Peptide YY release after colectomy in slow transit constipation.

BACKGROUND: The gut hormone peptide YY is abundant in the colonic mucosa. Circulating PYY inhibits gastrointestinal motility and decreases food intake. The aim was to determine whether colectomy decreases PYY release in patients with slow transit constipation. METHODS: Plasma PYY concentrations were measured in 10 patients with slow transit constipation before and 3-24 months after total abdominal colectomy with ileorectal anastomosis, and in 8 healthy controls. A liquid meal was infused intraduodenally to stimulate PYY release. RESULTS: Postprandial PYY significantly (P < 0.05) increased from a basal value of 15.6 +/- 1.8 pM to a peak of 71.2 +/- 11.6 pM after colectomy. Basal and postprandial plasma PYY concentrations were not significantly different from the results before surgery. Fasting, but not postprandial, plasma peptide YY after colectomy was significantly higher than that in healthy volunteers, 10.9 +/- 0.9 pM. CONCLUSION: Despite removal of a major source of PYY-secreting cells, colectomy with ileorectal anastomosis does not induce major impairment of PYY release in slow transit constipation.

Therapeutic immune reconstitution in HIV-1-infected children is independent of their age and pretreatment immune status.

OBJECTIVE: To evaluate long-term immune reconstitution of children treated with highly active antiretroviral therapy (HAART). METHODS: The long-term immunological response to HAART was studied in 71 HIV-1-infected children (aged 1 month to 18 years) in two prospective, open, uncontrolled national multicentre studies. Blood samples were taken before and after HAART was initiated, with a follow-up of 96 weeks, and peripheral CD4 and CD8 T cells plus naive and memory subsets were identified in whole blood samples. Relative cell counts were calculated in relation to the median of the age-specific reference. RESULTS: The absolute CD4 cell count and percentage and the CD4 cell count as a percentage of normal increased significantly (P < 0.001) to medians of 939 x 106 cells/l (range, 10-3520), 32% (range, 1-50) and 84% (range, 1-161), respectively, after 48 weeks. This increase was predominantly owing to naive CD4 T cells. There was a correlation between the increase of absolute naive CD4 T cell counts and age. However, when CD4 T cell restoration was studied as percentage of normal values, the inverse correlation between the increase of naive CD4 T cell count and age was not observed. In addition, no difference in immunological reconstitution was observed at any time point between virological responders and non-responders. CONCLUSIONS: Normalization of the CD4 cell counts in children treated with HAART is independent of age, indicating that children of all age groups can meet their CD4 T cell production demands. In general, it appears that children restore their CD4 T cell counts better and more rapidly than adults, even in a late stage of HIV-1 infection.

[Gastrointestinal surgery and gastroenterology. XI. Stomas and stoma surgery]. / Gastro-intestinale chirurgie en gastro-enterologie. XI. Stomata en stomachirurgie.

Stomas are an essential part of gastrointestinal surgery. Indications for stoma construction are faecal diversion from a distal diseased bowel segment, prevention of an intestinal anastomosis in intra-abdominal sepsis, and faecal incontinence. Pre- and postoperative counselling and nursing care is essential for a good functional outcome. Following stoma construction, complications such as dermatitis, retraction, prolapse, stenosis and parastomal hernia occur in 30-60% of cases. Thirty percent of stomas need surgical re-intervention in the first 10 years. For diversion of a distal anastomosis, construction of a loop-ileostomy is preferred to a loop-colostomy. Closure of a temporary stoma should not be done within eight weeks of construction. Preoperative evaluation of the distal segment is mandatory. Stoma closure involves an intra-abdominal anastomosis with all its associated complications. The incidence of complications after stoma closure is about 10%.

Effects of rectal mobilization and lateral ligaments division on colonic and anorectal function.

PURPOSE: Colonic and anorectal function are altered after posterior rectopexy. The aim of this randomized, prospective study was to evaluate the effects of rectal mobilization and division of the lateral ligaments on colonic and anorectal function. METHODS: Posterior rectopexy was performed in 18 patients with complete rectal prolapse. Anal manometry and measurement of rectal compliance, total and segmental colonic transit time, constipation score, and defecation frequency were performed preoperatively and three months postoperatively. Ligaments were divided in ten patients. RESULTS: Mean preoperative total transit time was similar between the two patient groups and doubled postoperatively (P = 0.03). Mean postoperative segmental transit time increased by a factor of 1.7 in segments I (ascending colon) and II (descending colon) and by a factor of 2.3 in segment III (rectosigmoid). The same pattern was found in both groups. Mean resting pressure decreased after division of the lateral ligaments and increased after preservation. Mean rectal compliance decreased after division of the ligaments and increased when they were preserved. Mean postoperative constipation score differed little from the preoperative score. Mean defecation frequency was decreased in the group with the ligaments preserved and increased in the group with the ligaments divided. None of the effects of rectal mobilization or division of the lateral ligaments on anorectal function reached statistical significance. CONCLUSION: Rectal mobilization had a statistically significant effect on colonic function. Total and segmental colonic transit times doubled. The effects on anorectal function were not significant. Division of the lateral ligaments did not significantly influence postoperative functional outcome.

Cumulative risk of developing polyps or malignancy at the ileal pouch-anal anastomosis in patients with familial adenomatous polyposis.

Restorative proctocolectomy with an ileal pouch-anal anastomosis is performed in an increasing number of patients with familial adenomatous polyposis (FAP). Two techniques are currently used to construct an ileal pouch-anal anastomosis: (1) a double-stapled anastomosis between the pouch and the anal canal and (2) mucosectomy with a hand-sewn ileoanal anastomosis at the dentate line. Although this procedure is thought to abolish the risk of colorectal adenoma, an increasing number of case reports have been published concerning the development of adenoma at the anastomotic site. The purpose of this study was to evaluate the overall cumulative risk of developing adenomatous polyps after ileal pouch-anal anastomosis and to compare the cumulative risk after either anastomotic technique. A total of 126 consecutive FAP patients undergoing a restorative proctocolectomy were identified from polyposis registries in The Netherlands, Denmark, Italy, Germany, and New York. Life-table analysis was used to calculate the cumulative risk of developing polyps in 97 patients with at least 1 year of endoscopic follow-up (median 66 months, range 12 to 188 months). A double-stapled anastomosis was used in 35 patients, whereas in 62 patients a hand-sewn anastomosis with a mucosectomy was performed. In 13 patients polyps developed at the anastomotic site, four with severe and four with moderate dysplasia. None of the patients developed a carcinoma at the anastomotic site. The cumulative risk of developing a polyp at the anastomotic site was 8% (95% confidence interval 2% to 14%) at 3.5 years and 18% (95% confidence interval 8% to 28%) at 7 years, respectively. The risk of developing a polyp at the anastomotic site within 7 years was 31% for patients with a double-stapled vs. 10% for patients with a hand-sewn anastomosis with mucosectomy (P = 0.03 [log-rank test]). Because FAP patients undergoing a restorative proctocolectomy with either a double-stapled or hand-sewn anastomosis have a substantial risk of developing adenomatous polyps at the anastomotic site, lifelong endoscopic surveillance is mandatory in both groups.

Impaired release of peptide YY in patients with proctocolectomy and ileal pouch-anal anastomosis.

BACKGROUND: Peptide YY (PYY) is a gut hormone produced by endocrine cells in the distal small bowel, colon, and rectum. PYY inhibits upper gastrointestinal secretory and motor functions. The aim of this study was to determine whether basal and postprandial plasma PYY levels in patients with proctocolectomy and ileal pouch-anal anastomosis (IPAA) are reduced and to determine the relationship between plasma PYY and plasma cholecystokinin (CCK) levels. METHODS: Plasma concentrations of PYY and CCK were measured before and after ingestion of a standardized breakfast in 14 IPAA patients and in 12 healthy control subjects. RESULTS: Basal PYY was slightly lower in the IPAA patients than in the controls (8.3 +/- 0.3 versus 9.3 +/- 1.1 pM; not significant). Ingestion of the meal induced a small but significant increase of PYY to a maximum of 10.9 +/- 0.9 pM in patients. Integrated postprandial PYY was markedly reduced in patients when compared with the controls (1725 +/- 66 pM*180min versus 3194 +/- 480 pM*180 min; P < 0.005). Plasma PYY concentrations were inversely correlated with plasma CCK concentrations in the 2nd and 3rd h after the meal (r = -0.86; P = 0.0001). CONCLUSION: PYY release in response to meal ingestion is markedly reduced but not completely absent in patients with proctocolectomy and ileal pouch-anal anastomosis. The inverse relationship between circulating PYY and CCK in the late postprandial phase is compatible with a negative feedback regulation of CCK release by endogenous PYY.

Small bowel obstruction after total or subtotal colectomy: a 10-year retrospective review.

BACKGROUND: The aim of this retrospective study was to determine the cumulative incidence of adhesive small bowel obstruction (SBO) after total or subtotal colectomy and to investigate the site of the obstructive adhesions in the abdominal cavity. METHODS: The records of 234 patients who underwent colectomy from 1985 to 1994 were reviewed for SBO, potential risk factors for SBO, and the site of adhesions causing obstruction. Mean follow-up, which was complete in 215 patients, was 63 months. RESULTS: SBO occurred in 56 patients (24 per cent) of whom 42 (18 per cent) had adhesive obstruction. The risk of SBO due to adhesions within 1 year was 11 per cent, increasing to 30 per cent 10 years after colectomy. With univariate analysis no risk factor for adhesive SBO, including previous laparotomies, septic complications and omental resection, was identified. The most common site of obstructing adhesions was the pelvis (ten of 28 patients). CONCLUSION: The incidence of SBO after colectomy is high. Colectomy may be a suitable model for studies of adhesion prevention.

[Measurement of colon transit time useful in the evaluation of functional constipation]. / Meting van colonpassagetijd nuttig bij de evaluatie van functionele obstipatie.

OBJECTIVE: To determine the colon transit time (CTT) in patients complaining of functional constipation and the correlation between abnormal transit times and the types of constipation and of the symptoms. DESIGN: Retrospective, descriptive. SETTING: Department of Surgery, University Hospital, Nijmegen, the Netherlands. METHOD: The signs and symptoms of 112 patients with infrequent or difficult defaecation, 93 (83%) of them women, with a median age of 42 years (range: 16-72), were recorded by means of a questionnaire. After ingestion of radiopaque markers per day for 10 days, an abdominal survey X-ray was made on day 11. The numbers of markers in the X-ray and per segment (right and left hemicolon and rectosigmoid) were counted; the CTT in hours was calculated by multiplying this number by 2.4. Slowness was defined as more than 45 h for the total CTT and as more than 15 h for the segmental CTT. RESULTS: The total CTT was normal in 33 patients (29%) and prolonged in 79 (71%). The CTT was prolonged only in the rectosigmoid in 14 patients with a normal CTT (42%) and in 50 patients with a prolonged total CTT (63%). Of the patients with a normal total CTT, 13 (39%) had a normal segmental CTT. No statistically significant correlation could be demonstrated between the presence of any symptom and a prolonged CTT. CONCLUSION: Functional constipation may be associated with a normal CTT. Disorders of colonic motility and of rectal evacuation could be distinguished by measuring the total and the segmental colonic transit times.

Pelvic floor procedures produce no consistent changes in anatomy or physiology.

PURPOSE: Postanal repair was designed to restore both anatomy and function of the anal canal in neurogenic fecal incontinence. In most series, the degree of continence is improved in fewer than 50 percent of patients. Adding anterior levatorplasty and sphincter plication (total pelvic floor repair) is claimed to improve functional results. We performed a randomized trial comparing postanal and total pelvic floor repair for neurogenic incontinence. METHOD: Twenty female patients were studied. All had Type D incontinence (Parks and Browning). Anal manometry, defecography, and grading of the degree of continence were repeated 12 weeks after surgery to assess changes in clinical, manometric, and radiologic parameters. Statistical analysis was done using Wilcoxon's signed-rank test and Wilcoxon's two-sample test. RESULTS: Continence improved in eight patients. Differences among clinical, manometric, and radiologic data were not statistically significant. CONCLUSION: Pelvic floor repair procedures produce no consistent changes in anatomy or physiology. Clinical improvement is caused by creation of a local stenosis or by the placebo effect rather than by improvement of muscle function.

Influence of Parks' anal retractor on anal sphincter pressures.

PURPOSE: The effects of the Parks' anal retractor on anal sphincter function were studied in a prospective, randomized trial. A closed hemorrhoidectomy was performed intra-anally in 20 patients using the Parks' anal retractor; in 20 other patients, the procedure was done perineally without the use of a retractor. METHODS: Anal manometry was performed before and at 6 and 12 weeks after hemorrhoidectomy. RESULTS: Mean squeeze pressure decreased by 4 percent whether or not a retractor was used. Mean resting pressure decreased by 23 percent after use of Parks' anal retractor (P = 0.01) compared with 8 percent when it was not used (P > 0,05). CONCLUSIONS: The internal anal sphincter is easily damaged with the use of the Parks' anal retractor. When possible, its use should be avoided to obtain better manometric and functional results.

The evaluation and treatment of functional constipation.

Constipation and defecation may be considered as the last taboo. The inability to defecate or to achieve this only by digital evacuation has never been a popular topic among patients and doctors. Application of tests from the colorectal laboratory has made it possible to study the function of the different parts of the colon and the mechanism of continence. We consider transit studies, defecography, EMG, and anal manometry, all useful as diagnostic procedures for functional constipation. Several causes of functional constipation can be distinguished in slow transit and difficult evacuation or colonic inertia, spastic pelvic floor syndrome, rectocele and intussusception. This article presents our view of the assessment and management of functional constipation.

Biofeedback treatment is ineffective in neurogenic fecal incontinence.

PURPOSE: This study was undertaken to assess biofeedback treatment (active sphincter exercises under direct electromyography vision) in neurogenic fecal incontinence. METHODS: Twelve patients with neurogenic fecal incontinence have been studied prospectively. External sphincter contractions were exercised under direct electromyographic vision twice per day for 30 minutes during 12 weeks. Manometry was done at the beginning and after 12 weeks of training to evaluate objectively changes in sphincter functions. RESULTS: No patient experienced any improvement in fecal control. Mean resting pressure increased from 7 to 9 kPa and mean squeeze pressure from 3.9 to 4.9 kPA, which was of no statistical significance (P = 0.20 and P = 0.46, respectively). CONCLUSIONS: External sphincter contraction exercises under direct electromyographic vision are not effective in neurogenic fecal incontinence. Degree of continence does not improve, and external sphincter function is not increased significantly.

Molecular genetic tests as a guide to surgical management of familial adenomatous polyposis.

BACKGROUND: In familial adenomatous polyposis the only curative treatment is colectomy, and the choice of operation lies between restorative proctocolectomy (RPC) and colectomy with ileorectal anastomosis (IRA). The RPC procedure carries a higher morbidity but, unlike IRA, removes the risk of subsequent rectal cancer. Since the course of familial adenomatous polyposis is influenced by the site of mutation in the polyposis gene, DNA analysis might be helpful in treatment decisions. METHODS: We evaluated the incidence of rectal cancer in polyposis patients who had undergone IRA, and examined whether the requirement for subsequent rectal excision because of cancer or uncontrollable polyps was related to the site of mutation. FINDINGS: Between 1956 and mid-1995, 225 patients registered at the Netherlands Polyposis Registry had undergone IRA. In 87 of them, a pathogenetic mutation was detected. 72 patients had a mutation located before codon 1250 and 15 patients after this codon. The cumulative risk of rectal cancer 20 years after surgery was 12%, and at that time 42% had undergone rectal excision. The risk of secondary surgery was higher in patients with mutations in the region after codon 1250 than in patients with mutations before this codon (relative risk 2.7, p < 0.05). INTERPRETATION: On this evidence, IRA should be the primary treatment for polyposis in patients with mutations before codon 1250, and RPC in those with mutations after this codon.

Sphincter-saving surgery for rectal and colorectal disorders.

BACKGROUND: Restoration of intestinal continuity by anal anastomosis after sphincter-saving rectal excision is feasible from an oncological, technical and functional standpoint. We present our experience. METHODS: The records of 223 patients with an anal anastomosis were reviewed. The anal anastomosis was performed hand-sutured transanally in 92 patients and double-stapled transabdominally in 131 patients. Coloanal anastomosis was performed in 39 patients and ileoanal pouch anastomosis in 184 patients. RESULTS: Operation time, blood loss and admission times were considerably less after double-stapling anastomosis. Relevant complications occurred in 15% after coloanal anastomosis and in 35% after ileoanal pouch anastomosis, failure rate was similar (13%). Complication (7% vs 43%) and failure rate (2% vs 27%) were less after double-stapled anastomosis. Prednisone did not influence the failure rate whereas previous abdominal surgery did. CONCLUSIONS: The double-stapling technique gives less complications and better results although effects of a learning curve are undoubtedly present in this series. The technique makes a temporary diverting ileostomy superfluous. The double-stapling technique is to be preferred for anal anastomoses.

Internal rectal intussusception--fact or fancy?

PURPOSE: There is still considerable debate whether internal intussusception represents a functional disorder. We have reviewed our results in an effort to define its symptomatology and to assess defecography. METHODS: Rectopexy has been performed for internal intussusception in 37 patients. Eighteen had solitary rectal ulcer syndrome (SRUS), and 31 had anterior rectal wall prolapse. Defecography demonstrated anterior wall prolapse in 13, circular prolapse in 21, and no disorders in 3 patients. Pelvic floor function was normal. Follow-up varied from one to nine years. RESULTS: Twenty-six patients became asymptomatic. Anterior wall prolapses could not be palpated anymore. All SRUS lesions healed. Patients with SRUS (P < 0.001) or circular prolapse (P < 0.001) became significantly more asymptomatic. Results in patients with anterior rectal wall prolapse were significantly worse (P < 0.001). CONCLUSIONS: Internal intussusception is a distinct functional rectal disorder. Its symptomatology and findings during physical examination are aspecific. Characteristic defecographic features and presence of SRUS are indications for surgery, provided pelvic floor function during straining is normal.

Seton treatment of perianal fistula with high anal or rectal opening.

Staged fistulotomy with a seton is considered to decrease the high incidence of continence disorders after surgical incision of a fistula. This retrospective study reports the results of the two-stage procedure with special emphasis on faecal continence. Thirty-four patients (aged between 20 and 57 years) were treated between 1981 and 1990 with a two-stage seton procedure for anal fistula (16 extrasphincteric and 18 trans-sphincteric) with a high anal or rectal internal opening. Thirty-one patients had normal preoperative continence. There were two recurrences. All trans-sphincteric fistulas healed. Twenty-nine patients with preoperative normal faecal control were available for follow-up. Postoperative continence was normal in 12 patients (category A according to Browning and Parks classification2); five patients had no control over flatus (B), 11 were incontinent for liquid stool or flatus (C) and one had continued faecal leakage (D). The two-stage seton technique is not recommended for fistulas with high anal or rectal openings.

Pain in chronic pancreatitis.

Pain in chronic pancreatitis is usually so intense and long-lasting that follow-up care of patients is often difficult and frustrating. Many therapeutical options to relieve pain have been recommended, but controlled studies are limited. The approach to patients with chronic pancreatitis complicated by pain is dependent on several factors. Medical therapy is initially attempted, but a switch to drainage procedure shortly thereafter in patients with persistent pseudocysts or a dilated pancreatic duct. Lithotripsy and endoscopic removal of pancreatic duct concrements may reduce pain in selected patients with a limited number of stones and strictures. In many patients, however, a drainage procedure cannot be offered and advantages and disadvantages of a resection or denervation procedure should be weighed against long-term treatment with analgetics. Resections should be limited to the most affected part of the pancreas. Usually this concerns the head. In such cases, a Whipple resection is often carried out, but duodenum-preserving procedures may offer several advantages.

Postoperative and long-term results of ileal pouch-anal anastomosis for ulcerative colitis and familial polyposis coli.

The immediate postoperative and long-term functional results of 51 ulcerative colitis patients and 21 familial polyposis patients who underwent ileal J-pouch-anal anastomosis were compared in this study. The incidence of postoperative complications requiring reoperation was not statistically different in both groups. The mean daily stool frequency was significantly higher in colitis patients. Pouchitis occurred in 44% of colitis patients but not in polyposis patients (P < 0.005). Symptoms of pouchitis included bloody diarrhea, urgency, abdominal pain, weight loss, fever, and arthritis. Six colitis patients required pouch excision because of intractable pouchitis. The overall pouch excision rate was 22% in ulcerative colitis patients and 5% in familial polyposis patients. Patient satisfaction was good in 46% of ulcerative colitis patients and 76% of polyposis patients (P < 0.05). Our data demonstrate that the long-term outcome of ileal pouch-anal anastomosis is more favorable in polyposis patients than in colitis patients. Pouchitis is a major long-term complication occurring exclusively in colitis patients.

Functional constipation: results of application of the colorectal laboratory.

Constipation and defaecation may be considered as the last taboo. The inability of defaecate or to achieve this only by digital evacuation has never been a popular topic among patients and doctors. Application of tests from the colorectal laboratory has made it possible to study the function of the different parts of the colon and the mechanism of continence. Two types of constipation can be distinguished: I slow transit, which is probably a systemic disease, and 2 functional colonic outlet obstruction due to abnormal pelvic floor function during defaecation straining, which is likely to be a behavioural disorder. Since 30 per cent of the patients with constipation have a normal total colonic transit time, constipation is not merely related to a low frequency of defaecation, but should be defined as a difficult and painful rectal evacuation which may even be impossible over several days.