Stapled stricturoplasty for Crohn's disease. A new technique.

PURPOSE: Stricturoplasty was originally used to treat multiple fibrotic strictures of tuberculosis. As the pendulum of treatment of Crohn's disease swung toward conservatism and bowel preservation, stricturoplasty was performed in Crohn's disease. Stricturoplasty can be used when there is limited, well-localized disease and should be avoided in the presence of grossly inflamed or infected material. We describe a new technique of stricturoplasty. METHODS: Typically stricturoplasty is performed in a manner similar to a Heineke-Mikulicz pyloroplasty. A stapled stricturoplasty technique has been previously described, but in actuality these are more similar to a bypass procedure. Our technique uses a stapled, open technique similar to the triangulating method of bowel anastomosis. This was performed in one patient to correct six strictures. RESULTS: Our patient did well postoperatively and developed no significant complications. He has no evidence of recurrent strictures. CONCLUSION: We describe a stapled stricturoplasty technique that is truly a stricturoplasty because the bowel lumen is increased; it is similar to the triangulating method of end-to-end stapled bowel anastomosis. It is safe, efficient, and effective. Additionally, it allows radiographic location of the stricturoplasty site, thus allowing determination of effectiveness of the procedure as well as recurrence.

Early postoperative feeding.

PURPOSE: Our intent was to show that immediate postoperative feeding of a regular diet after elective colorectal surgery was safe, tolerable, and feasible. METHODS: This was a nonrandomized, prospective study of 38 consecutive patients who underwent elective colorectal surgery over a three-month period. Our study parameters included operative length of time, intraoperative blood loss, need for transfusions, day to flatus or defecation, ability to tolerate a diet, placement of nasogastric tubes postoperatively, and length of hospital stay. These patients were compared with patients treated by different surgeons during the same time period but fed only after return of bowel sounds or flatus. RESULTS: Thirty-one of 36 patients eventually included in this study were able to tolerate our early feeding regimen. There were a total of seven other complications that were minor and unrelated to the early feeding. Patients who tolerated early feeding had shorter postoperative length of stays, 5.7 vs. 10.6 days. Patients who tolerated early feeding had shorter length of stays than patients treated in a more conventional manner, 5.7 vs. 8.0 days. Those who did not tolerate early feeding had longer procedures and greater intraoperative blood loss. CONCLUSIONS: Early postoperative feeding is safe and is tolerated by the majority of patients. Early feeding, if tolerated, decreases length of hospital stay and may decrease health care costs. Longer operative time and increased blood loss intraoperatively may indicate a more difficult procedure and identify those patients who will not tolerate early feeding.

Characterization of uterine epithelium apoptotic cell death kinetics and regulation by progesterone and RU 486.

The authors show here that progesterone suppresses apoptosis, and its antagonist RU 486 induces it in rabbit uterine epithelium, as assessed by morphologic and biochemical studies. The authors' studies demonstrate that internucleosomal DNA fragments are identifiable as early as 24 hours after ovariectomy of pseudopregnant rabbits, and become undetectable 6 days after ovariectomy. Maximal levels of DNA fragmentation (about 74% of total isolated DNA) were observed 36 hours after ovariectomy. The number of apoptotic cells appeared to increase parallel to the increased DNA breakdown, and accounted for approximately 26% of the uterine epithelial cells at 48 hours after ovariectomy. Levels of progesterone in serum dropped precipitously 6 hours after ovariectomy and remained very low for several days. Administration of progesterone, more than any other steroid hormone, to pseudopregnant ovariectomized rabbits, prevented the increase in apoptotic cell death. By contrast, administration of the anti-progestin RU 486 to pseudopregnant rabbits triggered apoptosis, which attained levels similar to those observed in ovariectomized animals. The authors' findings establish that uterine epithelium apoptosis occurs in a time-dependent fashion and provides strong evidence that the actions of progesterone in that tissue are not only to stimulate cell proliferation and differentiation, but also to suppress apoptosis.

Coordinated regulation of apoptosis and cell proliferation by transforming growth factor beta 1 in cultured uterine epithelial cells.

Cell and tissue growth is regulated through a complex interplay of stimulatory and inhibitory signals. We describe two biological actions of transforming growth factor beta 1 (TGF-beta 1) in primary cultures of rabbit uterine epithelial cells: (i) inhibition of cell proliferation and (ii) a concomitant increase in cells undergoing apoptosis (programmed cell death). It is proposed that proliferation and apoptosis together comprise normal cell growth regulation.

Estradiol-17 beta and progesterone regulate secretion of uteroglobin through different pathways.

Uteroglobin, the primary secretory protein of rabbit uterine epithelium, was localized by the direct immunoperoxidase method in uteri of control ovariectomized rabbits and of ovariectomized rabbits injected with progesterone or estradiol-17 beta. In control rabbits, staining for uteroglobin was almost entirely abolished six weeks after bilateral ovariectomy. Two days following progesterone injection of ovariectomized rabbits, intense staining for uteroglobin could be detected within the endoplasmic reticulum, Golgi complexes, and compact secretory vesicles of most endometrial epithelial cells. Estradiol-17 beta injection resulted in a different intracellular pattern of uteroglobin distribution. Two days following treatment with that steroid hormone, intense staining for uteroglobin was localized within large apical mucous droplets and moderate staining was present in the endoplasmic reticulum and Golgi complexes of these cells. The increased mucin content of the endometrial epithelium following treatment with estradiol-17 beta was confirmed by a periodic acid-Schiff histochemical reaction in the presence of diastase. Quantitation by radioimmunoassay of uteroglobin production in vitro by uterine fragment confirmed that progesterone had a greater effect on enhancing uteroglobin production than estradiol-17 beta and that both steroid hormones did not have any effect after 30 min of incubation in vitro. We suggest that progesterone not only regulates uteroglobin production at the transcriptional level, but that it also regulates the mode of uteroglobin secretion by the induction of a different pathway, compared with the one used when estradiol-17 beta is administered alone.

Primary closure of the perineal wound with closed continuous transabdominal pelvic irrigation after rectal excision.

The results of 27 patients who underwent rectal excision with primary perineal closure with continuous closed irrigation of the pelvis are presented. The perineal wound healed per primam within three weeks in 85 per cent of the patients. This technique is a comfortable and safe method of handling the perineal wound.

Decrease of estrogen receptors induced by 17 beta-estradiol and progesterone in cultured rabbit endometrial cells.

A whole cell technique to measure estradiol receptors in cultured rabbit endometrial cells is described. The estradiol receptors measured appear to be composed of at least two components: one component has high affinity but low capacity, while the other component has low affinity but high capacity. Using the assay, the effects of estradiol and progesterone pretreatment were examined on the estradiol receptor levels. It was found that both of the hormones decreased the number of estrogen receptors in the cultured cells. The finding that estradiol decreased its own receptors was unexpected and its possible relevance is discussed.