Factors affecting the incidence of early endoscopic recurrence after ileocolonic resection for Crohn's disease: a multicentre observational study.

AIM: Early endoscopic recurrence is frequently observed in patients following resection for Crohn's disease (CD). However, factors affecting the incidence of an early postoperative endoscopic recurrence (EPER) have not been fully determined. The aim of this study was to evaluate risk factors for EPER after ileocolonic resection for CD. METHOD: This was a retrospective, international multicentre study, in which 127 patients with a first ileocolonoscopy conducted between 6 and 12 months after ileocolonic resection for CD were included. Endoscopic recurrence was defined as a Rutgeerts score of ≥ i2. The following variables were investigated as potential risk factors for EPER: gender, age at surgery, location and behaviour of CD, smoking, concomitant perianal lesions, preoperative use of steroids, immunomodulators and biologics, previous resection, blood transfusion, surgical procedure (open vs laparoscopic approach), length of resected bowel, type of anastomosis (side-to-side vs end-to-end), postoperative complications, granuloma and postoperative biological therapy. Variables related to the patient, disease and surgical procedure were investigated as potential risk factors for EPER, with univariate and multivariate (logistic regression) analyses. RESULTS: 43/127 (34%) patients had EPER at the time of the first postoperative ileocolonoscopy. In univariate analysis, only preoperative steroid use was significantly associated with a higher rate of EPER [21/45 patients (47%) on steroids and 22/82 patients (27%) without steroids (P = 0.04)]. In multivariate analysis, only preoperative steroid use was a significant independent risk factor for EPER (odds ratio 3.28, 95% confidence interval: 1.30-8.28; P = 0.01). CONCLUSIONS: This study found that only preoperative steroid use was a significant risk factor for EPER after ileocolonic resection for CD. Prospective studies are necessary to evaluate precisely the impact of perioperative medications on EPER rates.

A qualitative study of GPs' views towards obesity: are they fighting or giving up?

OBJECTIVES: Several studies indicate that general practitioners (GPs) are not taking the issue of obesity as seriously as they should. Therefore, the aim of this study was to understand GPs' views about obesity and obese people and how these professionals perceive their role in the treatment of this disease. STUDY DESIGN: Qualitative study using semi-structured interviews. METHODS: Sixteen semi-structured interviews were conducted with Portuguese GPs. Data were analyzed according to thematic analysis procedures. RESULTS: GPs are negative about their own role in obesity treatment. Although they believe it is part of their job to advise obese patients on the health risks of obesity, the majority of doctors think they are not making any difference in getting their patients to make long term lifestyle changes. GPs hold negative attitudes towards these patients blaming them for being unmotivated and non-compliant and are also pessimistic about their ability to lose weight. Doctors are facing a dilemma in their practices: they want to play an active role but, due to a set of negative beliefs and perceived barriers, they are playing a relatively passive role, feeling defeated and unmotivated, which is reflected in a decrease of efforts and a willing to give up on most of the cases. CONCLUSIONS: This issue should be taken in to account during physicians' education since doctors should be aware of how their own beliefs and attitudes influence their behaviour and practices, compromising, therefore, the adherence to and the success in obesity treatment. They seem to need more precise guidelines and better tools for screening and management of obesity, more referral options, and improved coordination with other specialities.

Ulcer associated cell lineage glands expressing trefoil peptide genes are induced by chronic ulceration in ileal pouch mucosa.

BACKGROUND: Chronic ulcerative conditions in the gastrointestinal tract result in the appearance of the ulcer associated cell lineage (UACL). The glands of this new cell lineage secrete epidermal growth factor, transforming growth factor alpha, and the trefoil factor family (TFF) peptides, which are known to participate in repair processes. Pouchitis is the most frequent complication of ileal pouch-anal anastomosis. AIM: Our aim was to determine whether the mucosal ulceration present in pouchitis can induce the development of UACL glands. METHODS: Biopsies from ileal pouches with pouchitis (n=10), healthy pouches (n=5), and normal terminal ileum (n=5) were studied. Expression of TFF mRNA was assessed by in situ hybridisation. TFF1 and TFF2 proteins were localised by immunochemistry. RESULTS: UACL glands containing TFF1 and TFF2 were observed in six patients with pouchitis. In some glands, there was TFF3 mRNA as has been reported for Crohn's UACL. None of the biopsies from ileal reservoirs without pouchitis showed UACL glands (p<0.05). Neither TFF1 nor TFF2 expression was detected in ileal reservoirs without pouchitis. CONCLUSION: UACL glands arise de novo in ileal pouch mucosa of patients with pouchitis and express all three TFF peptide genes. Chronic inflammation alone, present in healthy pouches, is not enough to stimulate the growth of the UACL, and additional stimuli consequent on ulceration may be needed.

Enhancing release of peptide YY after near-total proctocolectomy: jejunal pouch vs. ileal pouch-distal rectal anastomosis.

Reconstructing the enteric tract after near-total proctocolectomy by interposing a jejunal pouch between the distal ileum and the distal rectum slows small intestinal transit and decreases the number of stools per day compared to a conventional ileal pouch-distal rectal reconstruction. Our hypothesis was that the jejunal pouch operation brings about these results by protecting the ability of the ileal mucosa to secrete peptide YY, thus augmenting the hormonal ileal brake on small intestinal transit and decreasing the stool frequency. In five jejunal pouch dogs and five ileal pouch dogs, more than 6 months after the operation, serum peptide YY concentrations were determined before and at 30-minute intervals for 180 minutes after a standard meal. Fasting serum concentrations of peptide YY, measured by radioimmunoassay, were greater in jejunal pouch dogs (mean +/- SEM, 1340 +/- 143 pg/ml) than in ileal pouch dogs (804 +/- 52 pg/ml; P < 0.01). Postprandial peptide YY concentrations in jejunal pouch dogs were also greater at 30 minutes (jejunal pouch = 1524 +/- 131 pg/ml, ileal pouch = 913 +/- 67 pg/ml; P = 0.01) and 60 minutes after the meal (jejunal pouch = 1723 +/- 250 pg/ml, ileal pouch = 1001 +/- 70 pg/ml; P = 0.05) and peaked sooner (jejunal pouch = 81 +/- 17 minutes, ileal pouch = 147 +/- 12 minutes; P = 0.01). We concluded that the jejunal pouch operation results in greater ileal fasting and postprandial secretion of peptide YY than the ileal pouch operation. The greater release may account, in part, for the slower small bowel transit and decreased number of stools after the jejunal pouch operation.

Bile acid absorption after near-total proctocolectomy in dogs: ileal pouch vs. jejunal pouch-distal rectal anastomosis.

Bile acid malabsorption is often present in patients after near-total proctocolectomy and ileal pouch-anal canal anastomosis, suggesting ileal dysfunction. Experiments were performed in dogs to compare bile acid absorption after a modified procedure, in which a jejunal pouch was interposed between the terminal ileum and the distal rectum, with that after a conventional ileal pouch operation. Fecal bile acid output (equivalent to hepatic bile acid biosynthesis) and composition were determined by gas chromatography/mass spectrometry in five jejunal pouch dogs and in five ileal pouch dogs more than 6 months after operation. Fecal bile acid output in the jejunal pouch dogs (mean +/- standard deviation) was 215 +/- 59 mg/day (10.1 +/- 2.7 mg/kg-day), a value similar to that obtained in the ileal pouch dogs (261 +/- 46 mg/day [12.8 +/- 3.1 mg/kg-day]; P >0.05). These values were also similar to those reported by others for healthy unoperated dogs, indicating that increased bile acid biosynthesis occurring in response to bile acid malabsorption was not present. Fecal bile acids in pouch dogs were completely deconjugated and extensively 7-dehydroxylated (jejunal pouch = 90.4% dehydroxylated; ileal pouch = 88.6% +/- 6.6% dehydroxylated) and consisted predominantly of deoxycholic acid derivatives. We conclude that when either a jejunal pouch or an ileal pouch is used as a rectal substitute in dogs, an anaerobic pouch flora develops that efficiently deconjugates and dehydroxylates bile acids, rendering them membrane permeable. The resultant passive absorption of unconjugated bile acids appears to compensate for any loss of active ileal absorption of conjugated bile acids, and bile acid malabsorption does not occur.

The jejunal pouch as a rectal substitute after proctocolectomy.

Our hypothesis was that a jejunal pouch used as a rectal substitute after proctocolectomy would slow enteric transit, delay defecation, and decrease stool frequency compared to an ileal pouch so used. Twelve dogs underwent proctocolectomy; six had a jejunal pouch-distal rectal anastomosis and six had an ileal pouch-distal rectal anastomosis. After recovery, postprandial mouth-to-anus transit was slower in jejunal pouch dogs (253 +/- 18 minutes [mean +/- SEM]) than in ileal pouch dogs (112 +/- 7.9 minutes; P <0.05). Moreover, jejunal pouch dogs passed only 4.1 +/- 0.3 stools during the 12 hours after eating, whereas ileal pouch dogs passed 6.3 +/- 0. 9 stools (P <0.05). The mean frequency of proximal ileal pacesetter potentials after feeding was less in jejunal pouch dogs (12 +/- 0.4 cycles/min) than in ileal pouch dogs (16 +/- 0.3 counts/min; P = 0. 01), and jejunal pouches had more action potentials (jejunal = 82% +/- 4.3% of pacesetter potentials had action potentials, ileal = 61% +/- 3.0%; P <0.05). In contrast, gastric emptying and pouch motility, emptying, mucosal integrity, and bacteriologic and histologic properties were similar in the two groups of dogs. We concluded that the jejunal pouch operation slowed enteric transit, delayed defecation, and decreased postprandial stooling compared to the ileal pouch operation.

Use of a colonic pouch as a rectal substitute after rectal excision.

Mid or distal rectal resection with straight coloanal anastomosis effectively treats distal rectal cancer and avoids a permanent stoma. However, the straight colonic segment is a poor reservoir for stools, and patients usually experience varying degrees of impaired rectal function after operation, including frequent bowel movements, incontinence, tenesmus, and soiling. In contrast, a J-shaped colonic pouch provides an adequate neorectal reservoir after operation. Patients with a colonic pouch-anal canal anastomosis have fewer bowel movements per day than patients with straight colorectal or coloanal anastomosis. Furthermore, the morbidity of the colonic pouch is not greater than that of the straight coloanal anastomosis. An important technical aspect of the colonic pouch procedure is that the limbs used to form the pouch must be no longer than 5 to 6 cm. Patients with larger pouches experience emptying difficulties. Also, the level of the anastomosis between the pouch and the anal canal must be no more than 4 cm from the anal verge, again to avoid problems with defecation. With these caveats, the operation should be considered in patients who require excision of the mid and distal rectum for cancer.

[The physiology of intestinal pouches]. / Die Physiologie des intestinalen Pouches.

To summarize, J-shaped and W-shaped ileal pouches serve as adequate neorectal reservoirs after proctocolectomy. These pouches anastomosed directly to the anal canal are as distensible and capacious and as readily evacuated as the rectum in health. However, the use of S- or H-shaped ileal pouches, which have efferent limbs positioned between the pouch and the anal canal, sometimes leads to outflow obstruction and incomplete evacuation. There is little doubt that neorectums made of ileum can allow patients to have entirely "normal" patterns of fecal continence. Nonetheless, with pouch distension, large-amplitude, propulsive pouch contractions occur. These large pressure waves bring on the urge to defecate. They stress the anal sphincters more acutely than either the infrequent, small-amplitude, nonpropulsive contractions or clustered contractions of the healthy rectum. Nonetheless, patients learn to recognize the different signals heralding the impending need for evacuation from the ileal pouch and deal with them. Jejunal pouches, because of their greater distensibility and larger capacity, and the greater frequency of interdigestive migrating myoelectric complexes (MMCs) occurring in them, hold the promise of being a better rectal substitute than ileal pouches. They are more difficult to construct, however. Colonic pouches, when anastomosed to the anal canal after rectal resection, also act as adequate fecal reservoirs. Their main drawback is the inability of some patients to empty them. Small (5 cm) colonic pouches seem to empty better than larger (10-15 cm) ones. Jejunal pouches and colonic segments used as gastric substitutes after gastrectomy provide a better reservoir for ingested food than straight jejunal segments. The main drawback of the pouches is their inability to triturate the solid content of a meal and to regulate the rate of its emptying into the small intestine. Liquids and solids likely empty from these pouches at the same rate, in contrast to the slower emptying rate of solids from the healthy stomach. This likely leads to maldigestion of solids, perhaps contributing to the weight loss often found after gastrectomy.

[Technical aspects of esophagocardiomyotomy with divulsion for the surgical treatment of non advanced chagasic megaesophagus]. / Aspectos técnicos da esofagocardiomiotomia com divulsão para o tratamento cirúrgico do megaesôfago chagásico não avançado.

BACKGROUND: The authors describe a Heller's technique alteration used for treatment of early Chagasic megaesphagus (ECM): esophagocardiomyotomy with divulsion plus esophagocardiopexy. PATIENTS AND METHODS: Between June 1988 and March 1996, fifty patients were operated on at Surgery Department of FAMEMA. All had chagasic megaesophagus degrees I, II and III. RESULTS: The results were excellent in 86% (43/50) and good in 14% (7/50), for 6 months to 7.6 years of follow up. The radiological and endoscopic studies showed neither esophagic stasis nor food residues and esophagitis. CONCLUSION: The authors concluded that esophagocardiomyotomy with divulsion plus esophagocardiogastropexy is efficient in ECM degrees I, II e III and emphasize both technical facility and security.

Aspectos técnicos da esofagocardiomiotomia com divulsäo para o tratamento cirúrgico do megaesôfago chagásico näo avançado / Technical aspects of esophagomyotomy with divulsion for early chagasic megaesophagus surgical treatment

Objetivo. Os autores descrevem uma variante da técnica proposta por Heller para o tratamento cirúrgico do megaesofago: esofagocardiomiotomia com divulsao associada a esofagofundogastropexia. Casuística e Método. No período de junho de 1988 a março de 1996, foram operados, na Disciplina de Cirurgia do Aparelho Digestivo do Departamento de Cirurgia da Faculdade de Medicina de Marília, SP, 50 pacientes portadores de megaesôfago chagásico graus I, II e III. Resultados. Num seguimento de seis meses a 7,6 anos, os resultados sao classificados como ótimo, 86 por cento, e bom, 14 por cento. O estudo radiológico contrastado mostra melhora do clareamento esofágico e a endoscopia, ausência de restos alimentares e esofagite. Conclusao. Os autores concluem que esofagocardiomiotomia com divulsao associada a esofagofundogastropexia é eficaz no tratamento cirúrgico do megaesôfago chagásico graus I, II e III, e enfatizam a facilidade técnica e a segurança do procedimento.