Histological and macroscopic changes in the pelvic pouch: long-term follow up after restorative proctocolectomy for ulcerative colitis (UC).

OBJECTIVE: Our aim was to evaluate macroscopic and histological (inflammatory) changes in ileal pouch mucosa after restorative proctocolectomy with J-pouch-ileoanal anastomosis for UC during long-term follow up. PATIENTS AND METHODS: Thirty-six (56%) out of 64 consecutive patients operated at our Institute during 1985-90 underwent endoscopy of the reservoir in the years 1994 and 1998. Functional outcome and macroscopic changes were recorded and histological samples taken from the three levels of the pelvic pouch. Acute and chronic inflammation were graded in accordance with a well-established histopathologic scoring system. RESULTS: The functional outcome was unchanged in 26 (72%), became worse in eight (22%) and better in two (6%) cases during follow up. The number of macroscopic changes increased during follow up and there was a tendency for them to become more common in the distal pouch. Microscopic acute and chronic inflammation decreased during follow up. There were more severe inflammatory changes in the distal pouch. Both acute and chronic inflammatory scores were higher through the reservoir in the cases of chronic pouchitis. Chronic pouchitis occurred more often in males. CONCLUSION: Macroscopic and inflammatory changes in the pelvic pouch seem to have separate progress during long-term follow up. In chronic pouchitis both acute and chronic inflammation are pronounced and spread over the entire pelvic pouch mucosa.

Ileal pouch-anal anastomosis operation in children versus adults.

BACKGROUND AND AIMS: To evaluate early results of elective ileal pouch-anal operations in children under the age of fifteen as compared to adult patients operated during the same period by the same surgical team. MATERIAL AND METHODS: Eighty-two patients with ulcerative colitis underwent restorative proctocolectomy during a six-year period, 1991-1996. Twelve of them (16%) were under the age of 15 years. Peroperative and short term postoperative morbidity were compared between the two groups. RESULTS: Covering loop ileostomy was performed on one patient in the juvenile group and 5 (7%) in the adult group. There were no significant differences in postoperative complications between the two groups. Eight (11%) leakages occurred in the adult group as compared to none in the juveniles. The children had a higher incidence of unexplained postoperative fever (50% versus 21%). Seven adults (10%) but no children underwent re-operation for these early complications. CONCLUSIONS: It would appear that a team of experienced gastroenterologic surgeons can operate children as well as adults for ulcerative colitis with comparable early results without additional morbidity.

Functional results of anterior levatorplasty and external sphincter plication for faecal incontinence.

BACKGROUND AND AIMS: The aim of this study was to assess results of anterior levatorplasty combined with external anal sphincter plication for faecal incontinence. MATERIAL AND METHODS: The study involved 44 female patients, 27 with idiopathic and 17 with traumatic faecal incontinence. All underwent anterior levatorplasty and external sphincter plication in our institution between 1986 and 1997. The patients were followed up clinically for a mean 12 (range 2-54) months and 39 (89%) patients also underwent pre-and postoperative anal manometry. RESULTS: In the idiopathic group 5 patients (19%) estimated that the result of the operation had been good and another 18 (67%) reported feeling better than before; the corresponding figures in the traumatic group were 4 (24%) and 10 (59%). The Wexner incontinence score decreased significantly after the operation in both groups. Nineteen patients (70%) in the idiopathic and 14 (82%) in the traumatic group showed improvement of one or more scores on the Kirwan scale. Three patients regained continence completely, one in the traumatic and two in the idiopathic group. There were no significant improvements in mean resting anal pressure or functional anal canal length in either group. Mean squeeze pressure improved significantly only in the traumatic group. CONCLUSIONS: Although the results of anterior levatorplasty combined with external sphincter plication are not perfect, the approach seems to be a valuable alternative in the treatment of patients with idiopathic or traumatic faecal incontinence. Complete continence is seldom achieved, but the grade of incontinence is reduced in the majority of patients.

Eleven years' experience of postoperative morbidity and trends in handsewn ileo-anal anastomosis with pelvic J-pouch for ulcerative colitis.

BACKGROUND AND AIMS: Restorative proctocolectomy with mucosectomy and handsewn J-pouch-anal anastomosis is the curative operation of choice for ulcerative colitis. The aim of this study was to determine frequencies of various complications at perioperative time (within 30 days after surgery) with this operative method. We also evaluated the chances of failure of this restorative operation and the trends in operative management. MATERIAL AND METHODS: Evaluation was based on a register containing data on all patients operated for ulcerative colitis at our department since the beginning of 1985. Statistical analysis was made for all adult patients (over 18 years) who underwent an operation for ulcerative colitis during the 11 years' time period. RESULTS: A total of 170 adult patients underwent an elective operation for ulcerative colitis between March 1985 and December 1995. In 154 cases a restorative procedure was intended. In 142 (92%) cases this proved possible, and in 136 of these a handsewn J-pouch-anal anastomosis was created. The chance of failure in the restorative operation was higher in men (p = 0.0314). During the latter five years' period IAA operations were performed more often as a second-stage procedure. Uneventful recovery was reported in 62 (45.5%) cases. One or more complications were encountered in 74 (55.1%) patients. Corticosteroid treatment did not affect leakage frequency. In spite of the high morbidity there were no perioperative deaths.

Fibrin glue in perianal fistulas--a pilot study.

BACKGROUND AND AIMS: Anal fistula surgery is associated with considerable morbidity, mainly related to anal incontinence. As promising results of the use of fibrin glue in the treatment of complex anal fistulas were recently shown, we planned to do a randomized trial comparing the use of fibrin glue and surgery in the treatment of perianal fistulas. There were no reports of the use of fibrin glue in the management of previously untreated anal fistulas. MATERIAL AND METHODS: Prior to the planned study a pretrial pilot series of 10 patients with different perianal fistulas were treated. Informed consent was obtained from every patient. Under spinal anesthesia, the fistula track was identified and brushed to remove granulous tissue, then washed with hydrogen peroxide and thereafter filled with fibrin glue. RESULTS: We performed fibrin gluing on 10 patients with perianal fistulas of different etiology and type. The gluing was done once to 7 patients, twice to 2 and three times to one patient. In all but one patient the fistula and symptoms recurred after only one month. One patient with a low trans-sphincteric fistula of which the internal opening was not found, was symptom-free for 6 months. At the one-month follow-up visit the external opening of the fistula was almost unidentifiable, suggesting that the fistula had healed. However, due to recurrence fistulotomy was performed after 6 months. CONCLUSIONS: Fistulas around the anus, with or without associated inflammatory bowel disease, do not seem to heal after fibrin gluing.

Functional results of operative treatment of rectal prolapse over an 11-year period: emphasis on transabdominal approach.

PURPOSE: A variety of surgical procedures have been developed to treat rectal prolapse, but there is still no consensus on the operation of choice. The aim of this study was to evaluate the functional results of operative treatment of rectal prolapse during an 11-year period in our department. METHODS: All patients treated for complete rectal prolapse during an 11-year period, from 1985 to 1995, in a single university hospital were included. Of the 123 patients, 22 were men, and the mean age was 59 (range, 15-88) years. The medical records of all patients were reviewed retrospectively, and a questionnaire on bowel symptoms before and after surgery was sent to all 95 living patients. RESULTS: The majority of the procedures (91 percent) were performed by abdominal approach, and the most frequently used open technique was posterior rectopexy with mesh (78 percent). Of the incontinent patients, 35 (63 percent), all those less than 40 years of age and 64 percent of those 40 years or older, were continent postoperatively (P = 0.0001) after a median follow-up of five (range, 1-72) months. According to the questionnaire, after a median follow-up of 85 (range, 16-144) months, only 38 percent of the incontinent patients in the mesh or suture group, 78 percent of patients less than 40 years of age (n = 18), and 52 percent of those 40 years or older (n = 47) claimed to be continent postoperatively. The proportion of patients with constipation was greater after the operation than preoperatively (P = 0.02) and more patients used medication for constipation after than before the operation (P = 0.0001). The overall complication rate was 15 percent, and the mortality rate was 1 percent (1/123). In the mesh or suture group there were 6 (6 percent) recurrent complete prolapses and 11 (12 percent) mucous prolapses. CONCLUSION: Posterior rectopexy with mesh gave good results in our hands. Older age and longer follow-up seem to have a negative effect on the functional outcome of the operation and on the recurrence rate.

Ileal J-pouch--anal anastomosis, sexual dysfunction, and fertility.

BACKGROUND: Our aim was to establish what kind of changes take place in sexual functions after restorative proctocolectomy and ileoanal anastomosis with J-pouch (IAA) and whether the operation alters fertility. METHODS: One hundred and ten consecutive patients who underwent IAA operation for ulcerative colitis at our institute were sent a questionnaire after at least 2 years' follow-up with special emphasis on sexual functions. Analysis was made by an independent researcher. RESULTS: Ninety-five patients (86.7%) responded to the questionnaire. The mean follow-up of the patients was 71.5 months (range, 30-128 months). The median age of the 51 women in this study was 39.0 years (range, 23-74 years). Dyspareunia increased after the operation, but sexual satisfaction improved. The operation seems to reduce fertility slightly in women, and the rate of spontaneous abortion may be higher than in the normal population. The median age of the men was 43.0 (25-69) years. One (2.3%) case of retrograde ejaculation and six (14.6%) cases of erectile function problems were reported after the operation. The fear of leakage during coitus were reduced. CONCLUSIONS: Sexual satisfaction is improved after operation, mainly due to improved general health, despite minor disturbances in sexual function. There may be a risk of decreased fertility after restorative proctocolectomy.

Chronic inflammatory changes in the pouch mucosa are associated with cholangitis found on peroperative liver biopsy specimens at restorative proctocolectomy for ulcerative colitis.

BACKGROUND: The clinical syndrome of primary sclerosing cholangitis (PSC), diagnosed in about 5% of patients with ulcerative colitis (UC), has been shown to be associated with pouchitis after ileal pouch-anal anastomosis. The aim of this study was to ascertain whether UC patients with cholangitis on liver biopsy at proctocolectomy, with or without the clinical syndrome of PSC, have an increased risk of inflammatory changes in the ileal reservoir mucosa and clinical pouchitis. METHODS: Of the consecutive 81 UC patients treated with restorative proctocolectomy with ileal J reservoir at Tampere University Hospital between 1985 and 1991, 73 with peroperative liver biopsy were included. A peroperative liver biopsy was obtained during proctocolectomy. After a median follow up of 64 months, pouch biopsy specimens were obtained. Periods of clinical pouchitis were diagnosed by means of clinical criteria alone or by clinical criteria combined with the results of previous pouch endoscopies in all patients. RESULTS: Ten patients (14%) showed histologic features consistent with small-duct PSC on liver biopsy. Endoscopic retrograde cholangiography had previously been performed on four of these patients, and all four had large-duct PSC. Patients with cholangitis had significantly more severe chronic, but not acute, inflammation in the pouch mucosa than patients without cholangitis. At least one episode of pouchitis occurred in 30% of the patients without cholangitis as compared with 90% of the patients with cholangitis. Chronic pouchitis was more frequent in the group with cholangitis than in the group without it (70% versus 11%). CONCLUSIONS: The only means of detecting all UC patients with cholangitis is a liver biopsy. Cholangitis, either with the clinical syndrome of PSC or found on liver biopsy, seems to be a risk factor for chronic-type inflammatory changes in the pouch mucosa and for the development of pouchitis.

Y-V anoplasty combined with internal sphincterotomy for stenosis of the anal canal.

OBJECTIVE: To review the results of Y-V anoplasty combined with internal sphincterotomy in the treatment of anal stenosis. DESIGN: Retrospective study. SETTING: University hospital, Finland. SUBJECTS: 10 patients with stenosis of the anal canal. MAIN OUTCOME MEASURES: Improvement of symptoms and function. RESULTS: Nine patients improved postoperatively. Six of the patients had good results, three had fair results and one had a poor result. There were no postoperative complications. CONCLUSION: Y-V anoplasty combined with internal sphincterotomy is a safe and simple procedure that gives good results. We recommend its use to treat stenosis of the anal canal.

Castleman's disease of the mesentery in a child: a case of seven years' duration without typical X-ray findings.

This report describes a 9-year-old boy with intermediate variant type of giant lymph node hyperplasia or Castleman's disease (CD) originating from the mesentery. He had symptoms and signs related to the disease for seven years before the final diagnosis. The patient's general condition remained good, except for periods of fever and abdominal pain. Pallor and slow growth were the only abnormal findings on physical examination during the follow-up. Laboratory measurements showed worsening microcytic anemia, low serum iron level, and low iron stores in bone marrow samples. The erythrocyte sedimentation rate (ESR) increased to 110 mm/h, and the serum levels of C-reactive protein varied between 80 and 120 mg/l. The level of serum albumin was low, 25-28 g/l, and serum immunoglobulin G was somewhat elevated, varying between 17-13 g/l. The radiologic examination of intenstine gave pathological results suggesting a small bowel disease, but no tumor was detected. The abnormal laboratory values and symptoms of the patient resolved completely after surgical removal of the mass.

Frequency of hereditary nonpolyposis colorectal cancer. A prospective multicenter study in Finland.

PURPOSE: Hereditary nonpolyposis colorectal cancer (HNPCC) is an autosomal dominant cancer syndrome characterized by early onset of colorectal carcinomas (CRC). Recently, two HNPCC genes have been mapped and cloned, one in the short arm of chromosome 2 and another in the short arm of chromosome 3. There has been a major controversy about the frequency of HNPCC. The few estimates available have been based on series selected by age or series representing local area. The purpose of the present study was to design a nonselected, prospective, multicenter study, taking into account the family background and other risk factors of CRC. METHODS: The proportion of HNPCC of all (N = 406) CRC cases was evaluated in a prospective multicenter study. Family history and other risk factors were investigated over a 12-month period for all new CRC patients in ten hospitals. These cases constituted 23 percent of all CRCs diagnosed in Finland during the study period. RESULTS: Three (0.7 percent) cases of verified and seven (1.7 percent) cases of suspected HNPCC were identified, following the evaluation of all families with features indicative of susceptibility to cancer. The proportion of identifiable risk factors of CRC was 5.8-7.5 percent (HNPCC, 0.7-2.4 percent; previous CRC, 3.4 percent; ulcerative colitis, 1.0 percent; familial adenomatous polyposis coli, 0.7 percent). CONCLUSION. This prospective multicenter study revealed that the frequency of hereditary colorectal cancer is lower than in some previous studies, when diagnosis is based on extensive pedigree analysis. This result with recent findings of common ancestral founding mutation in Finnish HNPCC families indicates that there may be geographic differences in the occurrence of HNPCC. However, this does not change the fact that identification of HNPCC--perhaps one of the most common inherited diseases identified in humans--has become a question of vital importance now when diagnosis of the syndrome and large-scale screening of gene carriers using specific tests are on the horizon.

Does defecography help in diagnosis and clinical decision-making in defecation disorders?

Defecography is used to investigate patients with defecation disorders, especially obstructed defecation and anal incontinence. We studied 73 consecutive patients who complained of difficult defecation, anal incontinence, or idiopathic anorectal pain. The following defecographic parameters were recorded and compared in different patient groups: anorectal angulation, pelvic floor descent, formation of rectocele, and rectal invagination. Increasing number of childbirths correlated with pelvic floor descent in defecograms (r = 0.319, p < 0.05). There were no significant differences in defecographic parameters in patients with obstructed defecation, anal incontinence, or idiopathic anorectal pain. Thus, we conclude that defecography may be useful as an investigative tool in clinical research of defecation disorders, but it is of minor value in clinical diagnosis and decision-making.

Simplified solid sphere test to investigate anal sphincter strength in patients with anorectal diseases.

PURPOSE: The solid sphere test has not gained general acceptance to investigate anal sphincters, despite its simplicity and low cost. We studied continent and incontinent patients to evaluate whether the solid sphere test is suitable in assessment of anal sphincter function. METHODS: Seventy colorectal patients with anal incontinence of varying severity were studied by means of incontinence grading, solid sphere test, and anal manometry. RESULTS: Anal sphincter strength, studied using the solid sphere test, declined gradually with increasing severity of anal incontinence from 1,186 (+/- 334, SD) g in 28 continent patients to 619 (+/- 256, SD) g in 13 patients with daily soiling (P < 0.001). The test also correlated with anal manometry; there was positive correlation with maximum basal pressure (r = 0.643, P < 0.001) and maximum voluntary contraction pressure (r = 0.393, P < 0.01). CONCLUSION: The solid sphere test is useful in the primary assessment of patients with anal incontinence as a screening test, but alone it is too inaccurate for clinical decision making.

Parenteral single dose ceftriaxone with tinidatsole versus aminoglycoside with tinidatsole in colorectal surgery: a prospective single-blind randomized multicentre study.

A single dose preoperative antibiotic prophylaxis of ceftriaxone 2 g and tinidatsole 500 mg was compared with netilmycin (150 mg) or tobramycin (80 mg) in patients undergoing colorectal surgery by a prospective randomised single-blind trial. There were 628 patients from seven Finnish hospitals. The wound infection rate of 3% in the ceftriaxone group was significantly lower than 12% of the aminoglycoside group. Wound infection was related to the amount of perioperative blood loss, duration of the operation, type of operation and drainage in the aminoglycoside group. In the ceftriaxone group, wound infection was related to the patient's weight only.

Colonic volvulus. Diagnosis and results of treatment in 82 patients.

OBJECTIVE: To test the accuracy of initial diagnosis of colonic volvulus and the results of different treatment regimens. DESIGN: Retrospective population based study. SETTING: Tampere University Hospital (major referral center). SUBJECTS: All patients who presented with colonic volvulus from 1973-1990, 58 patients had sigmoid, 23 caecal and one had transverse colonic volvulus. MAIN OUTCOME MEASURES: Findings of endoscopic or operative treatment compared with the clinical diagnosis and plain abdominal radiographs. Association between treatment and risk factors. RESULTS: Diagnosis was difficult, despite some differences in clinical presentation. Gangrenous bowel was diagnosed only at operation, although caecal volvulus with gangrenous bowel was associated with a high white cell count. In 23 patients with caecal volvulus both right hemicolectomy (n = 11) and tube caecostomy (n = 7) were successful with one death after each procedure and no recurrences. In sigmoid volvulus, resection (n = 19) and detorsion with or without sigmoidopexy (n = 21) resulted in similar numbers of complications and deaths (6 and 4, and 5 and 3, respectively), though recurrences were more common after detorsion (1 (5%) compared with 5 (24%)). Endoscopic decompression was tried in 30 and was successful in 26 cases; it was the only treatment in 17/58 patients, with two deaths (12%) and five recurrences (29%). The overall mortality was 15%, but this was associated more with neuropsychiatric diseases, old age, and residence in mental or nursing homes than with gangrene of the bowel. CONCLUSIONS: Poor diagnostic accuracy is a problem. Caecal volvulus can be safely treated by resection or tube caecostomy. Sigmoid volvulus is best treated by endoscopic detorsion followed by operation in otherwise fit patients. Mortality is associated with neuropsychiatric diseases and old age.

Anal dilatation, lateral subcutaneous sphincterotomy and haemorrhoidectomy for the treatment of second and third degree haemorrhoids. A prospective randomized study.

Patients with second or third degree haemorrhoids were randomized for treatment by anal dilatation, lateral subcutaneous sphincterotomy or haemorrhoidectomy. The patients were studied by means of proctoscopy, anal manometry and symptom grading preoperatively, two months and one year after the procedure. After one year, more than half of the patients were symptomless in each treatment group. Both anal dilatation and sphincterotomy gave poor results in 25% of the patients, compared with 9% after haemorrhoidectomy. Young age was related to good results in anal dilatation or sphincterotomy, but not in haemorrhoidectomy. Results of anal dilatation and sphincterotomy in treating haemorrhoids are unpredictable, so they cannot be recommended as routine procedures. Maximal basal pressure was reduced after all three procedures, but neither the preoperative nor postoperative anal pressures were able to predict the result of the different treatment techniques.

Changes in biliary bacteria after endoscopic cholangiography and sphincterotomy.

This prospective study consisted of 32 patients. In each patient, bile was collected during two separate endoscopic retrograde cholangiopancreatographies (ERCP) to study changes in biliary bacteriology and cytology. The mean interval between ERCPs was 20 months (15-29 months). Twenty-three patients had gallstones in the gallbladder, bile ducts, or both. Nineteen of them had bactibilia compared to none of the 9 patients with normal ERCP (P less than 0.001). Fifteen patients had normal bile ducts in ERCP (Group 1). Four of these patients (27%) had bactibilia initially and 9 (60%) at follow-up (P = 0.069). Seventeen patients had bile duct stones and underwent endoscopic sphincterotomy (Group II). Fifteen of these patients (88%) had bactibilia initially, and 15 (88%) also had bactibilia at follow-up. Initially, anaerobic bacteria were detected in 37 per cent of Group I patients with bactibilia and in 50 per cent of Group II patients with bactibilia. At follow-up, the bile in Group I patients infrequently (11%) contained anaerobes, whereas in Group II patients anaerobes predominated (67%; P less than 0.011). Clear correlation between the biliary cytology and bacteriology could not be observed. The authors conclude that ERCP may result in increased incidence of long-term bactibilia and suggest that contamination occurred during ERCP. The bactibilia associated with bile duct stones does not subside after endoscopic treatment of the common duct stones.

Improvement of continence after abdominal rectopexy for rectal prolapse.

Twenty-seven patients with rectal prolapse and faecal incontinence were treated by abdominal rectopexy. They were studied clinically and by anal manometry both pre- and postoperatively. Postoperatively eleven patients gained full continence, eight had incontinence for flatus, six were incontinent for liquid stools and only two had daily soiling--none was totally incontinent. Those patients who gained continence had significantly higher maximal basal pressure (MBP) (p less than 0.05) postoperatively as compared to those who remained incontinent. There was an inverse correlation between MBP and grade of postoperative incontinence (p less than 0.02). The postoperative increase of MBP correlated (p less than 0.05) with improving incontinence score. Such changes did not occur with the maximal voluntary contraction pressure (MVCP). Our results suggest that functional recovery of the internal anal sphincter is better in postoperatively continent patients.