Acute compartment syndrome of the legs after colorectal surgery.

This review considers the causes, diagnosis and management of compartment syndrome affecting the legs after colorectal surgery.

Low mortality in ulcerative colitis and Crohn's disease in three regional centers in England.

OBJECTIVES: Recent epidemiological studies suggest that mortality rates for inflammatory bowel disease (IBD) are similar to those of the general population. However, most of this work has been done in referred populations or larger urban centers. We intended to estimate mortality rates for ulcerative colitis (UC) and Crohn's disease (CD) in three British district general hospital practices in Wolverhampton, Salisbury, and Swindon. METHODS: Consecutive patients with CD or UC were identified from 1978 to 1986 and followed prospectively. Demographic data, date and cause of death or health status at December 31, 1993 were used to estimate standardized mortality ratios (SMRs) and 95% confidence intervals. RESULTS: Sixty-four deaths occurred in 552 patients (UC 41 of 356; CD 23 of 196). The overall SMRs were 103 [95% confidence interval (CI): 79-140] for UC and 94 (95% CI: 59-140) for CD. The respective SMRs were higher only in the first year after diagnosis at 223 (95% CI: 99-439; p = 0.02) and 229 (74-535; p = 0.056), and even then, most subjects died from non-IBD causes (5 of 13). Nonsurvivors were significantly older than survivors in both UC and CD (p < 0.01). The SMR was also significantly greater during a severe first attack of UC at 310 (95% CI: 84-793; p = 0.04). Patients with perianal or colonic CD had an increased SMR [396 (95% CI: 108-335; p = 0.02) and 164 (95% CI: 82-335; p = 0.02)] respectively, partly related to the older mean age (52 vs 32 yr, p < 0.001). CONCLUSIONS: Mortality rates are not increased in IBD compared with the general population. However, older patients may be at increased risk of dying from other causes early in the disease clinical course.

Absence of prolactin gene expression in colorectal cancer.

AIMS: Previous studies documenting hyperprolactinaemia in patients with colorectal cancer have suggested that the tumour is the source of hormone production. The aim of this study was to determine the frequency of hyperprolactinaemia in patients with colorectal cancer before, during, and after surgery, and also to determine whether prolactin is produced by these tumours. METHODS: Serum prolactin concentrations were measured in 20 patients with colorectal cancer before, during, and after surgical resection of their tumours. Samples taken during surgery included peripheral venous blood and blood taken from the main veins draining the tumour. To determine whether the tumour was responsible for the production of prolactin in these patients, paraffin wax embedded sections of tumour specimens were subjected to immunohistochemistry and western blotting using a monoclonal antibody to prolactin. RESULTS: Five patients (three women, two men) had preoperative prolactin concentrations above the normal reference range, although this increase was of clinical importance in only two. After surgical resection of their tumours, prolactin concentrations remained high in both patients. All 20 patients had greatly raised prolactin values at the time of surgery, irrespective of whether this was measured in peripheral blood or in blood taken from veins draining the tumour. All 20 colorectal cancer tissue samples, including those with raised preoperative and/or postoperative prolactin concentrations, were negative for prolactin staining. Frozen tissue was also available in four cases. The absence of prolactin gene expression in these four tumours was confirmed both by repeat immunohistochemistry and by western blotting. A further 50 colorectal cancer cases examined by immunohistochemistry alone were also unreactive for prolactin. CONCLUSIONS: The results of this study suggest that serum prolactin concentrations may occasionally be raised in colorectal cancer patients, but that the tumour is not the source of hormone production.

Effect of anorectal eversion on long-term clinical outcome of restorative proctocolectomy.

Eversion of the rectum during restorative proctocolectomy with stapled ileal pouch-anal anastomosis (IPAA) remains a controversial surgical manoeuvre because of concern that it may impair anal sphincter function and adversely affect outcome. We have reviewed the long-term results in 41 patients whose operation included formation of a 20 cm J-pouch with stapled IPAA by the technique of rectal eversion. At median follow-up of 4 years (range 1-6 years), 4 pouches (10%) had been removed (2 for pelvic sepsis, 1 for rectovaginal fistula and 1 for Crohn's disease). In 34 patients with functioning pouches in situ, median stool frequency was 5 per 24 h (range 2-10). 11 patients (33%) regularly had to evacuate their pouch at night and 4 (12%) used antidiarrhoeal medication. No patients reported major incontinence; 2 (6%) had minor leakage, and in another 2 minor leakage had now ceased. 4 patients had had episodes of pouchitis. These favourable results offer no support for the contention that rectal eversion substantially worsens the long-term results of restorative proctocolectomy.

Sulphasalazine treatment and the colorectal mucosa-associated flora in ulcerative colitis.

AIM: To study the influence of sulphasalazine treatment on the mucosa-associated bacterial flora of rectal biopsy tissue specimens in patients with ulcerative colitis. PATIENTS: Twenty-four patients had newly diagnosed active ulcerative colitis; 20 patients had acute relapse of ulcerative colitis (10 not taking maintenance sulphasalazine); (40 patients had quiescent ulcerative colitis; 21 not taking maintenance sulphasalazine). The influence of 3 weeks of sulphasalazine treatment on the mucosa-associated flora was studied in the patients presenting with active disease. RESULTS: Comparison of patients according to sulphasalazine usage revealed few differences in the mucosal flora. In patients with quiescent ulcerative colitis, Escherichia coli was found at lower counts in patients taking maintenance sulphasalazine; however, this effect was not evident in patients with active disease. Inconsistent changes in other facultatives were seen between the two active disease groups, particularly for a miscellaneous group of unidentified Gram-positive rods. Three patients, all receiving sulphasalazine, were colonized with Clostridium difficile, but this did not appear to influence their disease. CONCLUSION: Sulphasalazine treatment in ulcerative colitis causes only minor disturbance to the populations of bacteria colonizing the colorectal mucosa.

A randomised trial comparing mesalazine and prednisolone foam enemas in patients with acute distal ulcerative colitis.

Distal ulcerative colitis can be treated with oral or rectal mesalazine, or both. A foam enema preparation has been developed and its efficacy investigated. The aim of this study was to evaluate the efficacy and safety of mesalazine foam enemas compared with prednisolone foam enemas in the treatment of patients with acute distal ulcerative colitis. Patients aged over 18 years presenting with a relapse of distal ulcerative colitis were randomly allocated treatment with mesalazine foam enema (n = 149 evaluable patients) and prednisolone foam enema (n = 146 evaluable patients) for four weeks. A randomised multicentre investigator blind parallel group trial was conducted. It was found that after four weeks of treatment, clinical remission was achieved by 52% of mesalazine treated patients and 31% of patients treated with prednisolone (p < 0.001). There was a trend in favour of more patients in the mesalazine group achieving sigmoidoscopic remission (40% v 31%, p = 0.10). Histological remission was achieved by 27% and 21% of patients receiving mesalazine and prednisolone respectively. Symptoms improved in both treatment groups. Significantly more mesalazine patients had no blood in their stools after four weeks of treatment (67% v 40%, p < 0.001). Prednisolone treated patients had significantly fewer days with liquid stools than mesalazine patients, with a median of 0 and 1 days respectively by week 4 (p = 0.001). In this study mesalazine foam enema was superior to prednisolone foam enema with regards to clinical remission, this was supported by favourable trends in sigmoidoscopic and histological remission rates. Both treatments were well tolerated.

Inflammatory bowel disease and domestic hygiene in infancy.

To test the hypothesis that Crohn's disease is caused by delayed exposure to enteric infections, we did a case-control study. We compared 133 patients who have Crohn's disease and 231 with ulcerative colitis who have controls selected from the general population and matched for age and sex. Crohn's disease was more common in subjects whose first houses had a hot-water tap (odds ratio 5.0, 95% CI 1.4-17.3) and separate bathroom (3.3, 1.3-8.3). Ulcerative colitis showed no clear relation to household amenities in infancy. These findings may explain why the incidence of Crohn's disease has increased in developed countries over the past 50 years.

Five-year follow-up study of the fat clearance technique in colorectal carcinoma.

PURPOSE: The aim of our study was to determine the five-year survival of patients with colorectal carcinoma whose Dukes classification had changed following fat clearance of the mesocolon or mesorectum. METHODS: One hundred three patients with colorectal carcinoma were followed up at a special clinic for at least five years after surgery. The tumors from these patients had previously been given a Dukes classification before and after fat clearance. RESULTS: Four of the five patients whose Dukes status changed from B to C as a result of fat clearance died of malignant disease during the five-year follow-up period. After fat clearance it was apparent that Dukes B patients survived, on average, 11 months longer than Dukes C patients. A significantly increased mean number of positive nodes was found after fat clearance in Dukes C cases, both in those who were alive at five years and those who died of their malignant disease. CONCLUSIONS: The fat clearance technique is a useful aid to improving the accuracy of the Dukes classification and has prognostic significance. It should be used in specimens of colorectal carcinoma, which on initial examination appear to be Dukes B cases.

The relationship between tumour volume and the extent of spread in colorectal carcinoma.

115 colorectal carcinomas were measured in three dimensions. To compare the tumour volume, greatest linear dimension and the maximum thickness of colorectal carcinomas with the extent of spread. A formula was devised for estimating tumour volume based on the oval shape of most carcinomas. Dukes staging was performed after xylene/alcohol fat clearance. The mean tumour volume of Dukes B tumours was greater than A tumours. The mean volume of C tumours was greater than that of A tumours. The mean volume of Dukes B tumours was greater than that of C tumours. The greatest linear dimension and the tumour thickness measurements also showed differences but were not as discriminating as the tumour volume. Using the Astler and Coller modification of Dukes staging, the mean tumour volume of C2 tumours was significantly greater than that of C1 tumours. Both C1 and C2 tumour volumes when considered separately were smaller than those of the B tumours. There was a significant positive correlation coefficient between tumour volume and the greatest linear dimension and also between tumour volume and the tumour thickness. There was no significant correlation within the C tumours between tumour volume and the number of lymph nodes with metastatic deposits. Colorectal carcinomas differ from other solid tumours in their growth pattern and metastatic behaviour. There is no direct relationship between increasing tumour size and progression in the Dukes staging. Some tumours appear to metastasize to lymph nodes while still small (C1 tumours); other tumours appear not to metastasize to lymph nodes regardless of size (B tumours).(ABSTRACT TRUNCATED AT 250 WORDS)

Mixed adenocarcinoma/carcinoid tumour of large bowel in a patient with Crohn's disease.

A 50 year old woman with a 20 year history of Crohn's disease underwent laparotomy which revealed extensive disease in the small and large bowel, and this was resected. Gross examination of the resected bowel showed features of Crohn's disease as well as a polypoid tumour in the caecum. Histopathological examination of the tumour showed it to be an infiltrating mixed adenocarcinoma/carcinoid tumour arising in a tubulovillous adenoma. Random sampling of the rest of the bowel affected by Crohn's disease also showed a focus of dysplasia and adenomatous change. It is suggested that Crohn's disease may have played a part in the pathogenesis of the tumour.

Adhesive and hydrophobic properties of Escherichia coli from the rectal mucosa of patients with ulcerative colitis.

The adherent properties and hydrophobicity of Escherichia coli isolates have been compared from the rectal mucosa of patients with active and inactive ulcerative colitis and from a control patient group. Patients with active colitis were colonised less frequently and with lower numbers of E coli than were control patients. Mannose resistant adhesion to HEp-2 cells was determined for 124 isolates of E coli and surface hydrophobicity was estimated by salt agglutination in 96 of these isolates. There was no significant difference in the distribution of adherent strains between the colitis patient groups or with disease activity. E coli from the control patients were marginally less adhesive than those from colitics. The hydrophobicity of isolates did not differ significantly between colitic and control groups nor were there significant differences correlated with disease activity. Furthermore, for these mucosal E coli isolates, hydrophobicity and mannose resistant adhesion were unrelated characteristics.

Randomised controlled trial of adjuvant chemotherapy by portal-vein perfusion after curative resection for colorectal adenocarcinoma.

About half the patients treated with curative resection for colorectal cancer do not survive long-term. Adjuvant chemotherapy given during and after surgery may prevent hepatic metastases and improve patient survival. In patients with colorectal cancer, we have done a multicentre, randomised controlled trial comparing five-year survival after intraportal infusion of fluorouracil (1 g per day) plus heparin (10,000 U per day) (130 patients) or heparin alone (123) during curative resection and for 7 days thereafter, or after resection alone (145). There was no reduction in liver metastasis or increased overall survival advantage in either active-treatment arm of the study. However, patients who had stage III, Dukes' C (lymph-node-positive) tumours resected and were treated with fluorouracil plus heparin had a significant (p less than 0.03) survival advantage of about 16% compared with surgery-only controls. Further study of intraportal infusion of chemotherapeutic agent as adjuvant treatment to surgery in patients with colorectal cancer appears worthwhile.

Subcutaneous rectal stump closure after emergency subtotal colectomy.

Subtotal colectomy with preservation of the rectum is now the procedure of choice for patients with severe colitis requiring emergency surgery. The use of subcutaneous 'rectal closure' when the retained distal bowel is placed at the caudal end of the abdominal incision in the subcutaneous or fascial layer is studied. An anal catheter may be placed to drain the rectum. Thirty-two patients (14 men, 18 women) of mean age 33 (range 17-77) years with severe inflammatory bowel disease (29 ulcerative colitis, one Crohn's disease, one indeterminate colitis, one Campylobacter colitis) underwent emergency colectomy with subcutaneous rectal stump closure. Twenty-three stumps were closed with staples, four sutured and five by both staples and sutures. Complications developed in seven patients (22 per cent), of which two required surgical intervention. One significant wound infection was treated successfully with a course of antibiotics. Three minor wound infections did not require specific treatment. The rectal stump was always readily located at the time of restorative surgery. This technique is recommended as a simple and safe alternative to an open mucus fistula provided that surgeons adhere to standard surgical principles; in particular the distal bowel should not be brought out into the wound under tension.

The rectal mucosa-associated microflora in patients with ulcerative colitis.

The rectal mucosa-associated flora (MAF) of patients with ulcerative colitis has been studied in 25 patients with newly diagnosed disease, 20 with relapse of existing disease, and 44 who were in remission. Patients with active disease were re-examined twice during treatment. The MAF was simpler and less dense than the microflora of faeces. Obligate anaerobes usually predominated in the MAF although the ratio of obligate anaerobes to facultative species was lower than that found in faeces. Viable counts of the total flora and of its constituent genera varied considerably between patients. Counts of the total flora, of obligate anaerobes (including bifidobacteria, eubacteria and clostridia), and facultative organisms and micro-aerobes (enterobacteria and lactobacilli) were reduced in patients with active disease compared with those with inactive disease; corresponding carriage rates were also lower. Counts and carriage rates increased during treatment and approached those found in quiescent disease. The alterations in the MAF were especially marked in patients experiencing their first attack of ulcerative colitis. The relationship between these alterations and the aetiology and pathogenesis of this disease remains unclear.

Search for enteric microbial pathogens in patients with ulcerative colitis.

Microbial pathogens were sought in faeces of patients with active ulcerative colitis and again after 3 months treatment. 64 patients were examined during their first episode of ulcerative colitis and 30 with relapse of chronic disease. At presentation, bacterial pathogens were not found; 1 patient had cryptosporidiosis. In 10 patients treatment appeared to result in some loss of colonisation resistance as evidenced by colonisation with beta-haemolytic streptococci, Staphylococcus aureus, candida and Clostridium difficile. Unidentified cytotoxic activity was present in the faeces of 4 patients at presentation and 2 patients during or after treatment. We conclude that enteric infection is an uncommon finding in patients with active ulcerative colitis.

Developmental regulation of heat shock protein synthesis and HSP 70 RNA accumulation during postimplantation rat embryogenesis.

Exposure of postimplantation rat embryos on days 9, 10, 11, and 12 of gestation to an in vitro heat shock of 43 degrees C for 30 min results in the induction of heat shock proteins (HSPs) in day 9 and 10 embryos, a severely attenuated response in day 11 embryos, and no detectable response in day 12 embryos. The heat shock response in day 9 embryos (presomite stage) is characterized by the synthesis of HSPs with molecular weights of 28-78 kDa. In heat shocked day 10 embryos, two additional HSPs are induced (34 and 82 kDa). In addition, two HSPs present on day 9 are absent on day 10. In day 11 heat shocked embryos, only three HSPs (31, 39, and 69 kDa) are induced, while in day 12 embryos no detectable HSPs are induced. Northern blot analysis of HSP 70 RNA levels indicates that the accumulation of this RNA, but not actin RNA, varies depending on developmental stage at the time of exposure to heat as well as the duration of the heat shock. Day 9 embryos exhibit the most pronounced accumulation of HSP 70 RNA while embryos on days 10-12 exhibit an increasingly attenuated accumulation of HSP 70 RNA, particularly after the more acute exposures (43 degrees C for 30 or 60 min). Thus, the ability to synthesize HSP 70 and to accumulate HSP 70 RNA changes dramatically as rat embryos develop from day 9 to day 12 (presomite to 31-35 somite stages).