A prospective randomized single blind trial of Fleet phosphate enema versus glycerin suppositories as preparation for flexible sigmoidoscopy.

AIM: This study compared the efficacy and patient acceptability of two methods of bowel preparation for flexible sigmoidoscopy. METHODS: Patients attending for outpatient flexible sigmoidoscopy were prospectively randomized to receive one Fleet ready-to-use enema or 2 x 4 g glycerin suppositories, 2 h preprocedure. Patient and endoscopist questionnaires were used to compare the outcomes. RESULTS: From November 2000 to August 2001, 203 (male = 95; female = 108) patients were randomized. Patient data available for 163 patients (enema = 93; suppository = 70) revealed: ease of use (enema = 52; suppository = 25; P < 0.02, Fisher's exact); assistance required (enema = 19; suppository = 3; P < 0.005, Fisher's exact); grade of effectiveness (enema = 83; suppository = 44; P < 0.0001, Fisher's exact), and whether patients wished to try another preparation in future (enema = 16; suppository = 24; P = 0.016, Fisher's exact). Endoscopist data available for 151 patients (enema = 76; suppository = 75) revealed: average depth of insertion (enema = 53.6 +/- 11.6 cm; suppository 46.3 +/- 13.7 cm; P < 0.001, Student's t test); acceptable (excellent + good) quality of preparation [enema = 60 (78.9%); suppository = 34 (45.3%); P < 0.0001, Fisher's exact]. CONCLUSION: Bowel preparation for flexible sigmoidoscopy using a single Fleet enema is acceptable to patients and more effective than glycerin suppositories.

Preoperative staging of rectal carcinoma by endorectal ultrasound: is there a learning curve?

BACKGROUND AND AIMS: Endorectal ultrasound (ERUS) is becoming an essential tool in the management of rectal cancer. However, accuracy in the assessment of disease staging may be dependent on operator experience. The aim of this study was to determine if a learning curve exists. MATERIALS AND METHODS: From October 1999 to December 2004, all patients with rectal cancer had a pre-operative ERUS performed by a single radiologist. ERUS staging was compared with post-operative pathology findings using the tumour, node, metastases (TNM) classification. The accuracy of ERUS in tumour (T) and node (N) staging after each additional consecutive ten patients was calculated. RESULTS: One hundred and thirty one patients were investigated by ERUS, of which 36 were excluded, leaving 95 patients in the study (60 men). Overall accuracy for T staging was 71.6%. No improvement with experience was noted (p > 0.05). With regard to T staging, ERUS tended to overstage more frequently than understage (24.2 versus 4.2%). The sensitivity, specificity, positive predictive value and negative predictive value of uT3 staging were 96.6, 33.3, 70.4 and 85.7%, respectively. Overall accuracy of uN staging was 68.8%. ERUS tended to overstage nodal disease more frequently than understage (16.1 versus 15.1%). Sensitivity, specificity, positive predictive value and negative predictive value were calculated for ultrasound-detected nodal disease (73.2, 62.2, 74.5 and 60.5%, respectively). Nodal staging accuracy improved from 50% after assessment of 10 cases to 77% after 30 cases were examined. CONCLUSIONS: ERUS is an accurate method for staging rectal cancer pre-operatively. Accurate assessment of tumour stage can be achieved immediately by an experienced radiologist without specific training in ERUS. Nodal staging accuracy tends to improve with experience but reaches a plateau after 30 cases.

The effectiveness of flexible sigmoidoscopy as the primary method for investigating colorectal symptoms in low-risk patients.

BACKGROUND: Flexible sigmoidoscopy as the preferred initial investigation for patients with low-risk colorectal symptoms requires formal evaluation. METHODS: From August 1999 to July 2001, 323 patients (166 men) attended the one-stop colorectal clinic. All the patients were examined using a 60-cm flexible sigmoidoscope. Presenting symptoms and findings were reviewed. RESULTS: The mean age of the study patients was 38.6 +/- 11.87 years, with the majority (89.1%) younger than 50 years. Rectal bleeding was the most common problem (86.6%), followed by bowel habit change (13.7%). For 65.6% of the patients, a view to the proximal sigmoid was obtained. The main reason for incomplete assessment was poor bowel preparation (67.5%). The most common finding, in 202 patients (64%), was haemorrhoids. Polyps were found in 9.9% of the patients, whereas four patients (1.2%) with cancer were identified. Overall, 269 patients (83.4%) required no further investigation. CONCLUSION: Flexible sigmoidoscopy is an effective method for assessing low-risk patients.

Restorative proctocolectomy with ileal pouch-anal anastomosis in 203 patients: the Auckland experience.

BACKGROUND: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become an established operation for patients with ulcerative colitis and familial adenomatous polyposis (FAP). The results of a 15-year experience with IPAA are reported. METHODS: Between September 1982 and June 1997, 203 patients had IPAA surgery. From a review of the charts, data were collected on the surgical procedure, the diagnosis and early and late complications. Pouch function was assessed by means of a postal questionnaire. RESULTS: Of the 201 patients (median age of 32 years; 89 women) with complete records, 122 had J pouches, 65 had W pouches and 14 S pouches were constructed. The pre-operative diagnosis in 88% was ulcerative colitis and in 10% it was FAP. During a median follow-up time of 6.1 years the diagnoses were changed for 8% of the patients; in 4% the diagnosis was changed to Crohn's disease. The overall mortality was 1.5% (early = 2, late = 1). The overall morbidity was 62% (early = 17%, late = 52%). The pouch was removed or was non-functional in 9%. All patients with a final diagnosis of Crohn's disease have had their pouch excised. The median stool frequency was 4.0 (range 1.3-8.7) during the day, and 0.7 (range 0-2.1) during the night. The fewer night-time stools (J = 1.0+/-0.6; W = 0.4+/-0.5 P < 0.0001) and the reduced requirement of the W-pouch patients for anti-diarrhoeals (P = 0.004) were offset by the need for two W-pouch patients to pass a catheter to empty their pouches. CONCLUSIONS: The type of patients who present for IPAA surgery and the outcomes observed in this series of Auckland patients are similar to those reported from major centres elsewhere.

Compressive characteristics of an internally threaded post system.

PURPOSE: The effects of oblique compressive forces were evaluated for extracted teeth restored with posts of solid and internally threaded designs. MATERIALS AND METHODS: A group of 25 roots was restored with crowns supported by Para-post dowels and pin-retained composite resin cores, and a second group was restored with gold copings cast to internally threaded stainless steel-post prototypes. Samples were then embedded in epoxy resin and loaded at 45 degrees until failure. Failure force and type were statistically analyzed to determine statistical difference (P < .05) between groups. RESULTS: No statistical difference was shown between groups for either fracture force or type. CONCLUSIONS: The internally threaded post system resisted oblique loading forces similarly to a solid post system.

Physical properties of casts prepared from disinfected alginate.

The dimensional accuracy, surface hardness and reproduction of surface detail of stone casts produced from alginate impressions treated with 4.65% sodium hypochlorite, were investigated. To test dimensional accuracy, a Reflex Microscope was used to compare casts from 10 untreated impressions with casts from 10 impressions immersed in the solution for 30 mins. Surface detail and hardness were investigated on casts produced from impressions of a master stainless steel plate with 10 micro-indentations of increasing size. Surface detail of the casts were assessed by observation and surface hardness by a Vickers Hardness Machine. The dimensional accuracy test showed no significant differences between the experimental and control groups. Surface detail was unaffected after immersion of up to 10 mins. Surface hardness decreased linearly with respect to immersion time, when this was greater than 5 mins.

Endotoxaemia and cytokine production in experimental colitis.

Systemic endotoxaemia is a well recognized feature of inflammatory bowel disease but its pathogenic role remains uncertain. This study examined plasma endotoxin and cytokine concentrations and the acute-phase protein response in a hapten-induced model of experimental colitis. On days 2, 8 and 14 after induction of colitis with trinitrobenzenesulphonic acid in ethanol (TNBS-E), plasma endotoxin, immunoglobulin (Ig) G and IgM endotoxin-core antibody (EndoCAb), tumour necrosis factor (TNF), interleukin (IL) 6 and alpha 2-macroglobulin (alpha 2M) concentrations and colon macroscopic inflammation score were determined. At all time points there was significant colonic inflammation when compared with control values (P < 0.0001). Animals treated with TNBS-E had raised concentrations of endotoxin at all time points (P < 0.04). In TNBS-E-treated animals EndoCAb concentrations were reduced on day 2 (P < 0.0001) and later increased. There were increases in IL-6 and alpha 2M concentrations in TNBS-E-treated animals but no significant change in TNF concentrations. Endotoxin concentrations correlated with macroscopic inflammation score, IL-6 and alpha 2M concentrations. There was a less consistent correlation between EndoCAb concentrations and these parameters. These results suggest that endotoxin is a mediator of the systemic response in this model of experimental colitis.

Topical glutamine therapy in experimental inflammatory bowel disease.

This study investigated the effects of glutamine and steroid enemas on disease activity in an animal model of colitis. Colitis was induced in male Wistar rats by intracolonic instillation of 30 mg trinitrobenzenesulphonic acid in 50% ethanol (TNBS/E). Controls were given an isovolumetric bolus of normal saline. After 24 h, animals were randomised to receive enemas (1 mL twice daily) of prednisolone (200 mg/L), or L-glutamine (500 g/L) or the suspending agent (placebo). On day 8, the colon was weighed and the degree of inflammation assessed using a colon macroscopic score (CMS). Thymic weight, splenic weight, percentage gain in body weight (%GBW), food intake, plasma interleukin-6 (IL6) and plasma alpha(2)-macroglobulin (alpha(2)M) were also determined. There was a significant increase in CMS, colon weight, splenic weight, IL6 and alpha(2)M in TNBS/E animals compared to controls (P< 0.01). There was also a significant decrease in %GBW, food intake and thymic weight in TNBS/E animals (P< 0.01). The therapeutic enema of prednisolone reduced colonic inflammation (CMS, colon weight), improved thymic weight, %GBW and food intake, and reduced plasma IL6 concentrations (P< 0.05). In contrast administration of glutamine enemas was associated with an exaggerated acute phase protein (alpha(2)M) response (P< 0.05) and failed to improve the colonic and systemic inflammatory response in this experimental model of colitis.

Manipulation of the L-arginine-nitric oxide pathway in experimental colitis.

The role of the L-arginine-nitric oxide pathway in the pathogenesis of colonic inflammation was assessed using L-arginine and its competitive analogue N omega-nitro-L-arginine methyl ester (L-NAME) in a rat model of colitis. In the first study oral L-arginine 2 per cent (control: 3.4 per cent L-glycine) was administered with and without L-NAME 100 mg/l. Orally administered L-arginine increased colonic inflammation (P = 0.004) and decreased thymic weight (P = 0.0007). Addition of L-NAME reduced the colonic inflammation and prevented loss of body-weight (P < 0.04). In the second study L-NAME was administered orally in concentrations of 100, 200 and 500 mg/l (control: no L-NAME). L-NAME 500 mg/l reduced colonic inflammation and increased thymic weight and body-weight (P < 0.01). Thymic weight and body-weight correlated positively with the concentration of L-NAME administered orally (rs > or = 0.3, P = 0.04). L-NAME l g/l was administered topically as an enema (control: suspension agent). Topical L-NAME reduced colonic inflammation and increased thymic weight (P < 0.05). These results suggest that the L-arginine-nitric oxide pathway mediates colonic inflammation in this model.

New implant surgical guide.

This article describes the process of making and using a surgical guide stent. It is intended to enable the surgeon to maintain the same horizontal and vertical axes of cylindrical endosseous implants during the surgical phase of implant placement as those determined at the treatment planning stage. Furthermore, the stent can be used with the entire series of surgical drills, thereby minimizing the chance of inadvertently enlarging the implant site as a result of freehand use of the handpiece.

Retentive characteristics of an internally threaded post system.

Internally threaded, stainless steel posts 10 mm in length and 1.82 mm in diameter or stainless-steel Para-Post dowels 1.7 mm in diameter were cemented in extracted human teeth with zinc phosphate cement. Titanium alloy screws 1.5 mm in diameter were placed in the internally threaded posts and tensile force was applied to the screws or Para-Post dowels until dislodgment of the post or fracture. The retention of the Para-Post system was significantly greater than the experimental posts. Although all screws exhibited deformation, there was no breakage or distortion of the internally threaded posts or Para-Post dowels. Retention for both systems exceeded reported forces generated in humans.

Ileal haemangiopericytoma and von Recklinghausen's disease.

Haemangiopericytoma is an uncommon tumour of vascular pericytes which usually arises in deep subcutaneous tissues or the retroperitoneum. There are few reports in the English literature of haemangiopericytoma arising in the ileum. Von Recklinghausen's disease, a condition of autosomal dominant inheritance with a prevalence of 1 in 3000, is often associated with tumours of neural origin. Tumours of non-neural origin also occur in Von Recklinghausen's disease but haemangiopericytoma has not been described. We report on a patient with Von Recklinghausen's disease presenting with massive haemorrhage from an ileal haemangiopericytoma.