The Quebec Association of Gastroenterology position paper on colorectal cancer screening - 2003.

Colorectal cancer is a leading cause of death and the third most common cancer in Canada. Evidence suggests that screening can reduce mortality rates and the cost effectiveness of a program compares favourably with initiatives for breast and cervical cancer. The objectives of the Association des gastro-entérologues du Québec Task Force were to determine the need for a policy on screening for colorectal cancer in Quebec, to evaluate the testing methods available and to propose one or more of these alternatives as part of a formal screening program, if indicated. Fecal occult blood testing (FOBT), endoscopy (including sigmoidoscopy and colonoscopy), barium enema and virtual colonoscopy were considered. Although most clinical efficacy data are available for FOBT and sigmoidoscopy, there are limitations to programs based on these strategies. FOBT has a high false positive rate and a low detection yield, and even a combination of these strategies will miss 24% of cancers. Colonoscopy is the best strategy to both detect and remove polyps and to diagnose colorectal cancer, with double contrast barium enema also being a sensitive detection method. The Task Force recommended the establishment, in Quebec, of a screening program with five- to 10-yearly double contrast barium enema or 10-yearly colonoscopy for individuals aged 50 years or older at low risk. The program should include outcome monitoring, public and professional education to increase awareness and promote compliance, and central coordination with other provincial programs. The program should be evaluated; specific billing codes for screening for colorectal cancer would help facilitate this. Formal feasibility, effectiveness and cost-effectiveness studies in Quebec are now warranted.

Management of intra-abdominal infections. The case for intraoperative cultures and comprehensive broad-spectrum antibiotic coverage. The Canadian Intra-abdominal Infection Study Group.

OBJECTIVE: To test the hypothesis that comprehensive broad-spectrum empirical antimicrobial therapy is superior to limited-spectrum empirical antimicrobial therapy in intra-abdominal infections. DESIGN: Prospective, randomized, double-blinded study. SETTING: University-affiliated hospitals in Canada. PATIENTS: Two hundred thirteen patients with intra-abdominal infections and planned operative or percutaneous drainage. INTERVENTION: Limited-spectrum empirical antimicrobial therapy consisted of cefoxitin sodium, 2 g, intravenously, every 6 hours (n = 109). Comprehensive broad-spectrum empirical antimicrobial therapy consisted of a combination of imipenem and cilastatin sodium, 500 mg, intravenously, every 6 hours (n = 104). MAIN OUTCOME MEASURES: Failure to cure the intra-abdominal infection (persistence of infection or death). RESULTS: Of initial isolates, 98% were sensitive to imipenem plus cilastin sodium compared with 72% for cefoxitin. No difference was found in the failure rate between treatment groups. Among various reasons for failure (including technical), 12 of 80 patients in the limited-spectrum empirical antimicrobial therapy group had resistant organisms at a second intervention compared with 1 of 74 in the comprehensive broad-spectrum empirical antimicrobial therapy group (P < .003, chi 2). One death in the limited-spectrum empirical antimicrobial therapy group was due to autopsy-proved disseminated Pseudomonas aeruginosa (blood, peritoneum, lung, and pleural fluid) that was resistant to cefoxitin, and the other was associated with peritonitis due to cefoxitin-resistant Enterobacter cloacae. One death in the comprehensive broad-spectrum empirical antimicrobial therapy group was associated with peritonitis from Clostridium perfringens that was sensitive to imipenem plus cilastin sodium, and the other was associated with peritonitis from Pseudomonas aeruginosa that was resistant to imipenem plus cilastin sodium. CONCLUSION: Treatment failure of intra-abdominal infection may be due, in part, to the presence of resistant pathogens at the site of infection. Therefore, routine culture of these sites seems worthwhile and empirical therapy should be as comprehensive as possible and should cover all potential pathogens.

[Ambulatory anal surgery: a feasibility study]. / Chirurgie anale ambulatoire: étude de faisabilité.

Because of the current economic situation, ambulatory surgery has become a "modus vivendi" for the surgeon. The aim of this study is to examine the feasibility of anal ambulatory surgery and the results obtained over a period of 12 months. 141 consecutive patients underwent anal surgery: 108 on an ambulatory basis (77%) and 33 were admitted to the hospital (23%). The reasons for admitting the patients were the complexity of the operation in 19 (8 sphincteroplasty, 5 complex fistulae, 3 recto-vaginal fistulae...) emergency procedures in 9 and miscellaneous reasons in 5 patients. All 108 patients operated on an ambulatory basis could be discharged at the end of the day but two, one for urinary retention and another because he underwent a more extensive procedure than first planned. Three more had urinary retention; they were catheterized and discharged on the same day. The four patients (3 women and 1 man) developed urinary retention following spinal anesthesia. Three patients (2.7%) had to come back to the emergency room in the first 24 hours for bleeding from the operative site. One of them had to be transfused and reoperated for hemostasis. In conclusion, ambulatory anal surgery is feasible in a large proportion of cases (77%) with a low rate of complications (7.4%) and low rate of unexpected hospital admission (2.7%). In a specialized colorectal unit, 23% of patients required hospitalization for a longer stay.

[Dilatation enteroplasty for obstructive Crohn disease. Experience of the University of Montreal]. / L'entéroplastie d'élargissement pour maladie de Crohn obstructive. Expérience de l'Université de Montréal.

Multiple small bowel resections for obstructive symptoms caused by Crohn's disease can lead to a short bowel and malabsorption. Preservation of intestinal length is possible by the use of strictureplasty. Between August 1983 and March 1993, ninety strictureplasties were performed in 25 patients. They were 13 males and 12 females with a mean age of 37 years. Fourteen (56%) previously had small bowel resection for Crohn's disease. A mean number of 4.3 strictureplasties per patient were performed. Concomitant resection of bowel with active disease was performed in 18 patients (72%). In this series, no perioperative death occurred and one patient developed an enterocutaneous fistula. The overall complication rate was 8%. Postoperatively, 18 patients (72%) were completely relieved of symptoms, 6 were improved (24%) and one became worst (4%). After a 27 month follow-up period, the symptoms recurred in 13 patients (52%); three had no treatment, 7 had medical treatment and 3 required reoperation (12%). Our results support the safety and the use of strictureplasty for stenotic bowel lesions associated with Crohn's disease.

[Results of anal sphincteroplasty for post-traumatic incontinence: with or without colostomy]. / Résultats de la sphinctéroplastie anale pour incontinence post-traumatique: avec ou sans colostomie.

Surgical repair of the anal sphincters after previous trauma is generally successful. In earlier publications, a protective colostomy was recommended but in most recent series colostomy is omitted. We have been through both phases and this is the first comparative study done on 82 consecutive repairs: 45 with colostomy from 1977 to 1986 (Group I) and 37 without colostomy from 1986 to 1992 (Group II). Causes of trauma were obstetrical: 50, surgical: 24 and violence: 5. Apart from colostomy related morbidity, postoperative complication rates were similar in the two groups. Results were graded excellent, good, fair or poor according to continence to solids, to liquids and soiling. Good and excellent results were obtained in 82% (Group I) and 87% (Group II) after a mean follow-up duration of 42 and 23 months respectively. Furthermore there was no difference between Group I and II in the rate of good/excellent results for cases who had undergone prior repairs (98% v. 100%) and also when the duration of incontinence was more than 10 years (71% v. 83%). We conclude that colostomy is not a determinant factor in the outcome and is therefore not required, avoiding all colostomy related morbidity and disability.

Surgical treatment of severe postshunt hepatic encephalopathy.

Hepatic encephalopathy is a major complication of portal-systemic shunts with an incidence ranging up to 52%. A small fraction of these patients are refractory to medical therapy. Shunt ligation and colonic procedures are the main surgical approaches. The goal of the latter is to diminish the colonic absorption of nitrogenous substances which are involved in the pathophysiology of hepatic encephalopathy. Six patients, whose average age was 55.7 +/- 2.6 years, were operated for severe postshunt encephalopathy requiring 4.3 +/- 0.9 admissions for a total duration of 76 +/- 26 days over 1-11 years. One patient had undergone a splenoral shunt and 5 had a portacaval shunt. One ligation of the shunt and 5 colon exclusions were performed. The average postoperative hospital stay was 21.5 +/- 3.9 days. The mean follow-up was 47 +/- 20 months. The patient with the shunt ligation remains free of encephalopathy 94 months after the procedure and has not bled from his esophageal varices. Among the 5 colon exclusion patients, there were 1 death and 3 complications. Three patients were completely relieved of their hepatic encephalopathy. One of those 3 died of a subarachnoid hemorrhage 28 months after the surgery. The fourth still needs medication to control a persistent, although improved, encephalopathy that required 2 further hospitalizations. Colon exclusion is a useful intervention in very selected cases. It has a lower operative mortality than total colectomy and the advantage over shunt ligation of not reestablishing hypertension in the portal system.

Preliminary results of coloanal anastomosis.

Coloanal anastomosis after resection of the rectum is the ultimate procedure to preserve the patient's sphincter and avoid a permanent colostomy. Carcinoma of the midrectum, and sometimes of the lower third of the rectum, may not require excision of the pelvic floor and anus for cure. A colonal anastomosis was achieved in 38 patients in whom the indications for surgery were carcinoma in 29, recurrent or extensive adenomas in four, radiation proctitis in two, rectal fistula following radical cystectomy in one, secondary low Hartmann reconstruction after a failed attempt in one, and stenosis of a very low colorectal anastomosis in one. Twenty-six patients were men and 12 women, with a mean age of 62. Dukes' staging for carcinoma were A: 9, B: 7, C: 11, and two had a palliative resection. The mean distance from the anus was 6.0 cm. All had a temporary defunctioning colostomy. There were no postoperative deaths and 17 (45 percent) had postoperative complications, major in 7 (18 percent), minor in 10 (26 percent). Mean follow-up is now 40 months (range, 12 to 64 months). Among patients who underwent curative resection, three have had pelvic recurrences. Two of these patients died of widespread distant disease and one underwent abdominoperineal resection and is now free of disease. All others are alive with no evidence of disease. The colostomy was closed in all but six (16 percent). Two (palliative) died within the colostomy and the other four are awaiting closure. Anastomotic stricture was the most common long-term problem, occurring in 16 and requiring more than one dilatation in eight. Six months after closing the colostomy, the mean daily number of bowel movements is 3.8. Twenty-six (87 percent) are continent to solid stools, two are incontinent to solid stools, and 16 have to wear a pad to prevent soiling. All but one prefer their present status to having their colostomy. In selected cases of rectal carcinoma with little or no extramural spread, the authors estimate that resection and colonal anastomosis is a good alternative with acceptable function and a low rate of recurrent disease, which is comparable to complete rectal excision but avoids a permanent colostomy. However, it should not be a substitute for standard abdominoperineal resection for extensive lower rectal carcinoma or for a colorectal anastomosis when the latter is technically feasible.

[Malignant colonic polyps: is polypectomy adequate treatment?]. / Les polypes malins du côlon: la polypectomie est-elle un traitment adéquat?

The management of patients with endoscopically removed malignant intestinal polyps is controversial. The risk of residual disease should be assessed against the risk of a surgical operation. The authors report 35 cases of malignant polyps (5.5% of 641 colonoscopically removed adenomas). Sixteen patients had carcinoma in situ and received no further treatment and 19 had invasive carcinoma (sessile in 6, pedunculated in 13). Of these 19, 7 did not undergo surgery--because of old age in 2, minimal invasion in 3, a low rectal location in 1 and refusal in 1. Twelve patients (3 with sessile, 9 with pedunculated polyps) underwent a surgical resection, and residual disease was present in 3 (25%), 1 with positive nodes. Reported criteria of increased risk of residual disease--cancer in lymphatics or veins, incomplete excision, tumour at resection margin, sessile and villous tumours--were present in nine. All three patients with residual disease had microscopically involved margins of resection. The authors believe that the increased risk of recurrence justifies the risk associated with subsequent surgical resection unless the patient is otherwise a poor operative risk.

Is preoperative colonoscopy in carcinoma a realistic and valuable proposition?

Colonoscopy was performed preoperatively in 100 consecutive patients as a prospective study to establish the feasibility of the procedure and its value, which was considered "adequate" when the colon remaining after surgical resection had also been examined preoperatively. Colonoscopy was adequate in 35 of 46 patients (76%) with malignant tumour located in the cecum and ascending and transverse colon, but in only 15 of 54 patients (28%) who had a tumour in the left colon or rectum. Synchronous malignant tumours were present in 2 patients, and 54 additional adenomas were discovered in 29 patients. These adenomas could be removed endoscopically in 13 patients and were included in the standard resection in 12. Extension of the planned operation was necessary in only four patients with synchronous adenomas. Routine preoperative colonoscopy to assess the presence of synchronous colonic tumours is more likely to be adequate in proximal or right-sided large-bowel tumours than in left-sided tumours because of the annular configuration of the latter. Because of the high rate (46%) of synchronous adenomas in adequate examinations, inadequate preoperative colonoscopy should be complemented by a repeat examination 3 to 6 months postoperatively in every patient with a malignant tumour of the large bowel.

Small intestinal transplantation using cyclosporine. Report of a case.

A case of small intestinal allotransplantation is described. Cyclosporine and Solumedrol were used for immunosuppression. A hemolytic episode occurred, caused by anti-A antibodies derived from graft lymphocytes. Sudden severe encephalopathy developed on the ninth postoperative day, followed by intractable hypotension and death. Hepatic and splenic microinfarcts were identified on postmortem examination. Allograft rejection was identified by serial stomal biopsies and correlated with a rise in monocyte procoagulant activity, a potentially useful serologic marker of rejection. The absence of an anatomic circuit for recycling of cyclosporine did not alter serum radioimmunoassay/high-performance liquid chromatography ratios.

Transplantation of the small intestine.

Experimental use of cyclosporine in animal models following small intestinal transplantation is reviewed. The authors' techniques for monitoring allografts and harvesting the small bowel in humans for transplantation purposes are described.

Small intestinal transplantation. A closer reality.

The purpose of this study was to determine whether small intestinal transplantation could be considered as an alternative in the treatment of patients suffering from the short-bowel syndrome. The site of absorption of oral cyclosporine A was determined as were the changes that follow small intestinal transplantation. The interactions between the lipophilic cyclosporine A molecule and fat emulsion solutions used for total parenteral nutrition were investigated. Finally, a technique for harvesting the entire small bowel in man was developed. The absorption of oral cyclosporine A in normal dogs, and in bowel-resected, autotransplanted, and allotransplanted dogs was determined. Cyclosporine A levels were monitored in all animals. This demonstrated that cyclosporine A is absorbed through the small bowel and carried through the lymphatics; that absorption is decreased to 40 percent of normal after autotransplantation or allotransplantation without rejection. Rejection further hampers cyclosporine A absorption. Administration of olive oil alone enhances absorption of cyclosporine A. We also administered cyclosporine A IV to five dogs, with and without a concomitant infusion of fat emulsion solution (Intralipid). No changes in plasma cyclosporine A levels, in the clearance of cyclosporine A, or in the in vivo distribution of cyclosporine A were noted. Finally, dissections in six cadavers and in four brain-dead organ donors were performed, and a reproducible technique for harvesting the small bowel in man was established. In selected patients with the short-bowel syndrome, small intestinal transplant may be considered as an alternative therapy to home total parenteral nutrition.

Pharmacokinetic profiles of cyclosporine in rats. Influence of route of administration and dosage.

This study was performed to determine the influence of different routes of administration and of variable doses of cyclosporine (CsA) on the pharmacokinetics of CsA in the rat. Seven groups of 4 adult female Lewis rats were given CsA once daily for 5 days: group 1: 5 mg/kg of CsA p.o. (by gavage); group 2: 10 mg/kg of CsA p.o.; Group 3: 5 mg/kg of CsA i.m.; group 4: 10 mg/kg of CsA i.m.; Group 5: 5 mg/kg of CsA s.c.; group 6: 10 mg/kg of CsA s.c., group 7: 10 mg/kg CsA i.p. CsA plasma levels were determined by RIA at 0, 2, 4, 6, 8, and 24 hr on days 1 and 4. Ease of administration was greatest in the s.c. groups (3 and 4), in which no anesthesia, no restraining device, and no special skills were required. Peak CsA levels varied greatly from group to group, as did trough levels and CsA bioavailability, as determined by the total area under the plasma CsA concentration-time curve. All groups exhibited great variation of CsA plasma level in the 24-hr period following administration, except group 3, in which the peak-to-trough difference was only 26.8% of peak level, as opposed to values over 60% in all other groups. We conclude that: (1) CsA may be administered to rats through different routes to achieve adequate plasma levels; (2) the route and dosage will greatly influence the pharmacokinetic profile of CsA; and (3) the SC route, in addition to being the easiest, provides reproducible and steady CsA plasma levels, with little variation over a 24-hr period.

Cyclosporine absorption in intestinal transplantation.

The absorption of oral cyclosporine (CsA) was studied in a canine small intestinal transplantation model. Absorption of CsA was almost absent in bowel-resected dogs. Autotransplanted dogs showed a persisting malabsorption of CsA (mean peak of 687 +/- 348 ng/ml vs. 1683 +/- 154 ng/ml in control dogs). Allotransplanted dogs with normal graft histology showed a similar malabsorption (mean increase in CsA level: 833 ng/ml), whereas allotransplanted dogs with rejection of the graft showed a markedly decreased absorption (mean increase: 368 +/- 31 ng/ml). In two autotransplanted dogs pretreated with olive oil alone, CsA absorption increased over four weeks to a mean peak of 2215 +/- 5 ng/ml. We conclude that oral CsA is absorbed through the small intestine. Absorption of CsA is decreased after autotransplantation and allotransplantation, and rejection of the graft impedes it further. Regular administration of olive oil alone enhances absorption of oral CsA in a canine model.

Experimental and clinical intestinal transplantation.

Before 1972 several attempts were made to perform small intestinal transplantation in man for the treatment of diseases leading to major losses of the small intestine. No patient had survived for more than 76 days despite intensive conventional immunosuppressants. Small intestinal allotransplantation has been investigated, experimentally, since 1959. Lillehei initially reported the results of allotransplantation of various lengths of small intestine in the canine model. Surgical techniques for successful allogeneic small intestinal transplantation as well as the methods for graft preservation, were clarified. Autotransplants of the total small bowel in dogs survived indefinitely. However, in dogs receiving total small intestinal allotransplants the mean survival period was 8-15 days. Both rejection and graft-versus-host disease have been implicated in the short survival of experimental animals. With the advent of cyclosporine and its known action against both rejection and graft-versus-host disease, we studied the results of parenteral cyclosporine on the survival of dogs following total small intestinal allotransplantation. Cyclosporine greatly prolongs survival to a mean of 103 days, following transplantation of the small bowel, compared to only 12 days in dogs not receiving any immunosuppressive agent. Two of the treated dogs lived for longer than 200 days and one dog lived for more than 400 days. Following this, we have developed a method of histological monitoring of the allograft by making two exterior isolated pouches of the allograft, representing the histological events leading to rejection of the in-continuity bowel.(ABSTRACT TRUNCATED AT 250 WORDS)

Motilin and the vagus in dogs.

The aim of this work was to determine the influence of the vagus on the circulating levels of immunoreactive (IR) motilin. Five mongrel dogs were equipped with chronically implanted electrodes in the small intestine to record the myoelectrical activity. The release of IR motilin during fasting, after a meal, and during an infusion of insulin was studied before and after truncal vagotomy at the diaphragmatic level. When tested at least two weeks after the operation, the motility pattern of the small intestine and the secretion of IR motilin remained unaltered by vagal section. Cyclic increases in IR motilin associated with phase III's of the interdigestive myoelectric complexes were still observed after vagotomy (maximum levels of IR motilin: 250 +/- 37 versus 239 +/- 19 fmol X mL-1, not significant), and they were still abolished by feeding or by insulin. However, an inhibitory influence can probably be mediated by the vagus since, in normal animals, vagal stimulation by a "modified sham feeding" (tease feeding or presentation of food) at the beginning of a period of phase III activity promptly interrupted this part of the complex and decreased significantly the release of IR motilin by about 20%. The release of motilin is not chronically altered by distal vagotomy in dogs.

[Fistulas in diverticular disease of the colon: study of 29 cases]. / Les fistules dans la maladie diverticulaire du côlon: étude de 29 cas.

In analysing 29 patients with diverticular disease of the colon complicated by fistula, the authors encountered four types of fistula: colovesical, colovaginal, coloileal and colocutaneous. The commonest was the colovesical fistula (50%), which was diagnosed by the history and the suggestive cystoscopic findings. Colovaginal fistula was also suspected by the history and the presence of a pelvic mass in hysterectomized patients. Colocutaneous fistulas are demonstrated by fistulography whereas coloileal fistulas, which do not have clinical signs, are discovered only at operation. Surgical treatment, consisting of resection and anastomosis of the involved segment of the colon, is necessary. A one-stage procedure is usually feasible with little morbidity if the delay between the acute phase and the operation is longer than 3 months. When the operation is attempted sooner, the surgeon may have to use more than one stage with a longer period of disability and the possibility of more complications. Because the development of a fistula with diverticular disease seldom needs urgent surgical exploration, the authors recommend 3 months of conservative therapy after the acute phase to allow the local inflammatory reaction to subside so a one-stage operation can be performed.