Cumulative incidence and risk factors for pouch adenomas associated with familial adenomatous polyposis following restorative proctocolectomy.

BACKGROUND: The emergence of restorative total proctocolectomy has significantly reduced the lifetime colorectal cancer risk associated with familial adenomatous polyposis (FAP). However, adenomas may develop in the ileal pouch over time and may even progress to carcinoma. We evaluated the cumulative incidence, time to development, and risk factors associated with ileal pouch adenoma. AIM: To evaluate the cumulative incidence, time to development, and risk factors associated with pouch adenoma. METHODS: In this retrospective, observational study conducted at a tertiary center, 95 patients with FAP who underwent restorative proctocolectomy at our center between 1989 and 2018 were consecutively included. The mean follow-up period was 88 mo. RESULTS: Pouch adenomas were found in 24 (25.3%) patients, with a median time of 52 mo to their first formation. Tubular adenomas were detected in most patients (95.9%). There were no high-grade dysplasia or malignancies. Of the 24 patients with pouch adenomas, 13 had all detected adenomas removed. Among the 13 patients who underwent complete adenoma removal, four (38.5%) developed recurrence. Among 11 (45.8%) patients with numerous polyps within the pouch, seven (63.6%) exhibited progression of pouch adenoma. The cumulative risks of pouch adenoma development at 5, 10, and 15 years after pouch surgery were 15.2%, 29.6%, and 44.1%, respectively. Severe colorectal polyposis (with more than 1000 polyps) was a significant risk factor for pouch adenoma development (hazard ratio, 2.49; 95% confidence interval: 1.04-5.96; P = 0.041). CONCLUSION: Pouch adenomas occur at a fairly high rate in association with FAP after restorative proctocolectomy, and a high colorectal polyp count is associated with pouch adenoma development.

Effect of partial rectal resection with transanal stapler in the treatment of rectum protrusion / 中国基层医药

Objective@#To investigate the clinical effect of transanal stapler partial rectal resection for rectocele.@*Methods@#From January 2012 to January 2018, 90 patients with rectocele treated in Changzhi Traditional Chinese Medicine Hospital were divided into control group (45 cases) and observation group (45 cases) according to the operation method.The control group was treated with closed transrectal repair, while the observation group was treated with partial rectal resection with anal stapler.The operative effect, incidence of postoperative complications, recurrence rate, degree of pain after operation, length of hospital stay and cost of treatment were compared between the two groups.@*Results@#The total effective rate of the two groups was 100.0%.The incidence of complications in the observation group was 2.2%(1/45), which was lower than that in the control group [17.8%(8/45)] (χ2=4.444, P=0.035). The recurrence rate in the observation group was 0(0/45), which was lower than that in the control group [13.3%(6/45)] (χ2=4.464, P=0.035). The hospitalization time in the observation group was shorter than that in the control group[(7.01±2.06)d vs.(11.31±2.42)d]. Compared with the control group, the treatment cost of the observation group was higher[(0.836±0.164)×104CNY vs.(0.605±0.136)×104CNY], and the post-operative pain score was lower[(4.24±1.33) vs.(6.45±1.17)](t=9.076, 7.273, 8.369, all P<0.001).@*Conclusion@#Transanal stapler partial rectal resection is effective in the treatment of rectocele, with less complications, lower recurrence rate and less pain after operation, but the cost of treatment is higher.

Effect of partial rectal resection with transanal stapler in the treatment of rectum protrusion / 中国基层医药

Objective To investigate the clinical effect of transanal stapler partial rectal resection for rectocele.Methods From January 2012 to January 2018,90 patients with rectocele treated in Changzhi Traditional Chinese Medicine Hospital were divided into control group (45 cases) and observation group (45 cases) according to the operation method.The control group was treated with closed transrectal repair ,while the observation group was treated with partial rectal resection with anal stapler.The operative effect ,incidence of postoperative complications , recurrence rate,degree of pain after operation ,length of hospital stay and cost of treatment were compared between the two groups.Results The total effective rate of the two groups was 100.0%.The incidence of complications in the observation group was 2.2%(1／45),which was lower than that in the control group [17.8%(8／45)] (χ2 ＝4.444, P＝0.035).The recurrence rate in the observation group was 0(0／45),which was lower than that in the control group [13.3%(6／45)] (χ2 ＝4.464,P＝0.035).The hospitalization time in the observation group was shorter than that in the control group[(7.01 ±2.06)d vs.(11.31 ±2.42)d].Compared with the control group ,the treatment cost of the observation group was higher[(0.836 ±0.164)×104CNY vs.(0.605 ±0.136)×104CNY],and the post-operative pain score was lower [(4.24 ±1.33) vs.(6.45 ±1.17)] ( t＝9.076,7.273,8.369,all P＜0.001).Conclusion Transanal stapler partial rectal resection is effective in the treatment of rectocele , with less complications, lower recurrence rate and less pain after operation ,but the cost of treatment is higher.

Are radiologic pouchogram and pouchoscopy useful before ileostomy closure in asymptomatic patients operated for ulcerative colitis?

OBJECTIVES: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the "gold standard" procedure for patients with ulcerative colitis (UC) requiring surgical intervention. A de-functioning ileostomy is usually performed, as a step for the IPAA procedure. The aim of this study is to present the methodology and results of the routine double assessment of IPAA integrity in asymptomatic patients prior to the ileostomy reversal and evaluate its necessity. METHODS: This is a retrospective study of 61 UC patients, who underwent IPAA construction, in 2010-2016. A diverting ileostomy was created after IPAA construction, which was reversed at least 3 months later. A double assessment, with pouchogram and pouchoscopy, of IPAA integrity was performed, before stoma closure. Post-operative symptoms and signs of complications, imaging studies, and endoscopic findings were recorded during follow-up. RESULTS: Prior to the ileostomy reversal, both pouchoscopy and pouchogram identified no patient with evidence of anastomotic leakage. During a mean follow-up of 3.67 years after ileostomy reversal, 11 patients developed complications but only one had signs of leakage, which presented as a pouch-vaginal fistula. The specificity of both the pouchogram and pouchoscopy reached 100% and the negative predictive value ranged between 98.4 and 100%. CONCLUSIONS: The specificity of pouchoscopy and pouchogram prior to ileostomy closure, in asymptomatic patients with IPAA for UC, is very high in recognizing an intact anastomosis, but their combination did not alter the diagnostic accuracy or had any effect in further management. At least, pouchogram could be selectively performed only in patients with high-risk clinical indicators. KEY POINTS: • The double assessment of ileal pouch-anal anastomosis with pouchogram and pouchoscopy, prior to ileostomy closure, specifically in patients with ulcerative colitis has not been evaluated before. • The specificity of pouchoscopy and pouchogram prior to ileostomy closure, in asymptomatic patients with IPAA for UC, is very high in recognizing an intact anastomosis. • However, their combination did not alter the diagnostic accuracy or had any effect in further management, in asymptomatic patients.

Endoluminal vacuum-assisted therapy as treatment for anastomotic leak after ileal pouch-anal anastomosis: a pilot study.

BACKGROUND: Anastomotic leak after ileal pouch-anal anastomosis (IPAA) could lead to poor functional results and failure of the pouch. The aim of the present study was to analyze the outcomes of the vacuum-assisted closure therapy as the unique treatment for anastomotic leaks following IPAA without any additional surgical operations. METHODS: Consecutive patients with anastomotic leak after IPAA treated at our institution between March 2016 and March 2017 were prospectively enrolled. After diagnosis, the Endosponge® device was positioned in the gap and replaced until the cavity was reduced in size and covered by granulating tissue. A pouchoscopy was performed every week for the first month and monthly subsequently. No additional procedures were performed. RESULTS: Eight patients were included in the study. The leak was diagnosed at a median of 14 (6-35) days after surgery. At the time of diagnosis, seven patients had a defunctioning ileostomy performed as routine at the time of pouch formation, while one patient was diagnosed after ileostomy closure and underwent emergency diversion ileostomy. The Endosponge® treatment started after a median of 6.5 (1-158) days after the diagnosis of the leakage and was carried on for a median of 12 (3-42) days. The device was replaced a median of 3 (1-10) times. The median length of hospital stay after the first application of the treatment was 15.5 (6-48) days. The complete healing of the leak was documented in all patients, after a median of 60 (24-90) days from the first treatment. All patients but one had their ileostomy reversed at a median of 2.5 (1-6) months from the confirmation of the complete closure. CONCLUSIONS: Endosponge® is effective as the only treatment after IPAA leak. Based on the results of our prospective pilot study, application of Endosponge® should be the treatment of choice in selected pouch anastomotic leaks not requiring immediate surgery. These results will have to be confirmed by future prospective studies including a larger number of patients.

Outcomes of ileal pouch-anal anastomosis without primary diverting loop ileostomy if postoperative sepsis develops.

BACKGROUND: The aim of the present study was to assess the short-term and long-term consequences of diverting loop ileostomy (DLI) omission in ileal pouch-anal anastomosis (IPAA) surgery complicated by postoperative pelvic sepsis. METHODS: This was a retrospective review of a prospectively maintained database. Of 4031 patients who underwent IPAA in 1983-2014, 357 developed IPAA-related pelvic sepsis with or without anastomotic dehiscence. Patients with Crohn's disease or cancer were excluded. The patient cohort was divided into two groups, depending on the presence or absence of DLI. Patient characteristics, short-term and long-term outcomes were compared. Long-term pouch survival was estimated with the Kaplan-Meier method. Quality of life (QOL) in the groups was compared at the latest follow-up. RESULTS: Three hundred and twenty-six patients developing pelvic sepsis had diversion at the time of IPAA (D group) and in 31 who developed pelvic sepsis DLI had been omitted (O group). The length of hospital stay was significantly longer in the O group 11.5 (3-33) days versus 8 (2-59) days in the D group (p = 0.006). Forty-eight percent of patients from the O group with anastomotic leak underwent reoperation and had a DLI formed at this second procedure versus 12% in the D group requiring reoperation (p < 0.0001). In long-term follow-up, there was no difference in pouch survival between the groups: 99 versus 97% after 5 years and 88 versus 87% after 10 years, in the O group and D group, respectively (p = 0.40). There was no difference in QOL observed between the groups. CONCLUSIONS: Omission of DLI in selected patients who had IPAA surgery did not increase pouch failure or adversely affect QOL in the long term, if pelvic sepsis occurred.

Patients' perspective on bowel resection for inflammatory bowel disease.

PURPOSE: The study aimed to determine whether patients are receiving adequate counselling about elective bowel resection and timely surgery for inflammatory bowel disease (IBD). METHODS: Patients with IBD who underwent an elective bowel resection in a tertiary referral centre between April 2012 and Dec 2014 were identified from a prospective database. Patients under the age of 16 years were excluded from the study. Patients were contacted over the phone to complete a questionnaire regarding their perspective on their surgery, including the consultations that took place, preparedness and timing of surgery, as well as patient attitude towards bowel resection and satisfaction with post-operative outcomes. Demographic details were recorded. RESULTS: Thirty-one patients participated in the study. Twenty-one (68%) patients were diagnosed with Crohn's disease, nine (29%) were diagnosed with ulcerative colitis, and one (3%) had indeterminate colitis. Twenty-seven (87%) patients reported that the timing of the initial consultation regarding the option of bowel resection was appropriate. Twenty-five (81%) patients felt prepared after a consultation with the surgical team with regard to perioperative issues and potential complications. Fourteen (45%) patients reported that the timing of bowel resection was appropriate, while 15 (48%) reported that it should have been earlier. A significant improvement in patient's pre- and post-operative attitudes towards bowel resection was demonstrated (p = 0.004). Thirty (97%) patients were either happy or very happy with their results and symptom improvement post-bowel resection. CONCLUSION: Most patients are receiving adequate counselling about elective bowel resection for IBD, although there is room for improvement for preoperative education and optimising timing of surgery.

Laparoscopic resection of metachronous colorectal carcinoma / 中华普通外科杂志

Objective To evaluate laparoscopic radical resection of metachronous colorectal carcinoma.Methods A total of 13 patients with metachronous colorectal carcinoma undergoing laparoscopic resection in Department of Gastrointestinal Surgery,Union Hospital,Tongji Medical College,Huazhong University of Science and Technology from January 2013 to December 2015 were analyzed retrospectively.Results The mean time of surgery was (156 ± 9) min.Tumors were located in the right hemicolon in 3 cases,in the transverse colon in one,in the left hemicolon in 2,in the sigmoid colon in four and in the rectum in 4.The mean blood loss was (66 ± 21) ml.There was no conversion to open surgery.Two patients were done with protective ileostomy.Postoperative gastrointestinal function recovery time was (2.5 ± 0.7) days.One postoperative intra-abdominal bleeding was successfully controlled laparoscopically.Posteperative length of hospital stay was (26.2 ± 2.9) days.The median follow-up was 12 months (5-30 months) with no cancer recurrence.Conclusions Laparoscopic radical resection of metachronous colorectal carcinoma has good curative effect,and high success rate in spite of previous history of laparotomy.

Subtotal colectomy and 90 degree rotation cecorectal side-to-end anastomosis for slow transit constipation / 中华普通外科杂志

Objective To analyze the clinical efficacy of subtotal colectomy,90 degree rotation of the cecum and cecorectal side-to-end anastomosis for slow transit constipation (STC).Methods Clinical data of 31 STC patients treated by subtotal colectomy,90-degree rotation round its long axis and cecorectal anastomosis were retrospective analysed.Results Open surgery was performed in 14 cases,and laparoscopic-assisted surgery in 17 cases.There was no perioperative mortality.Anastomotic fistula occurred in 1 case.4 cases suffered from intestinal obstruction including early postoperative inflammatory bowel obstruction in 2 cases,and incomplete intestinal adhesions in 2 cases.All were cured by conservative treatment.In postoperative one month stool frequency averaged at 8 times/d,after half a year the stool frequency was averaged at 6 times/d,after 2 years it was 4 times/d.There was no stool seepage during night time.Conclusions Colon subtotal resection and 90 ° rotation cecal rectal anastomosis in the treatment of STC is effective and without severe complications.

Effect of probiotics (Lactobacillus plantarum 299 plus Bifidobacterium Cure21) in patients with poor ileal pouch function: a randomised controlled trial.

OBJECTIVE: Poor pouch function after restorative proctocolectomy for ulcerative colitis is a considerable problem. Pouchitis and functional disorders are the most common reasons. Probiotics seem to have a beneficial effect in pouchitis but have not been assessed in functional pouch disorders. The aim was to analyse the effects of probiotics in patients with poor pouch function. METHODS: Thirty-three patients were randomized to probiotics (Lactobacillus plantarum 299 and Bifidobacterium infantis Cure 21) or placebo in a double blinded, 1:1 fashion. The treatment effect was assessed by the pouch functional score (PFS; 0-15, 15 worst), pouchitis disease activity index (PDAI; 0-18, 18 worst), and levels of four faecal biomarkers of inflammation (calprotectin, lactoferrin, myeloperoxidase [MPO] and eosinophilic cationic protein [ECP]). RESULTS: Thirty-two patients were included (probiotics = 17, placebo = 16). There was no difference in change in the PFS from before to after treatment between the groups (median difference: -1.00, 95% C.I. -3.00 to 0.00, p = 0.119). Furthermore, probiotics had no effect on PDAI (median difference: 0.00, 95% C.I. 0.00-1.00, p = 0.786), or on faecal biomarkers. Significant correlations were observed between PDAI and each of the faecal biomarkers at study start. There were no correlations between PFS or PDAI symptom subscore and the biomarkers. PDAI endoscopic and histologic subscores correlated significantly to each of the biomarkers. CONCLUSION: The hypothesis that probiotics improves pouch-related dysfunction was not confirmed. Faecal biomarkers could play a future role in the management of pouch patients.

Comparison of the influence on the healing of anastomotic stoma between two kinds of alimentary canal reconstruction after laparoscopic radical resection of low rectal cancer / 中国基层医药

Objective To investigate the different influencing on the healing of anastomotic stoma between two kinds of alimentary canal reconstruction after laparoscopic radical resection of low rectal cance.Methods The clinical data of July 2013 -January 2016 suffering from stage Ⅱ -Ⅲ low rectal cancer and in our hospital underwent laparoscopic colorectal cancer radical surgery patients was retrospectively analyzed.Through accessing to medical records,the patients of diabetes,hypoproteinemia,malnutrition,preoperative uncorrectable cases and received neoadjuvant therapy were excluded.More than a total of 59 cases were enrolled,34 cases of them received traditional alimentary canal reconstruction(traditional group,including 26 cases of low rectal cancer,8 cases of super low rectal cancer,also 21 cases of them in stageⅡand 13 cases in stage Ⅲ),25 cases of them received anal anastomosis resection (including 18 cases of low rectal cancer,7 cases of super low rectal cancer,also 20 cases of them in stage Ⅱ and 5 cases in stageⅢ).Results In the traditional group,1case of 34 patients with anastomotic leakage,3 cases of anastomotic bleeding, while in the improved group,2cases of 25 patients with anastomotic leakage,2 cases of anastomotic bleeding.There was no significant difference in the incidence of anastomotic leakage and anastomotic bleeding between the two groups (3cases vs.2cases,1case vs.2cases,χ2 =0.13,0.75,all P >0.05).All cases did not occur in patients with anastomotic stenosis,and all patients were cured and discharged.Conclusion Each of the two methods have their advantages and disadvantages.Through preoperative,intraoperative evaluation of tumor status,reasonable choice of tumor treatment and anastomosis,is more conducive to postoperative recovery.

Laparoscopic assisted total colorectal resection for familial adenomatous polyposis / 中华普通外科杂志

Objective To evaluate the safety,feasibility and value of treating familial adenomatous polyposis (FAP) with laparoscopic assisted total colorectal resection.Methods Thirty six patients with familial adenomatous polyposis from June 2009 to May 2014 were reviewed retrospectively.16 FAP patients underwent laparoscopic assisted total colorectal resection and 20 FAP underwent traditional laparotomy.The clinical data,including short term follow up outcomes,safety,and recovery were analyzed retrospectively.Results Laparoscopic assisted total colorectal resection was performed successfully on 16 patients without severe complications.The mean operation time of the laparoscopic group was (178 ± 33) min,the mean operative blood loss (72 ± 30)ml in the laparoseopic group were not significantly different when compared with the mean operation time (159 ± 24) min and the mean operative blood loss (110 ± 50) ml in the conventional group.Incision length (5.6 ± 1.1) cm,the intestinal function recovery time (2.7 ± 0.9) d,hospital stay after surgery (8.1 ± 1.6) d in the laparoseopic group were significantly different when compared with incision length (15.8 ± 1.8) cm,the intestinal recovery time (3.8 ±0.9) d,hospital stay after surgery (9.9 ± 1.6) d in the conventional group (P ＜ 0.05).There was no severe complications in neither group nor local recurrence,distant nletastases or death found during the follow-up of 6-56 months.Conclusions Laparoscopic assisted total colorectal resection for FAP can be performed safely and effectively with the advantages of minimal invasion,quick recovery and good short term effect.

[Proctocolectomy with ileoanal anastomoses and desmoid tumor treated with resection. One case of familial adenomatous polyposis]. / Proctocolectomía con anastomosis íleo-anal y resección de tumor desmoide. Un caso de poliposis adenomatosa familiar.

BACKGROUND: Familial adenomatous polyposis (FAP) is a rare disease caused by a mutation in the adenomatous polyposis coli gene (APC). CASE REPORT: We report the case of a 32-year-old woman, with abdominal pain and increased abdominal perimeter, as well as melena and weight loss. She had a tumor of 12 cm in diameter in the right iliac fossa. After the administration of contrast media we found the abdominal tumor compatible with sarcoma versus desmoid tumor. We performed a colonoscopy and we found colorectal polyps. The biopsy reported tubulovillous adenomas. A panendoscopy showed polyps in fundus and body of stomach; the state of the duodenum was normal. Tumor resection was performed with abdominal wall reconstruction with mesh and restorative proctocolectomy with ileoanal reservoir and a temporary ileostomy. The histopathology report demonstrated an abdominal wall desmoid tumor and identified 152 tubulovillous polyps which affected all the portions of colon and rectum. CONCLUSIONS: FAP is an autosomal dominant disease caused by a mutation in the APC gene which results in the development of multiple colorectal polyps. Described in 1991 the APC gene is located at chromosome region 5q21. Without prophylactic surgery, virtually all patients develop colorectal cancer in the third decade of life. Desmoid tumors and duodenal polyps are now the leading cause of death in patients with FAP.

Introducción: la poliposis adenomatosa familiar (PAF) es una rara enfermedad causada por una mutación en el gen de la poliposis adenomatosa coli (APC). Caso clínico: mujer de 32 años, con dolor y aumento del perímetro abdominal además de evacuaciones melénicas y pérdida de peso. La paciente presentó un tumor de 12 cm de diámetro en la fosa iliaca derecha. Tras la administración de medio de contraste, en una tomografía se apreció el tumor abdominal con reforzamiento compatible con sarcoma frente a tumor desmoide. Se realizó colonoscopia, por medio de la que se encontraron pólipos en el recto y el colon. La biopsia reportó adenomas túbulo-vellosos. Una panendoscopía demostró pólipos en fondo y cuerpo gástrico; el duodeno se encontraba en estado normal. Se realizó resección del tumor en pared abdominal y reconstrucción con malla además de proctocolectomía restaurativa con un reservorio íleo-anal con una ileostomía temporal. Se reportó tumor desmoide en la pared abdominal y se identificaron 152 pólipos túbulo-vellosos que afectaban todas las porciones del colon y el recto. Conclusiones: la PAF es una enfermedad autosómica dominante causada por una mutación en el gen APC que da como resultado el desarrollo de múltiples pólipos tanto en el colon como en el recto. Descrito en 1991, el gen APC se localiza en el cromosoma 5q21. Sin cirugía profiláctica, todos los pacientes desarrollarán cáncer colorrectal en la tercera década de la vida. Los tumores desmoides y los pólipos duodenales son ahora la causa de muerte en los pacientes con PAF.

Restorative proctocolectomy: the current ochsner experience.

BACKGROUND: Restorative proctocolectomy with an ileal pouch-anal anastomosis is a technically demanding procedure to treat ulcerative colitis and familial adenomatous polyposis. Since its initial description almost 30 years ago, the operation has undergone technical and perioperative modifications to improve the patient's experience. METHODS: We performed a retrospective review of the records of patients undergoing restorative proctocolectomy at the Ochsner Clinic Foundation Hospital from 2008 to 2012 and compared data from that period to data from 1989-1995 (prior to laparoscopic pouch surgery) to determine factors associated with patient outcome. RESULTS: Ileal pouch-anal procedures were performed in 77 patients. The 30 male and 47 female patients ranged in age from 13 to 63 years (mean, 34.5 years). The indications for the procedure were ulcerative colitis in 62 patients, polyposis coli in 12 patients, and Crohn disease in 3 patients. Forty patients (52%) had laparoscopic-assisted procedures. The overall hospital length of stay for pouch creation averaged 6.9 days (range 3-29) and for ileostomy closure averaged 4.3 days (range 1-15). No perioperative deaths occurred within 30 days. Complications occurred in 37.7% of patients. Compared to a previous report of 72 patients from 1989 to 1995, the recent group had more laparoscopic procedures, shorter hospital stays, a smaller percentage of 3-stage procedures, and fewer general and pouch-related complications. Pouch failures were similar for both groups. CONCLUSION: Advances in operative techniques and perioperative management have improved the outcome of restorative proctocolectomies.

Clinical observation of rectal resection for 35 patients with rectal cancer / 中国基层医药

Objective To investigate the clinical efficacy of rectal resection for rectal cancer.Methods 35 patients with rectal cancer were diagnosed by pathological examination.They were treated with laparoscopic rectal cancer resection and conventional chemotherapy.The patients were followed up for 3 years.The operative time,blood loss,intraoperative and postoperative complications,postoperative recovery,death and so on were observed.Results The patients were operated successfully,and no tumor cells were found in the bowel edge.The average operative time was (171.74 ± 58.24) min,average blood loss was (85.74 ± 68.32) ml,there were no infection,bleeding,anastomotic complications.After 2 ～ 3 years of follow-up,there was 1 patient with liver metastases,and no local recurrence,no fecal incontinence and no deaths.Conclusion Rectal resection for rectal cancer had good effect and could improve patients' quality of life.

Cicatrização do cólon após mucosectomia mecânica e sutura evertente em ratos / Healing of colon after mechanic mucosectomy and evertent suture in rats

A mucosectomia é utilizada durante a confecção de reservatórios ileais nas proctocolectomias por doença inflamatória intestinal. Entretanto, tem-se relatado aumento da incidência de obstruções intestinais em pacientes submetidos ao procedimento, sendo que o contato de uma grande área de submucosa poderia ser responsável pela ocorrência de estenoses, além de poder relacionar-se com aumento da pressão de ruptura desses segmentos. Com o objetivo de avaliar as alterações macroscópicas após a mucosectomia e a pressão de ruptura desses segmentos, foram estudados 16 ratos Holtzman distribuídos em dois grupos: A (n=8), anastomose colo-cólica em plano único extramucoso invertente com pontos separados de fio absorvível e B (n=8), mucosectomia e anastomose colocólica em plano único evertente com pontos separados de fio absorvível. No terceiro dia pós-operatório, foram estudadas as alterações macroscópicas e a pressão de ruptura dos segmentos colônicos contendo as anastomoses. Os resultados obtidos mostraram aumento na incidência e intensidade das aderências peritoneais nos animais do grupo B (p=0,01), incidência de 100% de estenoses das anastomoses, sem que ocorresse qualquer estenose no grupo A (p=0,01) e aumento não significativo na pressão de ruptura das anastomoses no grupo B (4,3 ± 2,4 mmHg vs. 10,5 ± 8,2 mmHg). Concluindo, a mucosectomia aumentou a reação inflamatória tecidual, sendo causa não só de aumento na pressão de ruptura como na incidência de estenoses de anastomoses colônicas de ratos.

The mucosectomy is used during the making of the ileal pouch in proctocolectomy due to inflammatory bowel disease. However, there are reports of increased incidence of intestinal obstructions in patients undergoing the procedure, when the contact of a large submucosal area could be responsible for the stenosis, and can relate to the increase of burst pressure of these segments. To evaluate the macroscopic alterations after the mucosectomy and the burst pressure of these segments, 16 Holtzman rats were studied divided into two groups: A (n = 8), colo-colic anastomosis in extra mucosal single invertent plan with separate absorbable sutures and B (n = 8), mucosectomy and colo-colic anastomosis in a single evertent plane with separate absorbable sutures. On the third post-operatory day the macroscopic alterations and burst pressure of the colony segments containing the anastomosis were studied. The found results showed increase in the incidence and intensity of peritoneal adherences in the animals of group B (p=0,01), incidence of 100% of the anastomosis steanosis, with no occurrence of stenosis in the group A (p=0,01), and no significant increase in the burst pressure in the group B (4,3 ± 2,4 mmHg vs. 10,5 ±8,2 mmHg). Conclusion : the mucosectomy increased the tissue inflammatory reaction, giving cause to the increase of the burst pressure as well as the incidence of colonic anastomosis steanaosis in rats.

Update for Indeterminate Colitis

The distinctive diagnosis of Crohn's disease (CD) and ulcerative colitis (UC) is based on a combination of clinical, histologic, endoscopic, and radiologic data. Both UC and CD show characteristic, but non-specific, pathological features that may overlap and result in a diagnosis of indeterminate colitis (IC), which was proposed by pathologists for colectomy specimens in 1978, usually from patients operated on for severe colitis, especially in cases of acute fulminant disease of the colorectum. The subgroup of patients with an uncertain diagnosis has been classified as IC. Later, the same terminology was used for patients showing no clear clinical, endoscopic, histologic, or other features allowing a diagnosis of either UC or CD. More recently, the term IC has been applied to biopsy material when it is not been possible to differentiate between UC and CD. However, this term IC has suffered varying definitions, which in addition to numerous difficulties in diagnosing inflammatory bowel disease, has led to much confusion. In resected specimens, the term colitis of uncertain type or etiology is preferred. Over time, the majority of patients remain with a diagnosis of IC or show symptoms similar to UC. Ileal pouch anal anastomosis can be performed in such patients, with outcomes of pouch failure and with functional outcomes that are similar to those in patients with UC, but with increased risk of postoperative pouch complications. This review addresses the definition of indeterminate colitis, its pathology, its natural history, and the outcomes of restorative proctocolectomy.

Radical resection with total mesentery excision (TME) for the treatment of rectal cancer: a clinical analysis of 67 cases / 中国基层医药

Objective To discuss the clinical effect and the application value of total mesentery excision to the rectal cancerous patients. Methods The clinical data of 67 rectal cancerous patients who received the radical resection which following the TME principle,and with a 2 ～3 years follow-up were analyzed. Results All the 67 patients received the radical resection,including 1 anastomotic fistula,3 anastomotic stenosis, neither local recurrence nor distant metastasis. Conclusion TME played an important role in preventing the local recurrence of rectal cancer, and it met the standards of surgical treatment of rectal cancer better.

Surgical treatment of familial adenomatous polyposis: ileoretal anastomosis or restorative proctolectomy? / Tratamento cirúrgico da polipose adenomatosa familiar: anastomose íleo-retal ou bolsa ileal?

Context: Controversy regarding the best operative choice for familial adenomatous polyposis lays between the morbidity of restorative proctocolectomy and the supposed mortality due to rectal cancer after ileorectal anastomosis. OBJECTIVES: To evaluate operative complications and oncological outcome after ileorectal anastomosis and restorative proctocolectomy. Methods: Charts from patients treated between 1977 and 2006 were retrospectively analyzed. Clinical and endoscopic data, results of treatment, pathological reports and information regarding early and late outcome were recorded. Results: Eighty-eight patients - 41 men (46.6 percent) and 47 women (53.4 percent) - were assisted. At diagnosis, 53 patients (60.2 percent) already had associated colorectal cancer. Operative complications occurred in 25 patients (29.0 percent), being 17 (19.7 percent) early and 8 (9.3 percent) late complications. There were more complications after restorative proctocolectomy (48.1 percent) compared to proctocolectomy with ileostomy (26.6 percent) and ileorectal anastomosis (19.0 percent) (P = 0,03). There was no operative mortality. During the follow-up of 36 ileorectal anastomosis, cancer developed in the rectal cuff in six patients (16,6 percent). Cumulative cancer risk after ileorectal anastomosis was 17.2 percent at 5 years, 24.1 percent at 10 years and 43.1 percent at 15 years of follow-up. Age-dependent cumulative risk started at 30 years (4.3 percent), went to 9.6 percent at 40 years, 20.9 percent at 40 years and 52 percent at 60 years. Among the 26 patients followed after restorative proctocolectomy, it was found cancer in the ileal pouch in 1 (3.8 percent). Conclusions: 1. Operative complications occurred in about one third of the patients, being more frequently after the confection of ileal reservoir; 2. greater age and previous colonic carcinoma were associated with the development of rectal cancer after ileorectal anastomosis; 3. patients treated...

Contexto: As controvérsias quanto a melhor forma de tratamento da polipose adenomatosa familiar confrontam a morbidade da proctocolectomia restauradora contra a suposta mortalidade decorrente de câncer retal após íleo-reto anastomose. OBJETIVOS: Avaliar as complicações operatórias e a evolução oncológica dos pacientes submetidos a íleo-reto anastomose ou proctocolectomia restauradora. Métodos: Analisaram-se os dados dos doentes tratados entre 1977 e 2006, procedendo ao levantamento de dados clínicos gerais, endoscópicos, resultados do tratamento cirúrgico, dados anatomopatológicos e informações sobre a evolução precoce e tardia dos pacientes. Resultados: Foram tratados 88 pacientes, sendo 41 homens (46,6 por cento) e 47 mulheres (53,4 por cento). Por ocasião do diagnóstico, 53 pacientes (60,2 por cento) já tinham câncer colorretal associado à polipose. Registraram-se complicações operatórias em 25 doentes (29,0 por cento) dentre os 86 operados, sendo 17 (19,7 por cento) precoces e 8 (9,3 por cento) tardias. Houve mais complicações após proctocolectomia restauradora (48,1 por cento) em comparação às proctocolectomias com ileostomia (26,6 por cento) e íleo-reto anastomose (19,0 por cento) (P = 0,03). Não houve mortalidade operatória. O risco cumulativo de câncer retal após íleo-reto anastomose foi de 17,2 por cento após 5 anos, 24,1 por cento após 10 anos e 43,1 por cento após 15 anos de seguimento pós-operatório. Já o risco cumulativo idade-dependente começou a existir a partir de 30 anos (4,3 por cento), passando para 9,6 por cento aos 40 anos, 20,9 por cento aos 40 anos e 52 por cento aos 60 anos. Entre os pacientes submetidos a bolsa ileal com seguimento (26), apenas 1 doente (3,8 por cento) desenvolveu câncer na bolsa ileal. Conclusões: 1. Ocorreram complicações operatórias em cerca de 1/3 dos pacientes, sendo mais frequentes após a confecção de bolsa ileal; 2. idade maior, tempo de seguimento e câncer colônico prévio se associaram...

The correlation between the status of circumferential resection margin and the prognosis of patients With middle and lower rectal carcinoma / 中华普通外科杂志

Objective To study the relationship between circumferential resection margin status and prognosis of patients with middle and lower rectal cancer.Methods Specimens from 49 patients with middle and lower rectal cancer undergoing total mesorectal excision were studied by the large slice pathologic technique.The local recurrence,metastasis and five-year survival rate were evaluated by Kaplan-Meier Survival analysis.The related clinicopathologic factors were also analyzed.Results The cancer involvement rate of the circumferential resection margins was 24%(12/49).The overall local recurrence rate was 12%(6/49),the distant metastasis and recurrence rate was 27%(13/49),and the five-year survival rate was 67%(33/49).For the 12 patients in which the eircumferential resection margin was tumor positive.the local recurrence rate was 33%compared with 5%in those with negative circumferential resection margin(X2=6.577,P=0.010),distant recurrence was 50%compared with 19%in those with tumor negative margin(X2=4.491,P=0.034).Kaplan-Meier survival analysis showed that patient's survival time was statistically correlative with the circumferential resection margin status(log-rank.P=0.009).Five-year survival rate was 33%in patients with positive circumferential resection margin,compared with 78%in those with negative margins.Tumor diameter(X2=4.451,P=0.035),T staging (X2=20.283,P=0.000),N staging(X2=7.773,P=0.018),the distance away from the anocutaneous line(X2=6.502,P=0.04),tumor location(X2=4.421,P=0.035)and operation type(X2=5.754,P=0.016)were significantly correlated with the circumferential resection margin status of the middle and lower rectal cancer.Conclusions The circumferential resection margin status was an important predictor of local and distant recurrence as well as survival of patients with middle and lower rectal carcinoma.and the status is significantly correlated with tumor diameter,T staging,N staging,the distance away from the anocutaneous line,tumor location and operation type.