Management of colonic complications of type IV Ehlers-Danlos syndrome: a systematic review and evidence-based management strategy.

AIM: Type IV Ehlers Danlos Syndrome (EDS) is a connective tissue disorder affecting approximately 1 per 100,000-200,000 people. Life expectancy is reduced secondary to spontaneous vascular rupture or colonic perforation. Surgery carries significant morbidity and mortality. While strategies to manage colonic perforation include primary repair with or without a defunctioning stoma, Hartmann's procedure, total abdominal colectomy with end ileostomy and ileorectal anastomosis, evidence is contradictory and has not previously been evaluated in order to form a treatment strategy. We aim to review the published literature and identify outcome data relating to operative management of colonic perforation in type IV EDS. METHODS: Pubmed, EM-BASE, Cochrane library and Google Scholar were searched with the following details: Ehlers Danlos Syndrome AND colonic surgery. The main outcome measure was re-perforation rates following colonic surgery on patients with type IV EDS. If the nature of surgery and follow up were reported, data were recorded in a SPSS database according to PRISMA guidelines. RESULTS: One hundred and nine operations have been described in 51 patients in 44 case series. There were 26 visceral re-perforations, 2 affecting the small intestine and 24 colonic. Survival analysis favoured total abdominal colectomy compared with operations where the colon was left in situ. CONCLUSIONS: Total abdominal colectomy with end ileostomy or ileorectal anastomosis are the safest strategies after colonic perforation in type IV EDS. Anastomotic leak rates are high. End colostomy is high risk for colonic re-perforation and anastomotic leak rates are extremely high. Restoration of colonic continuity should be avoided.

Prophylactic antibiotics in acute pancreatitis: endless debate.

INTRODUCTION The development of pancreatic infection is associated with the development of a deteriorating disease with subsequent high morbidity and mortality. There is agreement that in mild pancreatitis there is no need to use antibiotics; in severe pancreatitis it would appear to be a logical choice to use antibiotics to prevent secondary pancreatic infection and decrease associated mortality. MATERIALS AND METHODS A non-systematic review of current evidence, meta-analyses and randomized controlled trials was conducted to assess the role of prophylactic antibiotics in acute pancreatitis and whether it might improve morbidity and mortality in pancreatitis. RESULTS Mixed evidence was found to support and refute the role of prophylactic antibiotics in acute pancreatitis. Most studies have failed to demonstrate much benefit from its routine use. Data from our unit suggested little benefit of their routine use, and showed that the mortality of those treated with antibiotics was significantly higher compared with those not treated with antibiotics (9% vs 0%, respectively, P = 0.043). In addition, the antibiotic group had significantly higher morbidity (36% vs 5%, respectively, P = 0.002). CONCLUSIONS Antibiotics should be used in patients who develop sepsis, infected necrosis-related systemic inflammatory response syndrome, multiple organ dysfunction syndrome or pancreatic and extra-pancreatic infection. Despite the many other factors that should be considered, prompt antibiotic therapy is recommended once inflammatory markers are raised, to prevent secondary pancreatic infection. Unfortunately, there remain many unanswered questions regarding the indications for antibiotic administration and the patients who benefit from antibiotic treatment in acute pancreatitis.

Rectal intussusception in symptomatic patients is different from that in asymptomatic volunteers.

BACKGROUND: Rectal intussusception is a common finding at evacuation proctography in both symptomatic and asymptomatic individuals. Little information exists, however, as to whether intussusception morphology differs between patients with evacuatory dysfunction and healthy volunteers. METHODS: Thirty patients (19 women; median age 44 (range 21-76) years) with disordered rectal evacuation, in whom an isolated intussusception was seen on proctography, were studied. Various morphological parameters were measured, and compared with those from 11 asymptomatic controls (six women; median age 30 (range 24-38) years) found, from 31 volunteers, to have rectal intussusception. Intussusceptum thickness greater than 3 mm was designated as full thickness. Intussuscepta impeding evacuation were deemed to be occluding. RESULTS: Twenty-two patients had full-thickness intussusception, compared with two controls (P = 0.003). Intussusceptum thickness was significantly greater in the symptomatic group (anterior component: P = 0.004; posterior: P = 0.011). Twenty patients in the symptomatic group, but only three subjects in the control group, had a mechanically occluding intussusception (P = 0.043), although only three patients demonstrated evacuatory dynamics outside the normal range. CONCLUSION: Rectal intussusception in patients with evacuatory dysfunction is more advanced morphologically than that seen in asymptomatic controls; it is predominantly full thickness in patients and mucosal in controls. However, caution is required when selecting patients for intervention based solely on radiological findings.

EXternal Pelvic REctal SuSpension (Express procedure) for rectal intussusception, with and without rectocele repair.

BACKGROUND: The results of conventional treatment for rectal intussusception and rectocele are unpredictable. The aim was to develop a less invasive surgical approach and to evaluate outcome in selected patients. METHODS: Seventeen patients (13 women; median age 47 (range 20-67) years) with rectal evacuatory dysfunction and rectal intussusception, 13 of whom had a rectocele, were selected. The intussusception was corrected by external pelvic suspension of the rectum, using collagen strips attached to the rectal wall and pubis. The rectocele was repaired with a collagen patch. Patients were assessed before and 6 months after surgery by symptom and quality of life questionnaires, anorectal physiological investigation and proctography, and were followed up for a median of 12 months. RESULTS: Sepsis requiring exploration occurred in two patients but there was no extrusion or need to remove the collagen. Of the 15 patients assessed after surgery, total symptom scores were significantly decreased (P < 0.001) and quality of life scores improved (P < 0.001). Proctographically, the degree of intussusception was improved in ten patients; six patients had normal postoperative proctograms. The rectocele was reduced in size in all patients, and was not demonstrable in eight. CONCLUSION: An effective procedure for rectal intussusception and rectocele has been developed in a selected group of patients with marked evacuatory symptoms.

External pelvic rectal suspension (the Express procedure) for full-thickness rectal prolapse: evolution of a new technique.

OBJECTIVE: The Délorme's operation for rectal prolapse is a safe procedure but has a high recurrence rate. We aimed to develop an operation akin to it, but designed to reduce this deficit. PATIENTS AND METHODS: Thirty-one consecutive patients with rectal prolapse were included in the study. Initially, a conventional Délorme's procedure was performed and sutures or strips of Gore-Tex were attached circumferentially to the apex of the prolapse, tunneled subcutaneously, and anchored to the external surface of the pelvis. Subsequently, the procedure was modified. Acellular porcine collagen strips were used and buried within the apex without plication of the denuded rectal musculature. Patients were formally assessed preoperatively and four months postoperatively by symptom and quality of life questionnaires and subsequently by regular clinical review. RESULTS: In the Gore-Tex group (N = 11; males:females = 10:1; mean age, 61 years) three patients underwent suture repair and eight had strip fixation. All suture repairs developed sepsis and one patient had a recurrence. Seven of the strip fixations (88 percent) developed sepsis that resulted in implant extrusion. There was one full-thickness and one mucosal recurrence after a median follow-up of 25 months. In the collagen group (N = 20; males:females = 2:18; mean age, 63 years), sepsis occurred in four patients, requiring surgical intervention in one patient (5 percent) (cf Gore-Tex group, P = 0.002). There was one mucosal and three full-thickness (15 percent) recurrences after a median follow-up of 14 months (cf Gore-Tex group, P = not significant). Significant improvements in symptom and quality of life scores were recorded in both groups at four months. CONCLUSION: A new, minimally invasive perineal procedure for rectal prolapse has been developed and initial data testify to its relative safety provided collagen is used. It remains to be seen whether long-term recurrence rates will be lower than those of conventional perineal procedures.

Open-magnet MR defaecography compared with evacuation proctography in the diagnosis and management of patients with rectal intussusception.

OBJECTIVE: The aim of this study was to determine whether open-magnet magnetic resonance (MR) defaecography could provide more useful clinical information than evacuation proctography (EP) alone in the evaluation of a cohort of patients with full-thickness rectal intussusception and could assist in decisions concerning management. METHODS: Ten patients (4 male; median age 43, range 30-65) with symptomatic circumferential rectal intussusception diagnosed on EP, underwent open-magnet MR defaecography. Pathologies visible with each technique were recorded and 12 parameters of anorectal configuration and morphology measured and compared. RESULTS: There was discordance in the diagnosis of rectal intussusception in three cases. In another two patients, MR defaecography demonstrated mucosal descent only. Measurements of anorectal configuration and morphology were similar between techniques; only rectal size and lateral dimensions of the rectocoele were significantly different, being smaller on MR defaecography than EP. Two patients were shown on MR defaecography to have significant bladder descent and two female patients had significant vaginal descent. CONCLUSION: EP remains the first line investigation for the diagnosis of rectal intussusception, but may not distinguish mucosal from full-thickness descent. MR defaecography further complements EP by giving information on movements of the whole pelvic floor, 30% of the patients studied having associated abnormal anterior and/or middle pelvic organ descent. If surgery is planned for patients with rectal intussusception, MR defaecography provides useful information regarding the presence and degree of anterior pelvic compartment descent that may need to be addressed if a good functional outcome is to be achieved.

Social integration and morale: a re-examination.

The concern for social integration among the aged lies in its implications for well-being in old age. Evidence about the link between social integration and morale is still inconclusive. This appears to be due to poor conceptionalization and lack of specification concerning the relationships between social integration and other correlates of morale. In this study, social integration is viewed in terms of both its subjective and objective aspects. The central hypothesis is that the relationship between objective aspects of social integration and morale is mediated by the subjective sense of integration. This hypothesis was examined through the use of a structural equation model. Four data sets were used for this inquiry which included surveys conducted in North Carolina, Wisconsin, Minnesota, and Detroit. Findings indicate that objective social integration only has an indirect impact on morale, with subjective sense of integration being the intervening variable. This relationship remains significant even when other factors such as socioeconomic status, financial satisfaction, and health status were controlled.

[Aspergillosis of the brain]. / Aspergillez golovnogo mozga.

A case of aspergillosis of the brain in a 49-year old woman is described. In view of the fact that there were no inflammatory changes in other organs, the assumption was put forward that the fungus had penetrated into the brain by the otogenic way, or through the accessory nasal sinuses. The results of experimental infection of laboratory animals aimed at obtaining a model of meningoencephalitis are discussed. It was shown that spores of the Aspergillus fumigatus fungus in low concentrations introduced into the otic veins penetrated into the lungs where they caused an inflammatory process, and then hematogenically entered the brain. The changes in the latter were characterised by endo- and perivasculitis, formation of numerous microabscesses with the presence therein of threads of the fungus mycelium.