[Restorative proctocolectomy for ulcerative colitis : Long-term functional results and quality of life]. / Restaurative Proktokolektomie bei Colitis ulcerosa : Funktionelle Langzeitergebnisse und Lebensqualität.

Restorative proctocolectomy with ileo-pouch-anal anastomosis is the standard procedure for ulcerative colitis. It provides complete removal of the diseased colorectum, avoids permanent ileostomy and allows the preservation of continence. Functional results and quality of life after restorative proctocolectomy are of great importance. Patients usually have 5-6 bowel movements per day, and continence is satisfactory in more than 90% of patients. A good pouch function strongly correlates with high quality of life. Postoperative septic complications are the main risk factor for bad pouch function and pouch failure; therefore nowadays most procedures are performed with a covering ileostomy. Quality of life is usually impaired by active ulcerative colitis, and restorative proctocolectomy improves the quality of life up to the level of a healthy reference population. Taken together, restorative proctocolectomy provides excellent results concerning function and quality of life.

Perineal herniation of an ileal neobladder following radical cystectomy and consecutive rectal resection for recurrent bladder carcinoma.

Secondary perineal herniation of intraperitoneal contents represents a rare complication following procedures such as abdominoperineal rectal resection or cystectomy. We present a case of a perineal hernia formation with prolapse of an ileum neobladder following radical cystectomy and rectal resection for recurrent bladder cancer. Following consecutive resections in the anterior and posterior compartment of the lesser pelvis, the patient developed problems emptying his neobladder. Clinical examination and computed tomography revealed perineal herniation of his neobladder through the pelvic floor. Through a perineal approach, the hernial sac could be repositioned, and via a combination of absorbable and non-absorbable synthetic mesh grafts, the pelvic floor was stabilised. Follow-up review at one year after hernia fixation showed no signs of recurrence and no symptoms. In cases of extensive surgery in the lesser pelvis with associated weakness of the pelvic compartments, meshes should be considered for closure of the pelvic floor. Development of biological meshes with reduced risk of infection might be an interesting treatment option in these cases.

The OTSC(®) proctology clip system for the closure of refractory anal fistulas.

BACKGROUND: To evaluate the efficacy of the over-the-scope clip (OTSC(®)) proctology set for the closure of refractory anal fistulas. METHODS: This retrospective single-center study included all consecutive patients undergoing an OTSC(®) proctology closure of anal fistulas between October 2012 and June 2014. The OTSC(®) was only used in refractory cases after previous fistula surgery, including patients with Crohn's disease, or multiple previous surgical approaches. RESULTS: There were ten patients (five males and five females) with a median age of 41 years (range 26-69 years). The etiology of the fistula was cryptoglandular in four patients, and perianal Crohn's disease in six patients (including one patient with an anovaginal fistula). The surgical procedure was technically successful in all patients. Permanent fistula closure was achieved in seven out of ten patients (70 %) within a median time of 72 days (range 31-109 days). Median total follow-up time was 230.5 days (range 156-523 days). There were three failures (30 %), including two cryptoglandular and one Crohn's disease-associated fistula. In all three cases, the OTSC(®) was lost spontaneously on days 22, 23, and 40, respectively. In three of the seven patients with successful closure, the OTSC(®) was removed after complete healing of the fistula. CONCLUSIONS: The novel OTSC(®) proctology system is a safe and effective method for the closure of even complex and recurrent fistulas.

Current status of laparoscopic surgery for patients with Crohn's disease.

PURPOSE: Minimally invasive surgery is increasingly utilized in treatment for refractory or complicated Crohn's disease, and new developments aim at further reducing the abdominal trauma and improving the outcome. This review evaluates current literature about minimally invasive surgery for patients with Crohn's disease, latest advances in single-incision surgery, and methods of specimen extraction. METHODS: Literature was reviewed with focus on the following topics: indications, surgical procedures, conversions, complications, and short- as well as long-term outcomes of laparoscopic compared to open surgery for refractory, complicated, and recurrent Crohn's disease. RESULTS: Short-term benefits such as shorter hospital stay and faster postoperative recovery are accompanied by long-term benefits such as better cosmetic results and lower treatment-associated morbidity. Single-incision surgery and minimally invasive methods of specimen extraction help to further reduce the surgical trauma and are gradually implemented in the treatment. CONCLUSION: In experienced centers, laparoscopic surgery for Crohn's disease is safe and as feasible as open operations, even for selected cases with operations for complicated or recurrent disease. However, accurate analysis of the data is complicated by the heterogeneity of clinical presentations as well as the variety of performed procedures. Additional long-term data are needed for evaluation of true benefits of the new techniques.

[Education in laparoscopic surgery: national survey on current strategies and relevance of simulation training]. / Ausbildung in der laparoskopischen Chirurgie: Umfrage zu vorhandenen Konzepten und der Bedeutung von Simulationseinheiten.

BACKGROUND: Laparoscopic surgery demands from the surgeon specific operative skills. Learning -curves have been described for many procedures in this technique. In order to evaluate the avail-able laparoscopic teaching resources and meth-ods in Germany an opinion survey was per-formed. MATERIALS AND METHODS: Directors of 284 surgical departments were polled using a questionnaire regarding department and operation statistics, -laparoscopic education and availability of simulation facilities ("Skills Labs" SL). RESULTS: The response rate was 54 %. 88 % of the department directors considered laparoscopic -simulation an efficient teaching method and 91 % felt that simulation improves operating room performance. A SL was available in 27 % of these -departments. The training modules most commonly offered were basic laparoscopic skills such as coordination exercises (100 %) and suturing techniques (89 %). The actual median acquisition costs amounted to 20 000 € in our evaluation, with annual running costs of a median of 1000 €. CONCLUSION: Although most of the questioned surgeons acknowledged the value of SL, this method of education is not widely available in Germany. Therefore we feel that simulation training in Germany still requires stronger support.

Insulin-like growth factor 1-coated sutures improve anastomotic healing in an experimental model of colitis.

BACKGROUND: : Exogenously applied insulin-like growth factor (rhIGF-1) may improve normal intestinal healing. This study examined the effect of rhIGF-1-coated sutures on anastomotic healing in experimental colitis. METHODS: : Acute colitis was induced in rats by dextran sodium sulphate (DSS). Inflammation was assessed by clinical Disease Activity Index (DAI), myeloperoxidase (MPO) measurement and histological examination. A distal colonic anastomosis was performed using sutures coated with rhIGF-1 dissolved in poly(D,L-lactide) (PDLLA) under general anaesthetic. Anastomotic healing was evaluated histologically, and by hydroxyproline measurement and bursting parameters after 1, 3 and 7 days, and compared with healthy, DSS and DSS + PDLLA controls. RESULTS: : DAI, MPO and histological inflammation scores were significantly increased in all animals treated with DSS. Bursting occurred less often within the anastomotic line on day 3 in the IGF group than in DSS controls (three versus eight of ten). On day 7, the IGF group had significantly increased histological healing scores (mean(s.e.m.) 12.5(0.7) versus 9.2(0.8) (P < 0.050)) and hydroxyproline content (4.6(0.3) versus 3.6(0.1) mg/g tissue; P < 0.050) compared with DSS controls. CONCLUSION: : IGF-1-coated sutures improve important aspects of anastomotic healing in rats with experimental colitis.

Expression of tight and adherens junction proteins in ulcerative colitis associated colorectal carcinoma: upregulation of claudin-1, claudin-3, claudin-4, and beta-catenin.

BACKGROUND: Tight junction (TJ) proteins play a critical role in cellular adhesion, glandular differentiation, and cellular proliferation. The function of these proteins is compromised in a number of intestinal diseases, including ulcerative colitis that has an increased incidence for colorectal carcinoma (CAC). The aim of this study was to determine the expression of TJ proteins, claudin-1-4, occludin, ZO-1, and the adherens junction (AJ) protein beta-catenin in CAC. METHODS: Sixteen colectomy specimens with CAC, adjoining intraepithelial neoplasia, and normal mucosa were studied by immunofluorescence. A semiquantitative evaluation of all investigated proteins was performed by scoring the staining intensity, and the TJ and AJ protein expression in neoplastic cells was compared to normal and intraepithelial neoplastic colonic mucosa. RESULTS: Using an intensity scoring system, mucosa of crypts and surfaces of CAC exhibited significantly elevated expression levels of claudin-1, claudin-3, claudin-4, and beta-catenin compared to intraepithelial neoplasia and normal mucosa (p<0.05). These data were confirmed by a comparative score. The expression of claudin-2, occludin, and ZO-1 showed no differences between the groups. CONCLUSION: TJ proteins claudin-1, claudin-3, claudin-4, and the AJ protein beta-catenin are overexpressed in CAC. This suggests that these proteins may become potential markers and targets in CAC.

Mechanisms underlying the anti-inflammatory actions of boswellic acid derivatives in experimental colitis.

Recent clinical trials of the gum resin of Boswellia serrata have shown promising results in patients with ulcerative colitis. The objective of this study was to determine whether a semisynthetic form of acetyl-11-keto-beta-boswellic acid (sAKBA), the most potent anti-inflammatory component of the resin, also confers protection in experimental murine colitis induced by dextran sodium sulfate (DSS) to compare its effects with those standard medications of ulcerative colitis like steroids and to examine whether leukocyte-endothelial cell adhesion is a major target of action of sAKBA. Clinical measurements of disease activity and histology were used to assess disease progression, and intravital microscopy was employed to monitor the adhesion of leukocytes and platelets in postcapillary venules of the inflamed colon. sAKBA treatment significantly blunted disease activity as assessed both grossly and by histology. Similarly, the recruitment of adherent leukocytes and platelets into inflamed colonic venules was profoundly reduced in mice treated with sAKBA. Because previous studies in the DSS model have shown that P-selectin mediates these blood cell-endothelial cell interactions, the expression of P-selectin in the colonic microcirculation was monitored using the dual-radiolabeled antibody technique. The treatment of established colitis with sAKBA largely prevented the P-selectin upregulation normally associated with DSS colitis. All of the protective responses observed with sAKBA were comparable to that realized in mice treated with a corticosteroid. Our findings demonstrated an anti-inflammatory effect of sAKBA and indicated that P-selectin-mediated recruitment of inflammatory cells is a major site of action for this novel anti-inflammatory agent.

Esophageal perforation as a complication of EndoCinch endoluminal gastroplication.

Endoscopic gastroplasty is being promoted as a new minimally invasive procedure for the treatment of gastroesophageal reflux disease. In the case presented here, however, we encountered abdominal perforation as a severe complication of this procedure. Because immediate action was taken when the symptoms developed, and by maintaining close collaboration with the surgeons, it was possible to keep the treatment minimally invasive: the leakage was detected endoscopically and the defect was closed laparoscopically and covered by a fundoplication. This experience emphasises the importance of appropriate management of complications as part of the evaluation of new endoscopic methods.

ICAM-1 and VCAM-1 antisense oligonucleotides attenuate in vivo leucocyte adherence and inflammation in rat inflammatory bowel disease.

BACKGROUND: Recruitment of circulating cells to the inflamed intestine is modulated by adhesion molecules expressed on the surface of both leucocytes and endothelial cells. AIMS: The objective of this study was to test whether 2'-O-methoxyethyl chimeric antisense oligonucleotides directed against endothelial intercellular adhesion molecule 1 (ICAM-1) and vascular cell adhesion molecule 1 (VCAM-1) can downregulate leucocyte-endothelial interactions and thereby attenuate inflammation in rat experimental ileitis. METHODS: Indomethacin (7.5 mg/kg ) was injected subcutaneously into Sprague-Dawley rats 48 and 24 hours prior to intravital microscopy. Animals were treated with either ICAM-1 (ISIS 17470), VCAM-1 (ISIS 18155), or scrambled control antisense oligonucleotides administered subcutaneously or intravenously in parallel with indomethacin. Leucocyte trafficking was observed in ileal submucosal collecting venules. Macroscopic and histological grades of inflammation were measured 48 hours after the first indomethacin application. ICAM-1 and VCAM-1 expression in ileal submucosal venules was detected by immunohistochemistry. RESULTS: Intravenous administration of ICAM-1 oligonucleotides 2 mg/kg (rolling leucocytes 5.7 (2.4)/0.01 mm(2) endothelial surface, adherent leucocytes 0.8 (1.1)) and VCAM-1 oligonucleotides 8 mg/kg (9.2 (4.4), 0.6 (0.8)) significantly reduced leucocyte adhesion compared with diseased controls (27.8 (5.3), 14 (4.4)) in a dose dependent manner whereas subcutaneous treatment did not. Correspondingly, macroscopic and histological inflammation was significantly decreased. ICAM-1 oligonucleotides markedly reduced endothelial ICAM-1 expression while VCAM-1 oligonucleotides clearly diminished endothelial VCAM-1 expression. CONCLUSIONS: Both ICAM-1 and VCAM-1 2'-O-methoxyethyl chimeric antisense oligonucleotides attenuate rat ileitis by downregulation of leucocyte adherence and thus are potential candidates for anti-inflammatory treatment in inflammatory bowel disease.

[Colonic pouch: indications and technique]. / Kolonpouch: Indikation und Technik.

Early functional outcome after low anterior resection with total mesorectal excision (TME) and colo-anal anastomosis for colorectal carcinoma can be improved by the restoration of the colonic reservoir. This can be achieved by the construction of a colonic J-pouch. The technique is safe and has been refined during the last years. A decrease in stool frequency, urgency, and incontinence rates during the first two postoperative years with an improved quality of life has been observed. Alternative methods with similar functional results are provided by the ileocecal reservoir, the transverse coloplasty pouch or the side-to-end anastomosis. Colonic J-pouch reconstruction should be considered as an superior alternative to straight coloanal anastomosis in patients undergoing anterior resection.

Acetyl-11-keto-beta-boswellic acid, a constituent of a herbal medicine from Boswellia serrata resin, attenuates experimental ileitis.

The gum resin extract from Boswellia serrata (H15), an herbal product, was recently shown to have positive therapeutic effects in inflammatory bowel disease (IBD). However, the mechanisms and constituents responsible for these effects are poorly understood. This study examined the effect of the Boswellia extract and its single constituent acetyl-11-keto-beta-boswellic acid (AKBA) on leukocyte-endothelial cell interactions in an experimental model of IBD. Ileitis was induced by two subcutaneous injections of indomethacin (7.5 mg/kg) in Sprague-Dawley rats 24 h apart. Rats also received oral treatment with the Boswellia extract (H15) or AKBA at two different doses (low and high) equivalent to recommendations in human disease over 2 days. Controls received only the carriers NaHCO3 (subcutaneously) and tylose (orally). Effects of treatment were assessed by intravital microscopy in ileal submucosal venules for changes in the number of rolling and adherent leukocytes and by macroscopic and histological scoring. Increased leukocyte-endothelial cell adhesive interactions and severe tissue injury accompanied indomethacin-induced ileitis. Treatment with the Boswellia extract or AKBA resulted in a dose-dependent decrease in rolling (up to 90%) and adherent (up to 98%) leukocytes. High-dose Boswellia extract as well as both low- and high-dose AKBA significantly attenuated tissue injury scores. Oral therapy with the Boswellia extract or AKBA significantly reduces macroscopic and microcirculatory inflammatory features normally associated with indomethacin administration, indicating that the anti-inflammatory actions of the Boswellia extract in IBD may be due in part to boswellic acids such as AKBA.

Effect of anti-CD11b (alphaM-MAC-1) and anti-CD54 (ICAM-1) monoclonal antibodies on indomethacin induced chronic ileitis in rats.

Leukocyte emigration from blood to sites of inflammation involves sequential interaction of specific adhesion molecules expressed by both leukocytes and endothelial cells. The central steps in leukocyte-endothelial adhesive interactions are leukocyte rolling, sticking, and transmigration. This study investigated the effect of monoclonal antibodies against CD54 (ICAM-1) and CD11b (alphaM-chain of MAC-1) on intestinal inflammation. Anti-CD54 and anti-CD11b were tested in rats with indomethacin-induced chronic ileitis. Macroscopic changes were assessed by a modified version of the Wallace et al. score. Leukocyte rolling and sticking were investigated by intravital microscopy. Results show that indomethacin administration led to a chronic inflammatory response characterized by significant increase (P<0.05) in rolling (from 5.41+/-2.87 to 32.41+/-15.03 100 microm(-1) s(-1)) and sticking (from 0.16+/-0.18 to 9.11+/-5.3 100 microm(-1) s(-1)) leukocytes. After antibody treatment only the anti-CD11b group showed significant (P<0.05) reduction in rolling (from 32.41+/-15.03 to 6.6+/-2.7 100 microm(-1) s-1) and sticking (from 9.11+/-5.3 to 0.07+/-0.09 100 microm(-1) s-1) leukocytes. This was also the case for macroscopic changes. Indomethacin led to a rise in the Wallace score from 0 to 4.29+/-0.76 points (P<0.05) and anti-CD11b to a reduction from 4.29+/-0.76 to 1.29+/-1.11 points (P<0.05). Anti-CD54 and combined anti-CD11b/CD54 administration was not followed by significant changes. Therefore we suggest that leukocyte-based CD11b but not endothelial-based CD54 contributes most to leukocyte adhesion in the setting of indomethacin-induced ileitis in rats.

Evaluation of regional systolic function in hypertrophic cardiomyopathy and hypertensive heart disease: a three-dimensional echocardiographic study.

Assessment of regional left ventricular (LV) function in patients with asymmetric LV hypertrophy is difficult with two-dimensional echocardiography mainly because of factors such as LV geometry, structure, regional wall stress, and ischemia. Multiplane transesophageal echocardiography with three-dimensional reconstruction of cross-sectional images was used for quantitative evaluation of regional wall thickness and fractional thickening. Fifteen patients (56 +/- 13 years old) with hypertrophic cardiomyopathy (LV ejection fraction 71% +/- 4%), 15 (62 +/- 13 years) with hypertensive heart disease (ejection fraction 66% +/- 8%) and 15 (53 +/- 11 years) healthy control subjects (ejection fraction 61% +/- 5%) were included in the analysis. Regional function was studied in four parallel equidistant short-axis cross sections from base to apex of the reconstructed left ventricle. In 15 degree intervals, 24 wall thickness measurements in each cross section were made at end-diastole and end-systole after endocardial and epicardial border tracing. A total of 192 measurements were obtained in each patient, and absolute wall thickening and fractional thickening were calculated. Absolute and fractional wall thickening showed a significant inverse relation to end-diastolic wall thickness in all heart conditions (r = 0.71, p < 0.0001). Regions of normal wall thickness in diseased patients were not hyperdynamic when compared with normal control subjects. Significant impairment in fractional thickening at identical end-diastolic thickness was observed in the septum compared with the lateral free wall in both hypertrophic cardiomyopathy and hypertensive heart disease. Thus regional systolic function is inversely related to end-diastolic wall thickness. The decrease in regional systolic function with increasing LV hypertrophy was similar in idiopathic and hypertensive cardiomyopathy. In both types of hypertrophy, significant differences in systolic function were observed in septal and lateral wall segments of similar wall thickness. This indicates that factors other than end-diastolic wall thickness influence myocardial thickening in patients with hypertrophy and preserved global function.