatively. Median long term follow up was 84 months. Ten patients (50%) needed further operations after colectomy: Three patients (15%) had surgery during the early postoperative period, seven patients (35%) during follow up. A total of 31 operations had to be performed in these patients. Twelve patients (86%) responded to the questionnaires. Their median Wexner constipation score was 11.5 (range 8-23). Six patients fulfilled the Rome II criteria for constipation. The median Vaizey incontinence score was 7.5 (range 0-22). The median GIQLI showed 80 points (range 32-129).

CONCLUSION

Morbidity and mortality rate after colectomy were inadmissibly high. Taking into account the poor functional results, we cannot recommend colectomy for slow transit constipation.