A unique 3D endoanal ultrasound feature of perianal Crohn's fistula: the 'Crohn ultrasound fistula sign'.

AIM: Using a high-resolution 3D endoanal ultrasound, we have observed that some perianal fistulas show a hypoechogenic fistula tract surrounded by a well-defined hyperechogenic area with a thin hypoechogenic edge in patients with Crohn's disease ['Crohn's Ultrasound Fistula Sign' (CUFS)], unlike conventional fistula tracks. The study aimed to determine the prevalence of CUFS in a consecutive series of patients with anal fistula. METHOD: Of 157 patients (median age 45, range 14-86 years, 100 males) with perianal fistula were examined with 3D endoanal ultrasound. All 3D volumes were stored and analysed retrospectively by two independent observers blinded to the clinical information of the patients. RESULTS: There were 29 patients with Crohn's disease of whom 20 (69%) showed CUFS. CUFS was absent in 125 (98%) of 128 patients without Crohn's disease. The positive and negative predictive value of CUFS for Crohn's disease was 87% and 93%, respectively. The kappa value of the two independent observers was 0.77, indicating a substantial interobserver agreement. CONCLUSION: This study provides a new 3D endoanal ultrasound criterion, CUFS, of perianal fistula in patients with Crohn's disease. The sign can be used to discriminate a Crohn's from other types of fistula, which may be useful in the management of patients with anal fistula.

Peripheral leucocyte count variations in rectal cancer treatment.

AIM: Mortality after curative surgery for rectal cancer is increased if surgery is not performed within a week of completed short course radiotherapy. A link to the suppression of leucocytes after neoadjuvant radiotherapy has been suggested. This study investigates the effects of radiotherapy on peripheral leucocyte counts, complications and survival. METHOD: Patient data variables from a retrospective database (Local and National Swedish Registries) of a total of 926 consecutive patients treated for rectal cancer disease at two surgical units (1993-2004) were analysed for leucocyte counts and mortality. In all 310 patients received radiotherapy. Mean follow-up time was 2.8 years. RESULTS: There was a marked suppression of leucocytes in the irradiated groups coupled with a reduction in leucocyte response to surgery (p<0.05) compared to non-irradiated patients. Long course radiotherapy resulted in a better postoperative leucocyte response. Irradiated patients with a low post/preoperative leucocyte ratio had higher complication rates. No association between leucocyte response and survival was seen in the irradiated group. CONCLUSIONS: Postoperative leucocytosis is impaired after neoadjuvant radiotherapy, independent of latency period to surgery. Irradiated patients with a suppression of leucocyte response had significantly higher complication rates. The true extent of survival could not be measured in radiotherapy groups due to the short median follow-up period.

The Swedish rectal cancer registry.

BACKGROUND: An audit of all patients with rectal cancer in Sweden was launched in 1995. This is the first report from the Swedish Rectal Cancer Registry (SRCR). METHODS: Between 1995 and 2003, 13 434 patients treated for adenocarcinoma of the rectum were registered with the SRCR; there were approximately 1500 new patients annually. RESULTS: Approximately half had an anterior resection, a quarter an abdominoperineal resection and 15 per cent a Hartmann's procedure. The median 30-day postoperative mortality rate was 2.4 per cent and the overall postoperative morbidity rate was 35.0 per cent. The 5-year cancer-specific survival rate was 62.3 per cent. The 5-year relative survival rate was 70.1 per cent after anterior resection, 59.8 per cent after abdominoperineal resection and 39.8 per cent after a Hartmann's procedure. The crude 5-year local recurrence rate was 9.5 per cent overall, 6.1 per cent after preoperative radiotherapy and 11.4 per cent after surgery alone. For 3868 patients who had a locally curative procedure the local recurrence rate was 7.4 per cent overall, 5.9 per cent for those who had radiotherapy and 10.2 per cent for those who did not. The local recurrence rate was 2.9 per cent (28 of 968) for stage I disease, 7.9 per cent (112 of 1418) for stage II, 13.9 per cent (188 of 1357) for stage III and 8.5 per cent (45 of 532) for stage IV. CONCLUSION: These good population-based results are due, in part, to the nationwide prospective quality assurance registration.

The extent of endosonographic anal sphincter defects after primary repair of obstetric sphincter tears increases over time and is related to anal incontinence.

OBJECTIVE: To describe and classify endosonographic obstetric sphincter defects at 1 week, 3 months and 1 year after primary repair, and to relate the endosonographic results to anal sphincter pressure and to symptoms of anal incontinence over time. METHODS: Forty-one women who had suffered a third- or fourth-degree perineal tear at delivery underwent anal endosonography and anal manometry 1 week, 3 months and 1 year after primary suture of the tear. The extent of the endosonographic defects was described using defect scores ranging from 0 (no defect) to 16 (maximal defect), the score taking into account the location and the longitudinal and circumferential extent of the defect. The women answered a questionnaire with regard to bowel function 1 and 4 years after delivery, the degree of incontinence being expressed as a Wexner score. RESULTS: Some 90% (37/41) of the women had endosonographic defects at 1 week, 3 months and 1 year. The endosonographic defect scores increased significantly between the first and second examinations and then remained unchanged. At 1 year there was a negative correlation between endosonographic sphincter defect score and sphincter pressure. At 1 and 4 years, 54% (22/41) and 61% (25/41) of the women, respectively, had a Wexner score >/= 1. There was a positive correlation between the endosonographic sphincter defect score at 1 week, 3 months and 1 year and the Wexner incontinence score at 1 and 4 years. The endosonographic sphincter defect score at 1 week was the variable that was most predictive of the Wexner score at 4 years (r = 0.48, P = 0.002). CONCLUSION: The higher the endosonographic sphincter defect score after primary repair of an obstetric sphincter tear the lower the sphincter pressure and the higher the risk of anal incontinence.

Endosonography of the anal sphincter in women of different ages and parity.

OBJECTIVES: To obtain reference data representative of normal findings at anal endosonography in pregnant and non-pregnant women. To determine intraobserver and interobserver agreement in the detection of endosonographic anal sphincter defects in asymptomatic women. METHODS: Twenty-five non-pregnant nulliparous women and 25 non-pregnant parous women (age range, 20-67 years) and 47 pregnant women (age range, 21-39 years) underwent anal manometry and anal endosonography. The endosonographic internal and external sphincter thickness and sphincter length were measured online. Endosonographic sphincter defects were measured and classified offline from videotapes by two independent examiners using an endosonographic defect score ranging from 0 (no defect) to 16 (maximal defect), the score taking into account the location and the longitudinal and circumferential extension of the defect. RESULTS: Endosonographic sphincter thickness and length did not differ between non-pregnant nulliparous and parous women and did not change substantially with age. The anal sphincter was thicker and the anal resting pressure area and manometric sphincter length were greater in pregnant than in non-pregnant women of the same age (20-39 years). There was good intra- and interobserver agreement with regard to detection of endosonographic anal sphincter defects (kappa > or = 0.70). Eighteen (19%) women had endosonographic sphincter defects but in only four (4%; 4/97) cases were they moderate or large (defect score, 7-10). Ten (20%) of the non-pregnant women reported minor gas incontinence and one reported minor incontinence for both gas and liquid stool. The frequency of incontinence did not differ between women with and without sphincter defects. CONCLUSIONS: Reference data representative of normal findings at anal endosonography have been established for non-pregnant women and for nulliparous women in the third trimester of pregnancy. Small endosonographic sphincter defects and minor gas incontinence are common in women without known sphincter trauma. They seem to be unrelated to each other and may be regarded as normal variants.

Results of endosonographic imaging of the anal sphincter 2-7 days after primary repair of third- or fourth-degree obstetric sphincter tears.

OBJECTIVES: To describe the endosonographic image of the anal sphincter 2-7 days after delivery in women who had undergone a primary repair of an obstetric sphincter tear. METHODS: Forty-eight women who had suffered a third- or fourth-degree sphincter tear at delivery and had undergone primary sphincter repair were examined with endoanal sonography 2-7 days after delivery. A score from 0 to 16 was used to describe the extent of the endosonographic defects, a score of 0 indicating no defect and a score of 16 a defect > 180 degrees involving the whole length and depth of the sphincter. Clinical information was retrieved from the delivery and operation records after the analysis of the ultrasound images and the classification of the sonographic defects had been completed. RESULTS: Clinically, 34 (71%) women had a partial third-degree tear, 11 (23%) had a total third-degree tear, and three (6%) had a fourth-degree tear. Forty-three (90%; 95% CI, 77-97%) women had sonographic defects, all hypoechoic. Twenty-three (54%) sonographic defects were confined to the proximal part of the anal canal and involved less than half of the length of the anal canal. Thirty (63%) defects were confined to the external sphincter. Five of nine women (56%) with an endosonographic sphincter defect score >/= 8 had undergone primary sphincter repair by a doctor in training vs. 9 of 39 women (23%) with an endosonographic sphincter score < 8 (P = 0.05), despite the fact that 86% (12/14) of the tears sutured by doctors in training were clinically partial third-degree tears vs. 65% (22/34) of those sutured by specialists (P = 0.15). Five (15%) of 34 women with a clinical partial third-degree tear had an endosonographic sphincter score >/= 8 vs. four (29%) of 14 with a clinical total third- or fourth-degree sphincter tear (P = 0.26). CONCLUSIONS: Most women (90%) with a clinical third- or fourth-degree obstetric sphincter tear have endosonographic sphincter defects if they are examined 2-7 days after primary repair. The extent of the endosonographic defects seems to be determined mainly by the surgical experience of the doctor performing the repair, and not by the clinical degree of the tear.

Rectal endosonography can distinguish benign rectal lesions from invasive early rectal cancers.

OBJECTIVE: To determine whether an experienced ultrasound examiner, using good ultrasound equipment with high multifrequency probes, can discriminate between a high grade or low grade dysplastic adenoma (pT0) and very early invasive rectal cancers (pT1). SUBJECTS AND METHODS: Sixty consecutive patients with clinically possibly pT0 or pT1 rectal tumours referred for transanal local excision underwent endorectal ultrasound examination. Lesions where the endorectal ultrasound image showed the mucosal layer to be expanded but the submucosal layer to be intact (uT0) were considered to represent a low grade or high grade dysplasia adenoma (pT0). An irregularity or disruption of the submucosal layer (uT1) was considered to characterize early invasive rectal cancers (pT1). The ultrasound staging was compared with the histological staging made on the basis of the diagnoses in the excised specimens. RESULTS: The histopathological diagnoses were: invasive rectal cancer (n = 18, 10 pT1, 4 pT2, 4 pT3 cancers); high grade dysplastic adenoma (n = 21); low grade dysplastic adenoma (n = 18); non adenomatous benign lesions (n = 3). Endorectal ultrasound incorrectly classified two of the invasive cancers (both pT1 tumours) as noninvasive lesions. Five of 42 pT0 tumours were overstaged as uT1 tumours. Overstaging was more common in patients who had undergone a previous excision and in tumours with peritumoral inflammation and desmoplastic reaction. The sensitivity of endorectal ultrasound with regard to invasive cancer was 89% (16/18), specificity 88% (37/42), positive predictive value 76% (16/21), negative predictive value 95% (37/39), and accuracy 88% (53/60). Among pT0 and pT1 tumours, the corresponding figures were 80% (8/10), 88% (37/42), 62% (8/13), 95% (37/39), and 87% (45/52). CONCLUSION: Endorectal ultrasound can distinguish between noninvasive lesions and invasive rectal cancers clinically of stage pT0 or pT1.

[Quality registry for better treatment of rectal cancer established. Economical support is required to use the benefits of the information]. / Kvalitetsregister etablerat för bättre rektalcancerbehandling. Nu krävs ekonomiskt stöd för att informationen skall komma till nytta.

The treatment of rectal cancer has changed significantly during the last 30 years. With improved surgical technique and the introduction of preoperative radiotherapy sphincter preserving surgery is now predominant and the rate of local recurrence has been reduced substantially. However, new therapy concepts may also introduce an increased risk of complications. A register to monitor quality control in rectal cancer treatment in Sweden was established in 1995. It covers over 95 per cent of the patients with rectal cancer reported to the Swedish National Cancer Registry. Collection of data and validation are done by six regional oncology centres under supervision of surgeons appointed by the hospitals involved. The results are then collated to a nationwide quality register, enabling regions to compare themselves with other regions, and hospitals with other hospitals.

[The Referral Field Hospital of the Emergency Response Unit (ERU) of the German Red Cross]. / Das Referral Field Hospital der Emergency Response Unit (ERU) des DRK.

INTRODUCTION: Emergency Response units (ERUs) have been developed as a part of the International Federation of Red Cross and Red Crescent Societies strategy to provide fast and effective medical and technical help to victims of disasters of any kind. ERUs provide timely, professional and organised response in a standardised and streamlined way by a balanced composition of professional staff and predesigned equipment. METHODS: The German Red Cross ERUs "Referral Hospital" and "Specialised Water" took part in the world wide humanitarian help for refugees during the Kosovo war and actually for earthquake victims in Turkey. During the Kosovo-operation the ERU "Referral Hospital" and "Specialised Water" were situated in Macedonia close to the kosovarian boarder at refugee camp Stenkovec I. The Field-Hospital was responsible for all kind of medical emergencies, for a total number of more than 50,000 refugees. RESULTS: During the mission 6225 patients were treated in our Out Patient Department; 541 were hospitalised. Among those 102 medium and major surgical procedures and 105 deliveries were performed. Surprisingly there was no increased rate of infections or perinatal deaths. CONCLUSIONS: During the Kosovo war and actually in Turkey the ERU concept prove itself to be a powerful strategy to provide fast needed medical help to victims of different kind of disasters. Humanitarian work in situations of war, internal disorder and various states of emergency in foreign countries and cultures demand flexibility and the ability to improvise while working under such conditions. The confrontation with non-combatants injured by buried landmines is underlining the growing world-wide demand for a total ban on these vile weapons.

Production and secretion of pancreatic secretory trypsin inhibitor in normal human small intestine.

The aim of this study was to prove the production and secretion of pancreatic secretory trypsin inhibitor (PSTI) in human small intestine. To achieve this we analyzed the content of immunoreactive PSTI (irPSTI) in rinsing fluid from isolated small intestine, using the urea method to estimate the volume of epithelial lining fluid recovered. IrPSTI, measured by an enzyme-linked, immunosorbent assay (ELISA), was present in both free and complexed form. The free PSTI showed intact biologic activity, binding trypsin in stable complexes. The complexed PSTI was dissociated on acidification. With the reverse transcriptase polymerase chain reaction (RT-PCR) and Southern blot hybridization, PSTI mRNA was demonstrated in the mucosa of the ileum. These findings indicate that PSTI is produced and secreted in the small intestinal epithelium and may be part of defence system in intestinal mucosa.

Localization of immunoreactive secretory leukocyte protease inhibitor (SLPI) in intestinal mucosa.

Secretory leukocyte protease inhibitor (SLPI) is the dominant protease inhibitor in the mucus secretions of the repiratory and genital tracts, and local production seems likely, as immunoreactive SLPI has been found in the corresponding mucosa. To our knowledge, SLPI has not been previously demonstrated in intestinal epithelia or secretions. In an earlier study, however, we found surprisingly high levels of SLPI in peritonitis exudate from patients with gastrointestinal perforations. This study extends these observations by demonstrating the presence of immunoreactive SLPI in intestinal mucosa. In the small intestine, SLPI was present in Paneth cells and in scattered mucosa cells of goblet-type. In normal mucosa of the large bowel, SLPI was also found in scattered cells of goblet-type in the epithelium. In addition, immunoreactive SLPI was frequently found in colonic adenomas. The findings in this study raise several interesting questions on the possible role of SLPI in the gut epithelial defense against inflammatory assaults.

Laparoscopic creation of loop ileostomy and sigmoid colostomy.

OBJECTIVE: To evaluate the laparoscopic approach in the creation of loop ileostomies and sigmoid colostomies. DESIGN: Prospective open study. SETTING: University hospital, Sweden. SUBJECTS: Eighteen consecutive patients who needed faecal diversion. INTERVENTIONS: Laparoscopic loop ileostomy (n = 6) or sigmoid colostomy (n = 12). MAIN OUTCOME MEASURES: Mortality, morbidity, and duration of operation. RESULTS: There was no 30-day mortality, and no patients developed infections. The operating time (median 47 minutes, range 45-115 for ileostomies and 50, range 42-102 for colostomies) was comparable to open surgery. Two operations had to be converted to open procedures because of dense adhesions. Postoperative paralytic ileus was transient, and all patients started oral intake on the first postoperative day. CONCLUSIONS: The laparoscopic technique is easy to do, it takes no longer than open surgery, and it causes minimal trauma, allowing the patients to recover faster.

Endoluminal ultrasound and low-field magnetic resonance imaging are superior to clinical examination in the preoperative staging of rectal cancer.

OBJECTIVE: To compare digital examination, endoluminal ultrasound (ELU), and plain magnetic resonance imaging (MRI), with histopathological findings in the preoperative staging of rectal cancer. DESIGN: A prospective comparative study. SETTING: University hospital, Sweden. SUBJECTS: 35 patients with rectal cancer who presented during the period February 1987 to February 1991. RESULTS: The digital examination of 19 patients could be assessed and was correct in 13 (68%). ELU was done in 34 patients; the accuracy was 88%. Extension of tumour was overestimated in two and underestimated in two. MRI was done for 35 patients with an accuracy of 66%; in 12 patients extension was underestimated. The diagnostic accuracy of the assessment of lymph node involvement was 71% with ELU, and 72% with MRI. CONCLUSION: These findings indicate that MRI seems to underestimate the extension of rectal tumours, but both ELU and MRI can be helpful in selecting patients with advanced tumours for whom preoperative adjuvant treatment is being considered. ELU is superior in staging tumours confined to the rectal wall, and could be of value in the selection of patients whose tumours were suitable for local excision. None of these techniques, however, can reliably identify the extent of lymph node involvement.

Pancreatic secretory trypsin inhibitor in human Brunner's glands.

Brunner's glands (duodenal glands) in humans are located mainly in the two proximal thirds of the duodenum. They are known to produce and secrete mucin. In recent years, human Brunner's glands have also been shown to express immunoreactivity toward epidermal growth factor-urogastrone (EGF-uro) and lysozyme. These proteins are considered to have a protective function within the gastrointestinal canal. Human pancreatic secretory trypsin inhibitor (PSTI) was recently identified in Brunner's glands. This present study was done by an immunohistochemical method, using monospecific polyclonal antibodies against human PSTI and human lysozyme, respectively. McManus/Alcian blue mucin staining was used to clarify the distribution of mucin. We found immunoreactive PSTI (irPSTI) in seven out of ten specimens. Lysozyme and mucin were present in all ten. While virtually all cells were stained for lysozyme and mucin, irPSTI was restricted to separate lobules and to cells in the ducts.

Quantification of pancreatic secretory trypsin inhibitor in colonic carcinoma and normal adjacent colonic mucosa.

AIMS: To measure the content of immunoreactive human pancreatic secretory trypsin inhibitor (irPSTI) in colonic carcinoma and adjacent normal colonic mucosa. METHODS: From a stable hybridoma cell line producing monoclonal antibodies specific for human PSTI, a specific enzyme linked immunosorbent assay (ELISA) for human PSTI was developed. In a precipitation assay system these antibodies bound human PSTI in a dose-dependent manner. The specimens were obtained from resectional surgery. RESULTS: The content of irPSTI was 19.9 micrograms/g protein (0.55 micrograms/g tissue wet weight) in colonic carcinoma. In adjacent normal colonic mucosa 43.6 micrograms/g protein (1.12 micrograms/g tissue wet weight) was shown. CONCLUSIONS: The enzymatic degradation of surrounding tissue necessary for tumour cell invasion could be facilitated by this relative deficit of the inhibitor in infiltrative carcinoma.

Immunoreactive pancreatic secretory trypsin inhibitor in normal, inflammatory and neoplastic gallbladders.

Operative specimens from normal, inflammatory and neoplastic gallbladders were analyzed for immunoreactive pancreatic secretory trypsin inhibitor (irPSTI) using a peroxidase-antiperoxidase method. In normal and inflammatory gallbladders no irPSTI was demonstrated, while irPSTI was found in neoplastic gallbladders.

Immunohistochemical demonstration of pancreatic secretory trypsin inhibitor in normal and neoplastic colonic mucosa.

Specimens of normal and neoplastic colonic mucosa from 52 patients were analysed by immunohistochemistry using a monospecific polyclonal antiserum against human pancreatic secretory trypsin inhibitor (PSTI). In normal colonic mucosa PSTI was found in the goblet cells in the basal parts of the crypts. In adenomas of tubular, villous, and tubulo-villous types PSTI was also found in the upper parts of the polyps, usually occurring in the regeneration zone. There was a more intense staining reaction in polyps with increased atypia. Carcinomas of different types and of various grades of differentiation and of in situ type did not contain PSTI. These findings indicate that PSTI could be a marker for adenomatous rather than carcinomatous epithelium in the colon. Furthermore, the absence of the inhibitor in malignant cells might facilitate tissue invasion by malignant cells because of deficient protease inhibition.

Compartment syndrome after prolonged surgery with leg supports.

Compartment syndrome has been reported in a few cases after prolonged surgery with patients in leg supports. A recent case in our hospital (57-year-old man undergoing cystourethrectomy because of cancer) made us interested in the problem. This case together with six from the literature are analysed. Moreover, the first 11 cases operated on with a pelvic pouch and ileoanal anastomosis at our department were reviewed. They had been in the leg support position for a median duration of 6.4 (5.8-8) h. In four of them leg pain and swelling developed within 12 h. Three showed regression within a few days, one after a week. In one patient with swelling compartment pressure was measured with a transducer tipped catheter. Intermittently the pressure was up to 50 mm Hg. There was an obvious decrease in pressure on knee bending. Also, in a patient without swelling large pressure variations were seen but not to critical levels.