A novel porcine model for chemically inducible Crohn's-like reaction.

BACKGROUND: New animal models provide insights into the pathogenesis of different types of inflammatory bowel disease as well as novel pathways for new therapeutic options. However, the scarcity of large animal models hinders the research and development of new surgical procedures and technological devices in inflammatory bowel disease surgery. Common small animal inducible models involve chemical agents that result in the development of acute intestinal inflammation. OBJECTIVES: To assess a novel method for the induction of Crohn's-like colitis using intramural injection of sclerosants in a porcine model. METHODS: Seven domestic pigs underwent several experimental protocols to assess the efficacy of intramural colonic injections of two different compounds (lauromacrogol, and phenol in almond oil).Twenty-five different large bowel segments were treated with intramural injections of the compounds. The animals were followed for 6 weeks, and treated colonic segments were resected for histopathological examination. RESULTS: Intramural injection of lauromacrogol resulted in non-specific, mild reactive foreign body changes only. Injection of various dosages of 5% phenol in almond oil caused a range of histopathological changes varying from focal fibrosis to Crohn's-like reactions com rising acute and chronic infiltrates, mucosal ulceration and focal necrosis with enteric and lymphoid non-caseating granulomas. CONCLUSIONS: Intramural colonic phenol in almond oil injection in pigs induces inflammatory reactions that histologically resemble Crohn's disease in humans.

Long-term results of fibrin glue treatment for cryptogenic perianal fistulas: a multicenter study.

BACKGROUND: Instillation of fibrin glue, a simple and safe procedure, has been shown to have a moderate short-term success rate in the treatment of cryptogenic perianal fistulas. OBJECTIVE: This study aimed to assess the long-term outcome of this procedure. DESIGN: This study included a retrospective chart review and telephone interviews. SETTINGS: This study was conducted at 4 university-affiliated medical centers. PATIENTS: Patients were included who underwent fibrin glue instillation for complex cryptogenic fistula between 2002 and 2003 within a prospective trial and had successful healing. INTERVENTIONS: Fibrin glue was instilled for complex cryptogenic fistula. MAIN OUTCOME MEASURES: The main outcome measure was long-term fistula healing. RESULTS: Sixty patients participated in the initial trial; the fistulas in 32 of these patients were healed at 6 months. We have located and interviewed 23 (72%) of those patients. Seventeen (74%) patients remained disease free at a mean follow-up of 6.5 years. Six (26%) patients had variable degrees of recurrence; 4 needed further surgical intervention and 2 were treated with antibiotics only. Recurrent disease occurred at an average of 4.1 years (range, 11 mo to 6 y) from surgery, and on several occasions was at a different location in the perianal region. None of the patients experienced incontinence following the procedure. LIMITATIONS: The retrospective nature of this long-term follow-up was a limitation. Twenty-eight percent of the potentially eligible patients were lost to long-term follow-up. CONCLUSIONS: Short-term success of fibrin glue in the treatment of cryptogenic perianal fistula is predictive of long-term healing, but a quarter of those healed in the short term may develop recurrent symptoms in the long run. Injection of fibrin glue remains a safe and simple procedure and may preclude extensive surgery.

Preoperative staging using transrectal ultrasound in high and low rectal cancer.

BACKGROUND: An accurate preoperative definition of tumor and lymph node status is needed for reaching the correct decision regarding rectal cancer treatment. Transrectal ultrasonography is the most commonly used diagnostic modality for the local staging of rectal cancer. OBJECTIVES: To determine the accuracy of TRUS in the staging of rectal cancer. METHODS: We conducted a retrospective study on 95 patients evaluated by TRUS. The rectum was subdivided into two parts (lower and upper). RESULTS: Sixty patients underwent radical surgery. Of these, 34 received no preoperative chemo-irradiation owing to microT1, was suggested to patients with adenocarcinoma that proved to be microT3). The overall accuracy rate was 80% for T stage. Overstaging was found in 13.3% and understaging in 6.7%. The N-stage was correctly assessed in 70%. The overall accuracy rate for tumors was 73.9% in the lower part and 90.9% in the upper. A trend towards a lower accuracy rate for low-lying tumors compared to high-located rectal tumors was found (P = 0.532), which did not reach statistical significance. CONCLUSIONS: TRUS gave better results for T1 and T3 stage rectal tumors but was inaccurate for stage T2, indicating the possible need for local excision in order to base the final treatment for T2 tumors on pathologic staging.

Predominance of younger age, advanced stage, poorly-differentiated and mucinous histology in Israeli Arab patients with colorectal cancer.

BACKGROUND: Colorectal cancer (CRC) incidence in the Israeli population is higher in the Jewish population than among Arabs. MATERIALS AND METHODS: To determine the differences in demographic, clinical, histopathological and molecular characteristics of CRC between these two ethnic groups, 125 Arab patients treated at 3 community hospitals over a 20-year period were compared to a group of 208 consecutive Jewish patients. The mutator (replication error-positive [RER]) phenotype was detected by immunohistochemical evaluation of hMLH1 and hMSH2 protein expression in tumor tissue. RESULTS: The Arab patients were younger than the Jewish patients with a higher percentage of poorly-differentiated and mucinous cancers and a higher percentage of advanced stage cancers (Dukes' C+D) at presentation. The mutator phenotype was detected at similar rates in both ethnic groups. CONCLUSION: Our study demonstrated that CRC patients from two major ethnic populations in Israel, Arabs and Jews, differed in terms of the prevalence of the disease, pathological features and age at presentation, but not in frequency of mismatch-repair-positive cancers.

Granulocyte-macrophage colony-stimulating factor for perianal hidradenitis suppurativa: report of a case.

Perianal hidradenitis suppurativa is a chronic inflammatory disease associated with significantly high morbidity, which severely affects the quality of life of those patients suffering from it. We describe a 46-year-old patient with extensive, severe gluteal and perianal PHS of 28 years duration. Repeated wide excisions, fistulotomies, treatments with hyperbaric oxygen, and finally a diverting colostomy were unsuccessful. A new form of treatment with repeated perilesional injections of granulocyte-macrophage colony-stimulating factor, in conjunction with surgical procedures, was performed with excellent results.

Prospective, multicenter evaluation of highly concentrated fibrin glue in the treatment of complex cryptogenic perianal fistulas.

PURPOSE: The surgical management of complex perianal fistulas is challenging and may be associated with the risk of sphincter injury. Instillation of fibrin glue to the fistula tract is a simple procedure that does not involve any muscle division, and potentially results in healing of the fistula. This study was designed to assess the use of highly concentrated fibrin glue with intra-adhesive antibiotics in the treatment of complex cryptogenic perianal fistulas. METHODS: Patients with complex perianal fistulas of cryptogenic origin were prospectively included in this multicenter study. Injection of the fibrin glue mixed with antibiotics was performed in a uniform fashion. After the procedure, patients were actively examined at fixed time intervals; in cases of recurrent fistula, reinjection of fibrin glue was offered. RESULTS: Sixty patients were enrolled; complete healing of the fistula was achieved in 32 patients (53 percent). Eight of 28 patients (29 percent) who were not completely healed had significant symptomatic improvement. All patients resumed normal daily activity the day after surgery and none had any deterioration in continence related to the procedure. The majority of the 26 (43 percent) adverse events were considered mild and spontaneously resolved; 2 patients (3 percent) with perianal septic complications were successfully treated by drainage. CONCLUSIONS: Injection of fibrin glue for the treatment of perianal fistulas is safe, simple, and associated with early return to normal activity. Although moderately successful, it may preclude extensive surgery in more than one-half of these patients.

Perioperative management of patients undergoing elective colorectal surgery in Israel: a national survey.

BACKGROUND: The approach to perioperative antibiotic prophylaxis, bowel preparation, and postoperative routines in elective colorectal resections has changed over the last two decades. The aim of this national survey was to document the current methods of perioperative management of those patients scheduled for elective colorectal resections in surgical departments in Israel. METHODS: A mail and telephone survey of surgical departments was conducted in 2001 in order to evaluate the routines of perioperative management of elective colorectal resections. Re-evaluation was performed in 2004. RESULTS: In 2001, all but one of the responders used low-residue diet preoperatively and combined oral and parenteral antibiotic prophylaxis. Polyethylene glycol or sodium phosphate bowel preparation was used by 69% of the responders. The most common oral regimens were a combination of neomycin plus metronidazole (43.5%) or neomycin plus erythromycin (47.8%). The most common parenteral regimens used were gentamicin plus metronidazole or gentamicin plus metronidazole plus ampicillin (56.5% and 17% of the responders, respectively). Cephalosporins alone or in combination were used in three departments. In 17 departments (74%), parenteral prophylactic antibiotics were continued for 24 h or longer (up to 72 h). All but one of the departments left a nasogastric tube for 1-5 days after surgery. There were substantial changes over the last three years-that is, less use of preoperative restriction diets, shorter duration of perioperative antibiotic coverage, more common use of cephalosporins, switch to sodium dihydrogen and sodium hydrogen phosphate bowel preparation, shorter use of postoperative nasogastric drainage, and faster resumption of peroral fluids. CONCLUSIONS: In 2001, the majority of surgical departments in Israel used a conservative approach to perioperative management of patients undergoing elective colorectal resections. Significant changes occurred during the last three years. The perioperative routines used today in most general surgery departments in Israel comply with current recommendations.

[A prospective, randomized double-blind study on the treatment of anal fissures with Nitroglycerin ointment].

BACKGROUND: Anal fissure is a common disease. Treatment includes conservative measures or surgery. One of the treatment options is topical Nitroglycerin ointment. MATERIALS AND METHODS: We present a prospective, randomized, double-blind study, encompassing 48 patients suffering from chronic anal fissure. The subjects were divided into three groups according to the dose of Nitroglycerin ointment received--group I--0% (placebo), group II--0.2% (0.75 mg) and group III--0.4% (1.5 mg). Demographic data, medical history and physical findings were recorded. Healing, pain relief and adverse events were evaluated during and after the treatment period. RESULTS: No significant difference (p<0.05) was found between the groups with respect to patient age, gender, past history, physical examination, amount of ointment used and adverse events. Thirty three of the 48 (69%) patients completed the study. No significant differences were found between the groups with respect to the reasons and rates of leaving the study (p=0.494). Fifteen patients failed to complete the study; eight patients (17%) due to headaches, one patient was operated upon and six patients left the study because of cooperation problems. No significant difference was found between the groups regarding healing (p=0.952) or pain relief (p=0.458-0.8 according to the type of pain checked). CONCLUSIONS: According to our study, there was no benefit regarding healing or pain relief, in treating patients suffering from an anal fissure with Nitroglycerin ointment in combination with stool softeners and sitz baths, compared to the same treatment without Nitroglycerin ointment.